Let’s not lose another rural obstetrics service
 
1 September 2017                  Dr Ayman Shenouda
 
Decline of rural obstetrics services
 
It was disappointing to see yet another decision without due consultation to downgrade rural maternity services recently and this one was particularly close to home for me. Temora Hospital’s maternity services will be reduced with patients requiring maternity surgery under general anaesthetic moved to other district hospitals. Only a month earlier, in July, it was Emerald in Queensland that was in the spotlight due to a maternity service closure. But none of this is really new, is it? Nationally we’ve seen more than 50% of small rural maternity units closed since 1995.[1]
 
In this latest downgrade, we’re told Temora’s maternity services for low-risk pregnancies will continue but caesarean births and gynaecological surgery will now be relegated to Cootamundra and Young hospitals. This just shifts the costs in my view and is not a sustainable solution for this community and could see broader impacts on other services too if works are not prioritised and essential staff leave. Surely, part of the cost equation has to also look at the costs transferred to the patient as well as the skills lost and broader safety aspects of NOT having a locally accessible service?
 
The NSW Health Minister Hon. Brad Hazzard MP says he was kept in the dark on the decision by the Murrumbidgee Local Health District (MLHD) and wants the service retained.[2] There is at least some hope for this community with the Minister making clear his views on the matter. But why do we need to get to this level in the first place? Local level planning and consultation should have occurred on such an important issue and well before it got to ministerial intervention level and preferably not debated through the media in this way.
 
Impacts for the local workforce
 
Putting aside the clear impacts of this decision - including higher risk birthing outcomes - for one moment. What now for the three obstetric providers who have been providing this service? One GP obstetrician in the town stated in the Harden Murrumburrah Express that she did not want to see Temora become a victim of bureaucracy.[3]
 
We know that driving decisions to close or reduce rural maternity services is often around doctor shortages, safety concerns or funding constraints. This decision according to media reports comes down to physical infrastructure costs. The issue is the obstetrics theatre room was deemed unsafe for surgery following an audit by the Australian Council of Healthcare Services.[4]
 
Rural patients need viable maternity and surgery services near to where they live. And doctors who invest in training to ensure a service for their community need some certainty around service continuity. They most certainly need to be involved in local service decision making which certainly seems not to have been the case in the Temora downgrade.
 
A strong focus on policy
 
This is a decision which seems contradictory to what we’ve seen from NSW HETI in terms of its rural generalist pathway. There has been an expansion of training positions this year with 40 positions being made available.
 
It is also contrary to the focus nationally which has seen committed action over an eight-year period. There has been a strong policy focus in the form of a Maternity Services Review (2009), a National Maternity Service Plan (2010-2015) and the current development of a National Framework for Maternity Services.  
 
We’ve seen such a strong policy response in recent years and it’s important that local level planning decisions work within these broader nationally set priorities. Both the National Maternity Services Plan (2010-2015) and new National Framework for Maternity Services (2017), which is still being finalised, have set specific priorities to secure more equitable outcomes for rural patients including in the areas of access and workforce.
 
Some great policy outcomes have resulted already including in terms of tools to inform planning and in areas of national data development.
 
The Australian Rural Birthing Index (ARBI) was a key outcome of the Plan which has provided an important index to help in the planning for maternity services in rural locations.[5] The index can be downloaded here: http://ucrh.edu.au/wp-content/uploads/2015/07/ARBI_FINAL_PRINT.pdf .
 
While the AIHW-led National Maternity Data Development Project aims to enhance maternity data collection and reporting in Australia. Both are important national planning tools which aim to utilise a population based planning approach as the basis for demand driven evidence-based decision making.
 
Protecting rural services
 
Despite such a strong policy focus and commitment, it is evident that we still need to improve maternity services in rural and remote communities. There is clearly state-level support for the development of rural GP procedural skills. However, this needs to also extend to rebuilding rural hospital infrastructure when required to ensure service continuity. Here in NSW, we have a policy commitment to develop workforce capacity by expanding rural generalists being potentially compromised by a local level decision driven by infrastructure costs which have led to the downsizing of maternity services. 
 
The critical role of procedural GPs – both GP obstetricians and GP anaesthetists – in providing maternity services in rural Australia is well understood. Decisions which see closures or a downgrade of services will have a direct impact on the long-term commitment of both current and future rural doctors. Let’s not lose another rural obstetrics service – operative obstetrics and gynaecological procedures are needed in Temora and funding should be found to upgrade the operating theatre.
 


