Rural maternity services: It takes a team to make it work
 
Dr Ayman Shenouda
 
Timing is everything - this is particularly true in healthcare - and in birthing services right now, it’s actually getting quite critical for GP obstetrics.
 
For the rural GP obstetrician, the discussion is no longer about a rebirth of rural obstetric services for rural areas but in has moved rapidly to the preservation of this critical role.
 
Two key discussions are occurring in obstetric care in Australia at the moment both lacking one vital component and that is valuing the key role of the GP obstetrician in providing this care.
 
The first, occurring at the national level, in setting national directions for maternity services prioritises access yet omits GPs almost entirely despite their reliance in rural and remote areas.
 
The other discussion involves a state-led shift in WA towards a new model of care which seems to locks GP obstetricians out completely.
 
We are seeing spot fires right around the country including in northern NSW but on a slightly different front in resistance of midwifery units to GP involvement.
 
Combined these are worrying developments and it is clear that major change looms unless we can work to reframe the discussion.
 
We have the solution
 
The vital role of the GP obstetrician has to now dominate the national discussion and the National Rural Generalist Pathway is the connecting policy thread here.
 
We are now at a critical point in building a future rural workforce which offers a single solution by factoring together all the required enablers in one.
 
The vital work done over the last twenty years has shown us solutions which brought together in one pathway will offer a sustainable way to address rural health needs.
 
It’s a model that will work – one that prioritises the skills needed – which are reflective of local health needs with the required training supports embedded.
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This is a model that brings flexible models of care bridging the primary care and hospital care continuum – it’s based on community need.
 
And it provides a way to keep it sustainable by enabling a highly skilled GP workforce integrating primary, secondary and tertiary care skills.
 
But it is reliant on enabling infrastructure too and in keeping it sustainable and so much is connected to a town’s capacity to preserve procedural services like birthing.
 
State of play
 
Here’s a brief outline of the current state of play.
 
Round 2 of the National Strategic Approach to Maternity Services Consultation has just closed (20 November).
 
The Australian Health Ministers’ Advisory Council’s consultation draft  Strategic Directions for Australian Maternity Services is structured around four values — respect, access, choice, and safety. Enabling access to services for rural and remote women is emphasised.
 
Our College has advocated strongly for the federal government to acknowledge the role of GPs when this strategy is finally released next year having previously outlined concerns about the marginalisation of general practitioners out of obstetric care.
 
Meanwhile, in Western Australia, the debate continues to heat up on hospital led changes to the obstetric care model in that State which is seeing GP obstetricians increasingly locked out.
 
The WA shifts
 
In WA we are hearing that this shift has been occurring gradually over a five-year period.
 
The move to a hospital system with very little GP involvement and reliant on the fly in fly out specialist with onsite junior staff is becoming more prevalent.
 
Local reports state that GP obstetricians are being excluded from being involved in intrapartum care with the new model using a salaried medical workforce and shift to midwifery-led care.
 
This model has resulted in a significant disconnect between the hospital staff and the local primary care workforce.
 
This being at odds with what the federal government is trying to achieve nationally through the NRGP in building a resilient rural GP workforce.
 
Choice for women
 
But perhaps the most important point is that with a new maternity model which favours salaried medical staff over GP obstetricians it is the patient that loses most of all.
 
With GP obstetricians unable to care for public obstetric patients’ the choice for women is now much limited as a result.
 
In these towns, the continuity of care role sits with GP obstetricians and carving this off piece by piece to a fly in fly out service model will come at a significant cost.
 
In other towns we are seeing services close - women and their families have to travel significant distances to access care for pregnancy and birth.
 
We know the risks that come with increased distance as well as the associated financial burden on already struggling rural families.
 
Delivering care close to the patient is what works. Rural communities depend on their GP obstetrician with more babies delivered by GP-obstetricians than specialists in rural areas.
 
A collaborative model
 
What is missing in these discussions is a real understanding of team care and what it takes to address patient need in small rural towns.
 
