Health services administration

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

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

Anne Kelso