Perspectives

The pandemic’s ultimate impact on cancer outcomes is likely to be multifaceted

Karen Canfell · Karen Chiam · Carolyn Nickson · G Bruce Mann

For tens of thousands of years, Aboriginal and Torres Strait Islander people have operated and thrived within sovereign societies. The sustained and systematic effects of colonisation — which enabled the combined denial of Aboriginal and Torres Strait Islander people's self‐determination, autonomy, leadership, and capability to mobilise health‐benefiting resources — have created the situation in which we find ourselves today of poor health and systemic differences in health care access and outcomes.1 For kidney health in Aboriginal and Torres Strait Islander people, this situation is illustrated through the persistent inequities in kidney failure incidence rates, health system access, and treatment outcomes.2 Recorded rates of kidney failure requiring dialysis or transplantation among Aboriginal and Torres Strait Islander Australians have risen progressively over the past 40 years, remaining consistently higher than rates for non‐Indigenous Australians (Box 1). This difference is even more marked for Aboriginal and Torres Strait Islander people living in rural and remote areas.2 Aboriginal and Torres Strait Islander people have age‐adjusted incidence rates of kidney replacement therapy (KRT) — dialysis or transplantation — eight to nine times higher than those of non‐Indigenous Australians, with the median age of Aboriginal and Torres Strait Islander people who experience kidney failure being nearly 30 years younger than non‐Indigenous people.3 Furthermore, for Aboriginal and Torres Strait Islander people receiving KRT, incidence rates vary considerably between location and age (Box 2), as well as sex (Box 3), with people in the Northern Territory, Western Australia, South Australia, and Queensland experiencing higher rates.2 Finally, the modality with which KRT is delivered differs, with Aboriginal and Torres Strait Islander people predominantly accessing dialysis through facility‐based haemodialysis, with lower rates of home‐based therapies (peritoneal and home haemodialysis).2 Access to kidney transplantation is substantially lower, reflecting lower waitlisting rates.2 Combined, these disparities mean that Aboriginal and Torres Strait Islander people with kidney failure are likely to spend substantially longer (typically years longer) on facility‐based dialysis, away from Country, community, and supportive networks. This dislocation serves to prolong and compound the disconnection, disempowerment and disruption felt by Aboriginal and Torres Strait Islander people when seeking kidney care in Australia.4 Why transplantation mattersFor people with kidney failure, kidney transplantation is the preferred treatment option where possible. Not only is transplantation associated with lower mortality, and a substantial improvement in quality of life,5 it is also less expensive in the long term, particularly when considering the cost of dialysis for rural or remote patients.6 Transplantation therefore provides direct clinical benefits to patients and financial benefits to health systems. Aboriginal and Torres Strait Islander kidney transplant recipients and family members — like nearly all other transplant recipients — also affirm the many health and wellbeing benefits of transplantation,7,8 and numerous community consultations have shown that Aboriginal and Torres Strait Islander people want a better understanding of, and access to, transplantation.9,10,11,12 Disparity in access to transplantation has been recognised for many years.13,14,15,16,17,18 Although absolute rates of waitlisting and transplantation have increased among Aboriginal and Torres Strait Islander peoples, substantial inequity remains in rates of waitlisting and transplantation compared with non‐Indigenous populations, as well as age at diagnosis, pre‐transplant treatment modality, and transplantation outcomes.2 Furthermore, the reasons behind the inequity remain. Studies have consistently shown that inequity in access to transplantation cannot be explained by patient‐ or disease‐related factors,14,15 and that the principal block is on getting onto the waiting list, rather than receiving a kidney once on the list.15 Receiving a kidney transplant requires patients to not just meet specific medical requirements, but also to navigate a complex process that includes multiple investigations, appointments, and ongoing reviews (Box 4). Each stage of this pathway can become a barrier to both waitlisting and transplantation. The difference in waitlisting highlights an important need to focus on the gaps in processes and the barriers within the health system, or more specifically, within clinical services caring for people with kidney disease. To better understand these systemic gaps, in 2018 the Australian Government funded an Expert Panel, through the Transplantation Society of Australia and New Zealand (TSANZ), to undertake a comprehensive review into the hurdles, service gaps, and practical challenges faced by Aboriginal and Torres Strait Islander people receiving treatment for kidney disease. The report recommended 35 high priority actions and mapped responsible agencies, identifying where the federal government could strategically enable cross‐jurisdictional consumer‐ and health service‐partnered approaches.19 From there, in March 2019, the then‐federal Minister for Health and the Minister for Indigenous Australians accepted the report, announcing a $2.3 million award for TSANZ to oversee a two‐year project to coordinate cross‐jurisdictional activity.20 This award established a national Taskforce whose overarching aim was to improve access to, and outcomes of, kidney transplantation for Aboriginal and Torres Strait Islander people. Establishing the TaskforceThe National Indigenous Kidney Transplantation Taskforce (NIKTT) was created to drive the development and implementation of initiatives that targeted knowledge and service delivery gaps identified by the TSANZ report, facilitating improved access to the kidney transplant waitlist and better post‐transplant outcomes for Aboriginal and Torres Strait Islander patients. As this supplement will go on to describe, the Taskforce set out to accomplish this through key objectives around: designing and implementing enhanced data collection and reporting processes on pre‐ and post‐transplant outcomes;improving the equity and accessibility of transplantation for Aboriginal and Torres Strait Islander patients by trialling a range of multidisciplinary service models and protocols; andreviewing existing initiatives that target cultural bias in health services to facilitate best practice care and support. To best inform Taskforce action on these objectives, the NIKTT also created a national network of Aboriginal and Torres Strait Islander consumers and established Indigenous Reference Groups at transplant units around the country. The development of a national Taskforce was critical to provide a focal point. Although many clinicians, researchers, patients and advocates have worked over the years to improve kidney health outcomes for Aboriginal and Torres Strait Islander people, there has not been a cohesive or coordinated approach to these challenges, nor has there been an opportunity to share and collaborate around service development. Led by an appointed Chair and Deputy Chair, the Taskforce was comprised of 24 other expert members including nephrologists, nurses, policy makers, researchers and, crucially, Aboriginal and Torres Strait Islander people with a lived experience of kidney transplantation and dialysis, as well as Aboriginal and/or Torres Strait Islander health workers. Although originally scheduled to be completed within two years, the onset of the coronavirus disease 2019 (COVID‐19) pandemic predictably altered the timeline of project implementation and the NIKTT was granted an extension until June 2023. A strategic focus of the Taskforce was embedding Aboriginal and Torres Strait Islander people's self‐determination and authority into designing models of care that aimed to improve access to kidney transplantation. The NIKTT set out to intentionally consolidate collaboration, partnership and leadership of Aboriginal and Torres Strait Islander people, as before the onset of the NIKTT, there was extremely limited systematic input of Aboriginal and Torres Strait Islander consumers into the processes of care in renal units and none in kidney transplant units. This supplement outlines the recommendations of the Taskforce through describing the outcomes and findings of each objective. We highlight the need for Aboriginal and Torres Strait Islander patient engagement and leadership, the importance of co‐designing models of care unique to local circumstances, and the challenges we still face as a community and health care system seeking to overcome cultural bias and institutional racism. We end this supplement with an overview of the Taskforce's recommendations for next steps and suggest direct actions that systems and services can take to build on the momentum established. The members of the Taskforce are privileged to be part of this foundational work with health communities and Aboriginal and Torres Strait Islander communities across Australia. As we progress equity from here, we look forward to working in partnership with patients, communities, health professionals, governments, health organisations, and research institutions to continue to improve access to kidney transplantation. We begin this supplement with a call to action for readers to join us in improving transplantation equity for all Aboriginal and Torres Strait Islander people with kidney disease. We, as Aboriginal and Torres Strait Islander people, know what is best for our health and wellbeing. While our people and cultures are strong and resilient, we continue to see harmful policies and practices implemented by government. While this can be difficult to hear, true change exists within discomfort, and progress is made when all parties are open to listening and responding. (Donna Murray, National Aboriginal and Torres Strait Islander Health Plan 2021–203121) Box 1 – Unadjusted incidence rate of kidney replacement therapy in Australia2 Reproduced with permission of the Australian and New Zealand Dialysis and Transplant (ANZDATA) Registry. Box 2 – Age‐specific incidence rates of treated kidney failure among Aboriginal and Torres Strait Islander Australians, by state and age at kidney replacement therapy start, 2016–20212 NSW = New South Wales; NT = Northern Territory; Qld = Queensland; SA = South Australia; Vic = Victoria; WA = Western Australia. Note the y‐axis scales vary between panels. Figure reproduced with permission of the Australian and New Zealand Dialysis and Transplant (ANZDATA) Registry. Box 3 – Relative incidence rate of treated kidney failure for Aboriginal and Torres Strait Islander Australians, by sex, compared with non‐Indigenous Australians, 2016–20212 Reproduced with permission of the Australian and New Zealand Dialysis and Transplant (ANZDATA) Registry. Box 4 – Generalised pathway to kidney transplantation, including key clinical milestones, for an Australian adult19 Adapted with permission from Garrard and McDonald.19

