Clinical supervision in rural Australia: challenges and opportunities

There is an urgent need to build clinical supervision capacity to support the rural medical workforce

Many of the pieces of the rural workforce puzzle are in place. There is good evidence around selecting the right people, teaching them the right things in the right places and ensuring the quality of rural placements. Positive outcomes from such approaches are well documented.1 Governments have invested in infrastructure and education, developing many training pathways.2 The missing piece, which needs urgent attention, is clinical supervision and training capacity. The rapid growth in trainee numbers has not been accompanied by growth in supervisory capacity. Failure to address the reduced supervision capacity will risk the success of this investment, with adverse outcomes for trainees, communities and the future workforce. The recent statement from the Australian Medical Association, Building capacity for clinical supervision in the medical workforce 2017, calls for “increased investment in supervision capacity and supporting infrastructure”.1

Infrastructure, sufficient mix and volume of clinical activity, and appropriate clinical supervision and teaching are all vital in ensuring that trainees (ie, medical students and junior doctors in post-graduate years 1–5) are taught and mentored effectively.3

Rural medical clinical supervision

Clinical supervision has been defined as “the provision of guidance and feedback on matters of professional and educational development in the context of the trainee’s experience and [the provision of] safe and appropriate patient care”.1 Recent studies highlight problems specific to rural and remote clinical supervision, including a lack of suitable clinical supervisors and the reliance on technology, such as videoconferencing, to undertake clinical supervision.4 While tele-supervision has clear benefits, the challenges include difficulty in establishing a supervisory relationship, technological barriers and higher set-up costs.5

Clinical supervision plays a vital role in the continuing professional development across the continuum from students to newly qualified and experienced staff. The western Queensland case study below illustrates the important role of clinical supervision in rural and remote areas in strengthening services and developing a self-sustaining workforce.6

The provision of clinical supervision has been linked with improved reflective practice, professional identity and interprofessional learning of supervisors in rural hospitals.7 However, historical medical workforce shortages mean there is a lack of suitable clinical supervisors.8 The position statement from the Australian Medical Association outlines specific challenges faced in regional and rural clinical supervision, urging governments to support practices through regional and rural infrastructure grants and provision of modern teaching and supervision facilities.1 This article explores clinical supervision issues pertaining to rural generalist9 (Box) and general practice training for medical students and vocational trainees, and concludes with some practical recommendations. Both general practice colleges recently developed the Collingrove Agreement (Box), which articulates a national framework for rural generalism.

Rural hospitals as teaching hospitals

Metropolitan teaching hospitals have well established arrangements to undertake teaching, such as economies of scale, large-scale workforce and funded teaching positions. In contrast, rural hospitals have a smaller workforce to undertake teaching on top of clinical and administrative commitments, typically with no medical education unit staff to assist with resources and delivery. One solution to bridging rural and remote workforce gaps is to transform rural hospitals into teaching health services. A Queensland report described three such hospitals, noting that a transformation into a teaching and research-intensive facility can increase quality and clinical capacity with “senior doctors functioning as true consultants with cascading supervision as in the traditional consultant–registrar–resident model”.10

Underfunding of the public health sector and resource constraints faced in rural areas are well known, with repeated calls to increase funding to optimise care delivery.11 While health systems are generally under strain, it is clear that workforce access and health indicators all worsen with increasing rurality.12 To recognise rural hospitals as teaching health services means that teaching and supervision need formal acknowledgement and funding. In addition to competitive remuneration and ongoing professional support to retain an appropriately skilled medical workforce, opportunities to foster teaching, supervision and mentoring are required. The chair of General Practice Supervisors Australia, who is a practising rural generalist, recently highlighted the need to support supervisors, noting limited resources, medico-legal risks and financial pressures: “We are about the only medical craft group where the specialist loses money while they teach”. He concludes, “unless there is a genuine recognition of our largely unseen workforce, the viability of [general practice] training may not be guaranteed”.13 While this is applicable everywhere, it is particularly felt in rural areas given the constraints noted above.