That is, what it actually takes to sustain a rural maternity service and those interconnective factors for why it matters so much for other services.
 
We know that it takes a collaborative approach and advanced clinical skills encompassing medicine, midwifery, nursing, Aboriginal health and allied health.
 
What’s important is understanding the role of the team and scope of practice enabling all to work together without comprising quality.
 
It takes the whole team to make this work. A sustainable model involves a coordinated team involving the obstetrician, GP obstetrician and midwives and a roster divided among all of them.
 
This is how the service is maintained and we only have to look at the success of places like Albury Wodonga to see how this model sustains their service – sharing on call and the prenatal and antenatal.
 
We also know the other sustaining factor here – that the maternity service often opens up ways for other procedural services to develop.
 
A vital skill set
 
GP obstetricians skilled in childbirth require support, not barriers, in retaining such a vital skill set.
 
At a national level, procedural training grants ensure they can maintain their skills yet on a state-level, at least in parts, this is not sustainable when access is denied.
 
These latest developments not only risk the provision of obstetric services in rural areas becoming even more of a rarity but there will be some very real flow-on effects for our discipline.
 
The attraction and retention of GPs to the region is closely tied to the GPO model and it is a skill set we need to nurture to preserve through the National Rural Generalist Framework.
 
It is about getting the right skilled workforce in place, supporting a collaborative team structure to secure and sustain birthing services across rural Australia.
 
The rural generalist model offers a way forward which will make a difference for rural patients - ensuring safe, affordable and accessible healthcare.
 

​Building healthcare capacity in the Solomon Islands
 
Dr Ayman Shenouda

Unmatched resilience
 
A recent visit to the Solomon Islands provided some new insights into what it really means to be resilient. It is one of the least developed countries in the Pacific Region, the population languishes in poverty yet they make the most out of limited resources.  
 
The community here face significant health challenges and on multiple fronts. They lack even the basic health infrastructure, and universal access seems an almost impossible health policy goal. Despite this, I found the healthcare teams here work with courage and resolve.
 
Health system challenges
 
Persisting social disparities mean they face significant health challenges through what is termed the “triple burden” of disease. The community deals with communicable diseases alongside rising rates of non-communicable diseases combined with the threat of climate change which we know already hits hard too regularly.
 
The Solomon Islands suffer from significant resource deficits and the underdevelopment of infrastructure is driving inequalities. There is no CT scanner in the country – that places new meaning on what it is to be deficient in resources here. This is a country of over 620,000 people spread across more than 900 islands and it is without essential imaging diagnostic tools.
 
Coverage of services is very weak. This is partly because past development efforts have lacked the required multi-level coordination to support any sort of integrated health system. Almost half of all health expenditure comes from donors which is mostly put to disease management with little left for service system development. [i]
 
The Good Samaritan
 
My visit to the Solomon Islands was unexpected and prompted by a local MP who approach me following some donations I made to the hospital in Tetere. They were relatively small contributions in the form of blood pressure and haemoglobin machines. From this visit, I learnt that while small they were vital and are the sorts of supports that help to develop capacity and reliability.
 
The Good Samaritan hospital is on the coast in Tetere in Guadalcanal province which is about 40km from Honiara. The caseload here is overwhelming. The hospital is basic with about 30 beds, that provides mainly chronic disease management, emergency medicine and obstetrics. There is one doctor per 60,000 population, two midwives and two nurses. But with that they perform miracles here - this team provides obstetric care averaging 170 delivers a month.
 
This is a population facing serious health problems yet you would be amazed by how well they cope with very little. The four most common conditions leading to critical illness are malaria, diseases of the respiratory system including pneumonia and influenza, diabetes mellitus and tuberculosis.[ii] Screening programs are grossly underdeveloped which increases critical care demand.
 
Most facilities are short staffed and without basic equipment. From Tetere it is one hour  to Honiara for Xray or just to do bloods.
 
Despite the many challenges, the team use their clinical skills to the highest levels to provide the best care for their patients. It is the practical supports that they need the most and I think as a community of GPs we are well placed to do more.
 
