Medical Research Future Fund Webinar: How to improve the health of rural, remote and regional communities (14 March 2024)

Ms Natasha Ploenges: Good morning. I would like to start by acknowledging the traditional owners and custodians of the lands on which we are meeting today. I myself, I am on Ngunnawal land, and I do also recognise the other people with connection to the lands of the ACT and surrounding region as well. I pay my respects to the elders past, present, and emerging, and I'd also like to extend that acknowledgement and respect to all Aboriginal and Torres Strait Islander people here with us today. I also do recognise that we are across country as well with our webinar. I do welcome you to our March, 2024 Medical Research Future Fund webinar, how to improve the health of rural, regional, and remote communities with a Medical Research Future Fund grant, which we refer to as the MRFF.

By way of introduction to myself, I'm Natasha Ploenges, I'm the CEO of the Health and Medical Research Office. The MRFF has a really strong background of supporting researchers and health services in rural, regional, and remote areas, and conducting that health and medical research that really meets local health needs. I hope the webinar today will really provide you with strategies and ideas and really help to create those research collaborations that we certainly hear that people are looking to do and looking to make those collaborations across regions, but also across organisations and groups. I do also hope that the webinar itself will help you with work in those settings, and I really do encourage you to consider applying for MRFF grant opportunities to support those solutions. This webinar is part of a series of webinars that we are holding. We are intending to hold future webinars.

Some of those future webinars will look to include a real focus on Aboriginal and Torres Strait Islander health and researchers. I will now hand over to Dr. Ruth Griffiths. She's the principal research scientist and a director here at the Health and Medical Research Office, and she will be co-hosting the webinar.

Dr Ruth Griffiths: Thank you very much, Natasha, and a warm welcome from me as well to everyone who's joining us today. It's a topic that's of key interest to our sector at the moment, and it's also of something that we are quite passionate about on this side of the funding fence as well. So I'm also very excited to welcome Professor Ruth Stewart. It's the Ruth and Ruth show today, which is an unusual thing nowadays. Ruth is not that common a name, so we're delighted to be co-hosting this webinar for you today. Ruth, of course, is the National Rural Health Commissioner and lives in the remote town of Roma in Queensland and is passionate about this topic as we're about to hear. We're also going to be joined by a panel of researchers with a breadth of experience in different areas of health and medical research being conducted in rural, regional, and remote communities.

And so we'll get to them shortly, but just in brief, just to whet your appetite, we've got associate professor Craig Underhill. He's the director of Cancer services at Albury Wodonga Regional Cancer Centre and lives in Albury Wodonga himself. We've got professor Sandra Thompson, who is director of the Western Australian Centre for Rural Health and lives in Geraldton. And then we've also got Professor John Wakerman from the Menzies, and he lives in Alice Springs. And so without further ado, I'd like to hand over to Professor Ruth Stewart, who is going to start us off with a little bit of information on the importance of research for improving rural health outcomes, but also the value of rural researchers and health services leading, designing, and implementing the research itself. So without further ado, over to you, the other Ruth.

Prof Ruth Stewart: Hello everyone. Thanks other Ruth, and I'm, yes, talking about conducting research in rural, regional, and remote areas. Now, I want to begin by acknowledging the traditional custodians of the land today. I'm on the country owned for so many, tens of thousands of years by the Gadigal people of the Eora nation. I pay my respects to the elders of this land, the sea, and the waterways, and the ancestors who have come before us and those who are with us and guide us today. I'd also like to acknowledge the emerging leaders, and I'm sure many of them are here with us today, those within our communities as well. I extend my respect to all Aboriginal and Torres Strait Islander people here today.

So today, I'm going to talk to you about a couple of concepts that I think are really important when we're considering rural health research because I don't think we've had an appropriate approach in the past to rural health research.

And I want you to think about these concepts. First will be geographic narcissism, concept of seagulls, and I'll explain that as we go along, and co-design.

Okay, so let's begin with geographic narcissism. This is a photograph of Marlin Fors who as you can see is in a far northern and very icy place. In 2018, Marlin published a paper in which she said geographic narcissism is a belief that urban reality is definitive. And that paper, which was in, what I would say is probably a relatively small journal, actually echoed around the world because it absolutely spoke to the experience of many rural and remote clinicians, as well as researchers.

Where the concept of geographic narcissism interacts with research is that the concept that research must be in the... So we need to see that research is in the best interest of the communities and not that of the researcher... In the past, very often, research has been done because of the interests of the researcher without adequate reference to the needs and interests of the community.

This is a photograph from the Torres Strait where I lived and worked for a long time. And on the board of the Torres and Cape Hospital and Health Service, we found that only 3% of research done in the Torres and Cape actually reported back to the local communities, and that had quite an impact on the Torres Strait Islander community response to the concept of research.

They talked to us about seagull research. You all know seagulls. They love chips, don't they? So the Torres Strait Islanders think about researchers as seagulls. They fly in from a long distance away, swoop down, pinch your precious whatever, your precious data, things about you, and take it away, and you never see it again.

So, and those research projects that the seagull researchers do have little local relevance or context. They're of little value to the community. And as I said, the findings are rarely shared with the community. One of the stories that still shocks me is, well, I have experienced watching a researcher come into a community, describing that there is a well-known phenomenon of a disease within Indigenous communities, and therefore it would be in this community, and nobody ever talked about it, there was no data about it, and so it needed to be researched. The local clinicians all said, "But we don't have that disease here." The FIFO researcher came in, got a grant for half a million dollars, did a research project that showed there was inflammation, but there wasn't any markers for that, any other markers for that disease.

The FIFO researcher then insisted that it was because the local clinicians hadn't been trying hard enough and had done inadequate data collection and clinical sampling and got another and larger grant to repeat the same study, even though the locals said that we see none of the end product of the disease that you are looking for, and nor do we see any of the active disease that you are looking for. In the end, $2 million was spent looking for a disease that the local community said wasn't a problem. This is in a community that has a huge number of problems, and $2 million was wasted on something that wasn't done. I still feel pretty angry about that. Anyway, so it had little impact on health outcomes for the people in our community. And FIFO research often does have little impact on the health outcomes for rural and remote Australians.

So what can researchers who live and work in the community do? Well, they can respond to local clinical questions and community concerns. They understand the local context so they know what will work locally and what won't, whether that's about logistics of moving around the communities, whether it's about what's a good time of year to do this research, who to talk to, to get the concept of your research accepted by the community, how to run local, all those sorts of things.

And we find that there's also... It's much more likely that local researchers who live and work in the community will conduct value-based research that's actually going to impact on the healthcare that's delivered locally, and they will present timely evidence to the local community, and that timely evidence can inform the strategic interventions and improve health outcomes for rural and remote Australians.

