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In addition, in 1998, federal funding was announced for a prototype rural clinical school in Wagga Wagga, while, in 1999, a new medical school with a particular focus on rural, remote, Indigenous and tropical health commenced at James Cook University in Townsville. The experiment is now expanding -- the 2000 Federal Budget allocated funding for a further three UDRHs and nine rural clinical schools.

We talked to the Professors of Rural Health at the UDRHs and James Cook University and to the Director of the Wagga rural clinical school to find how they are contributing to solving rural health problems and how they see the future.

The University Departments of Rural Health

What are the UDRHs?

Diverse origins: The UDRHs have evolved to be quite diverse in their activities and organisational arrangements, reflecting their individual histories and the needs and resources of their target regions. The first UDRHs were established in 1997 at Broken Hill and Mount Isa and have an emphasis on vocational courses and rural placements for healthcare students. At Broken Hill, the UDRH grew out of the public health oriented rural health training unit as "part of the evolution of the concept", said Head, David Lyle, becoming a department in the Faculty of Medicine at the University of Sydney. The Mount Isa Centre was established under Queensland Health and a management committee that includes representatives from rural health organisations, local health service providers and the community. It is unique in lacking a university affiliation, but will join James Cook University in 2001. The other UDRHs are the products of bids from single universities or consortia of universities and have varying mixes of activities.

Common features: Despite this diversity, the UDRHs share some interesting features. Firstly, they are not shoestring operations. Most receive core Commonwealth funding of $1.5 million annually for an initial five years. Many have also been successful in obtaining external funds and grants for infrastructure. Still, there are poor cousins. The Tasmanian UDRH received less initial core funding ($500 000 annually), but this year renegotiated a new fully funded contract. The Shepparton UDRH remains the least endowed, sharing $1.5 million with the Victorian Universities Rural Health Consortium (a consortium of Ballarat, Deakin, La Trobe, Melbourne and Monash universities that aims to develop statewide responses to key rural issues).

Secondly, the UDRHs are strongly multidisciplinary, both in their activities and staff. Most have between six and 12 academic staff (full-time equivalents), with many still actively recruiting. As well as medical practitioners, staff may include practitioners from a range of health professions (including nursing, allied health and pharmacy), and also experts in public health, Indigenous health, economics and the social sciences. Indeed, two of the UDRHs are headed by non-medicos. Many UDRHs also have Indigenous academics. In fact, Dennis Pashen (Mount Isa) expects that in five years 30%-50% of his UDRH's staff will be Indigenous, including the Head.

Thirdly, the UDRHs are "multi-level", undertaking activities at all stages of education and practice, from promoting careers in healthcare in rural high schools (applying research showing that people from a rural background are more likely to practise in a rural area) through involvement in undergraduate and vocational training, university higher education, continuing education and professional development.

The UDRHs are also collaborative. Their emphasis is on forming partnerships; they may have links with multiple universities, rural health organisations and services (eg, the Royal Flying Doctor Service and the Aboriginal Medical Service), local healthcare providers and the community.

Finally, they are all based in rural centres but serve large regions with several or many subsidiary sites. Linking through information technology (IT) is therefore a high priority. For example, the Mount Isa Centre has a satellite link, four videoconferencing units and computer laboratory, with videoconferencing and Internet links in all its affiliated communities, and has negotiated with Telstra for high level connectivity to allow video transmission via the Web.

A forerunner to the UDRHs that "established the model on which the UDRHs are based" was Monash Centre for Rural Health, said Head, Roger Strasser. Founded in 1992 as an initiative of Monash University and Latrobe Regional Hospital, Gippsland, it was "the first multidisciplinary, multi-level, rural health academic unit located in a rural setting". He is disappointed by the Commonwealth Government's failure to recognise the Centre through the UDRH program or core funding.

What do the UDRHs do?

Education: The Commonwealth's principal stated aim for the UDRHs was to promote education, training and professional support for rural and remote health workers and for city-based health workers interested in furthering their training and practising in a rural or remote setting.

Some UDRHs offer courses to prepare health workers specifically for rural and remote practice. For example, both Broken Hill and Mount Isa offer courses for Indigenous health workers and nursing courses (eg, the Master of Nursing [Rural and Remote] at Broken Hill prepares nurses for the expanded role of nurse practitioner). Alice Springs offers a Master in Remote Health Practice, which is "the first multidisciplinary postgraduate course that prepares for work in remote areas", said John Wakerman, "and has streams for doctors, nurses and other health professionals".