Tailored rural training pathways

Simply increasing the supply of rural medical and health professionals is a necessary but not sufficient solution for the Australian workforce challenges. Ensuring these clinicians are suitably trained and prepared to practise in underserved rural and remote locations is essential to overcome workforce maldistribution and achieve effective, socially accountable care. The Queensland Rural Generalist Program (QRGP)14 is one example; it commenced in 2007 amidst documented workforce shortages and reliance on overseas trained doctors to “develop and sustain an integrated service and training program to form a career pathway supplying the rural generalist workforce that the bush needs”.2 Its integrated service and training program provides a career pathway to build a rural generalist medical workforce. A 2013 evaluation estimated that for every $1 investment, the QRGP returned a saving of $1.20.2 The program has produced 118 Fellows, with another 324 currently training.15 This growth has improved rural and remote clinical supervision capacity, but challenges remain as workforce shortages persist.2 The principles of developing an attractive, incentivised training pathway enunciated in the pioneering Queensland program are being implemented in developing the National Rural Medical Generalist Framework, with jurisdictions developing specific approaches tailored to their needs.9

Case study

The QRGP has had considerable impact on communities such as Longreach, the largest town in Queensland’s Central West Hospital and Health Service (CWHHS), which covers an area of 385 000 square kilometres (about 22% of the state) and serves a population of 12 405.

Innovative strategies and workforce models that were implemented to stabilise and grow the medical workforce include managing the district’s workforce as one large practice rather than multiple small practices, developing new models of private and public employment and practice ownership, and developing pathways into practice for students and registrars. This strategy has resulted in Longreach’s medical workforce more than doubling, from five full-time equivalent (FTE) staff to 13.4 FTE in Longreach and 28 FTE across CWHHS over the past 8 years. This includes 13 FTE GP registrar positions and 6.4 FTE positions with supervision responsibilities.6 The Central West Single Practice Service Model provides a backbone to build a home for rural generalists enabling “the organisational structure within which the other systems (service planning, service administration, financing, education and clinical support) are brought into alignment to create overall system sustainability”.6

The growth in position numbers has enabled the introduction of many new and extended local services, including pre-anaesthetic clinics, rural generalist mental health clinics, increased antenatal services and enhanced multidisciplinary teamwork in the maternity unit. Development of a vertically integrated learning model, in which the senior and junior medical staff, as well as students, simultaneously learn and teach, has enhanced clinical supervision of students, which means that they can complete a variety of placements, including electives in CWHHS. The literature confirms this is a positive workforce recruitment strategy and addresses the paradox of the most skilled, motivated and experienced clinical teachers generally having the least time to teach.10

Growth in supervisory capacity means that student numbers have grown from two students in 2010, placed for a maximum of 8 weeks, to a minimum of four students at any given time in 2018 for a maximum of 9 months. Cascading supervision, for example, in which senior doctors supervise registrars who in turn supervise students, enhances overall productivity as well as individual trainees’ scope of practice. Positive experiences enhance recruitment, as the Longreach’s workforce figures show.

These principles are relevant across Australia, with adaptation to suit local jurisdictional needs and remuneration models. Learnings from this model for other jurisdictions include the importance of strong local leadership; enabling creative and innovative local solutions; developing relationships with key educational providers, such as the QRGP; the significance of role modelling and mentoring; and succession planning by developing pathways to “grow your own” workforce.

Experience in communities such as Longreach leads us to recommend:

• the urgent attention to a systematic program of support for supervisors of trainees, particularly in rural and remote Australia;

• the development of appropriate funding and incentives — for example, funded education packages to upskill new Fellows in supervision practices, backfilling to enable doctors to undertake training and engage in supervision, and harnessing technology to use distance supervision models involving experienced rural doctors now practising elsewhere;

• a stocktake of training capacity to ensure rural practices and hospitals receive the same teaching support and infrastructure as metropolitan teaching hospitals;

• the development of appropriate educational courses and qualifications, which is evidence-based and capable of meeting local needs and is delivered flexibly; and

• the establishment of rural directors of clinical training and dedicated clinical supervisors nationally.

Rural and remote health settings need to invest in clinical supervision and explore innovative models that enhance team building and improve recruitment and retention, thereby providing seamless, localised, high quality patient care. Dealing with these issues is vital to solving rural workforce shortages so that all Australians can enjoy the benefits of living in the “Lucky Country”.