There are well documented geographical, financial, social and professional barriers to continuing professional development (CPD) and peer support for rural medical practitioners, which significantly influence the recruitment and retention of health care professionals in rural areas.
The Support Scheme for Rural Specialists (SSRS) provides a coordinated and collaborative framework to support the CPD and peer-support needs of medical specialists practising in rural and remote Australia.
Since 2002, more than 80 CPD projects have been implemented by specialist medical colleges under the auspices of the SSRS. Projects have provided educational up-skilling or support for rural-specific clinical practice improvement initiatives aimed at strengthening clinician competence and capability, and workforce retention.
Australian medical specialists report that access to continuing professional development (CPD) contributes to their decision on whether to practise or continue to practise in a rural area.1 However, specialists working in rural areas have reported difficulty in accessing not only the same CPD programs, but also the same facilities, equipment, supporting workforce infrastructure and professional support that are available to specialists practising in metropolitan areas.1-4 Rural practitioners are often involved in more complex patient management and procedural care than their metropolitan colleagues.5 In addition to their clinical responsibilities, medical specialists working in rural Australia contribute to clinical leadership, quality assurance programs, patient and community advocacy, rural training and research.6,7 Many of these activities underpin the implementation of national and local health policy initiatives and help sustain health service infrastructure in rural Australia.
Recent publications in oncology, surgery and psychiatry have all reported that patient outcomes are often poorer in rural areas as a result of geographical isolation, delays in diagnosis and financial factors.8-10 Furthermore, social and economic barriers often prevent rural patients from travelling to regional or metropolitan centres for specialist medical care.4 Despite workforce shortages and, in some instances, diminishing medical capacity in rural areas, community expectation for the retention of locally based, safe and accessible specialist services is increasing.7,8
In 2001, the Australian Government Department of Health and Ageing (DoHA) Office of Rural Health commissioned a report to investigate factors influencing the recruitment and retention of medical specialists in rural and remote regions of Australia. The research cited numerous disincentives for specialist rural practice, and a number of options for reducing these disincentives were raised.1
In response to these findings, the DoHA asked the Committee of Presidents of Medical Colleges (CPMC) — the professional association of medical colleges in Australia — to devise strategies to reduce professional isolation and increase access to structured and relevant CPD for specialists working in rural Australia.1 As a result, the Support Scheme for Rural Specialists (SSRS) was established.
The SSRS is the first federally funded program dedicated to helping to provide the CPD and peer-support needs of rural and remote Australian medical specialists.11 Funding is available to specialist medical colleges and their faculties for developing, implementing and evaluating short-term rural-specific CPD programs through a coordinated and collaborative framework. The Royal Australian College of General Practitioners is not eligible for funding under this scheme, but the DoHA has separately funded programs to support general practitioners working in rural areas.
Projects funded under the scheme have focused primarily on providing clinical and professional skills, or on strengthening systems for clinical practice improvement. Box 1 outlines principles under which funding is granted and Box 2 contains evaluation findings reported by the Hunter Institute of Mental Health and outcomes reported by specialist medical colleges, the SSRS Program Management Committee, and individual specialists who have participated in the scheme.
Since 2002, the SSRS has enabled colleges to deliver more than 80 CPD projects. The first round of projects in 2003 enabled more than 300 rural practising specialists to access CPD and peer support.14 Through ongoing promotion and communication of the SSRS, including an interactive website, electronic newsletter and a collaborative annual forum, in Round Six of the scheme (May 2006 to April 2007), about 800 rural specialists were able to participate in or lead rural specific CPD initiatives.15,16
Between 2002 and 2006 the Hunter Institute of Mental Health was appointed by the DoHA to undertake a process-and-outcome-based external evaluation of the SSRS. Key outcomes that were reported included: (i) decreases in professional isolation and increased access to CPD for rural specialists; (ii) increased inter-organisation and inter-college collaboration; (iii) support of access to CPD for overseas-trained specialists; and (iv) identification of effective approaches for the provision of CPD to rural specialists.
In particular, a number of projects have highlighted how the use of technologies such as videoconferencing and web-based modules have provided specialists with easy access to educational events that they may not have otherwise been able to attend. This has had a particularly positive effect within radiology and dermatology specialties, and colleges continue to sponsor educational activities for rural Fellows through videoconferencing technology.2
A number of key partnerships have also been formed both among specialist medical colleges and with other key organisations. One example is a partnership between The Royal Australian and New Zealand College of Psychiatrists and the Centre for Rural and Remote Mental Health for supporting communities affected by drought. Another is collaboration between a number of colleges involved in emergency care of children (the Royal Australasian College of Physicians [RACP], the Joint Faculty of Intensive Care Medicine, the Australian and New Zealand College of Anaesthetists, and the Australasian College for Emergency Medicine) have combined to design and implement a project to support better integrated team-based care in rural paediatrics.
The SSRS has provided overseas-trained specialists who are not Fellows of specialist medical colleges with opportunities to participate in peer-support networks and CPD activities funded under the Scheme. Participation of overseas-trained specialists has continued to increase over the course of the Scheme.
