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IF the key to reducing the health inequalities experienced by rural communities lies in better access to health care, then the federal government is treading a very delicate path.
With universal access to primary health services still in question, the proposed higher education reforms also threaten to undermine years of initiatives aimed at addressing the rural health workforce shortage and the equitable provision of health care in rural Australia.
Obstacles are already placed in front of potential doctors who come from rural areas — such as lower average household incomes and educational disadvantage — and it is not only future doctors, but rural communities, who are set to suffer.
Evidence and our own experience at the University of NSW Rural Clinical School has demonstrated that doctors who grew up and went to school in rural areas are more likely to practise in rural and remote areas.
I was one of them. After completing all of my schooling in Wagga Wagga, the UNSW Rural Student Entry Scheme allowed me the opportunity to study medicine, which I would not have been able to do through the mainstream entry process. But the cost associated with this opportunity in terms of travel and living away from home was significant.
Fortunately, UNSW opened the Wagga Wagga campus of the Rural Clinical School, which allowed me to complete the final 3 years of my medical degree in my home town.
Studying in my home town developed my interest in rural health care and consequently I have remained practising in rural areas for more than 10 years.
The ability to study medicine in my home town also meant my family could afford to support my younger siblings through their university degrees.
Future students may not be so fortunate. The proposed deregulation of higher education will significantly increase the cost of studying medicine. With average incomes being lower in rural areas compared with metropolitan areas, higher costs represent a significant disincentive for potential future rural medical students.
When the Rural Clinical School surveyed medical applicants it revealed they felt most negative about supporting themselves financially during university and about the overall cost of a medicine program.
Perhaps as a consequence, this year the number of students who applied for our Rural Entry Scheme has been the lowest ever.
Our students are worried, not just about the immediate costs of their degree, but about their long-term career prospects and gaining postgraduate fellowship training positions.
The federal government has rightly increased general practice training places, indicating the importance of primary health in the bush. But with the average income of GPs significantly lower than that of other specialities, there will be a disincentive to pursuing general practice training for medical graduates who have significantly larger education debts needing to be repaid.
General practice is still the only specialist training pathway available to doctors which can be completed entirely in the bush, and this is of significant concern to the rural students I talk to.
The specialist colleges have not followed suit to increase fellowship training positions to match the increase in the number of medical students. We know that those who do go on to specialist training in the city are unlikely to return to the bush. By the time they have qualified they are married, their children are in school, and the incentive to relocate to a rural area has long passed.
To address rural health inequalities, rural Australia needs doctors who are committed to working in rural and remote areas. We need doctors who have grown up in rural areas and understand the issues that impact rural communities. We need to attract doctors who are able to relate to and support people living in these areas.
Whatever reforms the federal government introduces, it must ensure that primary health care delivered by doctors trained in rural medicine is not affected.
We must all be cognisant of the impact these government reforms could have, and work to ensure our students are kept interested in rural medicine, that they continue to be offered rural scholarships, and that attractive postgraduate rural training opportunities are available.
The practice of rural medicine is one of our best-kept secrets. There are few other jobs in medicine that provide the hands-on experience, the variety and the sense of collegiality that we enjoy in the bush.
Universities have the essential responsibility of selecting and training future rural doctors and the federal government needs to ensure there is no disincentive for young rural Australians who aspire to being a doctor working in rural and remote communities.
Dr Damien Limberger is the head of the Griffith Campus, Rural Clinical School UNSW.
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High time to strengthen rural medicine in Oz. The elephant in the room is the 40% overseas trained doctors who currently provide that service who don’t even get a mention in this article. Neither do the hurdles they face in getting accreditation of their often extensive medical experience or in acquiring full Fellowship and thus becoming available for long-term rural care provision in Australia.
After all they are the ones who already do it, who have a life and family in rural communities and are thus more likely to stay, who have a wealth of international and rural experience, who cost the tax payer nothing but pay taxes instead and who want to stay.
Give them at least a mention and think about how to make the Australian system fairer so not to lose them.
Well said Damien. True rural training should broaden to other specialties. Griffith Longlook students do as well or better in surgery than metro students. There’s no reason this training can’t be more routinely delivered in rural areas, as opposed to tertiary centres incidentally in regional areas. This would certainly lead to vocational training in these specialties in rural areas. Thanks for continuing the discussion.
While there can be no disputing the fact that “country kids” are more likely to opt for a life as a “country professional”, I am not sure Damien that this holds quite so true for the specialist medical workforce. It is here that the matter of remote versus provincial comes starkly into play. There is little prospect of truly remote specialist practice in any discipline being viable. This is the world of the FiFo, and will justifiably remain so. Provincial specialist practice in one of the many “hubs”, such as your own “home town” of Wagga, where I too have worked, is another matter. For the most part these are vibrant communities with schooling, arts, food and other social options as never before. Ideal places for a specialist to bring a family to. What must be considered today is the important extension of these “hubs” as centres of teaching, research and clinical innovation excellence. The advent of “Rural Clinical Schools”, now present in all Regional Referral Hospital towns, has begun to make this the case. If the Commonwealth was to do anything to promote support for first class, close-to-place-of-residence care it would be to greatly enhance the ability of these provincial clinical communities to engage meaningfully in expanded teaching and research roles. An exciting and potentially very attractive aspect of practice seen as a cultural norm in the city. Clearly it won’t be for everyone, but it most definitely will for a critical few who will sow the seeds of change in this area. Can you see “Orange Food Week” matched by “Orange International (and why not ‘international’!!!) Provincial Clinical Teaching and Research Week”? I know I can! In the meantime, well done.