Chapter 6
The role of universities and medical schools
Current pathways into rural medicine
6.1
The numbers of medical students in Australia has risen significantly in
recent years with domestic student numbers at Australian universities rising to
12 946 in 2010 from 8768 in 2006.[1] The Department of Health
and Ageing project that by 2014 graduate numbers will have doubled in the space
of a decade.[2]
6.2
According to evidence from James Cook University (JCU) this will place
Australia significantly ahead of countries like the US, UK, Canada or New
Zealand. However, they maintain that this increase is not reflected across
rural areas:
With the increase in medical students in the last decade, we
acknowledge that the number of doctors is increasing; however, it is becoming
apparent that maldistribution is still a problem. Australia now has more
doctors per head of population than at any other time. At about three per 1000,
we approach the OECD average, and we have significantly more than the US, UK,
Canada or New Zealand. We are still continuing to lift the number of medical
students; I think we are up to about 15.9 per 100 000 of population per
year, which is the second highest after Austria. However, on the ground it
appears that the structural problem is still a geographic maldistribution and
distribution of specialist medical workforce. Rural communities still have
fewer doctors per 100 000 than metropolitan areas.[3]
6.3
While these are global figures, and it is not possible to say how many
students will go on to become doctors in rural areas, there has been a gradual increase
in the number of rural clinical schools across the country and the majority of
these are in receipt of government funding through the Rural Clinical School
(RCS) program.[4]
There are now 17 RCSs across Australia and they are managed by 16 universities
across multiple training locations.[5]
Of the 17 schools, 10 were established in 2000–01 while another four were
launched in 2006–07 as a result of a second round of RCS support.[6]
The objective of the RCS is to increase the exposure of medical students to
training in a rural area, and hopefully attract them to rural areas.
6.4
This RCS program is part of the broader Rural Clinical Training and
Support Program (RCTS). The RCTS combines the RCS with Rural Undergraduate
Support and Coordination Program (RUSC). This program mandates that 25 per cent
of medical students must be from a rural background. This approach accords
with the submissions form various organisations and individuals that there is a
strong body of evidence that students from rural areas are significantly more
likely to work in a rural areas than those from metropolitan areas. Rural
Health Work Force Australia (RHWA) cited a South Australian review that
concluded 'that the likelihood of working in rural practice is approximately
twice greater among doctors with a rural background.'[7]
6.5
Ms Stronach from JCU concurred:
There is much national and international evidence now to show
that, to increase the rural and medical workforce, you need to select students
who have a rural or regional background; train them in a rural or regional
area; and give them enough meaningful and appropriate clinical exposure in
rural, remote and regional health environments. That is important at both the
undergraduate and postgraduate levels.[8]
6.6
The University of Western Australia also cited evidence in their
submission that supported the claim that students with rural backgrounds are
more likely to work in rural areas:
In a 2003 article for the Medical Journal of Australia (MJA),
Laven et.al., revealed the results of their national study on the factors
influencing where GPs worked, particularly those in rural locations. The study
found that ‘GPs who have spent any time living and studying in a rural location
are more likely to be practicing in a rural location. Those whose partners have
also lived and studied for any period of time in a rural location are six times
as likely to become rural GPs than those with no rural background’ (Laven
et.al., 2003, p.77)...The University of Western Australia recognises that medical
students with a rural background are more likely to be interested in working in
rural and remote areas their urban counterparts.[9]
Quota of students from a rural background
6.7
The RUSC program specifies a target of 25% of Commonwealth-supported
medical students must be from a rural background.[10]
The current program was implemented on 1 July 2011 and all universities
offering Commonwealth Supported medical school places are included in the
scheme apart from Griffith University who decided to opt out due to its focus
on servicing outer-metropolitan regions in Southern Queensland. [11]
6.8
Despite this program, and the increase in rural clinical schools, there
is still a low conversion rate for students graduating and returning to a rural
area. Health Workforce Queensland (HWQ) provided the committee with results of
a longitudinal study they have been carrying out to measure the proportion of
medical graduates from four medicals schools that are now working in rural
areas. The study measured the proportions from four medical schools—the University of
Queensland (UQ), JCU, Griffith and Bond Universities—and the numbers are generally disappointing,
with an average across the schools of 5.2 per cent of students now working in
rural areas. Although the figures show JCU has an 11.2 per cent conversion
rate. The HWQ submission reported the findings:
Health Workforce Queensland has been actively tracking the
number of Queensland trained doctors who are currently working in rural and
remote locations. Data indicates that of the 5,618 graduates from the
University of Queensland, James Cook, Griffith and Bond Universities between
1990 and 2010 only 294 (5.2%) are currently working in ASGC 2 to 5 locations.[12]
6.9
Charles Sturt University (CSU) is a strong proponent of increasing the
proportion of students from the current 25 per cent to a figure proportionally
more representative of the general population. The most recent figures
available have 31.4 per cent of people living outside metropolitan areas in
Australia.[13]
6.10
In evidence provided to the committee in Albury, CSU argued not only
that 25 per cent was not reflective of the population who live in rural and
regional areas but also that the definition of a rural background is also
flawed:
No matter how you define where the regions are, it is closer
to 30 per cent of the population of Australia, so for starters 25 per cent does
not make a lot of sense.[14]
...