Improving critical care
 
It is clear that the underdevelopment of healthcare infrastructure compounds inequalities.
 
In Pacific Island countries, including the Solomon Islands, there is a high need for basic critical care resources. Equipment such as oximeters and oxygen concentrators are needed as well as greater access to medications and blood products and laboratory services. [iii]  
 
A cross-sectional survey study examining critical care resources in the Solomon Islands found that inadequate resources from primary prevention and healthcare contribute to the high degree of critical illness. This study suggested that the solution lies in simple therapies and context-appropriate resources to mitigate the high burden of morbidity and mortality.[iv]
 
Therefore, the emphasis should be on the development and acquisition of simple and inexpensive tools rather than complicated equipment. This helps to prevent critical care from diverting resources away from other important parts of the health system. [v]
 
This makes perfect sense in these resource-poor contexts and certainly, the healthcare team in Tetere provide a stunning example of making it work with almost nothing at all.
 
Enabling partnerships
 
Empowerment is key to improving health service development in the Solomon Islands. The focus needs to be on strengthening the health system and improving access to services but bringing health care to these areas is no easy task.
 
It needs a partnership which filters right down to the community level. The Ministry of Health and Medical Services (MHMS) is really working hard towards enabling these partnerships to ensure a more planned approach to funding health services.
 
Australia is the largest provider of Official Development Assistance (ODA) to the Solomon Islands, providing almost two-thirds of overseas aid in 2016-17. We are the lead donor in the Solomon Islands health sector, with Australia’s main bilateral assistance provided through the Health Sector Support Program (HSSP) (equates to AUD 66m over four years to 2020). [vi]
 
Since 2008, the MHMS, with their development partners including Australia, has led a sector-wide approach (SWAp) to the delivery of health services in the Solomon Islands. The overall program goal for HSSP3 is to improve the access and quality of universal health care in the Solomon Islands. The current funding supports the Solomon Islands National Health Strategic Plan 2016-2020 and provides direct budget support, performance-linked funding and technical assistance.[vii]
 
What more can be done?
 
It is clear that Australia is doing its fair share for the Solomon Islands. There is now alignment in terms of ensuring best outcomes from this funding. This will certainly help build health services for this nation. But there is always more to do and GPs, in particular, can make a significant difference.
 
We need strategies to work through how best we can support our disadvantaged pacific neighbours from a community of GPs. Education partnerships being key and the RACGP already contributes in this way particularly in Papua New Guinea.
 
From my recent visit to the Solomon Islands, I have seen how the community there through their own resilience can achieve so much. Those working in Aboriginal Health would be familiar with what it takes to support patients in low-resource, laboratory-free settings. It would be great to share some of these learnings and provide more support for the Solomon Island communities.
 
[Ends]
 
[i] World Health Organisation. Article. Health closer to home: transforming care in the Solomon Islands. March 2017. Available at: http://www.who.int/features/2017/health-solomon-islands/en/
[ii]Westcott M, Martiniuk AL, Fowler RA, Adhikari NK, Dalipanda T. Critical care resources in the Solomon Islands: a cross-sectional survey. BMCInternationalHealthandHumanRights.Mar1,2012.doi:10.1186/1472-698X-12-1.Availableat: https://www.ncbi.nlm.nih.gov/pmc/articles/PMC3307438/
[iii] ibid.
[iv] ibid.
[v]  ibid.
[vi] Commonwealth of Australia. Independent Performance Assessment. Solomon Islands – Health Sector Support Program. Specialist Health Service. May 29, 2017; revised 24 July 2017.
[vii] ibid.

Dr Ayman Shenouda 

Announcing the Collingrove Agreement following the rural and regional health forum in Canberra on Friday 9 February 2018 from L–R: ACRRM’s Dr Michael Beckoff, National Rural Health Commissioner Professor Paul Worley, Minister for Rural Health Bridget McKenzie, RACGP Rural Chair A/Prof Ayman Shenouda.
 