So thinking about culturally appropriate research, communication is the key. You need to take the time and build rapport. And this is another reason as to why it's really important to have local researchers who are more likely to have been living in the community, get to know people, and build those relationships even before the research is considered. They're much better at getting informed consent, informing participants and gaining consent for the conduct of research. And research methods can be developed with the community that empower and engage the participants.

So the return of the data from research is also really important. If you go into a community that has had research done to it by FIFO researchers, it can be really hard to engage because, you know, a thing that is often said, “You people come here, you take our information, you take our things, and you don’t give back.” But when you have a precedent of returning data, it makes a huge difference. You need to present your findings to the communities and to the participants in ways that are meaningful to the community, and you need to share with your colleagues and networks the findings of your research. Just publishing a paper is not enough. And then use the evidence. Use the evidence in clinical practice.

So I talked about co-design. This are some learnings that I've adapted from a resource by the Victorian government, which I think is really good. Co-design brings citizens and stakeholders together to design new services and policies. There are benefits that builds confidence and consensus and ownership. It produces community-led services and policies, but there are challenges, and these are largely about the imbalance of power.

So that co-design relies on people's availability, so you have to take the time to get the meetings that everybody can come to. You can't just say, "Well, we invited them and they didn't come." The groups of experts at the table can often struggle to achieve that participatory mindset. Co-design will fail if inclusive strategies are not adopted, and you may not get consensus in large groups, especially if the experts dominate the process. So those ones there are all about power imbalance.

So there we go. You need to embrace co-design and co-development, understand the local context, challenge conventional urban design principles, conduct culturally appropriate research and share with your colleagues and networks. So, thanks.

Dr Ruth Griffiths: Thanks very much, Ruth. That was, I think, an incredibly useful way of setting the scene, and I've gathered a few phrases that I might just poach for future talks of my own, seagull researchers being one of them. So thank you very much.

We're going to move on to the first member of our panel group now. So I'd like to hand over to Associate Professor Craig Underhill from the Albury Wodonga Regional Cancer Centre, and Craig's going to talk us through a little bit more detail about his experience in collaborating with rural researchers and health services through the MRFF funded ReViTALISE clinical trials project. So over to you, Craig.

Assoc Prof Craig Underhill: Thanks very much, Ruth. And Ruth Stewart, that was a great talk. I’m going to borrow that phrase, geographic narcissism as well. I think that’s fantastic. I want to read that paper now.

So this is the title I was asked to speak to. Thanks very much for asking me to speak at this webinar. I’d like to also extend acknowledgement of country. So I’m on Wurundjeri Country, southern end of the colony of New South Wales and the northern end of the colony of Victoria. You can see the confluence of the Murray and the Mitta Mitta River in my background slide. There’s just a bit of a time lag with the Telstra as I click the slide, so I just have to pause there for a second. There we go. This is our cancer centre that was opened about 8 years ago. And when the site was being excavated, there was evidence of continuous occupation of the site by the traditional owners dating back many thousands of years.

So I’m speaking on behalf of a number of people that are participating in this research project under the auspices of the Regional Trials Network in Victoria. This was established in 2018 with a project grant from the Cancer Council of Victoria and the Victorian government. It was initially 6 sites, and we expanded it to 8 sites with the ReViTALISE project that I’m speaking to today. So you can see that geographically and the Victorian health regions. So it’s quite a large catchment. Victoria has a population dominated by Melbourne, but outside of Melbourne, it’s close to 2 million people across that network, and these sites capture all of the sites with resident medical oncologists and radiation oncology units either in place or being constructed. One of the elements, the Victorian Cancer Plan currently in place is to increase the overall number of new clinical trial enrollments in regional Victoria by 30%.

When this project started in 2017, there was some 400 regional Victorians enrolled in the clinical trial and cancer, but only 80 of those were enrolled in the regional sites. 320 travelled to the city to participate in a clinical trial, and we really wanted to overcome that inequity.

Sorry. Again, there’s a little bit of a lag here. I think it’s our lovely broadband. This is a slide from the Australian Teletrials Program, which is a large project funded by the MRFF in both cancer and non-cancer. It’s been quite well documented that there’s a 3 or 4% gap in 5-year cancer outcomes, metropolitan versus regional, and there’s a number of barriers that regional people face in participating in clinical trials. There’s good evidence from the US that if you improve the access, that the survival outcomes become equal. So it’s really important that we try and bring clinical trials to regional sites.

This is from, again, the Australian Teletrials program, which is, as I said, working in cancer and non-cancer, trying to implement the Clinical Oncology Society of Australasia Teletrials model shown in the cartoon on the bottom right with a primary site, satellite sites with different roles and responsibilities, all bound together with telehealth, and all bound together with an important document called the Supervision Plan, which is like a site delegation log across the network.

So sitting alongside that is our ReViTALISE project. This is it. Hopefully, that's coming up on your screen. Again, I’m seeing a bit of a lag. You might be seeing that as well. This is our project on a page for the ReViTALISE program, so setting that out geographically. So the Australian Teletrials program is focused on clinical trials. We’re focused on health services research predominantly. So this is the short title, ReViTALISE , which is a short version of regional Victorian Trials Alliance linkages, innovation, special populations, and equity. We’re hoping to bridge that metropolitan regional trials gap to improve outcomes for regional Victorians.

Sitting across our programs is this consumer group called ‘Every Voice’ that was established by some regional consumers. So it's a regional consumer-only group. They feel that they have a different spin on experience than the metropolitan counterparts, and they give advice throughout the program, including co-design with some early ideas and development, and they've become a resource for other programs as well who can go to this group and seek advice about their project ideas. Sitting across as well is what's called the Regional Research Teaching Hub. I'll show some slides on that in a moment, and that's about to launch online next week. And then 6 elements down the bottom, we have a devolved leadership model so that each of the 8 sites, either leads or co-leads in one or more of these programs. And so that everyone's participating, but there's a designated lead that volunteered to lead this program. So I think that's been a really important model to help improve capacity and confidence of the sites across the network. First element was adding Mildura and Latrobe to the network and improving their capacity. And then we've done some work in, really for the first time, in regional Victoria, enabling palliative care and supportive care research, doing some work with registry trials, immunotherapy trials have increased across the network, and we're working to help increase the knowledge of our non-cancer workforce in managing immunotherapy treatment side effects.

A really important Aboriginal and Torres Strait Islander People with Cancer Clinical Trial Access Initiative. I'll talk a little bit more about that, but that's been a true co-design with the Yorta Yorta community in the Goulburn Valley and their Aboriginal Controlled Health Organisation to co-design some work there.