As you are aware, there is a 25 per cent target for medical
schools to enrol students from rural backgrounds. We would suggest that the
definition may not be good and that it only requires five years of residence in
a rural area over the course of their life up to that point. That is not a very
good definition[15]... The
definition allows for you to have been born in Broken Hill, for your family to
have lived there for five years and for you to move to Melbourne for the rest
of your life and you could still be designated as a rural student. It is
ludicrous.[16]
6.11
However they emphasised that they did not see a definition of a rural
background as the most crucial aspect, but indicated that they would like to
see 'rural students' defined by a desire to work in a rural area:
A definition would involve a program where you looked at
applicants for medical school and discussed with them why they might be
designated a rural student. The fundamental issue they would have to convince
you of is that they had a rural background, they love rural life, they are
rural focused, their families have a rural focus. In other words, you would be
looking for evidence that they had a genuine intention, no certainty, to
practise their craft in a rural community on graduation[17]...We
believe that an orientation towards rural practice is actually more important
than that definition of rurality.[18]
6.12
Dr Lennox from Queensland Health described their approach to the quota
for students with a rural background which also does not entail an overly rigid
approach:
We have been working very closely with the medical schools,
particularly James Cook University, the University of Queensland Rural Clinical
School, and through Griffith and Bond medical schools to ensure that we provide
maximum opportunities for medical students with a rural background to stream
into the pathway. In fact, rural heritage is one of the selection criteria for
entry into the pathway. However, we do not disadvantage those who do not have a
rural background but have fallen in love with the idea of becoming a rural doctor.
In the merit selection process we also recognise what they have done to prepare
themselves for rural practice through the medical school years.[19]
6.13
Professor Humphreys from the CRERRPHC expressed his support for the
principle of having a target of students from rural backgrounds. However he
suggested that this was only one part of the equation:
I have to say I think that program has done very well at the
front end of the training spectrum. It has encouraged universities to train
their entrance programs, their selection processes; it has created dean's lists
and opportunities for disadvantaged rural people. It has done a lot there in
terms of early immersion. It is in need of a little bit of scrutiny at the
moment, because I think there is a bit of fudging of some of the figures around
25 per cent and what that really means, but effectively it has been a very
significant and worthwhile impetus to get the front end of the training
spectrum right. Within the graduate and undergraduate medical programs, I think
things are going well.[20]
6.14
There has been some recent controversy around whether all universities
subject to the quota have been meeting their target. The publication of the
figures from 2010 that detail the numbers of commencing students studying
medicine from a rural background stated that only 7.5 per cent of commencing
medical students at UQ had a rural background.[21]
The RDAA also reported from the same figures that only nine per cent of
students at the University of Adelaide, and 13 per cent of students
from the University of Sydney, were from a rural background.[22]
6.15
This UQ figure in particular was brought up by CSU in their discussions
over an appropriate target:
For medical student entrants in 2012, 141 places that should
be occupied by rural students are being occupied by metropolitan or overseas
full-fee-paying students. The University of Queensland only has 7.5 per cent.
The biggest medical school in Australia only has 7.5 per cent rural. [23]
6.16
On the back of that evidence the committee invited the UQ medical school
to give evidence. They strongly refuted the claim that they had not achieved
the target of 25 per cent, stating that the data was incorrect. Professor
Nicholson, the Head and Director of Research from the UQ School of Medicine,
took the opportunity to correct the record suggesting that administrative
processes were responsible:
The review panel report of 2010 into medical training stated
that six medical schools had not achieved the 25 per cent rural background
target and that for the University of Queensland it was 7.5 per cent. This hit
the press and has caused a great deal of difficulty. This data is incorrect but
has been used by some to advocate for changes in the funding model, so I think
it is quite important that I set the record straight. I do not know where the
7.5 per cent came from and neither does anybody at the school of medicine, but
presumably it came from information provided to MDANZ, which is Medical Deans
Australia and New Zealand, by central UQ administration. But the actual
situation in 2010 was that we had 25.7 per cent of 138 graduate entry students
who had a rural background and there had been a quota in place for a number of
years. But the rural background amongst the majority of 178 undergraduate entry
students was unknown. So we had a denominator of X and a numerator of Y and
ended up with 11.4 per cent, which was technically correct, not 7.5 per cent.
But I will be able to produce some data that corrects that. [24]
6.17
Professor Nicholson also suggested that the changing pattern of the
university's entry pathways may also have played a role in the incorrect data
collection systems:
It is important to understand there are two entry pathways.
