6.4.1 Funding levels
6.4.2 Parameters and objectives
6.4.3 Monitoring and policy research
6.4.4 Geographic coverage and operational models

6.4.1 Funding levels

Each UDRH receives the same amount of core funding each year ($1.66 million exclusive of GST in 2008-2009). This amount has not increased since the Program's inception, and an annual indexation was only approved in 2004-5, meaning that the real value of the Program's funding has effectively declined in the last ten years in terms of purchasing power.

UDRHs have been innovative in gaining additional funding from a range of other sources (through grant funding, research collaborations, and partnerships with local health services), and have been active contributors to health system development as well as health student education. Many UDRHs have been able to employ additional staff only because of particular grant and research money which they have acquired, and have used such contracts to employ staff who can also contribute to their core activities of teaching and professional development. Some UDRHs have been more proactive than others in seeking external funding sources. However, in the current competitive employment environment, the UDRHs' ability to continue their activities could be constrained without incremental annual increases to the core funding as well as annual indexation, putting at risk the significant investment which has been made to the Program to date. As was noted in chapter 4, attracting qualified people to rural locations is often difficult, and the levels of salary and incentives required to attract health professionals to the country (often raising the bar of what is considered a reasonable salary package) are a pressure for UDRHs to meet (and also for RCSs).

In addition, recent increases in costs of petrol and transportation, with corresponding increases to other costs of living such as food, make the organisation of placements more costly for both RCSs and UDRHs. In rural locations which are experiencing significant growth due to the mining industry, costs of housing have increased while availability of adequate housing has decreased, impacting both students and staff who might consider relocation. While RCSs have been able to acquire long-term accommodation for students, either through lease or purchasing agreements, accessing short-term accommodation for UDRH students undertaking placements is more difficult; although capital funding has been available to UDRHs from the Department, the extent to which it has been used for student accommodation varies. Infrastructure maintenance was also mentioned by several UDRH stakeholders as an expense for which they do not have adequate funding, and it would be useful to clarify between the Department and the universities where the responsibility lies for maintaining capital works which have been funded by the Department but whose ownership resides with the university.

Increasing levels of support available from UDRHs for accommodation and transport costs of placements would encourage students to undertake placements who might currently be deterred due to the costs of doing so, and thus provide additional encouragement for students to be exposed to rural practice. Increasing the investment in the Program would also signal that increasing nursing and allied health professionals in rural locations is a workforce priority. Top of page

The differential in student support available through the UDRH and RCS Programs is also significant and noted by students (see section 4.5.2). The Programs run a strong risk of structurally inculcating a privileging of medical students and a distinction in value between the health disciplines which the students themselves question. This has the potential to impede the ability for interprofessional education opportunities and also the development of a rural teamwork ethos which could be grounded in students even before they qualify. While recognising the importance of increasing the number of doctors in the workforce, many stakeholders also noted that in order to function doctors need nursing
and allied health providers available: 'they need someone to refer [a patient] to.'

It has been almost universally acknowledged that one of the factors in the RCS Program's success to date has been the level of funding, so it does seem reasonable for funding to continue at this level. In the foreseeable future at least, the need for funding will not diminish once the establishment phase of the RCS Program has been completed, due to the steadily increasing number of students who will require placements, accommodation, administrative support and teachers.

If RCS funding were to be reduced, it is likely that the length of time a student could be subsidised to study in a rural location would be reduced accordingly. As the whole impetus of the Program to date has been to increase the amount of time a student could spend outside of metropolitan areas, this would seem a retrograde step. As stakeholders consistently emphasised, 'The experience has to be long enough, and it has to be positive' for rural exposure to influence a student's career choices.

The cost per student ranges widely across RCSs: four operate on less than $40,000 per student, while five run at over $100,000 per student. These discrepancies are partly explained by age, size (with corresponding efficiencies of scale) and geography (remoteness and catchment area), but there are nomalies beyond these factors. Some students are keenly aware of the different amenities which universities are able to offer, and perceive that there are disadvantages which may accrue to them as a result of choosing one university over another. Accordingly, it would be of benefit to the Department, the universities and the RCSs to explore a more evenly distributed allocation across Program sites. It is
recognised that the latest funding round did partially address the discrepancy in funding across universities.

Recommendation 3:

That core funding for UDRHs be increased to accommodate increased staffing and operational costs, including continued annual indexation.

Recommendation 4:

That the Department clarify with universities the responsibility for funding infrastructure maintenance.

Recommendation 5:

That funding support for UDRH students in nursing and allied health be increased, including accommodation and transport costs for student placements.

