National Rural Health Network
	“Harnessing good intent”

Ms Litsa Kane
C/- ARRWAG
49 Drummond St
Carlton Vic 3053
lkane@arrwag.com.au

National Rural Health Network (NRHN)

Response to the Productivity Commission position paper on 

Australia’s Health Workforce

November 2005

About the National Rural Health Network (NRHN)

The National Rural Health Network (NRHN) is the national peak body representing 18 university Rural Health Clubs (RHCs) nationally.  The NRHN provides a national, united student voice on issues pertinent to rural and remote health through representation, networking, professional development and initiatives.  Of these 18 clubs, 11 have significant medical student involvement and the remaining 7 have predominantly allied health and nursing student representation.  The NRHN is funded by the Commonwealth Department of Health and Ageing (DoHA) and is auspiced by the Australian Rural and Remote Workforce Agencies Group (ARRWAG).

The main goal of the NRHN is to provide a communication network through the provision of communication between clubs that provides the individual clubs with opportunities to share ideas with one another.  Also, the NRHN serves as a forum in which a consensus of student opinion on issues relevant to rural and remote health can be achieved and it provides a forum for key stakeholders, both government and non-government, to share information and canvas ideas with the future rural health workforce.

The NRHN has a multi-disciplinary focus on healthcare and the nature of the Network and the rural health clubs is one of collaboration and teamwork. By providing the means for students around Australia to work together, harness the ethos and passion for rural and remote health and by encouraging a team work approach, the NRHN is working towards increasing the future health workforce in rural and remote Australia. 

The NRHNs response

The NRHN welcomes the opportunity to provide a response into the Productivity Commission paper on Australia’s Health Workforce.  Broadly, the NRHN supports many of the recommendations in the report, however this document focuses on the key area’s affecting the NRHN and its membership primarily in the areas of health workforce education and training (chapter 5) and rural and remote issues (chapter 10).  In addition, the NRHN has identified several key areas it wishes to highlight and provide comment from within the Commission’s report.

The NRHN highlights that the following document is in no means indicative of the numerous issues faced by the health workforce in rural and remote Australia however, it provides an overview of the key areas of concern for the NRHN in particular reference to the recommendations outlined in this report.

Chapter 5: Health Workforce Education and Training

Draft proposals 5.2 and 5.3

The NRHN is in support of draft proposals 5.2 and 5.3 of the report proposing that the Australian Health Minister’s conference should establish an advisory health workforce education and training council to:
provide independent assessments of opportunities to improve health workforce and training approaches; and
focus policy effort on enhancing the transparency and contestability of institutional and funding frameworks.
Regarding draft proposal 5.3 the NRHN highlights that there is a noted difference in clinical placements and teachings across Australia. The NRHN believes that the regulation of procedures on the national level should be considered and implemented.  The NRHN acknowledges that private sector funding could assist in reducing the funding that the government needs to provide, however this could compromise the much needed consistency at the national level.

Draft proposal 5.1

It is in relation to draft proposal 5.1 that the NRHN wishes to provide a more detailed response.  The NRHN supports the recommendation to transfer primary responsibility for allocating the quantum of funding available for university based education and training of health workers from the Department of Education, Science and Training (DEST) to the Department of Health and Ageing (DoHA).  The NRHN appreciates the practical and logistical impact such a move will have and recommends that these are clearly mapped out and planned prior to the transition.  However, the NRHN believes that this change will allow for health education providers to meet the needs of community demographic requirements for health practitioners in each region. For example it may eliminate universities that deliver only one health program and allow for health students to be trained in their own region thus increasing the chances of these students practicing in that region upon graduation.

In addition, this proposal fits with the current working structure of the NRHN and the NRHNs aim of encompassing a true multi-disciplinary approach to health provision in rural or remote areas.  For example, the NRHN is currently working with the Rural Education Forum Australia (REFA) to create a network for education students similar to that of the NRHN.  By providing a stronger link between the DEST and DoHA such initiatives will be more accessible and will work towards providing a more united solution to Australia’s health workforce shortages, particularly in rural and remote areas.

Further comments on Chapter 5: Health Workforce Education and Training

Several issues were raised in this chapter relating to training of undergraduate and postgraduate medical and allied health students. Primary discussion was on the funding arrangements currently in place for clinical training of which the NRHN wishes to provide additional comment.

It is well recognised that there are limitations on the clinical placement experiences for current health students. There is no formal approach that has been set out to determine how many students / trainees, one site can accommodate. This placement problem has been attributed to poor communicators between the funding providers (Federal) and placement providers (State and Territory). 

