5.5.1 Enabling factors
5.5.2 Limiting factors

5.5.1 Enabling factors

Funding

It is unanimously agreed that the funding for the RCS Program has been generous and, indeed, that this level of funding has been one of the key factors in the success of the Program to date. The funding has allowed RCSs to build or purchase excellent physical resources (including teaching facilities, office space and state-of-the-art information and communication technology) and human capital which have, in a short period of time, created a parallel university infrastructure to rival that found in urban environments.

At the inception of the Program, universities were asked to bid for the amount of funding they required to establish an RCS. Because of this open offer, universities sought varying levels of funding, which have largely been maintained in subsequent contracts. Some universities have therefore received greater amounts of funding and have been able to be more lavish with the resources provided to their students than neighbouring universities. Students have been quick to notice this.

'There are big differences across unis - [Uni A] students have to pay for their accommodation but [Uni B] students don't… I don't understand why there is such a difference.' (medical student)
'[There needs to be a] more even spread across the board for RCSs to - i.e. support and amenities - for unis to be transparent on what RCSs provide. Different geographies make a difference but there is still a big disparity - why is it so different when they are all trying to achieve the same thing?' (medical student)
The distinction between the RCS as a workforce initiative as compared to the rest of the university sector is considered to be significant, with several informants stressing that the funding should remain with the Department of Health and Ageing rather than with the Department for Employment, Education and Workplace Relations (DEEWR). There was strong consensus that the achievements to date had been due to the nature of the Program as a workforce initiative, with a corresponding focus on influencing students' career decisions, and that this would be lost if the Program were to be seen solely as another component of medical education (while recognising that the Program had to meet educational requirements and that it was already embedded within the educational sector).
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Vision and leadership

An important contribution to the Program's achievements to date was also considered to be due to the
passion and commitment of the early champions of the idea. Some participants pointed to the advocacy of the then Minister for Health and many other early champions as a key factor in the establishment of the Program, including those who crafted the original proposal for what became the RCS Program. Others acknowledged the role of the founding heads of individual RCSs, who often had to battle the reluctance of the wider faculty or medical profession in arguing the virtues of the initiative.

This need for vision and leadership continues, and succession planning was named by several as a risk for the future in ensuring that the RCS Program continued to demonstrate its effectiveness both as a training structure for medical students and as an influence on workforce career choices.

The quality of training places

Through the development of strategic personal and organisational relationships, RCSs have been
successful in creating a large number of training places across regional Australia, both in hospitals, GP surgeries and other primary care settings. In some cases, this was made easier because regional hospitals did not have a high demand from interns, residents or registrars (this is changing as RCS students seek placements, as discussed below). It was noted by almost all students that the quality of teaching, through the exposure to a greater range of clinical experiences, generally surpassed that available in the urban setting.

'Students are becoming more savvy. They are looking to the future, and with the increase in competition, they need to get high quality clinical education. They want to be able to differentiate themselves. You get better patient interaction (through the RCS model) and this is well known with senior doctors'. (medical student)
The greater intimacy of the rural training experience was named by some academics as one of the great benefits of the RCS Program, and one of the reasons for the increasing number of students seeking rural placements. It was noted that students have far greater supervision, with a long-term one-to-one relationship being developed in which the supervisor sees the student through a range of experiences, both academic and emotional, as the student grapples with the clinical workload as well as the adjustment to living within a new, often unfamiliar, community.

'I'd say [the quality of medical education] is far better than it is in [the city], where you have no one-on-one time with the consultant, on ward rounds you're the lowest of the low, the 20th in line to see a patient…And by the time it's your turn, the patient has put up a sign saying 'NO MORE STUDENTS'. (student)
While this relational aspect of rural training has been acknowledged as an enabling factor, there is a corresponding risk due to the increasing demand for training places, discussed below. Furthermore, while the quality of the educational experience needs to be highlighted as an enabling factor for the Program, there is some concern about whether this is likely to lead to better workforce outcomes for rural communities. To what extent are students opting to undertake an RCS place because they are interested in a rural health career, and to what extent are they doing it because of the recognised quality of the clinical experience and exposure to patients/clinicians, regardless of students' career
intentions?

5.5.2 Limiting factors

The capacity of health services to make training places available

As noted earlier, the number of long-term student placements that can be supported in any given area depends on the capacity of the health workforce and health systems to accommodate and supervise students. This was discussed by many stakeholders as a significant threat to the long-term sustainability of the Program.Top of page

In a sense, the RCS Program faces becoming a victim of its own success, as the positive feedback of RCS students leads to more students seeking places within the RCS. It has been suggested by some students, and recognised by some academics, that students may choose the RCS because of the quality of its training rather than because of an interest in rural medicine. This may have the unintended impact of reducing the availability of placements for students who are genuinely seeking to develop a rural career.