[1] Rural Doctors Association of Australia. Maternity services for rural Australia. Manuka: Rural Doctors Association of Australian, 2006.
[2] The Daily Advertiser. Media Article: Minister ‘kept in the dark’. Published 22 August 2017.
[3] Harden Murrumburrah Express. Media Article: Temora Hospital theatre closure could see expectant mothers transferred to Cootamundra or Young Hospital. Published 21 August 2017. Available at: http://www.hardenexpress.com.au/story/4870112/obstetrics-theatre-room-closing-at-temora-hospital/
[4] Ibid.
[5] Longman J, Pilcher J, Morgan G, Rolfe M, Donoghue DA, Kildea S, Kruske S, Grzybowski S, Kornelsen J, Oats J, Barclay L. (2015) ARBI Toolkit: A resource for planning maternity services in rural and remote Australia.  University Centre for Rural Health North Coast, Lismore.

25 August 2017                      Dr Ayman Shenouda
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RECRUIT, TRAIN AND RETAIN
 
Getting the policy settings right
 
I don’t think there’s ever been a better time to secure the next generation of rural GPs. Now more than ever before we have the right policy settings in place. We need to seize this opportunity to ensure we select the right doctors for rural Australia.
 
Once we’ve overcome that first hurdle in getting them there, we need to then ensure those registrars who choose rural practice, that once secured, they remain there. But not only remain there that they continue to thrive. To do this we need to ensure the right supports are in place.
 
The policy momentum has been building for some time with the help of thousands of rural GP champions – possibly most now reading this blog –  who have advocated for change over many years.
 
We now have the right set of policy conditions: an overall increase in medical school intake with quarantined placements for rural; a rural emphasis and exposure with a focus on generalism as a priority in the training; and, of course, the regional training hubs which will soon be in place to help link the various stages of training.  
 
We finally have the makings of an integrated rural medical training pathway. This includes a priority on rural community internships – a clear gap which needed fixing –  and soon with the regional hubs, training can be structured in a more coordinated facilitated way.
 
The hubs, in particular, will strengthen the efforts of the Rural Clinical Schools’ and help build the facilities and infrastructure and teaching capacity needed to make this work. For the trainee, it will help to provide the navigational supports that have been so lacking in the past from medical school to rural practice. Importantly, we have a focus on non-coercive strategies in securing the next generation of rural GPs.
 
Why enter, why stay, why leave?
 
We know that many factors influence rural intention and that it is getting those supports right and across the full training continuum that counts.
 
Ruralising the curriculum is a key one. Embedding more primary care early into the medical curriculum is essential and this has certainly been said often enough. But other simple things like placing a rural scenario in the exam would also help to formalise assessment to enforce primary care and emphasise the important role of the generalist.[1]

 
Getting them in early and interact as often as possible is another key requirement. Nurturing your registrars once there requires a whole of community effort.
I think it is instilling that sense of belonging that is vital at this point so the emphasis then needs to be multifactorial. Positive exposure offering a mix of rural experiences including clinical and nonclinical competencies[2] and of the latter leadership being a key one here, the ability to lead and work in teams cannot be emphasised enough.
 
Trainees want broad exposure and the opportunity for multiple levels of clinical learning through blended placements. Trainees need to be empowered to make informed career decisions and to obtain the skills they need in the local setting.[3]  A community with the right structures and partnerships in place can facilitate this well.
 
Next is community connection and engagement and getting that right. This really gets to the heart of the issue – this is why they stay – that sense of place and identity. Ensuring a strong rural connection is hard work in training terms but worth the effort in the long run.
 
This is all part of developing a professional identity and mentoring plays a key role here. Longer-term placements in and around the same community also help to build those lasting relationships.
 
While I think an intrinsic characteristic of most GPs is their altruism there are also limits. We need to formalise that mentoring point – and at every learning stage – so that rural GPs and broader teaching staff are able to commit their focus towards mentoring.
 
More funding for mentoring has to be part of the suite of incentives in support of rural intention. Formalising succession planning in this way would help to ease the pressure on those nearing retirement too. That’s the ‘gracious exit’ part that often gets forgotten but just as vital as ‘easy entry’ for rural.
 