A milestone agreement
 
Those who have been part of this journey will understand the significance of the Collingrove Agreement. Although I think on this topic, even the most casual observer will be across the division that has chocked us for so long.
 
It’s been a long and often dusty road but we’re now steered in the right direction and towards developing a national rural generalist pathway together.
 
Finding that common ground was relatively easy in one sense.
 
You see, the one thing I’ve noticed having travelled extensively over the past four years as Chair of the RACGP rural faculty is that patience, passion and persistence is a common trait of rural GPs or any GP for that matter.
 
From Longreach to Carnavon or Katherine to Goolwa and everywhere in-between and regardless of which camp they belonged – ACRRM or RACGP - there lies a great determination and commitment for their patient and rural community. An unbreakable connection which binds us all in addressing rural health disadvantage and securing a healthier future for all.
 
Navigating slightly rougher terrain
 
But in finding that common ground between the two GP colleges - while the destination remained the same - the road itself was indeed rocky. So rocky in fact it required an all-terrain vehicle for all involved and sometimes perhaps a tank may have been a slightly better choice!
 
Still, despite years of division, I think it was that same spirit that made the Collingrove Agreement possible.
 
An easy headline it may have seemed to those filtering the news last Friday, but the “RACGP and ACRRM collaborating on national generalist pathway” was truly momentous. And certainly, for those around the table at Collingrove Homestead in the Barossa Valley, South Australia, collaboration soon became the only solution.
 
Sharing a picture for history’s sake of those present on those momentous couple of days 11-12 January 2018. 

Securing the milestone agreement from L-R: Dr Melanie Considine, RACGP Rural Deputy Chair, RACGP Rural Chair A/Prof Ayman Shenouda, ACRRM Censor in Chief A/Prof David Campbell, our National Rural Health Commissioner Professor Paul Worley, ACRRM President A/Prof Ruth Steward and Dr Rose Ellis from the Rural Doctors Network.
 
A common goal
 
While the agreement itself is only four paragraphs long - the common ground here was significant. We had 7 million reasons to get this right.
 
It is about equity of access in meeting the health care needs of rural and remote Australians through a responsive needs-based solution.
 
Together we were determined to secure a strong, sustainable and skilled national medical workforce to meet the needs of these communities.
 
More than a definition
 
This is, of course, more than a about a definition but it was always a sticking point.
 
On one hand there were those focussed on the name or a tendency to favour a definition over others. On the other, we knew that developing skills around the ongoing care considerations are the areas that best serve the community.
 
And there’s the commonality – supporting doctors to acquire the skills to meet the needs of their communities. A dedicated and clear pathway for rural GPs to acquire those skills and utilise them in a way that is valued and recognised are important workforce factors.
 
This was the cohesion that brought the clarity to the definition.
 
So here is it -
 
“A Rural Generalist (RG) is a medical practitioner who is trained to meet the specific current and future health care needs of Australian rural and remote communities, in a sustainable and cost-effective way, by providing both comprehensive general practice and emergency care, and required components of other medical specialist care in hospital and community settings as part of a rural healthcare team.”
 
Pathway design
 
Beyond the definition, it is the careful design of the pathway itself that will make the most difference. It needs to be a lot of things but at its core it is about ensuring the right skill mix against demand with supportive elements offering flexibility and choice.
 
Key features which include a clear pathway for young doctors with flexibility that allows entry and exit at different stages. Ensuring adequate funding for the pathway itself alongside essential factors in establishing a critical mass of trainees but with enough flexibility for it to work within the varying jurisdictions.
 
It should also allow lateral entry for practising GPs and other rural doctors who want to acquire new skills to address the shifting need in these communities. Ever changing needs like mental health and palliative care and in dealing with the extra problems which depend on the health needs and context of the community.
 
The full range of competencies enabling them to deliver patient care closer to home in the primary and secondary care contexts. Or quite simply, training young doctors with the right skill set that makes them feel safe and supported to do their job which is addressing rural and remote community needs.
 