And then lastly, but not least, an important program really leading nationally and indeed internationally in some of the work that's come out from that in geriatric oncology research.

So, this is from the Cancer Australia's Optimal Care Pathway for Aboriginal and Torres Strait Islander People with Cancer. It sets out the care that should be delivered across the care continuum for cancer. But we wanted to take the clinical trials portion and try and enable better access with a pilot co-design with the Yorta Yorta people in the Goulburn Valley.

As part of that work, we commissioned the Menzies Institute for Research who did a literature review on the key challenges and barriers impacting access to clinical trials for Aboriginal and Torres Strait Islander people and came up with this cultural framework that can inform people not just in cancer, but also any health research in Australia in how to approach research and co-design with Aboriginal and Torres Strait Islander people. And that's published on our website.

I'll just switch now to talk about the regional trial hub that has now been rebranded and it's called @research Your Regional Research Training Network. So this was designed after quite an exhaustive, robust process. We did an integrative review of the international evidence for approaches to research training targeted at health workers. We did some structured interviews and focus groups to explore the needs of regional health workers, the barriers, enablers, and also interviewed consumers and health service administrators. And then we conducted an environmental scan to identify existing research, training, education opportunities and have designed this website to dovetail with those existing resources and to aggregate some of them.

And so, excuse me, again, there's a bit of a lag. This next slide will show some of the content of the website listed there. And so this is some important tools and research and education training components that have been brought together, some information about upcoming events and opportunities.

So it's pitched at regional health workers, but I think it may become a default important national repository of health services research opportunities. This is an example, one page, the education and training page. This is one tablet research design, learn the basics. And if we click on that, it comes up with a number of resources available to people, whether they could be videos, there could be PDFs, courses, and also details whether there's any costs involved in the participation.

So has it all worked? This is a graph showing over time the increase in clinical trial activity across the network. So you remember that I said we had 80 patients in 2017. We included Geelong in our network. Technically they're now a metropolitan site, but they service a huge number of rural patients. Downtown Geelong is now considered metro, so they're added to the network. So we had 80 plus 55 is 135 patients on, these are the core interventional clinical trials. And that number has essentially doubled up until the end of 2022. We're just cleaning the 2023 data. But that momentum's been continued. And then if we add in the registry trials, there's palliative care/supportive care trials, you can see quite a dramatic increase in the number of patients able to participate in clinical trials. And the last columns show some tele trials.

So, what are some of the enablers of success to date? We have quite a robust evaluation framework that we've developed with some experts in the field, which will capture a lot of the activity and some of these are successes. But these are some of my thoughts on what are the enablers and they're listed there. So giving people some capacity at the sites is really important. And these key investigators have a small amount of protected research hours paid for each week, which enables them to have the time really to focus on delivering on our plan. The devolved governance has been an important success. We're using telehealth to conduct the clinical trials, but also health services research and networking. We're focused on regional health issues as Ruth alluded to. We have I think, effective consumer engagement including the local Yorta Yorta people. And there has been this big focus on upskilling people in health services, research, training and implementation.

So, in conclusion, how can health services effectively collaborate with researchers to improve regional remote health? And I think it's providing some of these activities listed here. So, hopefully that has answered the questions that people have on the webinar of how to improve regional and remote health through research.

I'd like to acknowledge I'm just the voice today. There's a huge team involved in this across the 8 sites plus Cancer Trials Australia, our partner in Parkville. We also like to acknowledge our other partners from the Victorian Comprehensive Cancer Centre Alliance and Alpha Trial Hub and importantly our funders, both the national government and Victorian government. So thank you.

Dr Ruth Griffiths: Thanks so much Craig. And as the director who's had policy responsibility for the program that funded the ReViTALISE Program as well as the other two programs under the same initiative, it's been fascinating seeing just how much can be done in rural, regional areas with that investment of funding. So that's been exciting, certainly from our point of view as well. But it's not all about really, really large buckets of funding either. Sometimes it's about smaller buckets of funding and smaller and more local projects as well.

And so I'm hoping that's a good segue and I apologise to Sandra if it's not. But I'm going to hand over now to Professor Sandra Thompson who's going to speak from her perspective as the Director of the Western Australian Centre for Rural Health. So over to you Sandra.

Prof Sandra Thompson: Thank you very much, Ruth. And good morning everyone. I do want to also pay my respects to the traditional owners of the land where we're meeting on today all over the country, and also acknowledge that they have had a very hard time in the past and that we all have a responsibility to be doing much more around addressing some of those issues.

I work in Geraldton and it's a community which is 425 kilometres away from the capital city of Perth. We service a huge region and I look at some of the small rural communities in our region and I feel like they are very neglected and the populations are declining. And I think some of the things that we think are fantastic about how we service those communities also have some perverse and pernicious effects. But I think if you just look at these issues about place-based approaches, and this is very much what Ruth was talking about and that issue about shared design, how we work with people, how we involve community members, how we identify and respond to community needs, I think we're all on the same page there. And I guess one of my issues is how do the voices of those people who are in a long, long way away from Canberra get heard and how do they get represented through research and through knowledge and through investment into innovation and sustainable health approaches.

So, I put this in because I know that it would be great to present a very, very positive view of everything that has come out of the investment through MRFF into rural and regional health. And I absolutely want to commend the MRFF for their efforts around investment in rural health. I think they are genuinely on a journey and that they're learning along the process of that journey and that, you know, they are definitely in a process of improving their processes. Because the MRFF is about research translation. It's about how do we, I think, implement knowledge which is gained elsewhere into the context of rural and remote communities.

And I think many of us have felt that the MRFF is a bit of a breath of fresh air actually, and much, much more responsive to thinking about what benefits could come from research in rural and remote communities. And I also want to acknowledge their transparency because last year they did an analysis, which they reported in July last year on funding for rural, regional and remote health research. And I think, I imagine that Ruth might come back and talk about this at the end, so I'm not going to labour it, but they basically broke it down by Monash Modified Classifications and about the number of grant applications and then the number of successful grant applications. And they also reported on the limitations, and I think that can turn our attention to are we able to measure investment into rural research? And this, I think, is a really critical issue for improving investment and the nature of the research that is done.

And I think the problem is that Ruth's already talked about seagull research, about the nature of great ideas that are developed by very smart people with high capability and very good hearts, but that is not quite the same as investing in the research capability within rural regions with the resources that come with that, with the intellectual capability that comes with that.