Recommendation 6:

That RCS funding levels be maintained, and that efforts continue to achieve a more equitable distribution amongst RCSs.
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[<h2>]6.4.2 Parameters and objectivesMany stakeholders believe that the Department has shown wisdom in the way in which the Programs are managed, and that the supportive and flexible approach of the Department has been a key factor in the success of the Programs to date. For each Program, the original aims have largely been achieved, with established infrastructure, staff and educational, training and research programs. At this point in time it seems appropriate to re-define the Programs' goals for the next ten years, seeing each Program
as a long-term addition to national rural health workforce strategies. The reasons for this differ for each Program.
  • For the RCSs, the current funding parameters are properly seen as contractual requirements rather than ongoing objectives or outcomes. Each RCS reports regularly on their student numbers, curriculum requirements, research and other activities as well as on budgetary matters. Now that most RCSs have moved out of their initial establishment phase, developing objectives which describe what outputs and outcomes the Program is seeking to achieve would assist in future evaluation of the Program. These objectives should be linked to a strategic vision for the Program as a whole, including secondary benefits additional to the workforce distribution changes which it seeks to influence. Objectives for the next ten years might include challenges such as tracking students (already a focus of FRAME’s attention), developing vertically integrated training pathways, and increasing the level of research activity.

    For instance, it was acknowledged by most RCSs that the priority to date has been to establish a credible medical education training program in a rural environment. However, research is also recognised as important and many sites have developed a research program, with research activity tending to be more extensive the longer the RCS had been established. Most sites had plans to increase their research activity in the future. Including in the objectives the secondary benefits which the RCSs are widely considered to provide, such as the level of rural clinical research and innovation, contributing to recruitment and retention, and promoting rural health careers through the presence of the university in rural locations, might also be a means to recognise these achievements as legitimate aims of the Program.

  • The objectives of the UDRH Program are broad; this has been determined to be a strength in encouraging innovation and a locally relevant approach. As with the RCS Program, the UDRHs report regularly to the Department on the number of placements, level of research activity, collaborations, publications and budget. The KPIs which are currently monitored are largely process measures, and potentially could be more closely aligned with the strategic aims of the Program to assess short, medium and longer term impact on the local workforce and population health.
'The KPIs have improved but they are sometimes a bit irrational, there should be fewer KPIs and more strategic direction.' (senior university administrator)
As with the RCSs, developing a strategic long-term vision for a Program which has now moved past its establishment phase will assist in ensuring its effectiveness as a workforce initiative. This would require developing measurable indicators which focus more on outcome than process measures; for instance, seeking to measure the impact of publications in influencing Australian health policy and clinical practice rather than simply the number of publications (perhaps using the DEEWR Higher Education Research Data Collection specifications which universities already use to quantify their research output).

At the same time, the development of targets for nursing and allied health placements (discussed in section 4.4.2), would reinforce the importance of these placements as a workforce initiative, and might assist in raising the profile of rural health careers in these disciplines.

Some administrators have suggested that the reporting requirements are already onerous, with one Head of School suggesting that a .5 FTE position was dedicated to fulfilling reporting requirements for the Department and the host university. Developing Program-wide strategic
objectives should not add an additional level of reporting burden on to individual sites. Rather, for each Program, FRAME and ARHEN, in consultation with the Department and their universities, might consider developing objectives which focus on national strategic direction
rather than operational measures such as throughput which are ongoing contractual requirements. This could assist with more clearly defining the impact the Programs are seeking to have on the rural health workforce, and to measuring their success in meeting those objectives. A logical framework approach may be helpful in assessing what goals are actually measurable and attributable to the Programs, as opposed to those to which they contribute, such as influencing students' ultimate career choices.
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Recommendation 7:

That the Department, in consultation with ARHEN, FRAME and the universities, define long-term strategic priorities and objectives to reflect the Programs’ aims more clearly, and incorporate these into reporting mechanisms.

6.4.3 Monitoring and policy research

The lack of longitudinal and consistent data regarding students and clinicians hampers the Department's ability to monitor the extent to which the Programs are influencing the rural health workforce. The difficulties of monitoring and evaluating student and clinician career decisions is wellrecognised, and MDANZ and FRAME have both made efforts to create a process which will provide consistent data in the future. This evaluation has relied on reported personal experiences, anecdotal reports regarding workforce impact, published literature from the RCSs and UDRHs, and the few tracking studies or research projects which individual sites have conducted into their own local impact or contribution. While this provides an evidence base for a process evaluation of the Programs, assessment of the long-term impact of either Program will be dependent upon rigorous and continuing monitoring. Each UDRH or RCS is already evaluating its own performance on a regular basis in reports to the Department as well as through a variety of research projects. Developing mechanisms for assessing national Program impact would require an overarching, collaborative framework based on such objectives as described above in section 6.4.2.

Data available through such studies could inform a continuing quality improvement process for each Program so that problems may be addressed and changes incorporated before the next generation of policy assessments are made. It is acknowledged widely that the Programs will not see the outcomes of their efforts for some time to come; however if, as reported by Health Workforce Queensland (2008), only 4% of Queensland medical graduates since 1990 are operating in RRMA 4-7 locations, it is evident that there is a need to demonstrate that the Programs are increasing the rural health workforce over time. As one informant stated with regard to the dependence of the Programs on rural clinicians and health services, 'the problem is being asked to be the solution', and it will be essential to assess whether that strategy is bearing fruit over time.