There’s usually some bleeding before healing
 
Despite years of focus, the disparity of health service delivery in rural and remote Australia remains a key policy failure. Much has been left to our overseas trained doctors who have been the backbone in delivering this care over this time. The lack of a solid training or workforce solution meant that the rural health system depended on individual efforts with very mixed results.
 
Sometimes I feel the split between the colleges had to happen for us to be able to reach this agreement. The Collingrove Agreement is the culmination of 20 years of hard work by both Colleges in building capacity to deliver a needs-based solution for rural health.
 
We’ve seen more collaboration over the past year than in the preceding 20 - through Bi-College Accreditation to this historic Collingrove Agreement. So, let’s keep it up!
 
A Rural Generalist Pathway Taskforce is being formed in the coming months to work through the pathway design. There may still be a long road beyond Collingrove Homestead but I think this time it will be the recently resurfaced type! 
​
Ayman Shenouda 

 A significant step in securing a stable rural medical workforce
 
Dr Ayman Shenouda
 
 
A rural renaissance
 
It is great to see the Federal Government delivering on its commitment to increase the number of rural-based doctors in training.What we are experiencing right now in rural health can only be described as a rural renaissance. We have great leadership in our Rural Health Commissioner and now in our new Rural Health Minister making her mark and building on the great work of her predecessor.
 
More intern placements in general practice is great news for rural doctors and their communities. This is an essential step in securing the next generation of rural GPs by ensuring our trainees receive broad exposure through prioritising primary care and general practice.  These programs really work as they provide trainees with that essential insight to community medicine.
 
Intern rotations in general practice
 
The Rural Junior Doctor Training Innovation Fund (RJDTIF) program provides primary care rotations for rurally based first-year interns. It builds on existing state and territory arrangements to provide primary care rotations in addition to hospital rotations.
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Last week, Rural Health Minister, Senator the Hon Bridget McKenzie, announced a $1,304,967 Federal Government grant for the Murrumbidgee Local Health District to increase intern rotations throughout the region. I’m proud to be contributing with my practice in Wagga selected to participate and we will be rotating five interns a year through this program.
 
It was great to show Minister McKenzie around my practice and have a chance to discuss how to provide that valuable community exposure early. The Minister showed a deep understanding of what is required in placing policy priority on general practice. She shared my vision that every junior doctor should have a rotation in general practice as part of the first two to three years of training.
 
Quality training experience
 
In our practice, we have GP specialists, new fellows, GP registrars, interns and medical students working alongside nurses and allied health professionals. We aim to support the integration of vertical and horizontal teaching enhanced through a multidisciplinary team environment.
 
A strong teaching culture and established education networks also ensure we have the hospital and community partnerships to enhance exposure and demonstrate for our trainees the diversity of general practice. We’ve worked hard to build the required supportive infrastructure and systems to make this work which needless to say is also reliant on a solid business model.
 
Keeping them there
 
Targeted exposure strategies like these ensure trainees can develop the broad range of skills required. It provides essential rural exposure for interns to learn the complexities of delivering services in rural areas while in a supportive general practice setting.
 
My own experience with the PGPPP where I had 12 interns rotated in my practice really yielded results. From that cohort, about 70 per cent of them have chosen general practice as their training speciality. They loved the diversity and complexity general practice offered. It challenged them, kept them engaged and provided that important insight into the doctor-patient relationship.
 
A little on the policy journey
 
Addressing maldistribution has been dominant in the discussion at many Rural Health Stakeholder Roundtables in Canberra over recent years.
 
Certainly, greater exposure to general practice for junior doctors has been central to RACGP Rural advocacy around securing an integrated rural training pathway. Particularly in ensuring more emphasis on primary care and generalism early in medical education.
 
But really making generalism a foundation of junior medical training – a discussion made more difficult on the back of a defunded PGPPP. This was a significant policy obstacle when you consider that what we were pursuing was more of a supercharged PGPPP but specifically for rural areas.
 