CPD programs, especially those that are designed to bring about practice change, are resource intensive in terms of cost, time and infrastructure.17 Some colleges have also expressed concern that within the current SSRS program framework, there is an expectation that colleges have comparable capacity and infrastructure to compete for program funds. This includes the capability to develop and implement rural-specific CPD projects that deliver practice improvement, or evidence of knowledge transfer.13
Another limitation, reported by both the programs’ external evaluators and the SSRS Program Management Committee is related to the implementation timeframes.17 Project funding timeframes are limited to about 12 months. This timeframe is often not conducive to the development and implementation of CPD programs aimed at facilitating practice change. Problems associated with current timeframes include: minimal time for consultation, application development and ethics approval. Project implementation, including marketing and communication, refinement of project tools and evaluation processes to measure knowledge transfer or project sustainability, has at times also been compromised; in some instances, limiting the achievement of project objectives.13
The delivery of CPD to specialists working in rural Australia is the shared responsibility and concern of medical specialists and their employers, specialist medical colleges, federal, state and territory health departments and professional associations. The 2005 Productivity Commission Report highlighted the role for targeted education and training initiatives for rural Australia, as a means of improving access to health services in rural and remote areas.4 An external evaluation of the Scheme by the Hunter Institute of Mental Health in 2006 reported that the SSRS offered an essential service, given the lack of educational opportunities and minimal networking opportunities currently available to medical specialists working in rural and remote Australia.13 To our knowledge, no other developed country with similar rural workforce concerns has a program like the SSRS available to medical specialists.
The CPMC has now implemented Round Seven of the Scheme, and project and program outcomes are currently being evaluated. Funding has been committed from the DoHA to continue the SSRS into 2009 using the current framework. Recognising the limitations of a program funded for only 12 months, the CPMC is continuing to engage with the DoHA about the potential benefits of a longer-term funding commitment. Learnings, outcomes, challenges and limitations from the implementation of this Scheme should be used to inform future policy and resource initiatives to support the rural medical specialist workforce and strengthen medical capacity and the sustainability of clinical services in rural and remote Australia. The DoHA is planning a review of all rural health-funded programs, and it is to be hoped that the outcomes of this review will inform the future of the SSRS program.
1 Key principles for eligibility for funding through the Support Scheme for Rural Specialists11
are based on consultation with rural specialists about their CPD needs;
are aimed at reducing professional isolation through facilitation of peer-learning networks;
are embedded within specialist college CPD structures and incorporate adult learning principles;
include cost-effective and sustainable approaches that will enable specialists to access CPD from their rural location; and
include an appropriate evaluation framework that includes measures such as participant satisfaction, increased opportunities to network, and increased knowledge base or demonstrated practice change.
Under the Support Scheme for Rural Specialists, “rural” is defined by the Rural, Remote and Metropolitan Areas (RRMA) classifications rural zones R1–R3 and remote zones Rem1 and Rem2.12
2 Key evaluation findings and outcomes as reported by the Hunter Institute of Mental Health,13 the Support Scheme for Rural Specialists Program Management Committee,14-16 specialist medical colleges and participating individual specialists
Delivery of over 80 continuing professional development projects to 800 rural specialists from 2002 to 2008.
Increased opportunity for specialists to access continuing professional development and peer support.
Reported increases in local rural workforce capacity-building practices and networking opportunities.
Increased use of videoconferencing technology by specialists to access educational events that they would not have otherwise been able to attend.
Reduction in professional isolation and increased ability for rural radiologists to network with both rural and metropolitan radiologists about clinical and professional issues including new radiological techniques.
Ability for rural psychiatrists to undertake clinical educational activities led by experts in clinical practice and mental health research. Professional relationships formed through participation in the program have supported the facilitation of rural professional networks to undertake peer reviews.
Increased ability for rural dermatologists to meet college continuing professional development requirements.
Self-reported enhanced clinical and professional knowledge and confidence in the use of technology to participate in interactive educational activities.
Support for rural obstetricians and paediatricians to reflect on adverse perinatal events within their clinical environment and to develop and implement strategies to improve patient care.
Support for clinicians in rural areas to achieve best practice standards of care for stroke patients from prehospital to subacute care.
Improved compliance with National Performance Indicators in all project sites for acute stroke care.
Self-reported improvement of audit, investigation and peer review skills of specialists and their colleagues.
Five-step model developed which includes data collection, review of performance, and monitoring.
Use of simulation as a model for specialists and their teams to improve the quality of care for children in rural areas, through strengthening teamwork, communication, peer appraisal and reflective practice.
Delivery of a collaborative training program for all specialists to increase knowledge in developing and implementing clinical practice improvement and evidence-based practice projects within their workplace.
Multidisciplinary-team-based learning in the specialists’ environment.
Activities engaging local employers and colleagues to support implementation and sustainability.
Simulation and scenario-based learning models to enhance professional competence, reflective analysis, debrief and feedback in a safe environment.
“Virtual” specialty and interprofessional educational networks to strengthen access to professional support and clinical up-skilling activities.
Activities involving audit and peer review to build peer capacity and to support specialists in reflecting on measures of safety and quality within their rural context.
Programs including a combination of educational and peer-support strategies and resources such as an online web forum along with an interactive videoconference education program.
RANZCR = Royal Australian and New Zealand College of Radiologists. RANZCP = Royal Australian and New Zealand College of Psychiatrists. ACD = Australasian College of Dermatologists. RANZCOG = Royal Australian and New Zealand College of Obstetricians and Gynaecologists. RACP = Royal Australasian College of Physicians. RACS = Royal Australasian College of Surgeons. ANZCA = Australian and New Zealand College of Anaesthetists. ACEM = Australasian College for Emergency Medicine. JFICM = Joint Faculty of Intensive Care Medicine.
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