So I did, the other day, in anticipation of this, just reach out to a couple of colleagues and ask them for their comments and whether they'd been successful with MRFF grants and so on. And I think we've all been beneficiaries in some ways of MRFF funding. But there is a very strong sense I suppose that we are often, we are not necessarily always the lead player in it. We get to partner, but we don't get to lead and that the resources are managed elsewhere. I think they're, for somebody who spends a fair bit of time on the end of a video conference, I would just say that there are some things that have been going on over the last 10 years, which is about the way in which research is undertaken and the investment, and I noticed, Craig, you mentioned investment in digital health as being part of the solutions and it absolutely is.

But I think we need to think, if we think telehealth is the answer to everything, it isn't. And from where I sit, where some of my colleagues sit, based in smaller rural areas, we see telehealth as hollowing out communities. So much of the health services being delivered through telehealth, none of that sort of intellectual capability, none of the real understanding of context that comes from having people living in the community and certainly visiting the community. Now, I think some of these quotes may be a little bit unfair. Grants come out at short notice. It feels like it's a done job. And I'm not saying it is always like that. I'm just saying that most of us who are based in a more remote community, we are not really part of the big machines, but where we're informed, we don't have a whole group of people sitting behind us writing grants. So every grant that we submit is a big effort.

So I did want to just put in a little bit of a plug about, when I say we, who am I talking about? I am based in Geraldton, which is number two on that map and at the Western Australian Centre for Rural Health. And that there is a whole network of University Departments of Rural Health around Australia. And that we do collaborate, we do talk together. We've got a very active research staff network and we've got lots of other projects which are now happening. And I would say that really has really taken off in the last 5 years. Even though like the centre I'm in, we've been going for 20 years and it's not like it never happened before, but it's starting to happen at a much greater pace now. And I just put the timeline there because clearly this is a network that's been growing over that time.

So there are now 19 university departments, but two of those only started in the middle of last year. And these are AHREN's strategic priorities. So AHREN is our peak body under which the UDRHs collaborate and network. We are focused on building the evidence base on rural health issues through high quality research and knowledge translation that addresses the priority and needs of local communities. And that's what we are talking about today.

And then our research priorities, very, very, very simple. One, we want to show what we can do. And we've done a little bit of work around that starts to look at that. We are very keen on looking at how strategically we can build rural and remote research capacity. We're all very committed around promoting Aboriginal, Torres Strait Islander health and wellbeing. And when I think, talk about health and wellbeing, that is not just about health service delivery. And this is one of the things because a lot of the grants that come out are targeted around a specific health issue, but we are talking about how to holistically, how do we improve the health and wellbeing of Aboriginal, Torres Strait Islander people. And then obviously we are keenly interested in knowledge translation across rural and remote areas as well.

And I just wanted to, I put this in because in my trawl, thinking about this talk, I went back to some of our old priorities. We have been in this game for a long time. We have basically said the same things over a long period of time. Our interest in improving rural health capacity and our interest in Aboriginal and Torres Strait Islander health and what might be a strategy that we could adopt to do that.

Not keeping a very good eye on my time here. So I'm going to push through this. So this is just one little bit of work where we've gone back and we've got a database that looks at… We've pulled together all the outputs of university departments of rural health over time from 2010.

So doing it, this is just the Aboriginal Health Research, Aboriginal Torres Strait Islander Health Research publications. And basically, I think it's a pretty fair effort given the under-investment in rural health research, which clearly Susie Teagan from National Rural Health Alliance has been talking about. I don't want to say endlessly, but she has been trying to get this on the agenda. And, of course, Lesley Barclay and David Lyle looked at the under-investment in rural health research. And that paper now really, we've talked about updating that to look at what is the investment now and MRFF may well be contributing to that.

So, I won't labour this point, but I will say that sometimes investment might look like it's going into rural health research, but the investment is going into research institutes and universities that are based mostly in urban areas and that the benefits, that the resources, the people are not there in rural areas. And the other thing I think we need to be very aware of is that there's a predominance of descriptive research and we really need to get away from describing problems and just measuring whether we've made any progress or not and get into doing some of the very, very hard stuff around interventions. And that doesn't easily happen in 3 and 5-year projects.

So just moving on then to the capacity building. Quite a long while ago I was involved in some capacity building projects and it made me think, what is this building capacity? What is it about? And so I've always liked that I actually finally found something that helped me a little bit. It wasn't about health research, but I think we often think about, well, we need to teach people how to use SPSS or something, how to write an ethics application, but actually we need to teach them all of these other things as well, or we need to involve them so that they get the opportunity to learn about it. But valuing community is there, learning how to use information, building the networks and obviously leadership and what good leadership is as well.

And so because we were asked to give examples, and I'm sorry this slide isn't a very good slide, but I did want to talk about a couple of examples. Quite a while ago I was involved in, okay, I need to wrap it up pretty quickly. But when HIV was there, NHMRC set up the Commonwealth AIDS Research Grants Commission. They brought together affected communities, gay men with researchers talking about the nature of the research. So they really fostered collaboration, the capacity building grants. I put this photo in because I reflect upon this capacity building grant and the leaders that came out of that, and I won't go through all the names, but I mean most of them are professors these days and have a huge role. And I really want to promote the rurally-based academic centres as well. So these are the issues I would really, really like to be highlighting. Most of what we've talked about, brand applications are very, very onerous. There are short timelines for submission. We don't have research machines of big metro universities to crank it out or just to turn it around for the next one. We need a more facilitatory approach and we need to be working with our colleagues across metro areas and in big institutions as well. But I think more of the resources need to be based in the rural areas, and we absolutely recognise that the solutions don't always sit at a local level. We need that advocacy. We need the grant that comes from people who are very, very well-connected into policy and planning.

I've put this idea at the bottom because it's one that AHREN has talked about, and I've looked at the Indigenous research mission of rural and remote and how they had planned to do that. I think it's fantastic. It's a big chunk of money over a period of time, a much more collaborative process around planning. I think that we need to think about with us, we could have something like that, that would serve rural and remote researchers and the needs of rural and remote communities. Thank you.

Dr Ruth Griffiths: Thanks so much, Sandra, and appreciate you bringing the meaty topics forward, because I think these are the things that we have to wrestle with if we're going to engage in this space. Band-aid solutions are not going to be the answer, and so thank you for bringing these up and I think these will probably trigger some nice questions in the chat. I forgot to mention before, for anyone watching online if you have questions, we are going to have a Q&A session at the end, so please do pop them in the chat. Apparently, it's on the right-hand side of your screens, so please do put some in there. We've already had a question about whether the Powerpoints are going to be available. Yes, absolutely. No need to scribble your notes or take your photos of the screen. We are recording the webinar as well, which will be available later. So, just a quick plug to put your questions in the chat if you want to engage, particularly in some of these meaty areas. I'll just ask some more questions of the panellists later.