All the UDRHs are extensively involved in increasing the exposure of undergraduate healthcare students to rural and remote health, most commonly through provision of rural placements. For example, Broken Hill provides a centre for rural experience for healthcare students, at present mainly medical students. "Although we support the Sydney University medical program, we take students from anywhere -- primarily the Universities of New South Wales, Sydney, Adelaide and Newcastle", said Lyle. Placements (usually four to six weeks) "are structured to suit each university and provide experience of hospital and community-based practice and a remote health service. The competition is for people to come to us". Although medical students form the main market for placements at present, many UDRHs also provide placements for increasing numbers of other healthcare workers, including nurses, pharmacists, allied health workers and even dentists.

Some UDRHs are aiming for longer programs -- Alice Springs is developing six-month placements for final-year medical students, and Tasmania a one-year integrated program in north-west Tasmania, similar to the Flinders Riverland scheme.

In contrast, the WA focus is not so much on bringing students to the Centre -- the Department of General Practice at the University of Western Australia, under Professor Max Kamien, has run a very successful program of placements with rural general practitioners (GPs) for many years. Rather, the UDRH is "working with existing departments to look systematically at the rural health and Indigenous content of their curricula, assist in building and integrating it, so that placements become part of a broader educational thrust", said Ann Larson. The Tasmanian UDRH has a similar philosophy of "working with academics in medicine, nursing and pharmacy to raise the profile of rural health and contextualise it across the curriculum, rather than designing specific blocks of rural health", said Judi Walker.

Nevertheless, both these UDRHs work to enhance the quality of placements, with Tasmania having set up a network of seven (soon to be 10) teaching sites around the State. These provide residential accommodation for students, as well as training and resources to allow local health professionals to be effective teachers and researchers, such as reliable information technology (IT), videoconferencing and journals.

The UDRHs also contribute to vocational training for medical practitioners. The Monash Centre is particularly involved in GP and surgical registrar training and has run a regional training program for GP registrars in Gippsland since 1998. With the Commonwealth move to regionalise GP training, other UDRHs are working to develop regional GP training programs, while the Shepparton UDRH is developing a registrar training program for physicians. David Simmons explained: "A major barrier [to doctors entering rural practice] is the city focus of most training programs. That is the time when you get married, have your kids, buy your house. We want to bring doctors into rural areas at that stage", he said. Other UDRHs also support registrar and intern training programs. Interestingly, Mount Isa supervises a population health registrar working not with a public health unit but with the local Division of General Practice.

In addition, the UDRHs offer university higher degrees. For example, staff at the WA UDRH supervise 16 postgraduate students, including one from the National Centre for Epidemiology and Population Health -- "the elite training ground for field epidemiology in Australia", explained Larson. She believes this is the first such rural placement.

Continuing medical education (CME) and professional development are other important activities of the UDRHs. Not only do many offer seminars, lectures and other forms of CME, but they "provide the opportunity for local people to develop professionally in ways they would not have been able to in the past", said Lyle. "Now you can take on academic pursuits in Broken Hill which would have been difficult before we were here."

Research: The UDRH research programs are at varying stages of development and, not surprisingly, tend to focus on rural and remote health issues, primary healthcare and public health. David Wilkinson is proud of the "strong focus on academic research" at Whyalla UDRH, "which has established posts for postgraduate fellows and a stream of publications". Major projects include an investigation of the distribution of health workers in rural Australia and a comparison of health status between rural and urban populations, in collaboration with the SA Department of Human Services. The WA UDRH is also particularly excited about its research and is recruiting for two new research positions -- an anthropologist and an epidemiologist.

Research is often integrated with the other activities of the UDRHs. For example, WA "tracks rural school children and young adults thinking about tertiary education and health careers, to inform our interventions in education", explained Larson. The Tasmanian UDRH has used its research on the application of IT in healthcare to develop a strong health informatics teaching program.