We needed a solution that would boost the number of GPs as well as address the gap in the rural pathway by providing intern rotations in general practice and primary care. We knew there was a strong learner preference for rurally based internships. We also knew that potentially we had lost a cohort of potential rural GPs as the gap from the PGPPP hit hard and narrowed our opportunities.
 
A win for general practice
 
It certainly was a long policy process getting here. This is the why this program, which was the result of a long period of sustained advocacy, is such a significant win for general practice. It is clear much of the hard work over many years is starting to pay off particularly in rural health. This is a significant step forward in securing a stable medical workforce to address maldistribution. 

​National Rural Health Commissioner: Putting the rural health agenda back on track
 
Dr Ayman Shenouda
 
A rural champion
 
A visit this week to Wagga from our National Rural Health Commissioner Professor Paul Worley provided a great chance to work through some of our highest rural health priorities.
 
This new champion for rural patients is exactly what we needed.
 
He fits the job description well – independent, impartial and “a fearless champion” for rural health. He also has alongside him a strong rural health sector full of ideas for building a strong Australian rural health system.
 
Getting the agenda back on track
 
Rural patients are finally getting the focus they deserve and this is our chance to get the rural health agenda back on track.
 
I think we finally have the policy settings in place for this to occur. But it all has to be orchestrated in a way that sees very specific locational needs acknowledged and addressed.
 
This is where the new rural commissioner role comes in. We all have a key role here. There’s still a great deal of work which now needs to occur to ensure every instrument in this vital ensemble can be fully utilised.
 
It is those featured instruments – whether string, woodwind, brass or percussion – each with its own unique qualities that really need to shine. These are the ones that fill in a critical gap and vital if we are going to provide a performance worthy of rural Australians.
 
National Rural Generalist Pathway
 
The first task is the National Rural Generalist Pathway.
 
If we are to get this policy right we will need a broad policy lens with a commitment to needs-based planning encompassing all disciplines.
 
We know that a sustainable health workforce solution for rural Australia needs to factor in flexibility in policy design. By this, I mean allowing for an optimal skill mix which is capable of meeting the very specific service needs of that community.
 
Local needs analysis
 
It is clear that we need reforms that can address maldistribution to meet growing service demand. But to do this we need to look at what is really happening in these communities.
 
Skills planning through a rural generalist pathway solution must, therefore, encompass a much broader skill mapping exercise. This needs to be steered toward more integrated care and with a focus on the full multidisciplinary skill mix required to keep those services going.
 
We need to find ways to capture current skill depth so that this can be prioritised better in policy. Reinforcing the importance of primary care and coordination of care so that the policies can follow. But really plotting that essential skill mix required to support rural models of care.
 
Future supply and demand (against need)
 
It is about having that critical mass of health professionals to achieve a sustainable service environment.
 
This not only lifts constraints enabling more equitable access to services but creates a way to mobilise and build on peer support. In turn, reducing burn-out by formalising mechanisms for peer support-support networks. It provides safer working hours and leaves room for internal backfill for relief, as well as professional development or space to take on a supervising role.
 
There’s been plenty of workforce planning occurring – PHNs, LHNs, and RHWAs – but we lack that common formula.
 
No-one can see at a national level where the true hotspots are. We need to establish what constitutes a minimum workforce requirement or mix for a particular population size and then apply that across the country.
 
Matching and forecasting the needs is complex but we have evidence-based approaches to estimating health workforce demand. HWA did years of work around it. I think we must clarify this area of workforce policy as a first key step.
 
Once we have this formula then we’ll see a situation where training investment meets demand.
 
There is just not enough aligning in terms of training pathways with workforce planning. This is vital as you can’t have a situation where you have three GP anaesthetists and no GP-obstetrician.
 
This level of planning would also help in terms of succession planning and reassure those committing to these pathways that there is or will be a position for them. It provides a planned career pathway for them.
 
Broad skill depth
 
Broad skill depth is vital to addressing patient need in rural communities. We need to find a way to embed in workforce policy those skills most relied on in meeting this need.
 