Without any further ado, I'm going to move on to introducing our last panel member before I get the honour of talking about what we're doing in the MRFF to try and address some of these issues. I would like to introduce Professor John Wakerman. He's from the Menzies School of Health Research at Charles Darwin University, and he's going to talk to us a bit more about research and health services collaboration in the Northern Territory. Over to you, John.

Prof John Wakerman: Thank you, Ruth, and thank you to the MRFF. I agree with Sandy's comment that it's really a breath of fresh air having you there and engaging with us and visiting us and so forth, so thank you. I'd like to acknowledge the country. Usually, I'm on Central Alawa Country in Central Australia, but today, I'm on Wurundjeri Country, and so I'd like to acknowledge all the traditional owners and the leaders, past, present and emerging, and also, the First Nations peoples that are on this webinar.

I think we've heard some common themes across the presentations thus far in terms of community engagement, capacity building. I'll try and focus on some practical examples of how to do that as I speak. I also like to acknowledge before I move on, the input of Deb Russell, a colleague of mine who we worked, for many years, together and who had made significant input into this presentation.

I also like to say that as you can see from this photo, I'll be talking about remote and rural, but most of our work has been in remote places such as this small community, about 300 kilometres northwest of Alice Springs.

I want to touch on 4 issues that I think are relevant to the topic of this webinar. First, is around long-term relationships, building those relationships between local health services and researchers, building local critical mass of researchers, formalising partnerships between health services and research organisations, and then the communication and interaction with funders, which I think is really, really important and I think we're witnessing something that I haven't seen for a long time.

Firstly, long-term trusting relationships. We've heard about this topic from other speakers already, and this is in large part maintaining effective and regular two-way communication with local services and communities. Some examples from our work for most of our sizable projects, we have project steering committees where we invite CEOs or senior health staff from the health services that are engaged with us to join these steering committees. This means that we have good governance, it ensures that we maintain relevance to health service needs, but also provides an important forum for dialogue. We quarantine time for services to report on current issues and priorities at steering committee meetings, so quarantine time for the service providers to talk. This has worked very well because not only do the service providers like to get together and talk about their common issues or different issues. It also informs us about what's going on.

We've already heard mention about providing regular communication with health services, and we don't wait for two years after the end of a project when we send along a peer-reviewed publication. We maintain regular research updates to health services as we go every couple of months. We also provide customised reports to each health service of relevant findings to them. At the moment, we're doing some workforce turnover and stability work with some of the Aboriginal Community Controlled Health Services. We provide them with customised reports that report on their service and compared to the larger group. This is time-consuming, but it's important. This is really critical that timely feedback happens.

These ongoing relationships may lead to ad hoc but significant requests. For example, the workforce work that we're doing with some of the community-controlled health services came out of the fact that when we published our results from work that we'd done with the NT government remote clinics, a couple of the community-controlled health services approached us and said, "Well, we think we can do better than that, so can you work with us?" It's developed into a large-ish grant, partly funded by MRFF. We're looking at those community-controlled health services now. Whilst we're just in the analysis phase, I think there'll be some very interesting findings there in terms of models of service delivery and funding for workforce issues.

Now, the practical example relates to the medical retrieval service here in Central Australia. In the early days of CAAHSN, which is the Central Australian Advanced Health Science Network, one of 11 NHMRC accredited research translation centres, I did the rounds of all the major services in the region to get an idea about their priorities and potential research priorities that might be relevant to this new organisation. Despite my lack of enthusiasm, the regional director of the health department was very clear about what she wanted done, so they created a new model for medical retrievals and consultations. It really did some tension, and she wanted that evaluated to see whether it was working or not.

So we engaged with the retrieval staff who enthusiastically joined the research team, and the results were very positive for the new model. Remote clinic staff were more confident, not to evacuate patients. They co-managed acutely ill people in the clinic with the retrievalists that provided clinical advice, and it led to a 10% decrease in number of emergency evacuations and hospital admissions. This was a substantial saving, not only related to direct costs, but also the potential social costs of remote residents stranded in Alice Springs. This work has gone on to involve us in some work in the top end, looking at retrieval service there and also looking across the top of Northern Australia, looking at these remote retrieval services as a whole and developing a performance framework for them.

We do need funding in grants that reflects the real cost of regular field visits to remote sites, to maintain engagement with community organisations, community leaders, elders, and to support community-based researchers, so it's important that this aspect of the work also is funded.

The second area I want to touch on is about building local critical mass of experienced researchers. This follows on with Sandy's comments. We've already heard about the importance of local context and place-based approaches, and place is absolutely central to remote or rural health. This is a logic framework that we've used in some of our work. Not only the inputs and outputs and outcomes are important, but the context in which this happens is important. The social, political, geographical, cultural, epidemiological context actually are really essential to our consideration of service delivery and research.

For example, models of service delivery change as you move from rural out to remote areas and researchers need a deep understanding of context. We need researchers who are embedded in this environment to ensure rigour, so they're context experts. To reiterate Ruth Stewart's comments, we don't want more seagulls, and FIFO researchers tend not to have long-term relationships and understanding of local context. Building this critical mass is difficult, but it's important. Firstly, we need to budget to employ Aboriginal community-based researchers and support their training and opportunities. We are currently working on a digital health project, funded through the digital health CRC. We're co-designing digital health technology solutions that are consistent with remote consumers and healthcare workers' preferences in order to improve access to comprehensive primary healthcare, working with two remote communities in the top end in central Australia. There, we've employed community-based researchers who can liaise with individuals, the local council community elders, so those run focus groups and organised interviews. These community-based researchers are invaluable to what we do. We also need to employ more Aboriginal researchers and develop flexible pathways into research. We need to understand health service research processes and needs. There are different processes, different reporting requirements for different services. Also, we may need to look at developing critical mass across organisations, not just within organisations. In Central Australia, there's interest from Alice Springs Hospital, from Central Australian Aboriginal Congress, from Menzies, to form that critical mass of researchers.

We need to formalise these partnerships between health services and research organisations. Many health services now acknowledge the power of research, however, they need to prioritise service delivery. Some services in NT have declared a moratorium on further research because of the pressure of service delivery and generally underfunded, under-resourced environment. This is a critical point. Services need to be appropriately funded to engage with researchers and research. This is an absolutely critical issue. We've had experience with different strategies to build research capacity. We've employed local community-based researchers. We've embedded researchers in services to build research capacity. We've developed MOUs, which make explicit mutual needs and values and so forth. We continue to provide expert advice and service-led projects, but we need to look at more comprehensive structures over time. CAASN, the Central Australian Advanced Science Network, is starting to realise this opportunity, but we need ongoing long-term funding to do this, and that underscores Sandy's point.