A rural pipeline functioning well can support these broader retention outcomes in terms of supplementing supply over time through a constant stream of new entrants. This would help make rural practice even more attractive as it provides an exit strategy for rural GPs without having to make that lifetime commitment. Rural GPs could stay for a shorter period, up to five years, without causing the workforce disruption that currently occurs upon exiting. Rural practice could become a standard part of the GP journey with supportive policy offering more flexibility and opportunity to spend at least part of your career within a rural community.
 
Now finally, getting to the hardest bit. Once you have them, then the focus then shifts to keeping them there. And getting to the bottom of that is a whole new set of questions which tend to include broader impacts including those on family.
 
Factors including an adequate income, appropriate workload, locum provision, access to specialists’ advice and continuing education, spouse career opportunities and children education all come in to play.[4] Again, it takes a whole community to help make this work.
 
Bringing it all together
 
Piecing it all together there are a lot of factors that need to come together to get rural recruitment, training and retention right. Ensuring we have the right set of incentives in place for those making the commitment is key to policy success including rewarding advanced skills, procedural and non-procedural.
 
In understanding intentions to practice rurally, we know that rural origin plus a rural clinical school placement is a significant predictor.[5] But there are many ways to get there and we should keep an open mind as many get there by accident. I think I fit that last category having only come to rural practice at the age of 35 after commencing in a completely different specialty to being with.
 
In securing strong rural outcomes, it comes down to nurturing those with an interest and being able to bundle those known influences. We’ve certainly come a long way in securing the right supports and focus to realise a fully integrated rural training pathway. It’s a multitude of factors including supportive policy and a strong local commitment from each and every one of us, but not least the trainee to secure the next generation of rural GPs.
 
[1] RACGP. New approaches to integrated rural training for medical practitioners. Royal Australian College of General Practitioners. 2014. Available at: http://www.racgp.org.au/download/Documents/Rural/nrffinalreport.pdf
[2] Parlier AB, Galvin SL, Thach S, Kruidenier D, Fagan EB. The Road to Rural Primary Care: A Narrative Review of Factors That Help Develop, Recruit, and Retain Rural Primary Care Physicians. Acad Med. 2017 Aug 1. doi: 10.1097/ACM.0000000000001839. [Epub ahead of print]Availablat: http://journals.lww.com/academicmedicine/Abstract/publishahead/The_Road_to_Rural_Primary_Care___A_Narrative.98154.aspx
[3] RACGP 2014, op. cit. p.65.
[4] Humphreys J, Jones J, Jones M, et al. A critical review of rural medical workforce retention in Australia. Aust Health Rev 2001;24:91-102. [PubMed]
[5] Walker JH, DeWitt DE, Pallant JF, Cunningham CE. Rural origin plus a rural clinical school placement is a significant predictor of medical students’ intentions to practice rurally: a multi-university study. Rural Remote Health. 2012;12:1908.PubMed

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5 August 2017           
Dr Ayman Shenouda
 

 
Often a really good policy solution will in turn place more pressure on a part of the health system it relies. This isn’t necessarily a bad thing and is usually indicative of good policy spend. It is sometimes an outcome of optimal policy coverage as is the case for disease screening measures. The National Bowel Cancer Screening program, introduced in 2006, is an example of a policy working well.
 
We know that one in 12 Australians will develop bowel cancer by the age of 85 which makes it the second most common cause of cancer-related death in Australia after lung cancer. But, if detected and treated early the cure rate is around 90% which makes policy intervention through prevention and in this case, through screening measures, so vitally important. [i]
 
The is a great policy intervention which we’ve seen expanded under successive governments with broad coverage now currently available to Australians aged 50, 55, 60,64, 70, 72 and 74. Once fully implemented by 2020, all Australians aged 50 to 74 will be able to be screened every two years.[ii] 
 
But as a result of this policy, we’ve seen demand increase for lower gastrointestinal endoscopies. This growth in demand means there is a need for the endoscopic workforce in Australia to be well planned in order to cope with future demand associated with expanded cancer screening, particularly with an ageing population. Service solutions to address current demand including nurse endoscopists are now being rolled out in Queensland and Victoria. But is this the right workforce response for Australia or is it more of a temporary fix to a growing system issue?
 