Jaquelyne T Hughes · Katie Cundale · Kelli J Owen · Stephen P McDonald

Kidney transplantation provides better quality and quantity of life for people with kidney failure.1 However, of the 14% of all prevalent dialysis patients who identify as Aboriginal and Torres Strait Islander within the Australia and New Zealand Dialysis and Transplant (ANZDATA) Registry, only 2% were waitlisted in 2021, compared with 8% of non‐Indigenous patients who were waitlisted.2 Equitably addressing this waitlisting gap was a significant priority of the National Indigenous Kidney Transplant Taskforce (NIKTT).3 Many barriers impede Aboriginal and Torres Strait Islander people who live with dialysis from accessing waitlisting, including slow or delayed assessments and referrals, cultural bias, misinformation, and the difficulties of distance (Box).4,5,6,7,8,9 The Commonwealth Department of Health and Aged Care awarded $1.3million to the NIKTT to enable competitive project sponsorships for health care providers to develop models of care that promoted waitlisting attainment. All funded projects extended previously successful models of care to address context‐specific barriers to waitlisting and transplantation. These sponsorship projects were pilots of local care delivery that aimed to overcome context‐specific barriers to kidney transplantation waitlisting. A more detailed evaluation of each of these projects will be available in the NIKTT's final report.10 Here, we provide a commentary on elements of each project that acted as enablers or challenges, to better understand what could be scaled or used to improve services in the future. We outline the strategies used to overcome barriers, what was learned from the projects, and the implications for further practice change. Outreach assessment clinics A substantial barrier to waitlisting in Western Australia is the travel burden required to attend workup appointments, as transplantation assessments typically occur in Perth. Sponsorship was provided for two projects to initiate outreach assessment clinics — found to be culturally sensitive models of care11,12 that increase equity of service delivery13,14 — into regional WA. Led by clinicians at Royal Perth Hospital and Sir Charles Gairdner Hospital and at Fiona Stanley Hospital, these projects were designed to increase the identification, assessment and waitlisting of suitable patients. Multidisciplinary teams, including transplant surgeons, nephrologists, transplant coordinators and renal nurses, attended eight to 15 days of clinics across three to five outreach visits. Alongside these outreach clinics, projects ran transplant education sessions for patients, communities, and health staff. Outreach assessment clinics led to increased numbers of patients activated and transplanted. Outreach clinics increased the number of patients commencing workup, the number of patients waitlisted (while decreasing the time to listing), and the number successfully transplanted (Supporting Information). Communities found the education sessions empowering, with groups in East and West Kimberley now working to form Indigenous Reference Groups.15 Key enablers of these outreach clinics included: (i) a full‐time transplant coordinator role, based locally or in Perth, who aided patient and clinic management; (ii) working closely with local Aboriginal medical services; (iii) patient, community and staff education sessions; and (iv) creating transplantation champions, both patients and staff, who understood regional barriers to transplantation and could motivate others. Key challenges, outside of coronavirus disease 2019 (COVID‐19) travel restrictions, involved the sustained funding of the outreach visits and transplant coordinator roles, as well as regional workforce vacancies. Patient navigators Institutional racism, and its impact on how cultural differences (including language, communication and protocols) influence service delivery, inhibits access to transplantation care.5,6,9 Funding was granted to groups in the Northern Territory, South Australia and Queensland to assist in the employment of patient navigators (or mentors; PNs) — roles that have been found to improve waitlisting through bridging cultural differences and providing otherwise unavailable support.16,17,18,19,20 PNs in this context are Aboriginal and/or Torres Strait Islander people with a lived experience of kidney failure and transplantation. PNs at Purple House (Panuku) in Alice Springs, Port Augusta Hospital Renal Unit, and Cairns and Hinterland Hospital and Health Service were employed to help patients by advocating for their needs, translating health knowledge, and providing culturally safe support. The projects found that PNs helped to increase the number of patients being assessed for eligibility, commencing workup, and being activated on the waitlist (Supporting Information). Navigators were able to develop a level of trust, understanding, effective two‐way communication, and enhanced informed decision making that was previously unseen in these contexts, because of their unique position as brokers of culturally appropriate knowledge and practice alongside lived clinical experience. PNs enabled better access to the waitlist through: (i) identifying and helping more patients undergo assessment; (ii) increasing awareness of transplantation through their presence in renal units and communities; (iii) providing culturally safe support through knowledge and guidance; and (iv) developing more suitable educational materials with renal teams based on patient feedback. Challenges included integrating PN roles into the health system, sustainable funding, and the potential for navigators to burn out without established support mechanisms. A key takeaway from the projects was the concept of the “invisible work” undertaken by PNs — such as late‐night phone calls or talking to patients and doctors about others’ issues when seeking care for themselves. This work is reflective of the holistic role that the navigators fulfil, but which cannot be easily translated into Western metrics. Further examination of this invisible work is ongoing. Educational resources A significant barrier to waitlisting involves the pervasive poor communication from health systems to patients, leading to missed opportunities and culturally unsafe care.6,8,9,21,22 The projects proposed the development of educational sessions and resources to educate patients and care providers on transplantation in local settings. Projects in the NT (Top End Health Service), WA (Royal Perth Hospital and Sir Charles Gairdner Hospital, Fiona Stanley Hospital), SA (Port Augusta Hospital Renal Unit and Pika Wiya Health Service Aboriginal Corporation), and Queensland (Princess Alexandra Hospital) developed patient and staff education sessions to improve understanding of waitlisting and transplantation. Educational sessions included topics such as workup process, remaining on the waitlist, medications, and post‐transplant care. Educational resources were tailored to local contexts by using place‐specific pictures and terms, translating documents into local languages, and consulting communities about the materials produced. Providing local, culturally relevant education to potential transplant patients led to better understanding of the complicated workup and transplant process, creating the opportunity for more patients to engage with workup while enhancing understanding of local processes. Education for health staff improved cultural awareness and understanding of local barriers (Supporting Information). A crucial element of both printed resources and in‐person educational sessions was that patients and communities participated in the development of shared content. The educational sessions especially benefitted from this structure, as they were able to adapt to changing circumstances (such as COVID‐19). Another important aspect of the educational sessions was that many were held on Country. By hosting sessions on the patients’ traditional lands, the projects promoted cultural safety for communities and also improved the cultural awareness and understanding of the visiting clinicians. Areas for development Recruiting, hiring and retaining Aboriginal and/or Torres Strait Islander staff proved challenging from both a workforce and institutional perspective.23,24,25 Two projects experienced workforce difficulties and did not achieve their outcomes. For one project, limitations on team members’ time and the inability to recruit suitable candidates meant the intended implementation of the project was not realised. For another project, significant staff turnover rendered assessment of activities impossible. In other circumstances, Aboriginal and Torres Strait Islander staff were employed but faced challenges within institutions, whether around their role, receiving renumeration, or encountering racism. It is critical that renal services — and the Australian health system generally — learn from these projects. Further development of Aboriginal and Torres Strait Islander roles and how they work with, and are supported by, health systems is essential.26 Most projects also suffered from workforce time pressures, with some finding assessment and reporting burdensome in addition to normal work. This is a common issue to all project‐based work in the health care system, where administrative support is often lacking.27,28,29 As further models are implemented, developing support teams around the delivery and evaluation of care would be beneficial. NIKTT projects found that local management and local answers to complex difficulties were vital to maintain transplant accessibility and project growth.30 A common element to all projects was delivery of the intervention closer to home, especially in regional areas. It is a priority, therefore, that we continue to develop and resource regional centres that can consistently deliver local innovations.31 Conclusion Achieving equity in kidney transplantation is a complex problem that continues to require distinctive solutions across multiple levels of service delivery. Providing workup assessments on Country, employing Aboriginal and Torres Strait Islander people as PNs, and investing in the transplant workforce are key enablers to improving waitlisting, as is the development of culturally and locally relevant education. The sustained resourcing of such models of care, alongside workforce support and integration, could substantially change disparities in waitlisting Australia‐wide. Box – Barriers to kidney transplantation for Aboriginal and Torres Strait Islander peoples in Australia5 Sociocultural Communication divides between patients and clinical staff Institutional racism experienced throughout the health care system, including a lack of understanding about the cultural elements of decision making, family commitments, and community obligations Culturally inappropriate educational materials Limited availability of appropriate interpreters Misinformed or culturally unaware health professionals Geographic Living in rural and remote communities not regularly serviced by transplant assessment teams Living in communities where access to dialysis facilities is poor The need to travel large distances to tertiary hospitals for follow‐up appointments Numerous trips off Country to attend workup tests Logistic and time‐consuming problems that arise from having to complete multiple trips to urban areas, including arranging transport, accommodation and bookings Biomedical A high burden of comorbidities such as diabetes, smoking and alcohol‐related illnesses, high body mass index, and cerebrovascular and cardiovascular diseases Frailty Persistent infection and malignancy

Katie Cundale · Stephen P McDonald · Ashley Irish · Matthew D Jose · Jillian Diack · Matilda D'Antoine · Kelli J Owen · Jaquelyne T Hughes

Inequities persist for Aboriginal and Torres Strait Islander people accessing health services in Australia, as evidenced by kidney health outcomes and the consistently lower rate of access to kidney transplantation experienced by Aboriginal and Torres Strait Islander people.1 The Australian Government has endeavoured to address this persisting inequity in access to kidney transplantation by establishing the National Indigenous Kidney Transplantation Taskforce (NIKTT), and tasking them to evaluate cultural bias interventions in Australia, with a focus on kidney services. The NIKTT's objective was to develop recommendations for best practice care and support that would enable health services to provide more culturally safe care for Aboriginal and Torres Strait Islander people. In this article, we highlight the main findings and recommendations from the Cultural bias Indigenous kidney care and kidney transplantation report.2 We reflect on the resulting recommendations and highlight key elements that the NIKTT anticipates could substantially improve the cultural safety of kidney care for Aboriginal and Torres Strait Islander people across Australia. Background to the report Racism continues to act as a barrier to accessing and receiving appropriate health care for Aboriginal and Torres Strait Islander people in Australia.3,4,5,6 Consumers accessing kidney services have continually stressed the importance of improving the cultural safety of care.7,8,9,10 The Australian Health Practitioner Regulatory Authority released its cultural safety definition and strategy in 2022, defining culturally safe practice as the “ongoing critical reflection of health practitioner knowledge, skills, attitudes, practising behaviours and power differentials in delivering safe, accessible and responsive healthcare free of racism”.11 For the purposes of this work, cultural bias is therefore defined as any mechanism, action or inaction — from health professionals, organisations and systems – that contributes to disparate treatment, treatment outcomes, or an unsafe experience of health care for Aboriginal and Torres Strait Islander people. To identify and evaluate what works best in addressing cultural bias in Australia, an NIKTT cultural bias working group was established. This group defined the scope and parameters of the review and evaluation, and approved the final recommendations. Based on advice from this working group, the NIKTT commissioned the Lowitja Institute, a renowned Aboriginal Community Controlled Research Organisation, to undertake the review in recognition of the need for it to be guided by Aboriginal and/or Torres Strait Islander researchers and include perspectives outside of nephrology. The objective of the review was to understand which interventions have been utilised to address cultural bias in Australian kidney care settings. Early literature searches identified severely limited available publications. The working group and review authors therefore co‐designed a three‐part approach that included: an assessment of initiatives that had been formally evaluated across kidney health and wider health care settings, which were published in the peer‐reviewed literature; a review of kidney health‐specific grey literature; and the inclusion of perspectives of Aboriginal and Torres Strait patients and kidney health care professionals through national consultations being undertaken by the NIKTT at the same time. The Cultural Bias Report was submitted to and approved by the Commonwealth Government in early 2022, and has since been disseminated and made public by the NIKTT.2 This work, developed during 2019–2021, also informed the Recommendations for culturally safe kidney care in First Nations Australians.12 The Cultural Bias Report, as well as a policy brief and translations of the recommendations into language more suitable for patients and communities, can be found on the NIKTT website.13 Further details of the report planning process can also be found in the NIKTT final report.14 Report findings The Cultural Bias Report identified that there were limited formally evaluated and published initiatives that specifically addressed cultural bias in kidney transplantation or dialysis settings. A range of evaluated initiatives were identified across other health care settings, and a number of small scale initiatives were identified within kidney care settings that were not published in peer‐reviewed journals. The report authors grouped the evidence, and consequent recommendations, into four domains for action (Box 1). These domains provide a framework through which services, organisations, and governments could address cultural bias by ensuring culturally safe and equitable care is made available to Aboriginal and Torres Strait Islander people. The first domain — Inclusion of Aboriginal and Torres Strait Islander people — identifies the necessity of privileging15 the voices and experiences of Aboriginal and Torres Strait Islander people as fundamental to effective, culturally safe interventions. Evidence found that reference groups, peer navigators, and Aboriginal and Torres Strait Islander health professionals were safe channels through which patients could provide feedback, without fear of reprisal. The second domain — Workforce — emphasises the need to focus on the roles, support, abilities and training of both the Aboriginal and Torres Strait Islander and the non‐Indigenous workforce. Evidence in this domain found that successful initiatives valued the mastery of cultural skills, knowledge and relational networks of Aboriginal and Torres Strait Islander staff who are health professionals and bring a specific scope of practice through their specialised perspectives. Domain three — Kidney health and kidney transplantation service delivery and models of care — highlights the importance of holistic continuity of care for clients and families to improve safety and outcomes. Addressing overall wellbeing and the specific socio‐economic situation and needs of Aboriginal and Torres Strait Islander clients, particularly transport and accommodation, were seen as critical. Domain four — Structures and policies — outlines the importance of institutional commitment and how national guidelines, policies and strategies are necessary to ensure that change is implemented, monitored, and followed through upon. Embedded evaluation, as well as continuous quality improvement through ongoing cycles of reflection and feedback from patients, were identified as important for improving service delivery and cultural safety. The report's domains and recommendations are listed in Box 2, mapped against the relevant National Safety and Quality Health Service (NSQHS) Standard that each relates to and addresses.16 Applying these recommendations to the NSQHS Standards illustrates how integrating the framework can create and monitor better and safer services. Recommendations for applying culturally safe (and unbiased) practice in nephrology The NIKTT convened a half‐day Cultural Bias Workshop in late 2021 to discuss the review's findings, the report, and its implications. Consumers, carers and members of the taskforce were invited to attend in person or online. Over 25 attendees joined, including Aboriginal and Torres Strait Islander people who were kidney transplant patients and health professionals, as well as non‐First Nations people who identified as transplantation coordinators, nephrologists, researchers, and other clinical and policy professionals. When reviewing the 14 recommendations listed within the report, the NIKTT and the workshop participants specifically recommended that five should be enacted immediately as essential steps towards effectively addressing cultural bias in kidney health settings. These actions are tangible, realistic steps that renal and transplantation units should implement to better ensure the cultural safety of services: Establish Indigenous Reference Groups in every transplantation unit. Support and increase the Aboriginal and Torres Strait Islander kidney health workforce. Establish and fund sustainable kidney patient navigator/peer support roles. Implement and evaluate comprehensive and ongoing cultural safety training programs. Fund, design, implement and evaluate tailored models of care. Moving forward with culturally safe care For clinicians and services, a comprehensive and standardised way to identify and track cultural safety, or the lack of cultural bias, is an essential step in progressing this work, but it needs well understood measurements. The report's four domains for action could be used by renal and transplant units to undertake an initial needs analysis of services, which could then be followed by specific resources to support the health unit and patient community to move towards equitable health care practice — as guided by specific recommendations. To best support kidney clinical services to apply this approach, the domains for action have been reframed in the form of sample questions that can be used by health services to prospectively evaluate the intent and commitment of delivered care. Box 3 provides an example of questions that have been informed by the work of the taskforce to provide unbiased care. The dearth of published research focusing on cultural safety or cultural bias in kidney health settings illustrates a gap in prioritisation within both research and practice. Health care services that work with Aboriginal and Torres Strait Islander people with kidney failure need to promote implementation and reporting of programs and research that address cultural bias and institutional racism. The creation of an archive of intervention outcomes that improve access to, and outcomes from, kidney transplantation would be an important advancement for patients. The NIKTT believes that further studies must concentrate on research and initiatives that identify and demonstrate best practices to reduce cultural bias, so that government, service and stakeholder investment can systematically implement evidence‐based recommendations and actions. Consumer and community engagement, tailored models of care (including patient support roles), improved workforce access to cultural safety training, and an empowered kidney workforce are tangible actions that federal, state and local organisations can implement now. By affirming the recommendations and domains for action discussed here, bodies such as the Australian Health Practitioner Regulatory Authority and the Australian Commission on Safety and Quality in Health Care could drive practice change throughout both nephrology and other health fields by setting standards and exemplifying conduct against which equitable service delivery could be measured. Box 1 – The Cultural Bias Report framework of four domains and their sub‐domains2 Domain Sub‐domains Inclusion of Aboriginal and Torres Strait Islander people Inclusion of family in care and decision making Indigenous governance, community consultations, reference groups Patient perspectives and feedback Workforce Indigenous workforce Knowledge and skills of all workforce Two‐way learning Service delivery and models of care Advocacy Case management, referral and follow‐up Collaboration Communication, understanding, trust and transparency Continuity of care and carer Cultural safety and responsiveness Flexibility Health promotion, education, prevention Responding to holistic health, wellbeing and socio‐economic needs Structures and policies Organisational governance, commitment, leadership and management Policies, guidelines and standards Physical environment Resources and funding Box 2 – Domains and recommendations from the Cultural Bias Report,2 mapped to corresponding National Safety and Quality Health Service (NSQHS) Standards16 NSQHS Standard Domain Recommendation Clinical governance Partnering with consumers Comprehensive care Communicating for safety Inclusion of Aboriginal and Torres Strait Islander people Establish Indigenous Reference Groups in transplantation units across Australia to co‐design culturally safe models of care and feedback mechanisms ✓ ✓ ✓ ✓ Increase the number of Aboriginal and Torres Strait Islander patients, families and health professionals on kidney health advisory boards and steering groups, especially in transplantation units ✓ ✓ Workforce Increase and support Aboriginal and Torres Strait Islander people to work as clinicians, transplant coordinators, and case managers in kidney health ✓ ✓ ✓ ✓ Employ Aboriginal and Torres Strait Islander people with lived experience of kidney disease in patient navigator and peer‐support roles, and ensure these are funded long term ✓ ✓ ✓ ✓ Deliver cultural safety training for all staff in transplantation and kidney health services ✓ ✓ ✓ Service delivery and models of care Co‐design new, holistic, culturally safe, and responsive models of kidney care and transplantation that actively involve patients and families in decision making; address inequalities and access issues; respect cultural priorities and obligations; and include traditional healers and a wider range of health professionals, healing, and support services ✓ ✓ ✓ ✓ Increase the use of telemedicine and videoconferencing, with Aboriginal health professional and interpreter support ✓ ✓ ✓ ✓ Improve access to, support of, and payment for interpreters ✓ ✓ ✓ Involve Aboriginal and Torres Strait Islander people in co‐developing new health promotion and health education resources and approaches to kidney transplantation ✓ ✓ ✓ Structures and policies Review and update quality improvement and feedback processes, policies, protocols, and guidelines in transplant units and kidney health services ✓ ✓ Use an institutional racism audit tool to assess levels of racism in transplantation units and kidney health services ✓ ✓ Develop and implement new clinical guidelines for Aboriginal and Torres Strait Islander kidney care and transplantation, and evaluate how effective they are in increasing access to kidney transplantation ✓ ✓ ✓ ✓ Adequately fund the implementation and evaluation of cultural bias recommendations ✓ ✓ Fund the National Indigenous Kidney Transplantation Taskforce to assess how each transplant unit scores in relation to cultural bias, and monitor improvements over time if/when recommendations are implemented ✓ ✓ Box 3 – Sample questions for applying the Cultural Bias Report2 domains for action Domain Questions for service delivery Inclusion of Aboriginal and Torres Strait Islander people Is there evidence of Aboriginal and Torres Strait Islander people being included in the governance, decision making, feedback loops, and leadership of clinical practice and health service delivery when services work with Aboriginal and Torres Strait Islander people? How are services confirming that these representatives are full and effective in their contribution to culturally safe delivery of health care? Workforce Are Aboriginal and Torres Strait Islander people represented throughout the health workforce? What is the evidence of worker support to practice in a health care system free of racism? How are they supported and resourced to provide adequate cultural safety for Aboriginal and Torres Strait Islander patients? Service delivery and models of care Which indicators demonstrate service delivery has been specifically created, or modified from existing practices, to ensure cultural safety for Aboriginal and Torres Strait Islander people who are at work or are recipients of care? What is the selection and review process and how is the service enabling implementation of recommendations? What are the timeframe, review, complaints and resolution processes that alert the service to successful implementation or persisting issues? Structures and policies Which structures, policies and processes are in place to ensure that auditing, accountability and responsibility are applied to providing culturally safe kidney care for Aboriginal and Torres Strait Islander people?