Lastly, just a few words about MRFF. We really appreciate the MRFF strategies to foster research in areas of high needs, such as rural and remote. The interaction has been very positive. We've had senior staff visiting Central Australia to get a feel for what goes on, and of course, organising this seminar. I think this is a change and we'd like to develop that relationship further. Thank you.

Dr Ruth Griffiths: Thanks very much, John. Can I just reiterate, we love coming out and visiting as well, even though sometimes I look a little bit like a deer in the headlights because it is so different, but I think that's the only way that we can engage and formally, I guess formalise our policies that are actually fit for purpose for people on the ground. I think that's a really good point.

It's a bit of a good segue too, because I think I'm the one that's speaking next, and I'm conscious we're running a little bit behind time and I do want to get to questions. So, let me try and skip through a little bit of a few of my slides. They will be available on the website and as part of the recording later. I'm going to try and just touch on the highlights of what we are trying to do as part of the MRFF to address the needs and the issues that have been raised today in terms of from a research funders' perspective and of course, we are not the only solution, we are one part of a problem. As Sandra said, this is a journey where we've started, we've tripped at times and we've had to backtrack and correct some of what we're doing, but we are trying to genuinely learn and improve and ensure that our rural targeted funding is fit for purpose. Next slide, please.

The focus for the MRFF does start with the priorities and that we have included people in rural and remote communities as a priority population. That's the starting point, to name it, to put it out there and to have that as a focus for some of our grant opportunities. We also understand the value of research, and so we want to promote it. We also understand the issues that have been raised today in terms of the challenges with. putting grant applications in, maybe the different types of research that's done in rural, regional and remote areas and so one of the things we're trying to do is incorporate assessment of MRFF grant applications, sorry, opening of grant opportunities with specific focuses, which means that there is targeted funding available, meaning that the success rates are higher. That's one of the things we are doing to try and say, look, we recognise it's an important area, we're naming it as a priority population, but even more so, we're putting money where our mouth is and making sure that there's targeted funding available. What we found is that we have documented an increase in awarded funds to support projects that are undertaken in rural, regional, remote areas, noting the limitations raised by Sandra before about the data that we do collect. There's some limitations that we can't change, but we're trying to look at what we can do with the data that we do have to accurately reflect what we are funding.

And just to note, we are working, or we will be starting shortly, to work on a new release of that rural funding report, so we are committed to ongoing transparency. Next slide, please.

So, as we mentioned, this is a journey. One of the things we are doing is we're refining the eligibility requirement in our grant opportunities to try and further address some of the issues such as the fly in and fly out researchers, the research funding that may sit in a metro-based university and not be controlled by rural researchers and those sorts of things. We do consider those issues that we are trying to address in what we're doing. We do have the targeted funding through separate streams, but also consultation with a range of stakeholders has meant that we've now started really tightening up on our definitions of what do we mean by rural.

Currently, the organisation leading the research, not the administering institution, which can still be metro-based, because we understand that often people have affiliations with metro-based universities, but the organisation actually doing and leading the research on the ground. The chief investigator, a 50% of the team and all of the research participants have to be located in a rural area or a location that's MM2 or above. We started off with more looser criteria, and now over time, we've started to tighten it up because we're not quite sure if we're quite hitting the mark yet. That's just one thing we're doing to try and really increase the support for this type of research. We are also working on ensuring that grant applications from rural areas are assessed by rural researchers, noting that rural researchers are already under the pump. They're often clinicians as well. They don't actually have a lot of time. Capacity is a real issue and we don't want to overburden rural researchers. But we're also trying to ensure that like is being compared to like, we're not comparing apples to oranges in the grand assessment process. That is something else that we're trying to do from the MRFF's point of view as well. Next slide, please.

We've just put in some of these slides that are some examples of grant opportunities that are open at the moment that have targeted funding for rural and research for rural-based stream research or research-based in these areas or place-based research, which is a term that I learned more recently. For example, in our primary health care research plan, primary health care research happens across our country, not just in metro areas. It has targeted streams where this requirement for the majority of the research, the chief investigator, a 50% of all chief investigators, et cetera, et cetera, are primarily resident in those areas. It's just to highlight there is grant opportunities out there. Next slide, please.

This next slide includes some of those specifically. Have a look at these grant opportunities later, go and see if that's relevant to you in your situation. They cover a range of different areas, some are broad like primary care, which is very broad. There's inequalities in access to high quality care for older Australians, which is quite broad, but also an issue for people living in RR areas. Then obviously, long COVID is not geographic specific who it affects. Have a look for those if you're a researcher and you're interested in applying for some of that funding. Next slide, please.

As mentioned by Sandra, we did put a report together, which has a lot of data on what we've done. It was actually quite nice when we crunched the data that we could demonstrate quite nicely on the left hand of this slide that we've been increasing the number of grants awarded in MM2-plus or MM3-plus areas, plus also, the total quantum of funding.

I'm going to leave that for you to digest later. Just to note that we have shown that we can improve success rates, which is a bit of a durr moment, but it's nice to be able to demonstrate that, but just by making that targeted funding available, which is really, I think saying to show some dividends in the increasing the number of projects that we do fund. Also, what we’re seeing anecdotally is we’re getting applications from, I guess universities or institutes that we don’t usually see applications from, and that’s what we want. We want to encourage people to go, yes, there’s a place at this table for me, acknowledging all the other issues that we could all do be addressing as well. Next slide, please.

Again, one of the things we highlighted in the report that there's gaps, basically, areas where we can improve. Again, in the interest of transparency, we want to say, yeah, we noticed that we don't fund a lot of mental health research, which is obviously a great need in rural, regional and remote areas. It's something that we've put out there and we've documented and something that we now need to take on board ourselves as a funder and say, okay, well what do we need to do in this area? Next slide, please.

Opportunities for us as the MRFF, noting it's an ongoing conversation. We're looking at those high burden, low-investment areas that we've noted. We're looking at creating opportunities for research and to promote research through a range of opportunities, and that includes eligibility criteria, plus targeted funding, plus assessment processes.

We're also trying to raise awareness of what's going on because we find people say, "Oh, I didn't know that was out there." So we're trying to increase our awareness of them by advertising through peak bodies, the standard MRFF newsletter, Department of Health social media, et cetera. But if you are not hearing about them, then let us know how we could increase promotion of what activities or what our grant opportunities are available.

We also want to encourage collaboration between different networks, I don't think we've landed that yet. We want to encourage it, but I don't think we've landed yet about what that looks like from our point of view and how we can facilitate that.