Here’s the policy background to the issue. The policy response to limited endoscopy capacity a few years ago saw the now defunct Health Workforce Australia (HWA) invest in a project to train nurses to perform endoscopic procedures. Expanding the scope of practice of health professionals was a typical policy response being keenly pursued at that time by HWA. This particular decision though saw unprecedented action with a policy preference to train non-medical endoscopists and build capacity from within nursing.
 
At the time, the medical press reported that doctors were calling for a moratorium on nurse endoscopy.[iii]  From a resource perspective, it is important to also note that this was a decision undertaken within the broader context of increased medical graduates coming through and claims of impending oversupply.
 
The Advanced Practice in Endoscopy Nursing (APEN) program was modelled on approaches elsewhere including in the UK where the nurse endoscopist was well established. Although nurse endoscopy training and delivery of endoscopic services is not a new policy response: the first report of nurse endoscopy in the US was more than 35 years ago for flexible sigmoidoscopy.[iv]  But I think it is important to work through policy alternatives for Australia particularly if one solution has limitations both in terms of efficacy and coverage.
 
The University of Wollongong evaluation of the HWA-funded APEN sub-project in 2014 highlighted some key points in terms of the validity of a nurse-led model as a workforce solution.
 
Firstly, it stated that one of the main drivers for the program was the need to respond to growing demand for lower gastrointestinal endoscopies arising from bowel screening. However, it also stated that only about a quarter of same-day colonoscopies are performed in public hospitals. A key detail that severely limits the ability of nurse endoscopists to meet this growing demand. The evaluation also stated that given full implementation was not achieved, that relative advantage in terms of effectiveness and cost effectiveness of the model could not be evaluated and could only be measured after trainees were qualified and working at full capacity. [v]
 
The Australian Medical Association of Queensland (AMAQ) in commenting on the Queensland roll out of nurse model to Cairns and Townsville, stated that medical endoscopists were more cost effective than nurses as surgery could be performed at the time of procedure.[vi]
 
Cost-effectiveness of the nurse-led model as a workforce solution has also been challenged in a study published in the World Journal of Gastroenterology in 2015. The study examined the available evidence on safety, competency and cost-effectiveness of nursing staff providing gastrointestinal (GI) endoscopy services. The study concluded that the empirical evidence that supports non-physician endoscopists is limited to strictly supervised roles in larger metropolitan settings and mainly flexible sigmoidoscopy and upper endoscopy for asymptomatic or low complexity patients. [vii]
 
This same study also stated that contrary to general beliefs, endoscopic services provided by nurse endoscopists are not more cost effective compared to standard service models due largely to the increased need for subsequent endoscopies, specialist follow-up and primary care consultations. It stated that studies measuring cognitive competency were limited and providing endoscopic services is more than mastering the technical skills required to safely advance the scope. Further, that making clinical decisions in the context of the patient’s full clinical picture is critical to delivering efficient and meaningful services.[viii]
 
In finding an effective solution, the most obvious question for me in terms of utilising the available workforce is around why we are not looking to general practice to address excess demand? Some of the pressure placed on endoscopy units in managing this increased demand can certainly be addressed by general practitioners.
 
General practice offers a particularly viable solution for rural communities in endoscopy. Keeping trained procedural GPs in rural areas should be made a priority and this is a good example of where support is needed to sustain local solutions where rural GPs fill a service gap like this. Access to diagnostic endoscopy is limited in rural and remote areas and service expansion by GPs provides significant patient benefits in terms of time and costs.
 
While savings including around reduced costly patient transfers are obvious to most, the investment in GP procedural practice where it offers a sustainable service model should be sufficient for policy makers. It would help to reduce the demand placed on regional tertiary services and could help make GP procedural practice more viable in the smaller towns. We know that rural GP proceduralists must be supported to consolidate their skills in the communities they serve and this is one service solution which can help realise this aim. It is a workforce solution that needs to be considered.