I think the discussion is also broader than the training pathway itself. We have to have an equal focus on the requirements of the existing workforce in meeting shifting community need.
 
Training solutions need to enable private community-based practice. We really need to ensure we encompass a range of approaches factoring both procedural and non-procedural skills if we are going to align closely to need.
 
If we support the full skillset required then we are closer to reflecting within the training the full scope of skills practised in rural general practice to meet community needs. This is how we can ensure we produce the next generation of doctors with the skills needed to provide both primary and secondary care.
 
Training Hubs
 
Past policies have had an impact on both recruitment and retention. It all comes back to securing that critical mass (of students). Early exposure which can establish that community connection early which can continue through to intern, prevocational and vocational training years.
 
We’ve always said that we need to invest in more localised training solutions to provide for that community connection and rebuild a teaching culture. The hubs are well positioned to facilitate that vital community connection and link the various stages of training in a rural setting across the full training continuum.
 
The training hubs provide that essential framework now but it is about facilitating those vital partnerships. This is how we can structure training against local healthcare need and service construct and build in those supportive factors so early exposure can be a positive experience.
 
Nurture rural intention
 
We need to nurture rural intention through targeted incentives and sufficient rural exposure strategies.
 
A strong commitment to rural should come with benefits. Capture those wanting to pursue rural through a nurtured pathway and supports which include an investment in mentoring. Truly support RMOs skills and career path aspirations and reinvesting in these years by getting back the PGPPP in its true form.
 
Newly developed policy offering primary care rotations through the new rural community-based interns is certainly acknowledged but it is a minimised model which really needs to be expanded.
 
Vertical continuity over time
 
Focusing more effort on areas that provide both a training benefit and meet a community health need is a way to secure an enduring rural benefit. Realising that a focus on the full multidisciplinary team is key to providing more integrated and improved patient-care strategies.
 
Building this capacity through vertical integration of teaching and learning which promotes shared responsibilities. It’s that continuity that is needed most – vertical continuity over time to allow for varied exposure which results in the more resilient doctor.
 
Flexibility is needed to ensure training reflects the local service context with an equal focus on community-based training. It helps develop that understanding of optimal care pathways providing continuity of care and a collaborative integrated care approach.
 
Team and teaching culture
 
Developing a strong team culture early has to also be a key focus. Those working in rural Australia know that it takes a dedicated team and an enduring local commitment to tackling the many challenges in delivering regional, rural and remote healthcare.
 
We need to ensure more exposure to multidisciplinary team environments as well as enabling hospital and community partnerships through supportive policy. This is where the pathway solution has to extend beyond a focus solely on medicine.
 
Improved support for supervisors has never had the policy focus it deserves. We need to increase the teaching capacity of rural communities while minimising the impact of burnout. Practice viability is a major consideration here.
 
All these factors need to be considered in terms of ensuring a rural GP can take on a training or teaching role. Succession planning and providing that easy entry, gracious exit is key and would lift the load for many already overcommitted.
 
A more sustainable future
 
In designing rural policies which can provide a more sustainable future, the focus clearly has to come back to addressing health disparities between rural and urban Australians. A resilient multi-skilled generalist workforce capable of meeting current patient need now and into the future is all part of meeting that key requirement.
 
We really need to capitalise on the policy settings we already have in place. The strong planning role of the PHNs and LHNs in identifying local level need. The facilitation role of the new training hubs in ensuring a more positive rural training experience. Existing strong College pathways and well-developed rural skills training program with inter-professional partnerships to build from.
 
We now have that vital role in the National Rural Health Commissioner to ensure a more coordinated national policy and planning effort can occur. We’re well on our way in putting the rural health agenda back on track ensuring lasting change for rural Australians.
 
[ends]
 
 
Source: RACGP 2014. New approaches to integrated rural training for medical practitioners. Final Report. Available at: https://www.racgp.org.au/download/Documents/Rural/nrffinalreport.pdf