One is an undergraduate...[t]he other entry pathway is graduate entry. Initially,
the University of Queensland was entirely graduate, but about five years ago
they started to introduce the undergraduate program. It started with quite
small numbers but then ballooned to become the majority of the entrants. That
explains some of the other data I am going to present to you[25]...After
this information came out I initiated a survey of the entire year 1 and year 2
cohorts. That is 609 students. We had a very high response rate of 93.2 per
cent. If we look at the rural background by MBBS year, 22 per cent of year 1
and 21 per cent of year 2 students reported having a rural background. This is
based on the standard criteria of RA2 to 5 for at least five years since
beginning primary school. I am very happy to table that report if the committee
would like that.
In addition we have surveyed all students in the
undergraduate pre-med course and consistently find around 13 per cent of those
have a rural background. There is a clear difference between the proportion
with rural background in the undergraduate versus the postgraduate program, but
I would like to say very clearly that we are absolutely committed to achieving
the 25 per cent target. Quotas will be in place next year for both streams, and
we will ensure that the 25 per cent is met or exceeded. Very senior management
has taken responsibility for this.[26]
6.18
The committee also discussed the issue with the Department of Health and
Ageing when they appeared for the second time in Canberra. On hearing of the
disputed data claims the department said they were 'aware there have been
issues with the UQ's reporting under the Rural Clinical Training and Support
program. We are working with them again on this year's data, so if that is a
continuing problem we can get that sorted out with them.'[27]
6.19
While the issue of a quota was discussed as a contributing factor in
increasing rural doctors, none of the evidence received by the committee
suggested that there was one single solution to the problem.
Committee View
6.20
The committee understands the call for an increase to the target for
students from a rural background from 25 per cent to a figure more
representative of the general population. The contributors who proposed an
increase highlighted the performance of some universities in meeting that
target. In the case of the University of Queensland, the committee is
satisfied that the reported figure was incorrect, though it remains unclear
what the accurate figure may be. The committee is not persuaded that
increasing the target will mean that universities will then meet that new
target. In fact the opposite may occur, given the problems that some medical
schools have been facing in meeting the current target.
6.21
The evidence from across the board suggests that while the target should
be met and enforced, it is only one element of a complex problem, and by itself
holds no promise of an increase in the rate of graduates practicing in rural areas.
However the committee heard evidence that suggests that regional universities
are more likely to meet the target and consequently provide more graduates that
will practise in rural areas. The committee supports meaningful sanctions for
those institutions that do not meet the current target, and although it
understands that this is now a mandatory target with funding conditions
attached, it would like those sanctions to be in the public arena, and would
also like evidence of those sanctions being applied where appropriate.
6.22
The committee also considers that the definition of a rural student for
the purposes of a quota needs to be reviewed.
Recommendation 10
6.23
The committee recommends the publication of those cases where
universities do not meet the target of 25 per cent of medical students from a
rural background, and subsequent publication of information about the sanctions
that are applied in those cases.
Recommendation 11
6.24
The committee recommends that the commonwealth government explore
options to provide incentives to encourage medical students to study at
regional universities offering an undergraduate medical course.
Recommendation 12
6.25
The committee recommends that the definition of a rural student for the
purposes of a quota be reviewed, and that the review should consider
strengthening the definition to only include students who have spent four out
of six years at secondary school in a rural area; four out of the last six
years with their home address in a rural area; or city students showing
'ruralmindedness', defined as an orientation to work in rural and regional
areas, and demonstrated by a willingness to be bonded.