Jaquelyne T Hughes · Kelli J Owen · Janet Kelly · Katie Cundale · Sandawana William Majoni · Matilda D'Antoine · Stephen P McDonald

Consumer engagement is invaluable for informing, and thus supporting, improvements in the quality of health care delivery by services. Indeed, consumer engagement in health care has become an essential paradigm for Australian policy over the past 20 years, with one of the eight National Safety and Quality Health Service Standards focusing entirely on partnering with consumers.1 For Aboriginal and Torres Strait Islander peoples living with kidney disease, several consumer engagement activities were enabled by support from the National Indigenous Kidney Transplantation Taskforce (NIKTT) and other partners in recent years.2,3,4,5 These consultations allowed communities around the country to provide feedback, opinions, and solutions to kidney care challenges. Partnering with patients to overcome complex transplantation challenges is crucial and must be done with recognition and acknowledgement of the ways of knowing, being and doing that exist for Aboriginal and Torres Strait Islander peoples.6 For Aboriginal and Torres Strait Islander peoples living with kidney disease and after transplantation, the health system must embed true partnership, engagement and, most importantly, real change from existing verbal feedback that is backed by evidence. Our health systems need to be empowered to embrace, accept and work with (and not against) Indigenous knowledges.7,8,9 The barriers that Aboriginal and Torres Strait Islander peoples face when contending with renal services are numerous, as discussed elsewhere in this supplement. The kidney transplant pathway has aptly been described by one Aboriginal patient as “fragmented, confusing, isolating, and burdensome”.10 In order to address some of these barriers, through authentic engagement with consumers, the NIKTT catalysed the establishment of Indigenous Reference Groups (IRGs) within transplantation units around Australia. Five transplantation units were initially selected to host these IRGs — these represented the hospitals that serve the largest proportion of Aboriginal and Torres Strait Islander peoples on kidney replacement therapy: the Royal Adelaide Hospital (RAH) in South Australia, Princess Alexandra Hospital in Queensland, Westmead Hospital and the Royal Prince Alfred Hospital in New South Wales, and Sir Charles Gairdner Hospital in Western Australia. In this Perspective article, we describe the establishment of the RAH IRG to demonstrate how consumer engagement can deliver effective, culturally safe change. Doing it right: establishing an effective Indigenous Reference Group in Adelaide At the RAH, Aboriginal and Torres Strait Islander patients come from South Australia, the Northern Territory and western New South Wales to receive kidney transplantation care. This unit therefore provides care to people from many different Nations, each with their own languages, practices and ceremonies, and each with a distinct history of colonisation and health care experiences. These patients and their families travel enormous distances to receive care in a system that was created by, and predominantly for, an English‐speaking, Western‐orientated population. Although located on Kaurna Country, an out‐of‐the‐way wall is the only welcome in Language that consumers coming to the RAH experience. Due to the complexity of care for patients on kidney replacement therapies, especially those undertaking or having received a transplantation, a specific IRG was established to help patients’ voices systematically report on barriers to care from within the hospital system. To best achieve this, the NIKTT first established a Consumer and Community Engagement (CCE) working group and a dedicated CCE officer role to guarantee consumers were not only consulted but, more importantly, were leading the process of improving access to transplantation. The RAH IRG originally consisted of 20 patients, but as members unfortunately died, membership was subsequently opened to carers and family members. Seven key design elements (Box 1) for the IRG were developed throughout the establishment of the RAH group. Reflective practices11 were used so that what worked, and what did not work, was continuously discussed and allowed to guide future meetings and partnership growth. From the experience of establishing this reference group at the RAH, the CCE working group found that specific enablers paved the way for the IRG's successful engagement, integration and activism. Creating a Blak space Aboriginal and Torres Strait Islander voices were privileged by the creation of a safe, decolonised space through which the IRG could communicate with the clinical world. As no non‐Aboriginal people attended the IRG meetings, the space was seen as a wholly “Blak space”,12 where only Aboriginal and/or Torres Strait Islander people were invited to participate, lead and govern meetings. The IRG was positioned as a catalyst to forming trusting relationships between the patients and the hospital staff, as two‐way communication and Aboriginal and Torres Strait Islander‐led change were actively embraced at a local level. Reflective practices were employed to ensure meetings were examined and improved upon, a practice that reflects Aboriginal ways of knowing, being and doing by valuing the acts of deep listening and reflection.12 Questions such as “have the communities’ needs been heard and met?”, “what worked for us and what did not?”, and “how can we do it better next time?” were asked after each IRG meeting. This reflection and real‐time feedback allowed for each meeting to advance and develop based on feedback from within the Blak space. Engaging clinicians Clinical support and renal unit “buy‐in” were instrumental in helping to gain traction within the hospital system, specifically formalised first through a letter of support from the head of unit and then through another letter committing to undertake change based on the IRG recommendations. The CCE officer and another member of the IRG formally presented these recommendations to the transplant management meeting in the form of a message stick and a written letter. Without the support of doctors, nurses, coordinators and administrators, the success of the IRG would have been limited: non‐Aboriginal allies throughout the hospital system allowed for doors to be metaphorically opened and lines of communication begun. Box 2 illustrates this process for change and integration. Leading from within Aboriginal leads, and strong community connections, allowed for a resilient network to be built and maintained. Having Aboriginal kidney patients drive meeting times, agendas and outputs allowed for powerful momentum within the group to carry its message forward. In addition, having an Aboriginal person lead from within the renal unit was seen as vital to drive the project and maintain momentum. Early outcomes from the Adelaide Indigenous Reference Group Real practice change has occurred within the first year of the RAH IRG's existence, due to the strong relationships and trust built between IRG members and clinical staff. These changes include: Smoking (organ cleansing) Ceremonies are available on hospital grounds. In June 2022, the first kidney transplant Smoking Ceremony was held to pay respect to the organ donor and their family, while connecting the recipient and organ to the present. By facilitating such ceremonies, the RAH has enabled a holistic view of healing, delivering a more culturally sensitive system of care.13 A new cultural safety training course is being developed by Aboriginal kidney patients. More Aboriginal health practitioners are being employed in the renal unit. Non‐Aboriginal staff have expressed gratitude for the opportunity to better understand cultural protocols to facilitate culturally sensitive, and therefore safer, care. A formal evaluation of this group, and the impact and outcomes it has on the transplantation and renal unit, has been recommended by the CCE and IRG members. What could hold us back Although the establishment of the RAH IRG has been successful and provided learnings for NIKTT, there are general challenges for establishing and sustaining IRGs. Funding IRGs need financial support for both establishment and continued engagement. Costs are as low as $500 per meeting to cover sitting fees, catering and venue. Secured funding for the sustained support of IRGs is an easy obstacle to overcome once the benefits are considered. As units create new Aboriginal and/or Torres Strait Islander staff positions within kidney teams, more facilitators become available to ensure the cultural safety and continuity of each group. Powerful partnerships Although fundamentally enablers, trusting partnerships can also be obstacles if not continuously considered and acted upon. Aboriginal and Torres Strait Islander peoples have experienced innumerable broken promises over the hundreds of years of colonial subjugation. It therefore comes as no surprise that further broken promises or commitments unhonoured lead to frustration, mistrust and, ultimately, lack of engagement from Aboriginal patients. Taking time Finally, an important consideration for both the creation of and continued engagement with patient reference groups is time. It takes time to develop the trust and relationships that must occur for IRGs to be effective, and it takes time to implement the cultural considerations of deep listening and reflection. Follow‐up is crucial to this process: anything raised in a meeting, reflected upon after a meeting, or brought up outside of a meeting by members or hospital staff must be recorded and revisited until everyone feels the issue has been managed. These ways of working take up dedicated physical and mental time — a notion that may be antithetical to some hospital processes. Talking to take action The benefits of establishing IRGs, from ensuring voices are heard to creating trusting relationships, far outweigh the challenges to implementation. Transplantation units around Australia must prioritise and ensure the sustainable funding of IRGs for them to become embedded within the system. While we continue to grapple with an inequitable health system, new models of care are needed that best serve disparate consumers. Establishing IRGs within hospitals is one important way to enact positive, meaningful and active consumer‐led change. Box 1 – Essential design elements for the creation of a successful Indigenous Reference Group (IRG) Transplantation unit directors and heads of units were consulted before the establishment of the IRG and asked to clearly commit, in writing, to engaging with IRG suggestions on an ongoing basis. This was essential for engaging patients so they could trust that their voices would lead to meaningful change, rather than be sought, collated, and then ignored. The Consumer and Community Engagement (CCE) officer identified local clinical leaders and staff in the transplant unit that would be involved with the delivery of care and system change suggested by the IRG, to distinguish advocates and allies. The CCE officer used relational networks, clinical patient contacts, and community connections to identify potential IRG members. A “Blak space” was created wherein IRG meetings were only led by, and involved only, Aboriginal and Torres Strait Islander peoples. This space was deliberately set up to exist both physically and strategically within the transplantation hospital. Crucially, a terms of reference document was created that outlined the way in which the IRG worked together and in partnership with the hospital. The IRG then created a list of priorities that provided a positive framework for the unit specifically, and the hospital generally, to improve the cultural safety. These priorities were presented to the head of unit and the transplantation team in the form of a report and a specially commissioned message stick. Meeting minutes were made available to the transplantation team after each meeting. All IRG members were compensated for their time and the expertise that they shared. Finally, the IRG was brought together every three months using the considerations of time, deep listening, and reflection. Box 2 – The design and process of the Royal Adelaide Hospital's Indigenous Reference Group (IRG)* NIKTT = National Indigenous Kidney Transplantation Taskforce. * This workflow illustrates the ongoing flow of consultation and knowledge exchange allowed both for patients to feel more heard and for clinicians to gain a better understanding of cultural practices and protocols.