[i] Cancer Council Australia. Position Statement. Bowel Cancer. Available from: http://www.cancer.org.au/policy-and-advocacy/position-statements/bowel-cancer.html
[ii] Ibid.
[iii] Australian Doctor. Doctors call for moratorium on nurse endoscopy. 30 January, 2015. Available from: https://www.australiandoctor.com.au/news/latest-news/nurses-expand-scope-into-endoscopy
[iv] Spencer RJ, Ready RL. Utilization of nurse endoscopists for sigmoidoscopic examinations. Dis Colon Rectum. 1977;20:94–96. Available from: https://www.ncbi.nlm.nih.gov/pubmed/844404
[v] Thompson C, Williams K, Morris D, Lago L, Quinsey K, Kobel C, Andersen P, Eckermann S, Gordon R and Masso (2014) HWA Expanded Scopes of Practice Program Evaluation: Advanced Practice in Endoscopy Nursing Sub-Project Final Report. Centre for Health Service Development, Australian Health Services Research Institute, University of Wollongong. Available from: http://ro.uow.edu.au/cgi/viewcontent.cgi?article=1384&context=ahsri
[vi] ABC News. More gastroenterologists needed rather than using nurse endoscopists in hsopitals, AMAQ says. 18 Apr 2016. Available from: http://www.abc.net.au/news/2016-04-18/amaq-more-gastroenterologists-rather-than-nurse-endoscopists-qld/7336202
[vii] Stephens M, Hourigan LF, Appleyard M, et al. Non-physician endoscopists: A systematic review. World Journal of Gastroenterology : WJG. 2015;21(16):5056-5071. doi:10.3748/wjg.v21.i16.5056. Available from: https://www.ncbi.nlm.nih.gov/pmc/articles/PMC4408481/
[viii] Ibid.

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Broad skill depth is what makes general practice unique and so central to addressing patient need. An essential part of that skill mix and key to addressing an aging population with more complex health care needs are non-procedural advanced skills.

The development of specialist clinical interests by GPs has always been a key feature of general practice. These are often the skills needed to meet identified patient need and provide an effective way to address access constraints, particularly for rural areas.

It makes sense then that in order to provide training to match demand that we don’t over emphasise or value certain skills over others. It’s also important to value the workforce you have as well as prioritise policy to support the next generation of GPs. This is the case for both urban and rural GPs we need to provide more opportunities in those extended skills or advanced skill areas identified and prioritised by the profession.

This is particularly important for practising rural GPs who need flexible training options so that they can acquire new skills to address unmet service need. And in meeting this need this requires an equal focus on both non-procedural and procedural skill acquisition.

We need an equal focus on both recruitment and retention strategies which in turn means factoring into the policy design both learning stage and time in career. To achieve this, we need targeted strategies to support both the existing workforce and those at an earlier learning and career stage.

Funding not only needs to be prioritised for skill acquisition but also for maintenance. Skill certainty is also crucial so that the GP can utilise the skills they’ve acquired to support their community. The return on investment is substantial and means that patients get the services they need and deserve.

Research led by RACGP Rural in 2013 helped to clarify the extent of advanced skills used and needed by GPs in rural and remote Australia. Not surprisingly the number of advanced skills acquired and used across most areas increased with rurality.

Mental health came out in front as the most commonly practised advanced skill in the study, followed closely by emergency medicine and chronic disease management. Of those skills GPs would seek to acquire to meet a community need, emergency medicine was the most prevalent, but this was followed by palliative care, paediatrics, and mental health.

Skills in emergency medicine were expectedly prominent with approximately 60% of respondents indicating that emergency medicine was relevant in rural general practice. However, only 38.7% had acquired it and 33.6% were currently using it. More broadly though, of those who had acquired an advanced skill, most were continuing to use that skill which was most reassuring.

The most important policy points from the study had to be the high prevalence of non-procedural advance skills as well as the continued reliance on emergency medicine in addressing need. There would be no surprises here particularly for those rural GPs currently overstretched to keep providing emergency and in-patient services. But also to those struggling to meet an increasing need in palliative care, paediatrics and mental health which extend to psycho-geriatric skillsets.

The policy requirement extends beyond providing training opportunity with a need to address system constraints which act as deterrents to working outside of the practice setting. Increased training opportunities need to be delivered in a supportive framework which enables skill utilisation facilitating service continuity otherwise it’s like doing half the job.

Capturing service complexity and rewarding GPs working across settings or in targeted areas of need offers a service solution in these areas. Investment in these skill-specific solutions based on need with a focus on GP-led models of care offer real solutions for health service viability.

We need to focus on enhancing health system interfaces where those non-procedural advanced skills factor strongly. In managing demand at the interface between primary and acute health care settings or various stages of illness – in palliative care or those with multiple chronic conditions for example – requires much more focus and across the full multidisciplinary team.