A multifactorial problem
6.26
CSU referred to reports from RHWA and the Deloitte Access Economics that
show the current policies designed to provide enough rural health and medical practitioners
are not working:
Some of the figures that have been mentioned, for instance,
by Rural Health Workforce Australia and the Deloitte's report, are that
possibly only 2.7 per cent of 3,000 medical graduates actually intend to pursue
a career in rural practice. We think that is an indictment of the current
policy settings. A number of reports have been released over the last several
months, but the Rural Health Workforce Australia report on the workforce in
2025 very clearly said that the policy settings are not delivering what is
required for rural and regional areas, and are unlikely to unless there are
changes to the policy settings into the future.[28]
6.27
Many submissions and evidence received throughout the inquiry has
outlined that the problems of recruiting and retaining rural health
professionals are complex and involve a number of factors. The University of
Western Australia cited evidence that a student's background is only one of the
factors that will impact on the decision of where someone will work after
graduation:
The decision of whether or not to work in a rural area is a
multifactorial one and the influence of a multifaceted rural backgrounds is
only one part of this complex decision making process.[29]
6.28
This position is supported by the CRERRPHC, which cited a number of
studies in its submission that found that there are many variables that
influence a practitioner's decision:
Health workforce recruitment studies have highlighted the
importance of student background, aspirations and interest in rural practice,
needs of spouses and partners, the extent to which the training program has a
rural mission, rural mentoring and support systems for students and rural
educational experiences as the best predictors for taking up rural practice. While some of these background variables (such
as rural background and interest in rural practice) continue to influence
practitioner satisfaction in rural practice, other research has found that
practice issues such as income and workload were far more significant
predictors of practitioner retention in rural areas.[30]
6.29
Professor Murray, President of the Australian College of Rural and
Regional Medicine (ACRRM) and Dean of the JCU's medical school, also acknowledged
the issues are complex and outlined what the medical schools can do to address
some of the issues:
Recruit rurally so that there is a better mix and make sure
that you have also got underrepresented groups. Indigenous students, low SES et
cetera is part of that. This helps to form a peer culture and a sense of values
and belonging. Provide curriculum that is rurally rich with lots of inspiring
experience. Our member medical students here, for instance, do not darken the
doorstep of a city teaching hospital unless they do an elective. It is a
completely different experience, and all of them do 20 weeks of small rural and
remote placement. They are making choices, which we are very pleased to see, that
are actually extraordinary and unprecedented.[31]
6.30
Professor Murray also described what he sees as a current opportunity
being missed with the increase in medical students flowing through the system:
We have engineered a solution to these three problems, which
is to more than double the number of medical schools in the country and increase
by about 2½-fold in a decade the production of medical graduates so that we
will now almost top the OECD...However, we have not built the pipeline so that
these new graduates—my new colleagues—will be going into the sorts of careers
that we need them to do, that is, careers which are regional and general with a
population health and a team orientation...There is an imperative of now.' We
call it a national policy emergency. Jobs will be found for these young doctors
in training. They will be shoehorned into the big city teaching hospitals
supplemented by the big private hospitals. They will be doing transplant
matters in their second year. It is a workforce that we do not need and that we
will rue for a long time.[32]
6.31
As part of the discussion on future health care needs CSU informed the
committee of their current proposal to the Commonwealth government to establish
a new rural medical school in Orange that would provide placements for both health
and medical practitioners, expanding its current campus. The proposal emphasises
that future health care needs will be serviced by multidisciplinary primary
care teams with a focus on preventative health.
6.32
Unlike the Rural Clinical Schools that primarily service students for
rural medicine rotations, the CSU proposal is for a full rural medical school
that would introduce a 'six year undergraduate medical program...with the
following features':
...an annual intake of 80 students; a Positive Rural
Recruitment Program with 60% of students from a rural, regional or Indigenous
background or disposed to rural practice; and, streaming of students from their
fourth year to focus on providing those students committed to rural practice
with procedural skills suitable for rural practice.[33]
6.33
In addition CSU proposes that health related courses other than medicine
would be doubled to 'build the skills and capabilities of graduates for
integrated health care' and 'significantly increase the number of rural
doctors, nurses and other health and human service professionals in rural
areas.' [34] The
proposal recognises that there are similar professional, social and economic
factors that limit the supply of those health professionals in rural areas.[35]
Of particular importance is the intention to integrate an e-health curriculum
into the courses to prepare students for current and future utilisation of
e-health and telemedicine. [36]
6.34
The Commonwealth government does fund the Nursing and Allied Health
Scholarship and Support Scheme which is a program that supports
allied health and oral health students to undertake a clinical placement in a
rural or remote Australian community during their degree. However the
committee received evidence that the program was vastly oversubscribed. The
allied health component of the scheme is administered by Services for
Australian Rural and Remote Health (SARRAH) who pointed out that this is a
potential opportunity missed:
...applications for the 2012 intake under the Allied Health
Clinical Placement Scholarships Scheme, which we administer on behalf of the
government, recently closed. For the 150 places under the scheme we had 1,046
applicants, of which 864 were eligible. This scheme encompasses all allied
health professions and targets settings across rural and remote Australia. So,
basically we are saying that there are over 700 eligible applicants who were
unable to take up a placement in rural and remote Australia. Given that there
is a workforce shortage, it is not rocket science to work out one strategy that
could be adopted.[37]
6.35
The Department of Health and Ageing agreed that there are issues around
finding clinical placements for postgraduates and pointed out that this is one
the reasons why student placements are tightly regulated because of the flow-through
of students for periods of 10 years or more that have to be accommodated. In
response to questions about the proposal from CSU for a rural medical school,
the department discussed the issues that need to be considered:
...Commonwealth-supported medical places are capped under
legislation administered by the minister for tertiary education. The views of
the Minister for Health are sought on proposals to either establish new medical
schools with new Commonwealth supported places or to extend the number of
places within existing medical schools. The advice that the Minister for Health
has been providing for some time now is that the clinical training environment
is very stretched and there is not really the capacity to support additional
numbers of medical students because of the large expansion over the last few
years in the numbers of students training in Australian universities. Also, we
now have evidence—modelling, I suppose—provided by Health Workforce Australia
that shows that the number of doctors that we are producing and are expected to
produce out to 2025 is relatively in balance. There may be a short-term
oversupply followed by a fairly small comparative undersupply unless we change
policy settings, but governments have agreed that they need to change policy
settings rather than continue increasing the number of graduates...