Kelli J Owen · Katie Cundale · Jaquelyne T Hughes · Stephen P McDonald · Matilda D'Antoine · Shilpanjali Jesudason

Lasting improvement in access to, and outcomes of, kidney transplantation will take sustained focus and coordinated effort. Further gains in transplantation access and outcomes are immediately available with directed attention on racism, cultural safety, equity and Aboriginal and Torres Strait Islander‐led change by our kidney communities and change makers. Transforming our entrenched systems will not be easy, but it must be done. In this Perspective article, we focus not on re‐expressing the trauma of exclusion and racism experienced by Aboriginal and Torres Strait Islander people in renal care, but instead focus the discussion on what must be done to systemically change care delivery going forwards. We reflect on some of the underlying principles that will ensure true equity and health sovereignty are realised as we continue to improve access to, and outcomes of, kidney transplantation for Aboriginal and Torres Strait Islander people. These changes, supported by the generosity and commitment of Aboriginal and Torres Strait Islander people, allied partners and many others, must be grounded in Aboriginal and Torres Strait Islander sovereignty and leadership. Although there have been early improvements in access to waitlisting and transplantation, we look at which next steps are needed for continued and sustained change. Change through focus A focused, coordinated national effort to increase access to kidney transplantation for Aboriginal and Torres Strait Islander people has been intentionally resourced by the Australian Government over the past five years: first, with the funding of an expert panel to review extant barriers to transplantation,1 and then by the establishment of the National Indigenous Kidney Transplantation Taskforce (NIKTT) to address specific barriers.2 The timing of the review and the action of the national Taskforce coincide with an improvement in the rates of both transplantation and active waitlisting for Aboriginal and Torres Strait Islander people around Australia.3 Alongside quantitative evidence for improvements in transplantation and waitlisting rates,4,5 the NIKTT has found qualitative evidence around the various enablers and barriers to transplantation access for Aboriginal and Torres Strait Islander people in Australia, detailed throughout this supplement. Combining these findings, as well as a position statement on transplantation equity6 that was endorsed by many community and clinical members of the Taskforce and larger network, the NIKTT identified three key areas for action, and associated recommendations, to continue to improve access to kidney transplantation (Box). In this final Perspective article, we discuss how we, as a health care community, can continue to improve access to waitlisting and transplantation. Service redesign The complexity of changing service delivery within the current Australian health care system cannot be understated. Among renal units, staffing pressures and a lack of available dialysis chairs have created situations where delivery of even basic renal care is difficult in some situations. The challenge (and its opportunity) for the Australian health system lies in addressing multiple aims: improving access to kidney transplantation and dealing with limited haemodialysis capacity and the need to implement prevention programs, all while working within a resource‐limited system.7 These aims cannot be mutually exclusive priorities if we are to provide care to all who need it. Dealing with issues around transplantation access will involve sustained institutional and unit‐level practice changes. Increasing the Aboriginal and Torres Strait Islander kidney health workforce (discussed below) is a first step. Other changes, such as the establishment and maintenance of Indigenous Reference Groups or Patient Navigator programs, are tangible steps renal and transplantation units can take to directly involve patients and their families in the creation of safe care pathways. The benefits to patients and services are considerably higher than the modest resourcing required to sustain these activities once initiated, so they must be included in renal unit budget planning. Similarly, although coordination of care requires complex interactions between many health care actors, the benefits and value‐added of collaboration across and within institutional boundaries strengthen continuity of care and coordinated practice. These directly speak to what Aboriginal and Torres Strait Islander patients have called for and are integral facets of chronic and complex care pathways. As recommended by the NIKTT, outreach assessment clinics in rural and remote Australia are illustrative of how collaborative working arrangements between transplantation units and local primary health teams can achieve a greater magnitude of benefit when they are able to access, integrate and capitalise on ground‐level knowledge and coordination capabilities.8 Australia is presently struggling to deliver health care, particularly with nursing staff shortages9 and especially within renal services in regional and remote areas.10 Increasing the Aboriginal and Torres Strait Islander health workforce at all levels will be a fundamental part of the solution to this, as well as transplantation accessibility more generally. Strategies for immediate action include creating bespoke roles for Aboriginal Health Practitioners, exploring alternatives to dialysis nursing from within the community, and investing in culturally relevant positions such as interpreters or patient navigators. The NIKTT consistently found across pilot projects that Aboriginal Health Workers or Practitioners offered immeasurable benefits to renal services by leading culturally safe access to, and provision of, care and a crucial interdisciplinary team approach to care. Implementing this at a jurisdictional level will require a coordinated approach that includes design of appropriate scope of roles, role delegation, integration within models of care, creation and accreditation of appropriate training courses, and, ideally, a national framework that recognises expertise and training in this area. Maintained leadership, coordination and governance led by Aboriginal and Torres Strait Islander people A fundamental tenet of high quality care is a patient‐centred approach,11 yet, until recently, there have been very few mechanisms for patient engagement in service design, especially in renal services caring for Aboriginal and Torres Strait Islander people. Over the past two decades, activity‐based funding, and thus economic efficiency, have driven health care service models. These centre the needs of care providers rather than outcomes‐based models, which centre the needs, wants or particularities of patient‐users of services. In kidney transplantation settings that serve Aboriginal and Torres Strait Islander people, the opportunities for patient voices to influence the design of services and care models have been minimal.12,13 Shared responsibility for leadership and governance by health care users and health care providers was an important priority of the NIKTT community network, as evidenced through Indigenous Reference Groups.14 Even though the NIKTT has catalysed the formation of these bodies in several regions, ongoing support must come from the jurisdictions and health services involved. Although individual kidney transplant services are provided by state‐ and territory‐run hospitals, substantial elements of policy and practice are driven at a national level. Issues such as the acceptance criteria for waitlisting and the algorithms for kidney allocation are determined by national bodies, which have often lacked representation from Aboriginal and Torres Strait Islander communities. These processes that provide care for Aboriginal and Torres Strait Islander people, yet exclude Aboriginal and Torres Strait Islander people from making decisions or providing input, recolonise, subjugate and must be avoided.15 Similarly, we must continue to question processes around data collection and reporting. How are data sovereignty16 and governance maintained? Are we underestimating the number of Aboriginal and Torres Strait Islander people within registry datasets without self‐identification being the norm?17 At both national and local levels, we must ensure that Aboriginal and Torres Strait Islander leadership guides discussions about how we maintain, develop and use data going forward. The NIKTT strongly recommends that a national network or body be established, representing Aboriginal and Torres Strait Islander people living with kidney disease, failure and transplantation. Consumers, community members, and clinical advocates have called for such a body6 that centralises and coordinates efforts to improve the lives of people with kidney problems — from prevention through to post‐transplant care — allowing us to reduce duplicated efforts, build on the strength of networks, and share resources and knowledge for the betterment of communities across Australia. Health sovereignty will not be established within Australia unless Aboriginal and Torres Strait Islander people lead health system change. Research and evaluation to investigate additional barriers and alternative approaches to care Despite the many challenges to ongoing equity and change, it is broadly recognised that there is a strong and growing momentum for lasting improvement. This reflects the strength of actors calling for change, the political and clinical will to improve health outcomes for Aboriginal and Torres Strait Islander people, and the demonstration of effective interventions. The recommendations here are just the next steps. Undoubtedly, there will be other barriers and issues identified that need to be managed, alongside modifications to programs. Learnings from both successful and less‐than‐successful projects are critical. Ideally, current systems will evolve into learning‐health systems that are driven by Aboriginal and Torres Strait Islander people's priorities; this is likely to be an iterative process, creating the need for national coordination and facilitation of discussions and advocacy. As revealed throughout the work of the NIKTT, barriers such as obesity, treatment uptake, and systemic miscommunication and racism continue to reduce access to waitlisting. Initiatives that are led and designed by and with Aboriginal and Torres Strait Islander communities should be evaluated across Australia. Additional aspects of the transplantation pathway, such as post‐transplant care and paediatric transplantation, that were not within the scope of this iteration of the NIKTT's work must also be researched and initiatives evaluated. Next steps In March 2023, the NIKTT Secretariat submitted a funding proposal for $4.8 million over four years to the Commonwealth Department of Health and Aged Care. This proposal addressed the three key areas for action and the recommendations therein, asking for funding to support: the resourcing of a continued Secretariat to maintain collaborations; the development of a data dashboard to support monitoring and reporting on equity progress; the development of a national body that represents Aboriginal and Torres Strait Islander people living with all stages of kidney disease, failure and transplantation; and the resourcing of additional sponsorship opportunities for local service delivery change based on outstanding barriers and additional aspects of the transplant pathway. How inequalities are addressed and actioned in the kidney transplant sector is very relevant for the broader health system. The type of complex care pathways — involving multiple care providers in different institutions with different governance and funding streams — is an inevitable part of the multidisciplinary management of chronic diseases. There will be many lessons from the transplant sector that can be taken up throughout services that care for people with chronic kidney disease, other chronic health conditions, and, more broadly, for Aboriginal and Torres Strait Islander people across Australia. Box – Key areas for action, and their associated recommendations, identified by the National Indigenous Kidney Transplantation Taskforce Key area for action Detailed recommendations Service redesign Jurisdictions must sustainably fund the following: Outreach assessment clinics: clinics should be resourced to provide multidisciplinary team visits to rural and remote locations. Funding should include the provision of a full‐time transplant coordinator role and clinics should include educational sessions for staff and patients alongside clinic visits. Indigenous Reference Groups (IRGs): all transplant hospitals should resource and implement unit‐based IRGs alongside mechanisms for reporting and workflow integration. Groups should be led by Aboriginal and Torres Strait Islander kidney patients and/or Aboriginal and Torres Strait Islander renal health workers. Increased Aboriginal and Torres Strait Islander renal health workforce: identified renal health roles at all levels, including (but not limited to) patient navigators and transplant coordinators, should be developed and sustainably resourced at renal units and transplant hospitals that serve Aboriginal and Torres Strait Islander patients. These roles must be embedded and supported within renal and transplantation units. Maintained leadership, coordination, and governance led by Aboriginal and Torres Strait Islander people Coordinated efforts are essential to identify issues, catalyse activity, and maintain profile and focus on transplantation. A national Secretariat, guided by Aboriginal and Torres Strait Islander people, would provide leadership, collaboration, monitoring and reporting and should be resourced to continue national coordination of transplantation equity work. This group should be responsible for the implementation of the following: ‣ Ongoing monitoring: progress on improving waitlisting numbers, kidneys transplanted, and post‐transplant outcomes should be consistently monitored through the Australia and New Zealand Dialysis and Transplant (ANZDATA) Registry. This monitoring should include the development and implementation of an annual scorecard for renal units. ‣ Maintaining focus and engagement: a coordinated network should be maintained to ensure attention remains on transplantation access and outcomes until significantly improved. Such maintenance of a network should include an annual gathering, consistent community engagement, sustained online resource portal, and conference attendance. ‣ Developing a proposal for a National Aboriginal and Torres Strait Islander Body: a coordinated, collaborative approach should be implemented to develop a proposal for a sustainable national body that represents the holistic journey of Aboriginal and Torres Strait Islander people with kidney disease, inclusive of all modalities including transplantation. Secretariat support should include the development of partnerships, governance, terms of reference, and key objectives and deliverables. Research and evaluation Funding should be offered to support the investigation of solutions for further drivers of inequity. Research into, and implementation and evaluation of, initiatives that address additional drivers of inequity should be nationally resourced and coordinated to understand best practices. Additional barriers: further barriers to transplantation equity, including overweight/obesity, treatment uptake, and reversible health issues, should be researched and best practices identified to address these barriers across rural and remote regions. Design initiatives across the transplantation pathway: research into and implementation of solutions to additional transplantation pathway aspects, with Aboriginal and Torres Strait Islander people, should be resourced, including post‐transplant care, paediatric transplantation, culturally tailored transplant education, and donation.

Jaquelyne T Hughes · Katie Cundale · Angela Webster · Kelli J Owen · Stephen P McDonald

SGLT2 inhibitor use in heart failure patients without diabetes should have minimal risk of ketoacidosis