We also want to encourage health services to take the lead on research that actually meets their health needs. We do have limitations that health services can't apply for MRFF funding, it is something in our legislation, that's something we're conscious of and working in the background to address. But in the meantime, how can we still make sure that research being done in these areas does fit the needs of those living in those areas?

And as John mentioned, we are doing our best to try and get out there and visit people on the ground. So I'm off to Alice Springs next week. I’ve got a really good suite of meetings lined up with different people and it's the best way of getting an understanding of what's happening on the ground rather than sitting behind a desk at this end and going, oh, let me look at your progress report. Let me look at your variation requests without actually understanding the context from which it's coming. So it's something that we are trying to do more and engage more in. So next slide please.

That was a very fast whirlwind tour of what we're doing from the MRFF. Can I hand over to the other Ruth again? Would you like to make a few comments just to sum up before we move to some of the Q&As that are coming through in the chat?

Prof Ruth Stewart: Yeah, thanks, Ruth. Look, I have been very much struck by the confluence of thinking that was a thread throughout this whole presentation. And I know that actually that just came about because the issues are really important for all of us. Whilst each of us prepared our own talks, it wasn't much collaboration between us about what we were going to say.

So thinking about Craig's presentation, I was struck by his description of a large network of researchers across most of Victoria and into Southern New South Wales, improving access to clinical trials, but networking the various research teams and having a really strong governance around that.

Sandy talked about the positionality, I like that phrase, Sandy, and just that time-honoured ‘if you've seen one rural town, you've seen one rural town’. And how that translates into research, that we need place-based responses to research.

And I was struck by that figure of only 2.7% of MRFF funds going to MMM 3 to 7. And that visual, the bar graph showing how urban applications for MRFF grants absolutely swamp those coming from more remote communities. Your quote stuck out to me too. The interventions that come metro centric and researchers saying we partner but we don't get to lead, the resources are managed elsewhere. How about that for a disempowerment quote? So that capacity building is a strong theme. The focus on engagement with local communities.

Then looking at John's presentation, such an emphasis on the long, and descriptions of how long-term trusting relationships with local services and communities really strengthens both the value of health research in rural and remote communities, but also the application of the outcomes of the research and the importance of a local critical mass of researchers. If we are all just one isolated person sitting out on our own, it's really hard to get going. But if we are linked together... Which reminded me of Craig's description of those networks and how powerful they were.

So then it's great to have Ruth's summing up of the work that MRFF is doing to sharpen that focus on the rural and remote. We sometimes use the phrase making it more valid, the rurality more valid rather than just lip service, something that those people who live and work in rural and remote areas recognise as theirs. I like that concept of, that there needs to be more focus on those high burden but low investment conditions. That's something I'll be taking, thank you very much. And networks and networks and networks again. So there you go. That's what I'm taking home from this and I hope that others will find some similar take homes, but I'm sure you've all got your own special little gems because it's been a bit of a gem field I think this session. Thanks everyone.

Dr Ruth Griffiths: Thanks so much Ruth.

So I've got a few questions coming through here and apologies if we don't get to them all. We always do take them away and do a bit of an FAQ and get back to you afterwards if we can't get to them all. But we've got some good applications... Not applications, question and answer. I'm falling back into my day job language here.

The first one I think I might throw to you, Ruth, and then maybe Sandra as well. Someone has asked how do we avoid becoming seagulls if we are metro-based researchers, but we want to make a difference and contribute in to health and medical research in rural and remote communities. So how can I help without being a seagull?

Prof Ruth Stewart: Well, you build relationships is what I would say. And now I'll hand over to Sandy or John or Craig.

Prof Sandra Thompson: Thanks Ruth. I think it's a very good question and I think we absolutely need those partnerships with urban based researchers. We simply haven't got that capacity all on our own. But I think ideally some of that management of the research, it should sit within the rural community itself. And if the resources are all elsewhere and it's all being done over phone and video conferencing and so on, it doesn't really help. And I think that you can also be arguing the advocacy for it. I don't think there's a quick answer to this to be quite honest, and someone else might like to make a much better answer of it than me.

But I think there are lots of challenges in rural health at the moment. Like we're trying to recruit staff and we can't get accommodation, well, and that's all over the country, isn't it? But you've got so many less chances in a rural area. So how do we even attract people?

Dr Ruth Griffiths: Absolutely. Craig, did you have something you were going to chip in with?

Assoc Prof Craig Underhill: Yeah, I think Ruth and Sandra really hit the nail on the head there talking about the partnerships. And so it's about having those effective relationships and partnerships. So we have metropolitan partners, which I showed on my thank you slide. We have what we call a Research Advisory Committee and there's some metropolitan people on there. But our project is very much seen as a regionally based with the regional clinicians leading on it. And sure we're getting mentoring and assistance from metro, but they comment, "Wow, it's so fantastic to see regional people leading and I can see the improvement in confidence of my investigators."

So if you're crafting an application, I would truly make the regional partners the leads and the metropolitan people could be associate investigators to up-skill them, give them the opportunity. Ruth's doing thumbs up. I think Sandra, we did some research, what prevents people going regional in medical oncology trainees and it was their inability to participate in research. They felt they'd be missing out. And so all the ducks are lining up. So metropolitan people have put in application, being partners rather than leads, I think that would be, and co-design it, don't just drop in an idea, you'd go to the regional partners and say, "What do you think are the priorities that we need to solve?" and work from there.

Dr Ruth Griffiths: Great points. John?

Prof John Wakerman: Yeah, so I think the question that comes to my mind is whose needs are we trying to meet? And I think what we've been all saying is that we are trying to meet community and health service needs. So this doesn't preclude metropolitan based researchers, but what function are they serving? So for example, we've worked with a biostatistician who lives in Sydney for the last 20 years or so who understands workforce issues, he understands rural and remote areas because we needed a really good biostatistician. So it's a matter of making contact, I would say, if you've got particular skills that you think might be relevant to the sort of research that we're doing, make contact and talk to researchers on the ground and then see if the skills that that person has match the need in that rural and remote area.

Dr Ruth Griffiths: More great points. I'm hoping that gave some real food for thought for the people who have logged in. We might move on to a couple more questions. One actually maybe something that I can answer from the MRFF's point of view. Someone has asked and said that it's assumed that chief investigators are other researchers in that the application asked for top 5 publications and the impact of those. And we actually want our chief investigators to also include local health staff. Absolutely. 100%. So how do we share the power and promote the role of health staff, particularly our local Aboriginal staff as chief investigators and look at impact more broadly?