When people are doing their undergraduate training at
university, they need access to fairly extensive clinical training placements
in order to complete their undergraduate training. That is usually provided
through hospitals. Once they graduate, there can be issues with finding places
for junior doctors. Again, that is capacity within the large teaching
hospitals, generally public hospitals. There is also, once people are going
through vocational training, a need to find people access to clinical training,
so it is right through the scope of people's training.[38]
Committee View
6.36
The committee was impressed by the model proposed by Charles Sturt
University. The provision of a full scale medical school based in regional
Australia would have a significant impact on the numbers of doctors, nurses,
allied health and other essential health professionals that would come from
rural areas and would therefore be likely to remain in those areas after they
complete their training. The inclusion of telemedicine and integrated team
based care was also welcomed.
6.37
However the committee is also mindful that the current pressing issue is
not the student numbers but the capacity in the system to adequately train
those students all the way along a pathway from student to health professional
who will work in rural areas.
Student Entry requirements
6.38
Queensland Health gave evidence to the committee that they are going
further back in the educational pathway to try and attract rural students into
the health sector as a whole:
We have a program which deliberately targets rural based
secondary school students to interest them in health careers—not just in
medicine but in other disciplines as well. That has been operating over quite a
number of years now, so we have a good track record of the number of rural
secondary school students who have now tracked into health careers, and a
significant number of those in fact are now moving into rural generalist
medicine. [39]
6.39
There was also some discussion about the standard required for entry
into medical schools and whether this should be revised for students from rural
areas to take into account educational inequalities outside metropolitan
areas. Dr Lennox from Queensland Health described one of their 'affirmative
action' programs:
What I can share with greater authority is the selection of
secondary school students with a rural background through a program like our
Health Careers in the Bush, for example, giving them affirmative action or
assistance to enter into vocational training or enter into basic training in
health disciplines including medicine, and then, through programs like those of
James Cook University—and I think the University of Queensland now are
establishing a very strong affirmative action program as well—assisting those
students who have not had the best opportunity academically in secondary school
or, for that matter, even in primary school to be able to bridge those gaps and
move very well into tertiary education and vocational training in medicine.
From what I can see, the evidence is very strong that they are very worthwhile
programs. I have no doubt that we will see in the end strong evidence coming
out of that evaluation that students or trainees with a rural heritage,
including an Indigenous heritage, who have tracked through this program will
provide exemplary service in the long haul in rural practice in future.[40]
6.40
CSU also supported differential entry requirements for students from
rural and regional areas:
...a major driver of university behaviour is about the prestige
of student selection on entry, which is not necessarily anything to do with
their ability to study the course. Medicine is a very competitive field.
Sometimes the argument is put that we cannot let students in from rural and
regional areas because they are not sufficiently qualified. My answer would be
that they do not meet the market price but the market price is not necessarily
an indication of ability. As John pointed out, this was the experience at JCU.
There are entrenched factors which reduce the ability of bright students in
regional areas to compete. You do need to have some process of affirmative
action or at least recognise the educational disadvantage that feeds into this.[41]
6.41
Dr Mourik, a consultant obstetrician and gynaecologist in Wodonga
suggested a rural loading for rural students would be effective:
Any government program which supports rural students being
accepted into Medicine needs to be enhanced. Rural students in secondary
schools are disadvantaged compared to city students, so a rural loading of the
TER scores would improve the number of rural students entering medical studies
and subsequently returning to the country after they graduate.[42]
6.42
Dr Mourik further expanded on his submission when giving evidence to the
committee:
I do not think you have to be that smart to be a doctor, but
you do have to work hard. We know that rural students who go to rural secondary
schools do not have the same teaching as the [...] schools in the city. So there
must a loading for rural students.[43]
Committee View
6.43
The committee strongly supports the efforts of Queensland Health, James
Cook and Queensland University in their affirmative action programs. The
introduction of options for underprivileged young people to enter a career in
health and the provision of appropriate support throughout their training is
highly commendable. The committee urges other regional and rural institutions
and appropriate education providers to examine ways that can increase the
opportunities of young people in the health field, with the added benefit of
increasing the likelihood of retaining a health workforce if they are sourced
locally.
Teaching and mentoring places for medical students
6.44
There are a number of barriers in current pathways for medical students
to practise in rural areas. One of the most significant issues is whether the
number of internship places for medical students can keep up with the recent
expansion in medical graduates.