Research is also often related to the role of the UDRHs in health service and practitioner development. For example, the Monash Centre has a project seeking the best way to provide urgent care in towns that lack hospitals. At Alice Springs, research "focuses mainly on evaluation of remote health services and specific interventions. With a health economist on staff, this can incorporate economic analyses", explained Wakerman.

Health service development: Many of the educational and research activities of the UDRHs contribute to health service development. In addition, some UDRHs have more direct involvement. For example, Whyalla takes an "aggressive approach to medical workforce issues", said Wilkinson, owning and running rural general practices around South Australia and recruiting doctors, some from overseas, into rural parts of the State. Other UDRHs also run teaching practices and after-hours services.

The UDRHs are also involved in supporting public health and health-promotion programs. Several of the professors talked of "capacity building" -- providing rural and remote people with the infrastructure and resources they need to be effective, such as IT and libraries, and building links between rural practitioners.

International activities: The Monash Centre has taken a lead internationally in developing rural health, said Strasser, who chairs the working party on rural practice of WONCA (World Organization of Family Doctors). "We are also currently working on the World Health Organization to develop programs that focus on rural health", he said.

Rural medical schools

The Wagga initiative is a full clinical school of the University of New South Wales and will take medical students for the final three years of their six-year medical course, as well as continuing its rural placement program. "Research shows that if you train doctors in rural environments, 60%-80% will practise in those environments, while only 20% of doctors who train in urban environments do so", explained Director, Mohamed Khadra. He also encourages students to integrate into the local community, with honorary memberships of local clubs and organisations. "I have absolutely no shame as a matchmaker", he explained, putting into practice evidence that spouse background is a major determinant of the choice of rural practice.

The James Cook medical school represents another stage of evolution, having grown from a clinical school of the University of Queensland. Its aim is "to produce medical and other health practitioners who are capable of immediately working in rural and remote communities across northern Australia", said Associate Professor in Rural Health, Craig Veitch.

With the creation of these new schools has come the opportunity to experiment and develop new models for medical teaching. The Wagga school has developed a new curriculum and way of delivering it -- the patient-centred longitudinal model. Students are attached not to teams or doctors, but to individual patients, whom they accompany throughout their illnesses and who provide the "trigger" for problem-based learning. As students accompany patients through their illnesses rather than doctors, this model is very sparing of doctors' time. To deliver the curriculum, the school is putting enormous effort into building an IT infrastructure connecting the region, aiming for IT facilities in the 12 most-used towns. It is also developing IT resources with text, questions, guidelines and practice cases.

The James Cook school "is unique in Australia", according to Veitch, and has incorporated features from many models, including the medical schools at Newcastle, NSW, and Washington State, North Dakota and New Mexico in the United States. For example, it is discipline-based, not departmentally based. In the curriculum, the more basic medical subjects are integrated via the context of rural and remote health, Indigenous health and tropical medicine. The school has also appointed an academic to provide pastoral care and other support for Indigenous students.

Both schools also undertake vocational and continuing medical education and research. Wagga is developing collaborations between local clinicians and basic scientists at Charles Sturt University. At James Cook, research is Veitch's primary responsibility. The disciplinary structure of the school fosters collaborative research, he said. For example, the school was successful in its bid for a National Breast Cancer Centre demonstration site, which he attributed at least partly to the involvement of all disciplines in formulating the proposal.

What more is needed?

The problem of infrastructure is perhaps even more difficult in the outback. Wakerman (Alice Springs) would like to provide more physical and human infrastructure in the smaller towns, such as Tennant Creek, Katherine and Nhulunbuy, where people and organisations may be very keen to undertake academic activities but tend to miss out. Larson (Geraldton) needs some sort of satellite link to her more farflung constituents in the Pilbara and the Goldfields.

In addition, facilities at the central site are not always adequate for the future: Pashen would like to extend his Centre in Mt Isa, as it has almost reached capacity and aims to double its staff over the next three years.

The second most common priority was staff. Attracting and retaining experienced and skilled research staff was a priority for Lyle. Veitch would try to improve retention by offering research staff two- to three-year contracts rather than the shorter terms necessary when they are employed on research funds. A more flexible approach to staff recruitment using incentives is needed at Mt Isa, according to Pashen, who wishes "to be like the mining companies, able to pay big money to attract good staff".