So firstly I'd say it's actually not a requirement from the MRFF, I know this is going to sound a bit maybe at odds, but to have publications to be a chief investigator. It's there to demonstrate your researcher background if that's what you bring. But if you are not a researcher and you don't have publications that it is actually not required. And we've had this conversation more broadly, but we think there's still this perception that only academic researchers can be chief investigators, but it's actually not the case. We want that breadth of experience, expertise, background, impact to be brought as part of the team. And we actually train our grant assessment committees accordingly, that we don't call it track record of the team. We call it capacity, capability, and resources. And we explicitly say to them, we don't want you just looking at publications, grants, other traditional research metrics. We want to look at is this the right team to do the job? So I'd say even though it's there, it is there for alignment with some of the NHMRC schemes and it's actually of relevance to academic researchers. But if you're not an academic researcher, then you don't have to put the publications in. You demonstrate your impact in, I think it's a one-pager or two-pager that you put in per investigator in terms of the capacity, capability and records section. So I hope that helps and would love to disseminate that a little bit more widely.

So that's a little bit of a practical question. Let's go back to a more philosophical question. Someone has asked how do we encourage more research that has long-term impacts like preventing the impact of climate change in rural communities? That's an interesting one. Who would like to take that one for the team? Go for it, John. I saw a physical hand, not a metaphorical hand.

Prof John Wakerman: I think climate change is an incredibly important issue for us and I think there is work going on now and I think you need to familiarise yourself with the work that's going on now in terms of climate change and health. So there is a national collaboration called HEAL, Healthy Environment And Lives, and we have one senior researcher in Alice Springs who's doing a lot work in that area. I'm happy to provide you with details on how to contact Supriya Mathew if you want.

A lot of the basic information that we need, the basic evidence isn't there. Supriya's leading some fundamental work looking at climate change and its impact on primary health care services and monitoring temperature and climate change in parts of the country that are not really currently monitored at all. So we don't even have any basic data for some parts of the country around what the changes there are. So I think there is some work going on and happy to plug you into those networks if you contact me.

Dr Ruth Griffiths: Fabulous. Anyone else want to contribute? Go for it, Craig.

Assoc Prof Craig Underhill: I was just going to say, I don't know what the answer is, but I would think that that would be an MRFF project excellence to look at the potential modelling for impacts on health for regional and rural Australians in the context of climate change. It'd be great if someone was able to put together a collaborative network to tackle that. Ruth has a hand up as well.

Prof Ruth Stewart: Yeah, I'm thinking that it would be really good to run a session, a couple of our session in one of the forums that rural health people gather in. Whether it's the NRHA Scientific Forum, the Rural Medicine Australia, the CRANAplus Conference, one of those conferences and talk about climate change impact on health and structure the program so that you end up with an expression of interest from people in the audience who are interested in researching this and would be interested in becoming part of a group who work together to do that. And John and Supriya might be a really good person to lead some of that thinking and talk.

Dr Ruth Griffiths: Great thoughts. I think we've got time for one more, which I think is actually a really practical one, again that I'd be interested in the panel members' thoughts is how do other rural senior researchers manage the tension of metro-based university KPIs, which we all know are usually publications, grants, that sort of thing, and expectations as compared to potentially the value of doing work critical at the local level? I'd be interested in practical suggestions for researchers who are wrestling with those concepts. And maybe your answer is there is no wrestle, it just happens naturally. But I'd love to hear your thoughts.

Prof Sandra Thompson: Craig's got his hand up.

Dr Ruth Griffiths: I can't see everyone on my screen. Sorry, Craig.

Assoc Prof Craig Underhill: Look, I think it's a really hard question to answer, but I think that this is like everything in your professional life, just concentrate on doing a good job. And I think if you do regionally-based research that answers questions and proves outcomes, you're going to address all those KPIs from the university because you'll have lots of outputs. So it's really not focusing so much on the KPIs but focusing on doing a good job. And I'm in the privileged position, we've got this MRFF grant, but it's a 25-year overnight success. We started with a small research unit focused on clinical trials, other regional sites, developed trial units. We've linked them together that we then leverage this big program. So you just have to just encourage people to start somewhere, start small and build on those successes. Does that answer the question?

Dr Ruth Griffiths: I think that's a good start. Sandra?

Prof Sandra Thompson: I think it is a very interesting question because I think colleagues have certainly talked in the past about challenges with promotions because we don't quite fit the paradigm and so on. I would say from my experience, we don't have a lot of pressure around our KPIs. And I'd also highlight that I talked about AHREN as a network in the Royal Clinical School. We're not really funded to do research. I mean of course we apply for research, and we see the importance of doing that research and we want to give value for the research that we're funded for, but I think it would be false to sort of say we're under incredible pressure.

What I think is a big issue, and it was interesting, Ruth, you're talking about when the grant review panels meet because how do we know all that? Because when we look at the application forms, it's really hard. I mean, my heart sinks every time I have to do one of those applications because I feel so inadequate in terms of the paradigm by which things are measured. Because, how do you do it? Do you do it based on your citations? Do you do it on the ones that you really feel you contributed something when you did that? And it might be very barely cited, and yet it might be used in ways that are not about citation. So I think it's-

Dr Ruth Griffiths: True impact.

Prof Sandra Thompson: quite a good question.

Dr Ruth Griffiths: John, I might throw to you for the final comment, just conscious we're at time.

Pro. John Wakerman: I guess I just want to underscore Craig's comments. The important thing is, is what you're doing important and will it have an impact? And that's primary. And then the publications and the kudos and so forth is secondary. I think over time, if you focus on what's important and what's likely to have impact and are able evaluate that, then you will build your research track record to be as competitive as anybody that's metropolitan based. So I think it can happen. The bad news is you've got to do both.

Dr Ruth Griffiths: On that slightly depressing note we might have to wrap it up due to time. But genuinely thank you to all the panelists and also to my co-chair, the other Ruth, for your time today. I think it's been a really valuable webinar and just has triggered some really good conversations. There was some more questions in the chat as well that had some really good concepts that we couldn't get to like, how do we translate the learnings from rural to metro? Not just metro to rural, but rural to metro. And so there's a whole lot of conversations to be had in this area, which certainly at the MRFF we're keen to keep having those engagements and having those conversations and to keep iterating to try and address this critical area.

Please do stay in touch with us. There's a slide up at the moment which gives you some information about how you can find out more about us, how you can nominate for an MRFF grant assessment committee, how you can find out more information. But please do stay connected. Please log into these webinars. We will make the recording available on our website and it will be outlined in our newsletter when that is available. Sometimes it does take us a little bit of time as we curate the transcription of the dialogue, which obviously you'll understand is sometimes a bit messy. So sometimes it does take us a little bit of time, but it will always come out on our website and we'll let you know.

So I'm going to wrap it up there. Thank you again to everyone and thank you to those who logged in for the webinar.