6.45
The internship is the first year out of medical school and is followed
by one or more years as a Resident Medical Officer, or 'resident'. Both of
these stages usually involve work rotations in clinical departments in the
public hospital system.[44]
6.46
There has been recent media coverage of an article in the Medical
Journal of Australia that claims that there will not be enough intern places
available for the number of graduates leaving medical school.[45]
The AMA concurred with the assertion. Catherine Joyce form Monash University
suggested that 'what we need to explore is a wider range of settings in which
these internships take place', and this call was supported by Catholic Health.[46]
6.47
Professor Nicholson from UQ discussed the reliance on major teaching
hospitals for post graduate training which excludes rural and regional
hospitals:
...postgraduate training is not done by the universities; it is
done by the colleges and they basically rely on the state teaching hospitals.
There need to be positions in the hospitals that are fully funded for training.
Going back to my experience in Geelong, there was no position. I established
the position where essentially the senior doctors paid the salary of the
registrar in order to get somebody through, you needed to use innovative
schemes. It was not considered reasonable or proper to train somebody in a
regional hospital. I am sure that you will find that the vast majority of
training positions in all states, including Queensland, are situated in
metropolitan teaching hospitals.[47]
6.48
Professor Nicholson argued that this has direct consequences on efforts
to entice doctors and specialists into rural areas:
One of the drivers is that some students want to work rurally
but want to train in surgery, so they hang about metropolitan teaching
hospitals. Then they get married, get a mortgage and that is the end of it. [48]
6.49
The RDAA discussed the broadening of the settings of training
postgraduate rural doctors:
The Rural Doctors Association has published a set of national
principles on the pathway for advanced training. That set of principles clearly
identifies that there is an issue in some states for the availability of
training positions that are required to do rural medicine and that other states
may have to be brought in to provide some of that access. It is the same with
the Northern Territory, for example, where we do not have the number of public
hospitals required. So we believe that doctors should be able to move within
that pathway into those other areas as the training simply may not be available
in some of the smaller states. It may have to be provided by other areas with
more regional hospitals.[49]
6.50
The issue of training for potential rural GPs becomes more acute at the
registrar level, when training in rural medicine is normally delivered by GPs
in community practices. Dr Mara from the RDAA commented on the difficulties
and pressures that are placed on GPs in these scenarios:
I personally, in my practice, would not be able to take on an
intern in their vocational training year. The registration requirements, the
risk requirements and the other arrangements for their training are very
difficult to supervise. But I know that some practices are geared up to do it
and they do it very effectively and very well.[50]
6.51
The AMA in their submission commented on the impact of the age profile
of doctors in rural areas who are often relied upon to provide training and
mentoring services as part of rural clinical rotations:
The average age of rural doctors in Australia is nearing 55
years, while the average age of remaining rural GP proceduralists – rural GP
anaesthetists, rural GP obstetricians and rural GP surgeons – is approaching 60
years. This means that the ageing of the health workforce has serious
implications for sustainable health service delivery and for the supervision
and mentoring of trainees and new graduates into the future. These issues
impact on the health workforce nationally and in all settings, but are even
more pressing in regional, rural and remote areas.[51]
6.52
The Royal College of Physicians commented on how valuable the increase
in University Rural Clinical Schools has been in providing the opportunity for
training to be delivered in a rural or regional setting by senior
professionals:
These have provided education and training opportunities in
regional communities for some years and have enabled senior professionals to
engage in supporting the teaching and training of local or temporary residents
and trainees and is a win for both the professional community, the general
community and the students who wish to study, work or live in a community which
they have grown up in.[52]
6.53
The City of Mount Gambier, in discussing the success of the Flinders
University Rural Clinical School, added that:
These facilities enable students to experience the benefits
of rural living and medical practice informing them about placements in the
country on completion of their studies thereby improving the capacity of the
region to deliver medical services in our region. Without this, rural areas
tend to lose potential medical professionals from their own populations when
they are required to relocate to major capital cities for their education
needs.[53]
6.54
However this can also cause difficulties in supplying the colleges with
adequate teaching resources. Dr Mourik described the situation in Albury Wodonga:
I am teaching women's health at the university, and that is
one of the best initiatives the federal government has done. It really does
work well, except it lacks teachers. Out of the eight O&G specialists in
this town I am the only one who does teaching—and it is onerous—because they
are too busy doing the work...[w]e lack the teachers, and there is no incentive
for teachers.[54]
6.55
A report from the Rural Doctors Workforce Agency in South Australia
emphasised how important it is that young doctors studying at postgraduate
years one and two (PGY1 and 2) are provided with training from existing GPs in
a rural setting because 'there are no GP role models or champions in
metropolitan hospitals'.[55]
This view that hospitals are not appropriate for training GPs is supported by a
study by NSW Health that found that:
...the current NSW hospital service model does not meet the
accreditation requirements of ACRRM or the RACGP to enable GP trainees to
complete all of their GP training in a hospital setting. Continuity of care is
considered a necessary part of GP training and primary care under both College
programs and NSW hospitals do not meet this training requirement.[56]
6.56
The Australian College for Rural and Remote Medicine (ACRRM) emphasised
the need to invest in teaching, and in situ mentoring capacity in rural areas:
...we do need to invest more in developing the infrastructure
for teaching out there, really developing the mentoring and the supervision
type levels. We would like to be providing a higher level of mentoring and
supervision, particularly mentoring for overseas trained doctors, but, again,
we have not got funding to do that. You do need to. Infrastructure for training
in rural is essential.[57]
6.57
Dr Kirkpatrick from the Royal Australian College of General
Practitioners described the current situation for GP practices across the
country that have the capacity to teach:
We would like to see the number of rural places and the
length of rural placements increase, but it cannot be without support for supervisors.