Lisa M Raven · Christopher A Muir · Jerry R Greenfield

Rural communities across Australia face an ongoing shortage of doctors, which reduces access to care and leads to poorer health outcomes for people living in rural areas. Significant undersupply exists, particularly in rural general practice, priority-need generalist specialties and rural generalism.1,2 The coronavirus disease 2019 (COVID-19) pandemic exacerbated vacancies as immigration of international medical graduates came to a standstill and interstate movement of rural locum doctors reduced. The recently released National Medical Workforce Strategy emphasises the need to grow a workforce of our own that is fit for purpose, to deliver culturally safe and context-specific medical services to all Australian people.1 Over the past 20 years, there have been significant political and educational initiatives to increase the rural workforce, with accompanying research investigating their outcomes.3 Eminent rural researcher Denese Playford wrote: These data collectively build a portrait of candidates who are more likely to work rurally. The portrait suggests that a very convincing set of known factors are at play: rural background, lower socio‐economic status, locally‐born, quarantined rural pathway … entering with rural intent, Medical Rural Bonded Scholarship holders.4 Selection and support of rural students, rural placement immersions and development of comprehensive rural medical programs are within the control of medical schools and supported by Australian evidence. The pathways to rural practice are rich and varied. Successful approaches tailor these elements to local resources, needs and priorities (Box 1). In this article, we describe the elements of a comprehensive approach for medical schools. The Aristotelian notion that “the whole is greater than the sum of its parts” is important and medical schools need to apply a comprehensive approach to deliver more graduates who will work rurally. Enact a social mission statement for rural service Social accountability obliges medical schools to focus their own research, service and education undertakings specifically on addressing the health needs of their local community, region and/or nation. Priority health needs are to be identified jointly by local communities, health care organisations, health professionals and the government.5 As the majority of medical schools remain centred in large metropolitan areas, it is essential that these medical schools adopt a rural social mission statement as a way of expressing their commitment. Overt commitment enables the medical schools to put in place the strategies outlined below to produce more rural doctors, and build a supportive environment to fulfil this mission.6 Select for rural workforce outcomes Increase rural background cohort numbers Graduates from rural backgrounds are more likely to work in rural practice (odds ratio, 2.6 to 3.9).7,8,9,10,11 This “rural background effect” is independent of rural clinical training, but is augmented by it.7,8,9,12 The effect endures throughout postgraduate career stages,8,13 and has been found in some studies to increase over time.14 Rural background graduates are more likely to commence in rural practice, move to rural practice and remain in rural practice.13 Since 1995, in an effort to meet equity‐of‐access goals, the Commonwealth Government has mandated that 25% of medical student Commonwealth‐supported places are allocated to students with a rural background.15 With 28% of Australians living in rural areas,16 more recently funded rural programs, such as the Murray–Darling Medical Schools Network, have higher mandated proportions of rural background places (up to 100%).17 Medical school selections traditionally use university entrance examinations, which are expensive and less easily accessed from rural areas.18 Admitting more students from a rural background has been achieved in different ways across Australia. Equity adjustments have been used by many universities, such as adjusting academic and entrance exam scores, or keeping selection methods consistent and creating specific rural quotas. Other medical programs have adopted specific rural selection tools, including written personal statements and interviews, using community members to understand candidates’ rural interests.19,20,21,22 Despite these adjustments to admissions, rural background students demonstrate the same academic outcomes in medical school as other student cohorts admitted with higher entry scores.23 Select students from higher rurality locations The Modified Monash Model (MMM) categorises the rurality of Australian communities using a scale from 1 for metropolitan to 7 for very remote.24 Including MMM2 communities (regional, population>50000) in selection targets risks displacing students from more isolated locations. Applying a sub‐quota to MMM3–MMM7 communities ensures that students from smaller communities and remote Australia enter medical school. This focus is an important step forward in rural selection. Targeting selection of MMM3–MMM7 students from a specific geographic region within a university's regional footprint is a promising emerging strategy — it is informed by evidence that rural students are more likely to return to their own or a similar rural community.12,25 Many students in rural schools, particularly those from higher rurality areas, do not see medicine as an achievable career. Geographical, financial, social and self‐efficacy barriers prevent many potential rural applicants from considering medicine. Medical schools can play a key role in leading community‐engaged recruitment and support programs for high school students and other people living in rural areas who are eligible to access graduate‐entry medical schools. The impact of these recruitment programs can increase applications from students in rural areas.26 Provide early support, not constraints Strongly coercive interventions, such as bonded medical places, are associated with comparatively lower rural retention than interventions that involve less coercion.27 Currently about 25% of all Commonwealth‐supported medical students are bonded to areas of workforce need (including rural areas) for 3 years.28 Medical student bonding arrangements have reduced over time, due to limited evidence of long term success. Bonding conveys messages at the start of medical school that rural is less attractive, and it perpetuates inappropriate deficit discourse around rural practice. The current policy initiative of reducing Higher Education Loan Program debt for rural doctors is likely to have a much more positive impact.29 Promoting this financial support to students will assist with their choices to move to and stay in rural areas, but more needs to be done to overcome financial pressures for students from disadvantaged backgrounds during medical school. Rural students are a heterogeneous group, with potentially vast differences in rurality of background, socio‐economic status, and personal agency. When available, generous scholarships targeting rural students enable those experiencing financial hardship to participate in medical training. Access to safe, student‐friendly and affordable accommodation is invaluable for student success and rural retention. University‐owned and subsidised housing allows students to transition into medical school and access clinical placements in a range of locations. Make medical training locations more accessible for rural people Few medical courses are wholly based outside of capital cities in Australia.21 In 2019, the Commonwealth Government recognised the value of comprehensive rurally based programs that are more accessible for rural students by introducing legislation to reallocate 2% of medical school Commonwealth‐supported places from urban medical schools to rural end‐to‐end programs every 3 years. This redistribution of medical school training places, which commenced in 2020, facilitated the recent establishment of medical programs in regional areas of New South Wales and Victoria.17 Before the COVID‐19 pandemic began, this redistribution of medical places to rural programs may have been enough to provide an adequate rural medical workforce. Recent significantly reduced inward immigration of international medical graduates means that this policy needs to be reviewed. An expansion of Commonwealth‐supported medical student places is required in rurally located end‐to‐end medical school programs, rather than a reliance solely on redistribution, to ensure that each state has at least one rural medical school program that provides remote or rural training from the start to the completion of the medical degree. A national collaboration could share medical education and remote teaching resources to support this initiative, with the Federation of Rural Australian Medical Educators well placed to facilitate this (https://ausframe.org/). Highlight rural medicine in medical school curricula Showcase diverse rural contexts Medical curricula and assessments shape students’ views of rural career options.30 Traditional medical school teaching is predominantly metropolitan focused and specialist led. Medical students report that denigration of both rural doctors and general practice is still commonplace in Australia.31 Attitudes which fail to recognise the expertise of generalists influence students’ career choices away from rural practice. Medical schools with strong academic engagement by rural clinicians illustrate the value of rural doctors. Integrating rural clinical cases and management plans for rural practice within the formal curriculum can reinforce positive and realistic messages about rural medicine in Australia.30 Australian medical schools with MD programs require students to undertake research, providing an opportunity for students to undertake rural projects that contribute to rural communities, which in turn can draw students to rural careers. Teach generalist ways of working As generalists, rural doctors deal with high levels of complexity and uncertainty in clinical practice. Students who are ill prepared for clinical complexity can avoid specialties that have high loads of uncertainty. Modern curricula need to prepare students explicitly for uncertainty, multimorbidity, shared decision making and communication across clinical settings. Clinical cases set in rural contexts provide opportunities to build medical students’ generalist approaches to clinical care. Having rural doctors teach core medical content will encourage a broader scope of practice for all students. In addition, medical students need to learn to work in multidisciplinary teams. Ensuring that a broad range of rural health practitioners teach medical students alongside nursing and allied health students will promote good foundations for future work practices. These changes in the curriculum will ensure all medical students have the skills for 21st century health care. Invest in rural training pathways Immerse students in a rural place Immersive rural training remains a cornerstone for producing more rural doctors. Australian rural clinical schools have provided a generation of medical students with a year or more of rural clinical experience.32 Placement types vary from traditional hospital rotations in regional centres, with arguably less rural context, to placements based in general practices in small rural communities where students interleave general practice and hospital experience, often supervised by rural generalists.33 Rural placements enable students to build connections with rural clinicians and communities. Their influence can range from cementing intent for students already interested in rural practice to changing intent of students primarily interested in metropolitan practice.9,34 Longitudinal integrated rural clinical placements demonstrate consistently excellent academic outcomes and increased rural medical workforce outcomes by up to seven times those of metropolitan medical student clinical training.8,35 These programs, when situated in small rural towns, result in graduates who are up to five times more likely to work in small rural towns.36 This workforce outcome takes time, particularly in communities that are not big enough to provide prevocational training. Many rural clinical school graduates who have to leave rural areas for their postgraduate training come back 5–10 years after graduation.37 Students who become rural doctors often spend longer than their peers being undecided about their specialty intentions, highlighting the importance of regular positive rural experiences to promote the uptake of general practice and rural practice.38 Longer duration (18–24 versus 12 months) of rural training is associated with a threefold increase in returning to practise in the same rural region after training.7,39 Incrementally stronger associations exist for longer duration, a combination of regional hospital and general practice experience, greater remoteness and multiple placements.7,10,32 Apart from duration, there may be specific place‐based effects. For example, the Rural Clinical School of Western Australia distributes rural medical workforce in a clearly geographically patterned way, with Broome acting as a bridge to the remote north of Australia.40 In Victoria, those selected from a specific region and having greater than one year of rural training in that region had a 17.4 times increased chance of working in that same rural region compared with urban background students who had completed fewer than 12 weeks of training in the region.25 In rural communities, students make an authentic contribution to the clinical care of patients.41 They are seen by local people as contributing members of the community, and these meaningful relationships shape their learning and professional identity.41 As students on full year rural placements engage in community social activities, such as participation in sport, choir or church, they develop individual informal relationships with community members. Adopting a community‐engaged approach to training also includes facilitating rural communities to engage in the selection and education of students as patient‐experts and simulated patients. Prolonged rural placement experiences trigger aspirational, intellectual and emotional responses, particularly in students who have a strong motivation to help others and who value teamwork.42 Accordingly, students are drawn in and bound to their “own” town.43 Develop medical students’ rural identity For many students choosing a rural career, this requires simultaneous choices of rural location and specialty discipline, while urban medical careers tend to be shaped first by chosen specialty and later by location of practice.38 A medical school's social and cultural context shapes who students become (eg, rural community member), not solely what they practise (ie, discipline interest).33,44 This highlights the importance of fostering rural self‐identity during medical school. Rural practice self‐efficacy is an individual's sense of self‐confidence to thrive working in rural practice.45 It correlates with medical student rural practice intent and increased remoteness of location of practice after graduation.45,46,47 Rural doctors describe their practice as involving connection with their communities, comfort with clinical uncertainties and preparedness to undertake clinical activities at the edge of their scope.48 Students on rural placements are immersed in this culture of rural medicine, see others like them in rural practice, and thereby develop rural practice self‐efficacy.45 Students’ aspirations and expectations are strongly influenced by peers. Rural health clubs at universities celebrate and support students’ interests and facilitate contact with like‐minded peers. Students who undertake a rural stream in medical school develop strong ties, before and during rural placements, with each other and with mentors.49 Extended rural placements help students build firm friendships in the student group on location and between students in other similar rural sites. In rural areas, a strong community of practice is essential for developing and sustaining clinicians who thrive.50 An apprenticeship‐style mentoring model between rural medical practitioners and rural students enables students to feel supported and trained appropriately for rural and remote practice.51 Close working relationships between learners and their rural clinical supervisors enable rural professional identity formation over time.41,52 Mentors have a key influence on graduates’ career choices and practice locations.53 The John Flynn Placement Program, which previously supported medical students to undertake extracurricular rural placements (2 weeks annually for 4 years), demonstrated positive effects of mentorship on rural practice intent.11 Value rural practitioners and rural academics The rural medical workforce is under stress. Maintaining and developing training capacity is vital for all rural programs and Australia's future rural medical workforce. Junior doctors, registrars and international medical graduates compete for limited supervisor time and clinical space. Rural clinical schools play an important role in developing educationally supportive communities of practice for rural doctors. Schools also advocate for increased resources for rural areas, including financial remuneration for teaching and research, and clinical training infrastructure in rural general practices and hospitals. With proposed expansion of rural medical training pathways at all levels, the importance of appropriate support for rural clinical teachers, to ensure high quality clinical supervision, cannot be underestimated. Rural academic positions provide career diversity in rural Australia. Rural medical programs develop and support rural doctors to have blended roles, including clinician–teacher and clinical academic. Medical schools that include rural academics in curriculum design and delivery, assessment, research projects and wider opportunities within the university can improve advancement and longevity of engagement of rural staff.54 Having rural academics in senior medical school management teams secures rural oversight of rural missions. Rural clinical schools can provide academic skills for general practitioner and specialist registrars, enabling them to complete their training rurally. Many of these registrars will stay on or come back to the rural centre that provided this academic environment.32 Facilitate rural prevocational and specialist training Developing and sustaining rural and regional postgraduate training pathways is critical for supporting doctors to stay in rural areas.55 The Commonwealth Government's regional training hubs initiative funds rural clinical schools to develop, promote and sustain intern and vocational training opportunities in rural and remote Australia. Importantly, rural clinical schools connect students and junior doctors to vertically integrated training opportunities. Through regional training hubs, medical schools are increasingly engaging with other stakeholders contributing to workforce outcomes to maximise return on government investment and collaborate to address Australia's rural workforce needs. Several specialist training programs have now adopted a rural health equity strategy which sees rural background graduates privileged in college selection processes, particularly for rural training positions.56 The Australian College of Rural and Remote Medicine has recognised the value of rural connection and has incorporated a demonstrated connection with rural communities into its selection process for all candidates.57 Evaluate and recommit to the social mission Ongoing research into medical school influences on rural career choice will continue to influence medical school policy. Small changes in admissions policies can effect significant changes in terms of rural students entering medical school. Reporting on outcomes of rural pathways within the medical course must hold medical schools to account, ensure appropriate participation of students from under‐represented rural communities, and enable continuous quality improvement of rural training pathways. Tracking rural student progress throughout the course can facilitate access to social and academic supports when required to retain these students. Finally, the Australian Health Practitioner Regulation Agency collects data on location of practice, which enables universities to track their graduates to understand the impact on the end goal — more rural doctors. The rural workforce outcomes of medical school interventions can take many years to eventuate and will remain dependent on other factors such as specialty choice, rural postgraduate training opportunities, and individual, family and partner commitments. Conclusion Rural clinical schools in Australia have demonstrated the compounding effect of rural background, generalist intent, rural immersion, rural curricula, rural practice self‐efficacy and rural identity on rural practice outcomes (Box 2). Medical schools have an obligation to direct their activities to addressing priority health needs in rural areas. Incorporating a comprehensive approach to all the elements of selection, rural immersion and rural curriculum, based on a defined social mission and geographic binding to the communities they serve, will enable students to develop their skills and careers in rural areas across Australia. Box 1 – A comprehensive approach for medical schools to develop more rural doctors Enact a social mission statement for rural service Select for rural workforce outcomes ‣ Increase rural background cohort numbers ‣ Select students from higher rurality locations ‣ Provide early support, not constraints Make medical training locations more accessible for rural people Highlight rural medicine in medical school curricula ‣ Showcase diverse rural contexts ‣ Teach generalist ways of working Invest in rural training pathways ‣ Immerse students in a rural place ‣ Develop medical students’ rural identity ‣ Value rural practitioners and rural academics Facilitate rural prevocational and specialist training Evaluate and recommit to the social mission Box 2 – University pathway to more rural doctors PG = postgraduate.