In order to be able to both identify emerging challenges to the health system and design innovative models for addressing them, building on the academic culture of critical analysis to incorporate ongoing monitoring and evaluation will strengthen the capacity of each Program to respond to their operating environment. It will also assist in the identification of areas for future innovation as well as models of best practice.

Recommendation 8:

That FRAME and ARHEN, in collaboration with the Department and the rural workforce agencies, continue to develop mechanisms for national monitoring of each Program's workforce outcomes, including the existing FRAME tracking survey and the MDANZ student tracking database.

6.4.4 Geographic coverage and operational models

There is scope for the UDRH Program to be expanded to cover geographical areas not currently serviced by the program. Whether this should be through expanding the current UDRHs or through creating new ones is not clear. A strategic mapping process should be undertaken which looks at current coverage of the UDRHs, the needs of communities not currently serviced by UDRHs, the capacity and interest of host universities, and projected needs for services in the future. A transparent process would then need to be undertaken with universities to determine where expanded or new UDRHs should be based.
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One viewpoint expressed by some informants is that now would be a good time for the UDRHs or RCSs to expand because of the difficulties facing many rural communities due to drought or loss of services. Expansion would provide additional services to communities which may be struggling and promote a sense of hope that rural health services will continue or improve. It would bring academic clinicians to new locations and thus also increase the local workforce. To be effective, expansion also needs to include ownership from local communities, as the current sites have clearly demonstrated. Equally, there are some who would like to see the current model be proven before additional expenditure is
made for either Program.

There are a range of operational models currently extant within the RCS Program, developed according to the medical structures in place within the local region (e.g. GP-run hospitals, regional hospitals, GP surgeries, AMSs) and curriculum requirements of the university. As each model has demonstrated its capacity to fulfil the contractual requirements of the Program, there does not seem to be any need to develop one common unified operational model.

Currently, the greatest number of RCSs reside in the States with the greatest population base: four in NSW, two each in Victoria, Queensland and South Australia, and one each in the other States and Territories. At the moment, it appears that these 14 RCSs are able to accommodate their current demand for RCS student places; although many are receiving more applications than the available number of places allow, some see this as a positive opportunity to cherry pick’ the best students rather than having to fill positions with less enthusiastic candidates as sometimes happened in the early years. At the same time, the number of medical students is expected to continue to grow and whether the current number of RCSs can expand to accommodate these numbers or whether new RCSs are required will need to be determined through careful strategic and statistical modelling, which should include those universities who are already in discussion with the Department about establishing Program sites.

Most RCSs are now able to meet the target of accepting 25% of Commonwealth-funded medical students into their Program (Parameter 1, see section 5.2), and some regularly exceed this target. Increasing the target, say to 30%, would allow RCSs to claim additional funding as their student numbers would increase. However, the ability of RCSs to meet this target overall is unclear and an expansion of the target should be subject both to funding and capacity constraints. For now, 25% is slightly less than the proportion of Australians who live rurally39; any consideration of expanding the target should be considered carefully as the additional burden could potentially be significant on RCSs.

The two Programs, while having similar long-term aims, each have different operational models, the RCS focussing on delivery of the medical curriculum, the UDRH focussing on a broader range of teaching and training activities, as well as research and health service development. The level of activity undertaken within either UDRHs or RCSs is significant, through teaching and clinical training, through student placements and community engagement, through research and publications, and through health service delivery and innovation. Their different approaches to addressing the workforce shortage suggest that there would be no net benefit, but potentially an overall loss, to integrating the
two Programs as one. While there may be a natural integration in various locations over time, as for instance in those universities which have unified the two Programs into one School of Rural Health, this decision has been taken at a local level and for the aim of best accommodating local circumstances and the long-term vision of the particular university/ies. Overall, there seems to be no national benefit to integrating UDRHs and RCSs at a Program level at this time.
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Recommendation 9:

That the Department consider expansion of the Programs only after careful strategic demographic profiling targeted to areas of population growth, taking account of:
  • the capacity of current RCSs and UDRHs for expansion;
  • the capacity of regional, rural and remote health infrastructure and workforce to accommodate increased student numbers;
  • local population needs;
  • the demonstrated interest of the host university;
  • infrastructure requirements; and
  • the current coverage of UDRHs and RCSs (see maps in Appendix E).
Expansion considerations should include whether to increase the size and capacity of current universities or whether to include additional universities.

Recommendation 10:

That the Department maintain the two Programs as separate initiatives.

39 According to the Australian Bureau of Statistics, the percentage of the Australian population of Australia living in regional or remote settings in 2006 was 32%. (cat 4102.0' )(www.abs.gov.au)