We are already stretching our teachers, but there are only some 1,500 general
practices in Australia that teach. One of the things that we need to do is to
make teaching valuable to the teacher, but not to the detriment of providing
health care within the community.[58]
6.58
Dr Kirkpatrick also pointed out that there are developments overseas to
provide the teaching skills at an early stage that will increase the capacity
for students now to become skilled teachers later in their career:
Can I say that in Britain they are mandating education and
teaching models for all of their medical students and registrars so that
everybody has some degree of understanding of educational method and how to
teach. In Australia there is an understanding that everybody will teach but
often times there is no 'teach the teacher'. It is becoming recognised as a
need but it has not been a mandated activity. [59]
6.59
Ms Bell from the Central Australian Aboriginal Congress informed the
committee of the particular difficulties with regard to providing teaching and
mentoring opportunities in their delivery of Aboriginal health services:
A challenge for us, when we are dealing with that number of
trainee positions, is that we do not have adequate training facilities for when
they are onsite. For instance, having four registrars and four trained
supervisors who look after each of them becomes an issue for us in ensuring
adequate space and opportunity for them beyond the clinic. That has been an
ongoing issue for us over the last three or four years of being recognised as a
training facility. Even though we only receive these trainees, there is an
impact on our environment when we have them there on site, and we do not have
adequate facilities to look after them in a way that students need to be looked
after when they are there.[60]
Committee View
6.60
Effective translation of medical students into rural and regional
practice requires appropriate support at all stages in the training and
placement process. There does not appear to be adequate systems that will
support the internships, rotations, or mentoring of the expanding number of
medical students. The committee did not receive detailed evidence on the
funding and policy mechanisms that support internships and workplace training,
but the situation will need to be improved in regional areas if the current
drive to expand the number of students is going to translate into actual health
professionals working on the ground.
6.61
The committee is looking forward to the Department's forthcoming review
of rural health and would like to see a full exploration of ways in which
blockages in the system such as the shortage of rural clinical placements can
be addressed. Support for training providers, be they public or private
hospitals or GPs in rural communities is essential. Infrastructure funding is
important to support these providers, but simple steps like introducing the
UK's recent policy of incorporating teaching training into the medical
curriculum could also provide local GPs with the tools and confidence to
provide high quality training in a local setting.
Recommendation 13
6.62
The committee recommends that the Commonwealth, state and territory
governments review their incentives for rural GPs with the aim of ensuring that
rural GPs who provide training to pre-vocational and vocational students are
not financially disadvantaged.
Recommendation 14
6.63
The committee recommends the Commonwealth government consider the
establishment of a sub-program within the National Rural Locum Program that
would provide support for rural GPs to employ locums specifically to enable the
GP to deliver training to pre-vocational and vocational medical students in
rural areas.
Accommodation issues during clinical placements
6.64
A number of contributors to the inquiry discussed the difficulties that
doctors and other health practitioners encounter in securing accommodation
during clinical rotations and placements in rural areas. The situation seems
to be ad hoc; there are no significant Commonwealth government policy
drivers in place,[61]
and there is a lack of coherent strategy across the medical school sector.