Matthew R McGrail · Zelda Doyle · Lara Fuller · Tarun Sen Gupta · Lizzi Shires · Lucie Walters

Inequities in the distribution of human resources in health around the world have long been a topic of concern and discussion. There is an absolute shortage of health care providers in many parts of the world, notably in sub‐Saharan Africa and parts of the Asia–Pacific region.1 However, here and in other areas the problem is that the available health care workforce is maldistributed, both geographically and in terms of specialty.2,3 Understanding these issues and their drivers is an important step in developing, implementing and evaluating potential solutions, but both the understanding and the solutions need to be contextualised to region and circumstance.3 Health professional educational institutions can be important engines in driving social and educational change and innovation to ensure that their products (medical, nursing and other health professional graduates) are fit for purpose in terms of meeting the needs of the populations that they serve.4 Recognition of this potential has led the World Health Organization to focus on its agenda of transformative health professional education, to consciously improve access to health services by distributing the health workforce and aligning its competencies with evolving health needs on the way to addressing the broader social determinants of health.5 Importantly, to deliver socially accountable health professional education, educational institutions must hold themselves accountable for delivering appropriate health professionals, and for working in partnership to strengthen the health system and the quality of care that it delivers. Investment in training of the health workforce and strong primary health care delivers real economic value.6 The Training for Health Equity Network: learning from each other The Training for Health Equity Network (THEnet; thenetcommunity.org), which was founded in 2008, is a community of practice that now includes 13 medical and health professional schools, selected on the basis of their commitment to social accountability. Located primarily in rural and underserved areas of nine countries (low and high income), they share a commitment to producing and supporting health workforces that will meet the needs of the communities they serve (Box 1). These schools share the aims of: recruiting students from underserved and under‐represented populations; providing primary care‐focused curricula; delivering medical programs mainly in underserved areas and within communities; and providing postgraduate training to address local health workforce needs.7,8 THEnet is a collaborative learning network, where members share challenges across sectors and countries, and partner schools learn from and share with other innovative schools worldwide. Research and evaluation using a self‐critical lens helps members to understand how best to improve health equity and how to maintain accountability for outcomes.7,8 Collaboration and commitment: building an evidence base As a learning network that aims to influence health systems and share lessons between partners, THEnet considered how best to measure progress towards, and outcomes of, social accountability in its early work. Collaborative creation of THEnet's Evaluation Framework for Socially Accountable Health Professional Education was its foundational work, which involved careful attention to the use of plain language and definitions that can be used and adapted across many contexts.8,9 This work has since been adapted and expanded to create other widely used frameworks, such as the Indicators for Social Accountability Tool, and has been incorporated into medical accreditation standards worldwide.10,11 THEnet partner schools share a commitment to finding out where graduates work and the difference that they make. Measuring impact is important. The THEnet evidence group conducts a program of research, including the THEnet Graduate Outcome Study — a prospective cohort study of more than 6000 learners enrolled across partner schools, from which data have been received from nine schools in seven countries.12 The THEnet Evidence Group designed the study to correlate learner characteristics and practice intentions at entry to and exit from medical school, and then follow these graduates into postgraduate practice for up to 10 years, to determine the location and discipline of their actual practice. In recognition of our work in this area, THEnet has contributed to white papers for the Pan American Health Organization and a recent WHO handbook on the rationale and strategies for graduate tracking.13 These data have highlighted that, relative to other medical schools, THEnet partner schools deliberately use diverse selection processes to ensure that their learner cohort has sociodemographic characteristics that are much more similar to the population they serve.12 Data have confirmed the association between rural or low socio‐economic background and intention to practise in rural and remote areas, and that this is maintained from entry to exit from medical school.14,15 Importantly, for learners in low and middle income schools in South Africa, Sudan and the Philippines, these demographic determinants are significantly associated with lower desire to emigrate after graduation, and thus contribute to a desire to meet the health needs of their home country.15 In response to local need, THEnet members have also designed and collaborated on studies of work readiness of graduates, perceptions of social accountability among faculty and students, impact on the health system, impact on health outcomes, and social return on investment.16,17,18,19,20,21 The evidence base produced by THEnet collectively, from studies involving partnerships between two or more partner schools from different contexts, is summarised in Box 2. Our research shows promising outcomes from THEnet partner schools in terms of: intending to practise and actually practising in rural, remote and underserved areas; practice in generalist disciplines rather than subspecialties; broadening health teams to include community‐based health workers and other mid‐level providers; and health professionals remaining in low and middle income countries rather than emigrating.15,18 Longer term data from some schools suggest that practice intentions translate well into actual practice.25 Global lessons: building a rural and remote health workforce By summarising and integrating evidence from our collective work and the experience of partner schools in diverse locations, we identified consistent findings that may help produce a fit‐for‐purpose global health workforce (Box 2). Locating health professional education institutions in remote, rural and regional areas is a key factor in terms of producing a fit‐for‐practice rural and remote health workforce. In addition, providing a contextualised primary care‐focused curriculum to a diverse body of students who are largely from remote, rural and regional areas themselves is important. Using these approaches has become known as training health professionals “from, in, with and for” the rural and remote communities that we would like them to serve.4 However, lessons from pioneering schools suggest that these approaches are necessary but not sufficient — that the building blocks necessary for success are broader still.26 A vital common factor is a clearly expressed and widely understood mission for each school, which is linked to meeting the health needs of the population served. Also, committed and charismatic leadership that conveys each school's mission to its faculty and students is essential. Likewise, schools need diversity among the staff and the teaching body, including a wide variety of inspiring community‐based and primary care practitioners or generalists, to mitigate against the hidden hospital‐centric curriculum that often deters students from pursuing careers in primary care.27 In addition, exposing learners to a wide variety of inspirational rural and remote service providers provides motivation and encouragement to both mentors and mentees. Two further critical elements for producing a fit‐for‐purpose global health workforce are: learning in and with rural communities; and recognising the role of community members as teachers, particularly with respect to the social and cultural determinants of health. Working alongside community extension officers, Aboriginal or Torres Strait Islander health workers and practitioners, community nurses, or other mid‐level health professionals is critical for these aspects of learning.28 In all of these areas, increasing skills in telehealth and digitally assisted education — accelerated by the coronavirus disease 2019 (COVID‐19) pandemic — can help build a rural and remote health workforce.7 However, we believe that nothing can replace the impact of a rural longitudinal placement. Future priorities: measuring impacts and outcomes of school activities THEnet's partner schools have cooperated to produce a significant collective contribution to the evidence base on approaches to education that can help build a rural and remote health workforce. They have highlighted important factors which can help ensure that we deliver on our collective social accountability mandate. However, there is still much work to do as we strive to measure and critically reflect on the impact of our activities on the health of individuals, communities and populations, and on strengthening the health system. We have started to develop and apply novel approaches to measure social return on investment — in settings within Australia, the Philippines and Canada — with a view to extending this to a broader range of schools. It is important to measure the economic and social impact of school activities and outcomes for communities. Current work is also focused on measuring the impact of a learning health system and is looking at how we can build a chain of association from health professional education activities to accessibility of health services (and other markers of quality of care) through to improved health outcomes. Despite marked differences in the settings where THEnet's partner schools operate, similarities in approach provide lessons that may support more equitable distribution of the health and medical workforce into the future. Box 1 – Health professional schools in the Training for Health Equity Network (THEnet)* Ateneo de Zamboanga University School of Medicine, The Philippines Ghent University, Belgium Flinders University, Australia† Imperial College, United Kingdom James Cook University, Australia Latin American School of Medicine (ELAM), Cuba Northern Ontario School of Medicine, Canada Patan Academy of Health Sciences, Nepal Walter Sisulu University, South Africa University of Gezira, Sudan University of New Mexico, USA University of the Philippines Manila, School of Health Sciences, Leyte, the Philippines University of Sherbrooke, Canada University of Texas, El Paso, USA * Reproduced from Murray et al7 under a CC BY 4.0 license. † Founding school; recently withdrew from THEnet. Box 2 – Summary of evidence collaboratively produced by Training for Health Equity Network (THEnet) partner schools, from studies on building a rural and remote health workforce that involved partnerships between two or more partner schools from different contexts Publication (schools involved) Methods and main findings Implications THEnet's evaluation framework Larkins SL, et al (2013)8 (JCU, ELAM, Ghent U, UPM‐SHS, ADZU, WSU, FU, NOSM U) THEnet's Evaluation Framework for Socially Accountable Health Professional Education was developed as a tool to assist schools in assessing progress towards social accountability. The framework considers three questions: ‣ How does our school work? ‣ What do we do? ‣ What difference do we make? The evaluation framework proceeded to pilot testing, and is now widely used and cited. Ross SJ, et al (2014)9 (JCU, FU, NOSM U, ADZU, UPM‐SHS) THEnet's evaluation framework was piloted at five THEnet partner schools. It was found to be relevant, acceptable and feasible across the schools. The evaluation framework can be used by health professional education schools as a tool to facilitate critical evaluation of school performance, progress and capacity towards social accountability, and to identify and inform improvements. THEnet Graduate Outcome Study Larkins S, et al (2015)12 (JCU, Ghent U, WSU, Gezira U, ADZU, NOSM U) An analysis of 944 first year learners from five THEnet partner schools was conducted. THEnet partner schools used various selection strategies: quota‐based approaches, use of selection criteria, involvement of community, and marketing the school to attract learners. The demographic profiles of first year learners were reflective of their respective populations (eg, in terms of socio‐economic status and population group). A high proportion of learners intended to practise in underserved communities, and there were associations between rural origin and intent to practise in rural populations. Diversity of the learner cohort is influenced by wider policy and school selection strategies. THEnet partner schools used broad selection strategies that selected a diverse and representative learner cohort. A high proportion of these learners were from underserved backgrounds and expressed higher intention to practise in rural populations, potentially addressing workforce maldistribution. Larkins S, et al (2018)14 (JCU, NOSM U, Ghent U, Gezira U, WSU, ADZU, FU, UPM‐SHS) Entry and exit data for 3346 learners from eight THEnet partner schools were analysed. A positive association between rural background and intention to practise in a rural location was found in entry and exit cohorts. Positive associations were found between intention to practise in rural locations and the following: rural background, low parental income and attending medical school in a regional location. Positive associations were also found between intention to work abroad and the following: urban background and high parental income. A higher proportion of learners intended to practise in family medicine or general practice at exit than at entry. Strategies focusing on social accountability in health professional education have positive impacts on intention to practise in rural populations and in family medicine, and are likely to help address workforce maldistribution. Johnston K, et al (2020)15 (JCU, ADZU, Gezira, WSU, UPM‐SHS, PAHS, NOSM U, FU) Data were analysed for 5078 learners from eight THEnet partner schools participating in the Graduate Outcome Study, including: 3849 learners at entry; 1229 learners at exit; 149 learners for whom entry and exit data were available; and 2041 learners from five schools in LMICs (Sudan, South Africa, the Philippines, Nepal). Differences were found between schools in high income countries and LMICs, in terms of wider policy support for general practice or family medicine postgraduate programs in high income countries. Intention to practise in rural areas was associated with: rural background at entry and exit, attending medical school in a LMIC (AOR at exit, 2.01), and being female (AOR at exit, 1.80). Intention to practise in general practice or family medicine was lower for learners in schools in LMICs than for those in schools in high income countries. Intention to work abroad for learners in schools in LMICs reduced over medical schooling. In LMICs, strengthening the rural health workforce involves: locating schools in rural and regional areas; active recruitment of learners with rural backgrounds; and a curriculum with a focus on primary health care, and which is supported by postgraduate training programs. Levers in health professional education for building a rural health workforce (rural background, low income background, medical school located in a regional area) may be more powerful in LMICs and could encourage learners to serve in rural areas and in their country. Understandings of social accountability Preston R, et al (2016)22 (FU, JCU, ADZU, UPM‐SHS) Interviews were conducted with 75 stakeholders (staff, faculty, students, health workers, members of the community) at four THEnet partner schools. Social accountability was perceived to be meeting workforce, community and health needs through learning and service in underserved communities by students and graduates. The concept may be explicit in a mission statement and/or seen as a moral obligation shown through service and beginning with values. The nature and content of school programs shaped social accountability, including student selection, involvement of communities in decision making and use of a curriculum that addresses the needs of underserved populations. Social accountability as a concept is not universal and should continue to be challenged and debated. Understanding of social accountability may be limited, even when enacted in school programs. Differences in understanding affect the ability of a school to work towards social accountability. Values‐based understanding of social accountability may not be shared at an institutional level, and an explicit mission could isolate those who do not share it. A mixture of both is needed. Ellaway RH, et al (2018)17 (NOSM U, Ghent U, JCU, FU, UNM, Gezira U, UPM‐SHS, WSU) Mission statements were analysed, and interviews were conducted with 72 senior learners at eight THEnet schools. Social mission was expressed explicitly and was central to identity at some schools. Social mission was reflected in: various modes of compulsory community service activities; optional community components; role modelling by faculty; and admission processes. Learners understood their school's social mission in terms of community, social justice in medicine and particular communities, and workforce distribution. Learners internalised the social mission through sensitisation (via institutional culture and curriculum), through personal experiences and by exposure to influential role models. Translation of the social mission to students’ perceptions is variable and affected by how explicit the school social mission is, how it is reflected in the education program, other institutional drivers and the processes that students use to internalise the social mission. Impact and outcomes Reeve C, et al (2017)23 (FU, JCU, ADZU, UPM‐SHS) A systematic review on the impact of health professional schools with a social accountability mandate was conducted. Socially accountable education included: selection processes that admit learners from local rural areas; partnerships between communities, health services and schools; and positive rural experiences through educational activities and clinical placements. Positive impacts of rural placement and training in communities were seen, including effects on competencies, learning experiences, and attitudes to general practice and/or community service. Longer rural placements were associated with increased likelihood of rural practice. Having learners based in rural communities was shown to have positive impacts for rural communities. Overall, there is a lack of studies about the impact of socially accountable medical education. Learning and attitudes towards communities are positively influenced through longitudinal placements in rural areas. Other relevant inputs are: selection strategies aimed at recruiting learners from underserved populations; mandatory placement in rural communities; and undertaking health projects in communities. Halili S Jr, et al (2017)18 (ADZU, JCU, FU) Graduate outcomes of a socially accountable THEnet partner school in the Philippines were compared with those for a conventional medical school in the Philippines. ADZU learners had lower family incomes, were more likely to become doctors to help others, were more likely to have attended ADZU due to the curriculum, and were more likely to intend to practise in family medicine at graduation than learners at the conventional school. ADZU graduates were less likely to be practising in family medicine and more likely to be practising in paediatrics. They were more likely to be working as a rural or municipal health officer or as a generalist medical officer than graduates of the conventional school. ADZU graduates were likely to have positive attitudes towards practice in communities. The socially accountable, community‐engaged medical education model at ADZU has produced graduates who have positive attitudes to communities and health equity, and who practise in areas and fields of need in the Philippines. Siega‐Sur JL, et al (2017)19 (UPM‐SHS, JCU, FU) The motivation for community‐based service, preparedness to address local health issues, career choices and practice location of graduates from a THEnet partner school were compared with those for graduates from a conventional school. UPM‐SHS graduates had more positive attitudes to community service and were more likely to work in rural areas and at rural government health services than graduates from the conventional school. The UPM‐SHS social accountability philosophy drives student selection strategies that include community nominations, social contracts with communities to support students, and extended community‐based training. This approach is successful in developing a fit‐for‐purpose, professional workforce that is committed to working with rural communities. Woolley T, et al (2018)20 (JCU, ADZU, UPM‐SHS, FU) The population and socio‐economic profiles of practice locations for graduates of two THEnet partner schools and two conventional schools were compared. ADZU and UPM‐SHS graduates were more likely to practise in communities with populations of less than 100000 and low income communities compared with those from conventional schools. Two THEnet partner schools have increased medical coverage in rural and economically disadvantaged areas in two regions of the Philippines. Policies that support rurally bonded places were filling workforce gaps. Woolley T, et al (2018)21 (JCU, ADZU, UPM‐SHS, FU) A non‐randomised controlled study was conducted to compare child and maternal health outcomes in five communities served by graduates and student interns who had been trained at THEnet partner schools and conventionally trained graduates. A total of 494 mothers were surveyed. Mothers in communities served by ADZU and UPM‐SHS graduates and interns were more likely than mothers in communities served by conventionally trained graduates to report: discussing results of prenatal samples; having their first prenatal check‐up before 4 months’ gestation; doctor‐assisted birth of their youngest child; receiving timely newborn and postnatal care across all USAID‐recommended core elements; their youngest child being in the normal birthweight range; and still breastfeeding their youngest child when they were 6 months of age. Graduates and student interns of ADZU and UPM‐SHS are: strengthening child and maternal health services in some communities served by these two schools, increasing access to child and maternal health services for economically disadvantaged mothers; and producing positive child health outcomes. This study added to evidence showing that socially accountable education helps address health workforce maldistribution and benefits underserved populations. Woolley T, et al (2019)16 (JCU, UNM, Gezira U) A total of 184 hospital and community facility staff were surveyed; they rated key competencies of graduates from three THEnet partner schools and those of graduates from conventional schools. Graduates (postgraduate year 1) of three THEnet partner schools were rated above average for overall performance, work readiness, overall clinical skills, teamwork, professional attitudes and commitment to health equity. Workplace‐based training in community and local hospital settings and a socially accountable curriculum that focuses on health equity produces work‐ready graduates with locally relevant competencies. Woolley T, et al (2020)24 (JCU, NOSM U) The impact of postgraduate training location on practice in the service area of the medical school was examined by surveying 149 JCU graduates (specialist doctors and fellows) and 400 fully licensed NOSMU‐trained doctors. 38% of JCU graduates were practising in the school's service area. For family practitioners, general specialists and subspecialists, regional training was positively associated with practice in the service area. Family practitioners were more likely to practise in the service area than general specialists and subspecialists. 92% of family practitioners who completed undergraduate and postgraduate training at NOSMU were practising in the school's service area compared with 54% who completed only postgraduate training at NOSM U. 30% of general speciality graduates were practising in the service area. Location of postgraduate training is positively associated with later practice location — two socially accountable medical schools found that a training pathway for family practitioners in the school's service area was associated with later practice location in the school's service area. The findings support specialty training programs based in rural and regional centres, with rotations for trainees into city locations when required. Murray R, et al (2022)7 (JCU, ADZU, PAHS, UPM‐SHS, NOSM U, Ghent U, UNM) In a perspective piece, the authors reflected on the implications of COVID‐19 in terms of speeding up uptake of equity‐promoting initiatives, such as distributed education and telehealth. Interruptions to medical education during the COVID‐19 pandemic have highlighted inequities across the health and health education systems, and prompted new and increased use of online learning (including for clinical skills), use of online examinations, and deployment of students to aid in the health response to COVID‐19. The COVID‐19 pandemic presents an opportunity to disrupt conventional approaches to medical education and consider how necessary adaptations can drive change that is beneficial for medical education and health equity. Lessons from THEnet partner schools provide guidance on successful innovations to achieve these aims. ADZU = School of Medicine, Ateneo de Zamboanga University; AOR = adjusted odds ratio; COVID‐19 = coronavirus disease 2019; ELAM = Latin American School of Medicine; FU = Flinders University; Gezira U = Faculty of Medicine, Gezira University; Ghent U = Ghent University; JCU = College of Medicine and Dentistry, James Cook University; LMICs = low and middle income countries; NOSM U = NOSM University (formerly known as Northern Ontario School of Medicine); PAHS = Patan Academy of Health Sciences; UNM = University of New Mexico; UPM‐SHS = School of Health Sciences, University of the Philippines Manila, Leyte; USAID = United States Agency for International Development; WSU = Walter Sisulu University.