'So students go out and have this great short placement in 1st year and it's all nice and fluffy, and then they go out in the 2nd year and it's all nice and fluffy, but then when they want to go out for their 3rd year [for a long-term RCS placement] there aren't enough placements. So it gives the message that rural medicine isn't in crisis and it's not that important to go rurally so they stay in the city. Also a lot of graduate medical students are not rurally inclined so they are doing these placements but commuting from [metro area] rather than staying and engaging in the community. The [graduate] program was touted as the solution to the…workforce crisis but it won't do it, it's shafting the rural students who really want to work there.' (student)
There are also additional constraints to the number of long term placements that can be supported, particularly where there is competition from other programs within medical education (e.g. shorter-term placements through programs like RUSC or John Flynn) or further up the 'vertical' training pathway (e.g. PGPPP, GP registrar training, specialist training). Some informants questioned the ability of rural communities and practitioners to absorb the increasing numbers of students who pass through their doors, for short-term exposure tours, for RCS training, or for intern or vocational training.

As the number of universities undertaking rural clinical education has increased, there have been some 'gentleman's agreements' as a result of which established universities have moved away from placing students at certain hospitals (e.g. UNSW making available placements at Shoalhaven Regional Memorial Hospital in Nowra for University of Wollongong students). In other areas universities have formalised an agreement, for example University of Adelaide and Flinders University, both of which place students in Angaston in the Riverland, and the University of Western Australia and Notre Dame University, which jointly fund the RCS of Western Australia.

Where universities are competing for clinical teaching, however, whether in general practice or in regional hospitals, there will be increasing difficulty in accommodating the growing numbers of students, interns and/or registrars who seek to train rurally. In some regions it was reported that the system is at capacity, with one stakeholder commenting 'there won’t be too many health services in the parts of [the State] that we operate in that don't have students.'

With the growth in student numbers a strategy is increasingly employed to recruit new general practices into teaching the GP-based or community-based education model, recognising there are limitations on the ability to increase student numbers in hospital settings. A further strategy borrows from the approach used in the Riverland, where 'teaching hubs' are established to support students in surrounding locations. The hub provides teaching space, reference texts, and some staff time.

The geographical distance involved in rural clinical education is one of the unavoidable difficulties of this Program. As one UWA stakeholder noted, 'we have the most dispersed medical school in the world.' Distance brings with it the cost of travel (in time and money), an increased cost of living, and the potential for isolation (e.g. limited access to teacher training for RCS staff). Some clinical trainers also noted that there are risks involved for students who are required to do a great deal of country driving, particularly when they are not used to travelling such distances or on isolated stretches of road, often unsealed. These costs are accepted as one of the consequences of the rural training infrastructure; however they are also recognised as limiting factors due to the greater reliance on and need for adequate information technology, additional administration costs (due to dispersed sites), and isolation.Top of page

All RCSs have been able to access (or invest in) accommodation for students, and it was consistently reported that subsidised or free accommodation was a significant factor in attracting students to the RCSs. Longer term placements (e.g. of one year) do make normal private rental arrangements viable in the way that short-term rental agreements for six-week placements are not, so in some cases RCSs do not have the critical student accommodation needs of a program like the John Flynn Placement Program. In addition, where an RCS expects to have a critical mass of students on a continuing basis they have often purchased units or houses for communal student living. The cost and availability of housing varies significantly and in some areas which are experiencing an economic boom, such as Port Hedland, the ability to access any accommodation is a challenge. Student accommodation has also been raised by some RCSs as a limitation to establishing training posts in new areas.

The challenges of living communally with students and working closely with them on a daily basis were noted by several students. Several RCSs spoke of the efforts which they made to allocate students together who knew each other or who they had determined shared common interests, to alleviate the inevitable tensions which might arise when students are essentially spending 24 hours a day living and working together. Issues were also raised by students about the suitability of the accommodation for people who have partners and/or children with them.

In addition, some students were quick to acknowledge the inadequacies of their current student accommodation, and some staff members perceived that the expectations of students had risen dramatically with regard to adequate housing, putting additional pressure on the RCS to meet student expectations out of a concern that they would otherwise not be able to attract students who might potentially become rural doctors. Some RCSs have intentionally developed accommodation to suit couples or families, particularly where it was a graduate program (and students are a little older than in undergraduate programs). Elsewhere, couples and families are not as easily accommodated, and in some instances this was seen as a limiting factor.

A shortage of adequate rural accommodation is not a problem confined to the RCSs; this has also been experienced by staff who might be recruited to a UDRH, or clinicians who might be taking up a joint appointment with the local hospital.

'The [hospital] accommodation was shocking so we bought our own, but it's harder to get into the market now.' (hospital clinician)
This same doctor wondered whether these sorts of difficulties discouraged students from considering rural careers.

'I've wondered whether students hear what doctors are saying about living here and make their own mind up.'
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Succession planning

There is a rich narrative history associated with the rural clinical schools, where the founders of RCSs
and, in particular, the preceding programs which led to the RCSs, have attained 'legendary' status for their substantial commitment and contribution to rural health over many decades. While there is no doubt these accolades have been earned, there is an associated risk emerging in regard to succession planning. In effect the founders represent the generation which forged the way and ensured rural and remote health reached the national health agenda, and they are strongly supported by highly committed teams of academic and administrative staff. While a model of 'charismatic leadership' has served the RCSs well, this is not generally viewed as a sustainable model.

The challenge now for RCSs (and to some extent UDRHs), is to cultivate the leadership capacity to steer the program into the future, following the inevitable retirement of the 'first generation' of leaders.