6.65
Dr Mourik described what his students regularly encounter when trying to
access affordable accommodation:
They find their own accommodation. A couple of students just
got digs with the midwives. Some of them share houses.[62]
6.66
He also suggested that significantly lower incomes for rural
practitioners are a real barrier to attracting doctors to rural areas:
How many years have we been talking about rural loading? We
pay the same insurance as a city obstetrician and our income is about
one-third. We can cope with a half, because the cost of houses and land and
other expenses is less, but not three or four times...We cannot attract a young
person here when they have HECS, a partner, two kids and a dog. By the time
they are a senior registrar or graduate as a specialist, they do not want to
come here and earn one-third of the income they can earn in the city. We cannot
attract them.[63]
6.67
Dr Lennox from Queensland Health informed the committee that there is
some provision for accommodation as students move through the training pathway
as part of their rural generalist model:
The key elements of this pathway is that trainees are able to
progress to the completion of training in-service with Queensland Health. So as
they progress through the pathway, they have an entitlement to accommodation,
particularly when they are appointed in the rural locations. Their appointment
as a senior medical officer provisional fellow entitles them to accommodation
by the health and hospital service in which they are located.[64]
6.68
The University of Queensland also has some provision for accommodating
its students, particularly if they are in rural areas:
Part of our funding requirements is that the students are not
disadvantaged, so there are a number of models. There is a rental subsidy. We
do home stay. They could be put up in Queensland Health facilities. In a few
places like Roma we have our own facilities... At all the other sites the 120-odd
students are essentially given free accommodation for the year or two years.[65]
6.69
SARRAH described the accommodation provided through the the Nursing and
Allied Health Scholarship and Support Scheme. The scheme supports allied
health and oral health students to undertake a clinical placement in a rural or
remote Australian community as part of their degree.[66]
The rural placement:
...entails students in their third or fourth year going out to
a rural and/or remote location for up to a maximum of six weeks—an
accommodation, travel and sustenance allowance is paid. Generally, that costs
around about $11,000 per placement. It has been running for two or three years
only.[67]
6.70
JCU also highlighted that difficulties in training medical practitioners
in rural areas are equally applicable to training the broader health workforce
including nurse and allied health practitioners:
Just focusing on the training of the broader health
workforce—medical, nursing, allied health—for rural service, there are
significant costs associated with training health professional students in
rural, regional and remote locations. These include all the common ones: the
provision of the teaching infrastructure, the difficulty in attracting and
obtaining appropriately trained supervisory staff, the travel costs for your
staff and your students, accommodation costs—which are a huge gate that is
holding back being able to place more students in small rural towns—and costs
for students in having to maintain two residences. At JCU we expect our
students to do a long placement in at least one rural area. We expect that of
all our health professional students.[68]
6.71
Tropical Medical Training, which manages the placement of a significant
cohort of JCU postgraduate students, also highlighted the importance of
accommodation and in the placement of all health practitioners and the work
that it has carried out:
There is also mapping about all the accommodation that is
being provided over the year and who owns it—which university, which medical
school and or which physiotherapist school, and where we can place the doctors.[69]
...
Obviously, especially with the mining boom at the moment, it
is very hard to get trainees into some of our western towns. It is $1,200 a
week for rent, which is fairly hard to sustain... so accommodation is
a big issue, whether it is renting or actually buying a building, which might
be cheaper in the long run, so that people have somewhere to stay.[70]
6.72
Health Workforce Queensland described the situation as being not only
difficult to house health practitioners on clinical placements, but also having
to provide appropriate professionals infrastructure for visiting practitioners:
Infrastructure accommodation is on a couple of levels. There
is the need for overnight accommodation for all health professionals. You have
heard the horror stories about the cost in mining towns. It is not only a
matter of availability; it is also about quality and safety. You need to be
mindful of those things. The other one which goes with it is the clinical space
for the health professional and the teaching space as well.
Then, on top of that, you have got fly-in fly-out services.
There are a number of very successful programs run across the country called
the SOAP programs, Specialist Outreach Assistance Programs—specialist outreach
programs—and others. They bring people into town, which is wonderful, but if
you have not got a second, third or fourth consulting room or a bed or this or
that or high speed internet then it is actually problematic. I mentioned
Cherbourg before and I would like to mention it again. There are something like
72 services going into that community, but put 72 single professionals in a row
and then try to put them anywhere.[71]
6.73
The housing difficulties for Aboriginal Health Workers was also
highlighted by the Aboriginal Medical Services Alliance of the Northern
Territory:
One of the biggest hindrances is housing. It is the policy of
this government in the Northern Territory to supply housing for police, for
Aboriginal community police officers, for nurses and for doctors, but it is an
explicit policy of this government not to supply Aboriginal health worker
housing. Apart from the fact that this is really discriminatory given that
these other professions—including health professions—get housing, we have lots
of places where housing is so overcrowded that Aboriginal health workers
basically have to go to the clinic in the morning to shower and get changed
into clean clothes, because their own living conditions are too poor and too
crowded.[72]
Committee View
6.74
The committee acknowledges that a placement program can only work
effectively if students have somewhere to live while undertaking it. The
committee notes that existing programs and stakeholders are seeking to address
this issue. Given the number of students coming through the system who will
require appropriate, and importantly, secure accommodation and support as part
of their rural placements and clinical rotations, it is imperative that
adequate policies and programs are established to manage the increasing
demand. While it may be argued that accommodation issues are not unique to
health workers it is an obvious impediment to increasing the health workforce
in rural areas and one that requires a whole of government approach involving
federal, state and other key stakeholders.
6.75
The specific issue of housing for Aboriginal Health Workers needs to be
addressed. The committee is aware of the difficulties this causes in Aboriginal
communities, both for staff working in remote communities and for attracting
staff to those communities. The committee urges to Commonwealth government and
the state and territory governments to work together to address this need.
Recommendation 15
6.76
The committee recommends that a coordinated accommodation
strategy for be developed for rural health workers, including Aboriginal Health
Workers, in the government's forthcoming review of rural health programs.
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