We need clear referral pathways which promote continuity of care for patients moving in and out of primary and tertiary care. The type of coordinated care planning made possible by that initial skill investment to enable an expanded role, but which is then further invested in terms of ensuring continued skill use across settings to provide for the required continuity of care.

[ends]

15 July 2017    Dr Ayman Shenouda
 

 
The Federal Government’s $54.4 million investment to create 26 regional training hub sites nationally sees yet another significant rural health reform realised. Providing a more seamless transition from undergraduate training into rural practice, I believe the hubs measure is one of the most important reforms since the establishment of the Rural Clinical Schools nationally in 2000.
 
Having this policy realised is also a proud moment for me knowing that RACGP Rural was at the forefront of this reform having developed rural medical training pathway options for the Commonwealth through a major study undertaken in 2013.
 
What we now have with this policy is the level of integration we called for with the hubs being our highest ask. It’s also clear that other aspects of the full pipeline investment were informed by this study, which was one of the largest member-led rural consultations ever undertaken. Collectively these initiatives represent a significant rural training investment and it’s a great achievement for the sector.
 
It’s a substantial package, the three-part integrated rural pipeline package provides just short of $94 million over four years with the regional training hubs forming a key policy component. It also includes a rural junior doctor innovation fund and further investment to expand the rural specialist training program. Three new University Departments of Rural Health have also been committed for strategic sites across WA, NSW, and Queensland.
 
We’re also seeing some policy shifts here which are significant. Particularly in those key areas where we’ve been calling for change in order to address the policy gaps which impede integration. These are those junctions which occur from student to intern and intern to registrar which offer real opportunity in terms of being critical rural commitment points.
 
Firstly, in this policy, we see a clear focus on embedding more primary care earlier into the training. A new strategy to provide more internships that include rotations in general practice addresses a really significant problem where the lack of exposure to rural practice at this critical time impacts our recruitment goals. Factoring rural primary care rotations for rurally based first-year interns ensures this exposure across multiple settings. It doesn’t minimise the required hospital exposure but ensures essential exposure to community-based rural general practice.
 
While the early linkage of intern positions with specialist training positions is also evident through providing up to 100 new rural training places. We need to ensure our next generation of rural doctors are nurtured and supported once captured. This investment will go a long way towards supporting that aim by ensuring there is the capacity to provide high-quality rural placements.
 
We know there is a link between where a student ends up and where they completed their post-graduate studies. But even with the strongest rural interest and the best intentions, not everyone is suited and it takes a substantial personal commitment to make it work and stay.
 
We now have more capacity through this pipeline initiative to get those supportive elements right in order to provide a stable learning environment to equip trainees with the skillset they will need. Even more importantly it helps to ensure support can be sustained long enough to provide trainees with the skills and confidence required which makes staying much more likely. 
 
The hubs provide for the right set of supports that will help us capture for rural the increasing domestic graduates coming through.  It enables the university-hospital-community partnerships we need to set the right conditions to encourage more doctors to practise in rural areas.
 
This model facilitates a level of integration that will allow adequate clinical exposure in a rural area across all training stages. Most of all it provides a way to maintain a link to a specific rural community and to facilitate longer terms in rural areas.
 
What also needs to be emphasised here is a program of complete immersion. The step beyond rural exposure and a commitment towards longer placements. Community connectedness can only be achieved through longer placements in the same community throughout the full training continuum.
 
More cohesive and tailored training options will result. A more varied training experience will be able to occur, one which is appropriate to the learning stage but also flexible enough to be in line with community health needs.
 
Longer placements with multiple levels of learning are more effective allowing for the required immersion. It connects the trainee to the key players in the community, developing a network and connection to community through mentorship. Importantly they learn the value of rural general practice on their way through.
 
Policy success will, of course, be determined by improvements in the rural retention rate over time but I have no doubt the pipeline investment will work to build the right supports to make rural training a much more viable option.
 
These measures provide for the supportive and coordination factors as well as some much-needed infrastructure to make rural training work. It helps to formalise the networks needed to provide a pathway continuum for medical education and training from medical school to rural practice. All this combined provides a comprehensive policy solution which will translate into rural recruitment success and workforce retention over time.
 
Further reading: RACGP Rural developed a Position Statement to support policy implementation of the Regional Training Hubs.