The need to improve the lot of rural GPs who take on teaching or research was highlighted by several professors. Walker would like to provide sabbaticals or release from clinical duties. "We expect so many rural clinicians to do things for nothing", she said. Indeed, Strasser would use extra funds to develop a new model for teaching in rural general practice, as the current system of clinical attachments has just about reached its capacity. He postulated providing rooms in general practices for students to see patients and study, IT resources and paid time for GPs to teach.

More support for Indigenous and remote students was a priority for Wakerman, particularly better support networks for Indigenous students in tertiary education and research, and scholarships to allow remote practitioners to study.

Wilkinson expressed the grandest dream -- to establish a rural stream in the University of Adelaide medical school that would turn current clinical training on its head. Students would undertake the bulk of their clinical training in the country and go to the city for placements. This might even be realised with the new funding for rural clinical schools.

How to fix rural health?

To tackle the shortage of health professionals in the bush at the educational level, the professors had a range of suggestions. Firstly, as students from the bush are more likely to return there after qualifying, both Veitch and Wilkinson suggested setting firmer intake quotas for students from rural and remote areas. Indeed, James Cook medical school has a funding-based requirement to take at least 25% rural and remote students. This could be applied more widely. In addition, Lyle suggested improving Indigenous communities' access to careers in healthcare.

Secondly, "to have doctors in the bush, we need to train them in the bush", said Khadra. But attracting academics to deliver this education is a common problem. "The pot must be sweetened", he said, "at least in the short term until centres of excellence develop, and more research dollars must be directed to the bush". Veitch also suggested rotations of academics from the "sandstone" universities to allow cross-fertilisation.

Thirdly, both Larson and Strasser suggested moving away from the fee-for-service model, which, said Strasser, "is neither sustainable in small communities nor attractive to new graduates". He proposed a contract arrangement with explicit negotiated contract periods to avoid the mismatch of expectations between communities (which tend to want doctors to stay for their entire careers) and recent medical graduates (who may want to stay only a few years). Strasser also suggested developing an alternative to the system whereby medical and other specialists drop into a town once every two to four weeks, with no real connection with local GPs and nurses. He would like specialist services to have a true consulting role to local practitioners.

Other bureaucratic measures to encourage doctors to practise in the bush were a system of geographic provider numbers, allocated according to the number of doctors needed in a particular community, and removal of the cap on registrar GP training numbers, which favours the city over the country (Wilkinson). Several professors also saw a need for structural changes in the approach to rural health. Lyle called for greater coordination between rural health programs and organisations to avoid fragmentation of resources. Simmons suggested devolution of healthcare: "With the ageing of the population and epidemics of chronic diseases, communities need to decide their own priorities for healthcare."

But the problem is larger than can be tackled by a Minister for Health alone. According to many professors, to attract doctors the bush needs to be made a more attractive place to live. "The process of regionalisation needs to be continued", said Lyle, with moving of resources, intellectual capital and infrastructure to the bush. "The Department of Education needs to follow the example of Health and put the same sort of resources into building up the intellectual capital in schools", suggested Simmons.

And improving health in the bush requires more than just more doctors and better access to health services, emphasised Pashen and Wakerman. Governments need to address the underlying social and economic determinants of health within rural and remote communities. We also need "evidence-based funding decisions", continued Wakerman. The Health Minister should "move away from individuals with bright ideas and use the available evidence for what works to improve access to health services and the socioeconomic determinants of health".

The future

One of the new UDRHs has been announced -- the Greater Green Triangle UDRH, a collaboration of Flinders and Deakin universities in the area straddling the South Australian-Victorian border. Successful bids for other UDRHs and schools are due to be announced soon.

Most of the professors applauded the government's initiative in creating this network of UDRHs and schools, although Khadra warned about the potential for underfunding of the new rural clinical schools. Wilkinson believes the network is a "unique initiative in the Western world and shows tremendous vision". The units are making use of "the untapped talent among rural health professionals and the great wealth of patients in rural areas", said Walker. They are bringing intellectual and social capital and infrastructure to the bush. The seeds have been sown; will the harvest be the desired improvements in rural health?

Authors' details

Reprints will not be available from the authors.
Correspondence: Dr K A Lawson, Medical Journal of Australia, Private Bag 901, North Sydney, NSW 2059.

©MJA 2000
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