Sarah L Larkins · Fortunato Cristobal · John Hogenbirk · Filedito Tandinco · Abu‐Bakr Othman · Jabu Mbokazi · Kaatje Van Roy · Shambhu Upadhyay · Karen Johnston · Andre‐Jacques Neusy

The positive impact of evidence‐based practice on health service performance and health outcomes is well described.1,2,3 Marita Titler, an expert in evidence‐based practice from the United States, has observed that “only by putting into practice what is learned from research will care be made safer”.4 However, the consistent and widespread application of evidence‐based health care is largely dependent on a health service's research culture and the research capacity of its staff.5 It is therefore important to build research capacity, as this improves the ability of clinicians to apply new knowledge to improve health outcomes.5 In addition, strong research culture has been shown to be associated with better patient outcomes.3 This is particularly important in rural and remote contexts, where health outcomes are notably poorer, and research environments are often less developed and more stretched. Rural and remote areas in Australia need relevant, context‐specific research to inform policy and practice that will ensure stronger and healthier communities for current and future generations.5,6,7,8 Research in rural and remote areas is under‐resourced relative to the health needs of people in those areas. For example, only 2.4% of the total National Health and Medical Research Council (NHMRC) funding in 2014 was allocated to rural health research, despite 30% of the Australian population residing outside of major cities.8 Research‐active organisations in rural and remote settings are well positioned to generate high quality and context‐specific evidence to support health policies and practices that will directly improve health outcomes and the delivery of health care in rural and remote parts of Australia.5,6 In this article, we use the term “rural and remote” to describe areas classified using the Modified Monash Model as MM3 to MM79 (ie, all areas outside of major cities with a population of <50000), while acknowledging that the communities in these areas are highly heterogeneous. Evidence from Australia and overseas has highlighted the importance of research activity in health settings in delivering high quality care, improved patient experience, reduced mortality, a culture of enquiry, and greater innovation and translation.2,3,10,11,12,13,14,15 Beyond the organisational benefits of research activity, clinician‐led research has been shown to improve identification of problems, which reduces research waste and ensures translation of findings into policy change.16 We believe that a sustainable and supportive health research environment across rural and remote parts of Australia is part of the solution to improving health outcomes in these communities. In this article, we discuss strategies for creating and sustaining health research environments throughout rural and remote parts of Australia. We provide an overview of the current state of play and key achievements in rural and remote health research, and recommendations for establishing positive research culture and research opportunities for rural and remote health care workers. Current state of play and key achievements While rural and remote health settings present unique challenges — such as geographical isolation, fewer specialist services and less professional support compared with metropolitan settings — these environments also provide great opportunities for innovation.15,17,18 In addition, rural and remote settings have unique opportunities for more rapid research impact, enhanced knowledge translation and sustainability.15,19,20,21 Over the past 20 years, research activity has dramatically increased in rural and remote parts of Australia, largely through the success of university departments of rural health, rural clinical schools and regionally focused research translation centres (RTCs), and an increased recognition of the importance of place‐based approaches to research.5,20,22,23 More recently, the NHMRC has invested in the Centre of Research Excellence for Strengthening Health Systems in Remote Australia and the federal government has funded the Rural and Regional Health Research Institute at Charles Sturt University.24 Despite the challenges of generating supportive environments for research in rural and remote contexts, there have been many success stories. There is clear evidence that the network of university departments of rural health across Australia has substantially increased the focus on rural and remote health issues, and provided considerable support to rural and remote health care workers, students and place‐based researchers.23 RTCs are also achieving significant improvements in the quality and quantity of health research in rural and remote parts of Australia. RTCs focus on translating evidence into practice and developing research capacity and capability within health services, which supports locally led research options. Five of the 14 RTCs accredited by the NHMRC are solely focused on rural and remote health research, and four others have a statewide remit. With collaborations across research institutions, academic institutions and health care services, RTCs are directly enabling rural and remote health care services to lead research that addresses local level health issues.25 Other successes include the Torres Strait Islander Research to Policy and Practice Hub. This initiative generates locally relevant research, based on a locally driven research agenda, to support sustainable ecosystems and health in the remote Torres Strait Island region and to build local research capacity.26 The Northern Australia Research Network is another example.27 This is a collaborative network of local researchers, clinicians, health managers and consumers who work together to improve the health and wellbeing of people living in Northern Australia through research focused on functioning, disability and health.27 A smaller scale example of a successful rural health service that is driving its own locally relevant research agenda is the Colac Area Health Research Unit in Colac, Victoria.20 Key enablers for the establishment of the unit were local champions, who provided proof of concept. They did so by running a successful locally driven project that was supported by the health service leadership (who embedded the unit into their organisational strategy), the local university department of rural health and the Western Alliance Academic Health Science Centre.20 Although significant progress has been made, multiple challenges and opportunities exist for further integrating research into practice in rural and remote settings. Research into the barriers to, and opportunities for, building health‐related workforce research opportunities in rural and remote parts of Australia has shown that, to date, there has been heavy reliance on an individual approach (ie, research has been led by individual academics and clinicians), leading to fragmented research efforts.18,28 Such activity, while undoubtedly beneficial, tends to be sporadic and opportunistic, mostly due to limited resources, lack of an overarching research strategy, and lack of internal and external structural support for sustained and aligned research efforts in rural and remote settings.18,29,30 The challenges faced by rural and remote health care workers in engaging in research include: limited time, owing to health workforce shortages; lack of research culture, mentoring and leadership; unclear career pathways for clinician researchers; and minimal rewards for developing research capacity and undertaking research.31,32,33 Recommendations for establishing positive research culture and research opportunities To continue building supportive research environments in rural and remote communities, positive research culture and research opportunities for rural and remote health care workers are needed. We have three key recommendations for this. States and territories should develop and implement rural and remote health research strategies Our first recommendation is that the states and territories, as providers of tertiary public health services in Australia, should implement rural and remote health research strategies that address the specific needs of communities, health care workers, health services and researchers. A recently published Australian Academy of Health and Medical Sciences report rightly states that addressing fragmented research efforts is a key priority for advancing research and innovation as core functions of the health system at a national level.15 However, the unique challenges and opportunities in rural and remote health research warrant dedicated state‐based strategies that will address the need for research capacity and capacity building within clinical and practice‐based roles. Such strategies would need to address the historical underinvestment in health research in these communities, along with critical workforce shortages that create barriers to building research capacity.29 In addition, federal government involvement will be crucial; this should include funding for primary health research, and engaging and integrating primary care providers in health research. Rural and remote health research strategies will need broad stakeholder input to ensure relevance, practicality and meaningful outcomes, plus adequate rewards and incentives for health care workers to undertake research, including research led by Aboriginal and Torres Strait Islander people. The strategies should also extend to organisations that integrate with but sit outside of the health research sector, such as local governments and not‐for‐profit health organisations, which are crucial partners in advancing rural and remote health. Equity of opportunity across rural and remote parts of Australia is also important, despite considerable heterogeneity in community size and population needs. Further, a focus on locally led identification of problems, co‐design, implementation and translation will help ensure that new and existing evidence is embedded into practice. Rural and remote health research strategies must also acknowledge and address the cross‐cutting themes relevant to all jurisdictions, identify gaps requiring further research, and identify opportunities to address critical issues using collaborative approaches. Critical issues include workforce recruitment and retention, socio‐economic determinants of health, and Indigenous health. These issues cannot be addressed broadly or sustainably without a concerted, collaborative approach from all stakeholders — governments, universities, health services, non‐government organisations and communities. To further support the integration of research in rural and remote health care services, we recommend that governments and funders embed research and translation in policy that guides critical activities such as hospital accreditation, and through the introduction of key performance indicators in research. National, state and territory policies and health funding agreements will need to prioritise research and incentivise health services to incorporate research and translation (and measurement of impact) into planning, policies and operations. This would provide structural support at individual, team and organisational levels. Recent policy changes, such as those adopted by the Medical Research Future Fund, will have lasting effects on building research capacity in rural and remote areas and improving career opportunities for the health workforce. These changes include requirements for rural and remote investigators on grant applications and equitable distribution of grant funds to rurally based organisations.34 We encourage other research funders to consider similar policies.9 Although the equitable distribution of grant funds is commendable, use of the Modified Monash Model for this purpose has limitations. The model was developed to understand workforce distribution; it is not necessarily relevant to health research funding. Further research is needed to determine the most equitable methods for awarding research funding.35 However, any increase in the proportion of funding allocated to rural and remote health research is positive and a key step in addressing health disadvantages in rural and remote parts of Australia. Health research must be driven by local need Our second recommendation is that health research must be driven by local need in rural and remote Australia. It is best done with, not to, those most affected by the outcomes. At the very least, health research should be co‐designed with local communities and stakeholders. This will ensure that research is locally relevant, appropriately contextualised and feasible. It will also ensure that research findings are adopted, which is particularly important in environments where opportunity, resources and infrastructure are scarce. Research leaders should actively involve local health care workers Our third recommendation relates to collaboration with and support from rural and remote research, health service and community leaders.15,20,22,23 These are key factors in successful rural and remote health research, along with partnerships with universities and research institutions. Strengthened partnerships between health services and universities will be essential for sustaining and supporting health research environments in rural and remote parts of Australia. To this end, we recommend that research leaders proactively identify opportunities to actively involve local health care workers in any health research conducted in rural and remote areas. This will have benefits for all involved, including through building capacity, capability and partnerships. The rise of online meeting platforms could augment these opportunities by facilitating collaborations between rural and remote health care workers, novice researchers and more established researchers. Conjoint university positions for health care workers would also support links with established research teams and assist researchers to understand the rural and remote context. While the Australian Academy of Health and Medical Sciences has recommended a national strategy and implementation plan for building a clinician–researcher workforce, it does not outline specific recommendations for the rural and remote context.15 This is critical if the proposed national strategy is to equally benefit rural and remote parts of Australia. Addressing both the pull and push factors will give rural and remote health care workers the best opportunity to develop their skills and participate in research. Conclusion Although rural and remote settings do not have the same capacity, resources, capability or critical mass as their metropolitan counterparts, there are multiple examples of success in building health research capacity and enabling research environments across rural and remote parts of Australia. However, more work is needed, and this requires much greater financial and political investment. Specifically, rural and remote health research strategies for each state and territory, with appropriate policy levers, can provide a framework and incentives for rural and remote health services and health care workers to engage in research. Strong, collaborative and respectful partnerships across health services, governments and research institutions can support high quality and impactful research and increase researchers’ understanding of health care delivery in rural and remote settings. Increased and meaningful consumer and community involvement at all stages and areas of health research in rural and remote Australia can help ensure that research addresses local needs. With appropriate support and leadership, rural and remote health services can drive the research needed to improve health outcomes in rural and remote Australia.

