Ten ideas for building a strong Australian rural health system

This commentary was written to generate ideas and provoke debate about priorities for rural health, in advance of the Australian National Rural Health Alliance 2009 conference. The conference will doubtless be packed with highlights as together we reflect on 20 years’ successes and failures in the rural and remote health sector under the conference theme: ‘ celebrating the sector’. Another key theme is ‘collaborating in health care teams and service models that work’. We propose that our communities can learn from models that work and build on recent successes in rural health policy and service delivery.

The conference will doubtless be packed with highlights as together we reflect on 20 years' successes and failures in the rural and remote health sector under the conference theme: ' celebrating the sector'. Another key theme is 'collaborating in health care teams and service models that work'. We propose that our communities can learn from models that work and build on recent successes in rural health policy and service delivery. Lacking is overall coordination and integration of these initiatives. It is important to clarify the key outcomes of these initiatives. It is essential to publish the richness of these programs to learn about the outcomes and transfer knowledge into practice. It is also time to establish appropriate budget incentives for vertical education templates to advance rural clinical training pathways. The newly established Office of Rural Health is well positioned to facilitate a comprehensive national approach to strengthening the rural health workforce and to ensure funding is invested for the greatest impact. A national approach should facilitate good education and training programs to maximize the retention of trainees and students in rural areas.
Health services, clinicians, education providers, rural communities and governments are interdependent and thus form a symbiotic system 2 . A symbiotic rural health system is successful when the parts of the system are working towards mutually beneficial outcomes. Education of the workforce needs to be at the centre of a symbiotic rural health system. Students add vibrancy in clinical practice and contribute to a better health service culture. Doctors experience increased work satisfaction when teaching students 3 . Furthermore, we know that longitudinal community-based placements are effective for clinical placements 4 . When medical students live and learn in rural communities they are more likely to take up rural practice 5 . However, such longitudinal clinical placements are currently confined to some medical programs, while there is a lack of training pathways beyond medical school.
Some rural areas struggle more than others to attract and retain clinicians. At a national level we still have a limited understanding of where and why there are critical shortages, and whether there is a lack of doctors, nurses or allied health professionals. A national rural health workforce strategy will require a whole of system approach with inter-professional education and training pathways at its core beyond a simplistic view of workforce strategies 6 . Using a systematic approach, a national rural health workforce strategy would need to give consideration to the following issues (examples are provided to show how these ideas may be established and implemented).

Rural medical training pathways
The development of rural medical training pathways will provide more creative and flexible training programs and pathways for medical students interested in rural practice.
There is an opportunity to expand these programs with the annual intake of medical students increased from 1200 students per year in 2000 to over 3000 students in 2009 7 .
Currently there is a lack of rural intern positions and now that rural Australia has a good intern curriculum framework, we need the government to fund more rural internships.

Consumer perspectives
Team function is assessable, in part, by gaining the views of consumers when their patient journey includes in-patient hospital care. Patient evaluations of health services are commonly used to gauge performance and to assist in the quality improvement cycle. This is consistent with the NRHA conference theme: 'Consulting our communities on health'. Community engagement is essential for effective rural health systems and services. Some patient evaluations give encouragement to functional teams -satisfaction being registered in areas that include patient involvement in care decisions, briefing about the risks and benefits of treatment, home follow up, the facility to enquire about treatment, and the safety and coordination of teams. However, areas of patient concern include health facility staff being under pressure, team communication issues, and tension or stress contributing to mistakes. Such studies provide compelling evidence for resource allocation that enables teams to function to their greatest potential and to address issues of safety and quality. © JA Greenhill D Mildenhall, D Rosenthal, 2009. A licence to publish this material has been given to ARHEN http://www.rrh.org.au 6 It is highly desirable that students of the health professions receive education about safety and quality, and are encouraged to reflect on their studentship and future practice.

Conclusion
In conclusion, in the current tenuous economic climate amid an aging population and major increase in chronic disease, rural areas have a much higher burden of disease to be managed by an aging workforce. Rural clinicians are confronted daily with the reality that the health status of people living in rural and remote areas is poorer than people in metropolitan areas. The increasing cost of delivering health care results in disproportionate funding for metropolitan hospitals with the expectation that rural people must travel long distances for health care. The need for quality health services in rural and remote Australia has never been greater. There is, however, also a groundswell of innovation and resourcefulness in rural and remote health policy implementation and service development. An opportunity beckons with the establishment of the Office of Rural Health and the upcoming increase in medical student graduates, to initiate a systemic approach to rural health policy beyond a 'one size fits all' or similar simplistic approach to the rural health workforce 6 .
The successful initiatives outlined would form the nexus for developing a systematic approach, coupled with interprofessional education and rural training pathways.
Regardless of drought, floods or fire in rural Australia, it is time for an approach to health care in the form of a national rural health workforce strategy.