Laura Alston · Lisa McFayden · Tarun Sen Gupta · Warren Payne · James Smith

The shortage of doctors in remote, rural and regional Australian communities is a longstanding health policy challenge. It is the main reason why almost 3000 overseas‐trained doctors enter the labour force annually1 — a similar number to the domestic graduate output of Australian medical schools.2 Most overseas‐trained doctors end up practising in major cities; 75% of all registered overseas‐trained doctors in clinical practice in 2021 were metropolitan based, with major cities also accounting for 76% of the growth in overseas‐trained doctors over the 2015–2021 period.3 In effect, rurally targeted recruitment of overseas‐trained doctors compounds the problem of geographic maldistribution that it is meant to solve. Achieving a substantial pipeline of Australian‐trained graduates who will willingly pursue regional careers as general practitioners, rural generalists and non‐GP specialists is therefore a first order policy priority. What it takes The evidence on what influences medical graduates to pursue non‐metropolitan careers has been accumulating over several decades.4 The best understanding is that a systems approach is required — an alchemy that combines the various factors known to enhance rural career choice.5 Putting aside remuneration and other incentives, a systems design in medical training must consider the full pathway from medical school applications through to GP and non‐GP specialist careers.4,6 Medical students who have a rural background are more likely to pursue rural careers than their metropolitan counterparts.4 However, not all students with a rural background will practise in rural areas, nor should they be expected to. Likewise, we cannot assume that all students with a city background are not keen to practise rurally. Strategies that can influence medical graduates to practise rurally include locating medical programs outside of major cities and aligning pathways for graduates with rurally based general practice training.6 While teasing out individual contributions of other elements of rural program design is difficult, interventions that are common to the programs that have the most success include substantial rural clinical exposure, longitudinal integrated clerkships, a rurally rich curriculum, rural health student clubs, rural teachers, rural clinical mentors, and rural social networks.4,6 Quality rural experience is also vital, as positive learner experiences are fundamental to driving rural interest.7 Australia has a strong record of investment in rural training, which has both applied and contributed to the evidence. This includes long term funding for regional health professional training through rural clinical schools and university departments of rural health.8 Under current arrangements, a quarter of all domestic medical students undertake at least one year of clinical training in rural and regional locations, with other students having access to shorter rural terms. Participating universities are required to admit at least 25% of their students from rural backgrounds and support rural health student clubs. The positive impacts of programs run by rural clinical schools and university departments of rural health are well documented.8 Encouragingly, domestic graduates accounted for 72% of the 4645 net growth in regionally practising clinician numbers over the period 2015 to 2021.3 Rural career interest among medical graduates is substantial, with 39% indicating a preference to work outside of a capital city.2 While it would seem evident that those graduates should be supported into regional postgraduate training, there are few resources in place to facilitate this. It is largely left to the wit of individuals to navigate the complex, city‐centric and large hospital‐oriented graduate training system. Much of the rural interest among graduates therefore goes unrealised. To bridge this continuity gap in regional training, various programs have been devised, albeit on a somewhat piecemeal basis. These include: Australian Government funding for supplementary specialist training posts in regional and private hospitals9; a stipulation that half the trainees in the Australian General Practice Training Program undertake their training outside of major cities10; and opportunities for a subset of junior doctors to gain rural general practice experience in addition to hospital rotations.11 In addition, the need for a more comprehensive approach to the regional medical training continuum is increasingly being recognised. Since 2017, the capacity of rural clinical schools to support medical training beyond graduation has been supplemented via the Regional Training Hubs program, with the aims of understanding and responding to regional needs, building regional capacity, and supporting students and graduates to do regional training and pursue regional careers.8 Despite modest resources and it being early days, this approach appears sound.8 A key challenge, however, is that while Regional Training Hubs are an Australian Government initiative, it is the state and territory governments that are primarily responsible for junior doctor training, non‐GP specialist training and hospital‐based components of general practice training through the public hospital system.8 A stronger collaborative model is therefore needed. Priority actions Australia must deliver a domestic medical workforce for the regions. This requires a reform of the medical training continuum, with buy‐in from universities, specialist medical colleges, public and private hospitals, and the primary and community care sectors. The Australian National Medical Workforce Strategy sets out overarching priorities for medical workforce reform, including better collaboration on planning and design of Australia's medical workforce, rebalancing supply and distribution, reform of training pathways and building generalist capability, and flexibility and responsiveness of the medical workforce.12 In terms of early reforms, and with unanimous support from its members, Medical Deans Australia and New Zealand is advocating four interrelated actions. Expand professional entry medical training in regional Australia Our current heavy reliance on overseas recruitment and hospital service demand for junior doctors suggest that a substantial increase in medical school places is required. Although we acknowledge that universities have an economic interest in medical school places, rural medical workforce is an urgent priority. Additional medical school places should therefore be deployed regionally into programs that apply the best evidence for delivering rural and primary care workforce outcomes. This should involve admissions policies, program design, and clinical training experience that emphasises learning in and for the following settings: rural and primary care, Aboriginal community‐controlled health services, rural hospitals, aged care services, disability care services, community mental health services and other community‐based services. The evidence on entirely regionally based programs vis‐a‐vis substantial rural placements is still emerging. However, improving access to medical programs for students and graduates wishing to be rurally based during their training offers additional benefits, and both models should be supported. In addition, to attract junior doctors and stem the loss from regional locations, rural practice must be fulfilling and sustainable throughout doctors’ training and careers. This requires funding reforms that enable: flexible business and clinical models; support for rural doctors to flourish in research, teaching and leadership; career paths that recognise fluidity in doctors’ vocations; and a flexible, needs‐focused approach to skills credentialling. Invest in the primary care sector as a quality teaching, training and research system If Australia is to build a stronger primary care system and achieve an equitable distribution of doctors, a greater emphasis on teaching, training and research (TTR) in primary care and rural settings is required. The Australian Government invested $2.2 billion in TTR in public hospitals in the financial year 2022–23,13 while support for teaching in primary care is limited to payments for GPs to supervise medical students, GP trainees and some junior doctors.11 Funding reforms must better embed TTR in primary care clinical and business practices; this is essential if the aspiration to “make primary care a first choice career”, noted in the Strengthening Medicare Taskforce report, is to be realised.14 Investment in primary care teaching infrastructure (such as additional consulting rooms, learning spaces and learning technologies) is sorely needed. Other community‐based settings need to be included too — Aboriginal community‐controlled health services that seek the opportunity, aged care services, disability care services, and community mental health services. A strong primary care teaching system can create an environment that strengthens vital primary care research and scholarship. It drives primary care‐based innovation and attracts and retains the next generation of primary care professionals. To deliver this, we need more equitable funding of TTR between hospitals and primary care or community‐based settings, and we need to grow the primary care TTR workforce. We also need: universities and research institutes to champion rural and primary care academics and researchers; medical colleges to preference rural pathways and experiences; hospitals to partner with primary care; and primary care and community‐based settings to embed TTR in their practice. This requires leadership, a funded strategy and key performance indicators for primary care TTR, plus more connected pathways into teaching and research for early career clinicians. Scale up intern and junior doctor posts in primary care settings and rural locations, aligned with the boost to graduate supply Medical graduates need high quality experiences in rural locations, primary care and other community settings in their junior doctor years, but achieving this is challenging because hospitals rely on trainee doctors to meet service demands.12 Reducing the reliance of hospitals on trainee doctors is important, as is progressing an outcomes‐focused approach to graduate training rather than conventional rotations through specialty units.12 The new national framework for prevocational medical training, set out by the Australian Medical Council, provides an impetus to take such an approach.15 That said, the main practical opportunity for growth of intern and junior doctor training in primary care settings and regional locations is aligning this with a substantial boost in graduate supply through medical schools. To ensure that these rural positions attract graduates and interns, we need to address the “hidden curriculum” that elevates city‐based subspecialisation within the training system and the profession. Selection into specialty training programs needs to preference rural experience and ensure strong rural trainee support and professional networks. Trainees need to know that going rural does not mean going it alone. Establish integrated regionally based postgraduate training capacity via regional training collaboratives Medical Deans Australia and New Zealand is advocating for the establishment of regional training collaboratives to draw the various currently discontinuous elements of medical training into functional alignment and deliver critical mass. Building on the Regional Training Hub initiative, regional training collaboratives would leverage two decades of investment in regional medical training. They would also enable stronger connections with regional hospital medical education units and with GP and non‐GP specialty training. Such place‐based approaches would support local strategies to grow training capacity that are based on local needs, local networks and local opportunities.16,17 Moving to integrated, collaborative models would coordinate regional training pathways, and provide consistent support for doctors in training, particularly across transition points and for those needing additional support. While a key challenge is connecting federal‐ and state‐funded elements, a principle of the 2020–25 National Health Reform Agreement is “joint planning and funding at a local level”.18 This provides both direction and a mechanism to progress the required collaborative funding, governance and accountability. Action is needed now Greater self‐sufficiency for Australia's medical workforce has never been more important. A boost to regional graduate supply that is aligned with rural, primary care and community‐based training and capacity building will be a key reform in producing medical graduates more aligned to future community need. Leadership, collaboration and a focus on outcomes will be key to delivering on the intent of this investment in Australia's future health care.

Richard B Murray · Helen Craig