1.	From the CDAMS submission Creation of new medical schools must take account of the availability of clinical placements and not continually create the need for reactive responses to political whim. (sub. 49, p. 10)
 
On the theme of clinical placements, it has been shown that there is an informal relationship between universities and private providers for the training of students. As the burden of training will be further shifted to other sites, private medical providers are seeking appropriate funding. Currently they receive small amounts of university funding which is variable and dependant on institution. 

2.	However, in an environment where the private sector will inevitably play a more significant training role, and with a likely greater emphasis on explicit payment for training services, the question arises as to whether one level of government should be responsible for providing all, or the majority of, public subsidies for the service – Commission Report

If the funding issue is un-resolved there may be a move towards “simulation” based teaching, which is not without its problems such as expense.  Simulation based teaching may significantly lead to clinical deficiencies in the students trained via this method. Simulation is applicable for higher level training such as in surgical techniques but it should not make the basis for basic undergraduate / postgraduate medical or allied health teaching. 

3.	There is a huge amount of pressure placed on public hospital physiotherapy departments to provide undergraduates with the experience they need to be job ready. The system largely functions on the goodwill of clinicians and is unsustainable. (Australian Physiotherapy Association, sub. 65, p. 12)

This issue was also identified by the College of Nursing and the NRHN wishes to highlight the merit behind such concerns.  Placements for nursing students are difficult, as there is an undersupply of clinical training placements and there is much competition. There is currently no identifiable “network” approach to allocation of nursing students and there is competition between the nursing schools rather than cooperation for allocation of clinical placements. The NRHN believes that the establishment of networks should be implemented for nursing students nationally. 

The NRHN believes that a key way to produce health graduates with adequate knowledge in order to work effectively within the health care system is through the development of clinical training positions. The NRHN recommends that adequate resources should be allocated for the availability of such positions for all health students. The NRHN firmly believes that If Australia wishes to produce a sustainable health workforce, governments need to invest in training rather than being forced to rely on short term measures.  The NRHN in no means underestimates the value of such short term measures or of Overseas Trained Doctors (OTDs), however in the longer term the NRHN believes that training of Australian health students is better sustainable on many levels.  

4.	Access to quality clinical teaching placements is likely to emerge as the major rate limiting factor in an effort to ramp up professional training programs. CDAMS

In addition to this, the NRHN highlights other limiting factors including a lack of resources for training in rural environments and an increase in incentives for students to practice in rural and remote areas.  The NRHN notes that rurality and issues connected to education and training were not highlighted in this chapter and considering within medical schools there is an increasing burden being placed on rural and remote areas the NRHN believes this is an area in deep need of exploration by the Commission.  The NRHN does acknowledge that there is some funding provided in this area and acknowledges the substantial contribution of current RUSC funding to rural and remote training at the medical student level.

Chapter 10: Rural and Remote issues

Draft proposal 10.1

It is highly recognised that the challenges faced by health practitioners in rural and remote areas varies greatly to those working and living within urban areas.  The NRHN agrees with Draft proposal 10.1 that the Australian Health Ministers’ Conference should…make explicit provision to consider the particular workforce requirements of rural and remote areas however the NRHN would like to ensure that not only are provisions considered, but that the means are provided to ensure that they are also implemented.   

Such rural and remote workforce requirements include greater financial assistance to health professionals, planning and financial assistance at the undergraduate health level and importantly, resource assistance to residents of rural or remote areas for greater and fairer access to medical treatment as those in urban centres across Australia.

Financial incentives provided to employees who are new to a rural and remote area do assist with recruitment, however the NRHN believes that as long as they continue to cease at a certain point in time (approximately 5 years) this will be less likely to encourage the retention of these health professionals.

The NRHN recommends that further assistance both at the planning and financial levels needs to be provided to improve student access to rural and remote placements during study. Under the current system, each university has a “first preference area”. This may work in principal, but it potentially shuts students out of placements in many rural or remote areas particularly a student’s home town.  This in particular is of a large concern to the NRHN given that the Federal Government is currently providing substantial resources into the recruitment of health students back into their home towns given the higher likelihood of both recruitment but importantly of retention into these areas post graduation.

In addition, the NRHN proposes that the additional costs associated with the provision of health services in rural or remote Australia should be factored into all state and federal funding allocations.

Draft proposal 10.2

The NRHN believes that a key element for the improvement of health outcomes in rural or remote areas can be achieved through job satisfaction, position redesign and flexibility, new funding opportunities and in particular within a framework that is suitable and tailored to rural or remote areas and location specific needs.  The NRHN supports the recommendation for the health workforce improvement agency to work on implementing such changes.

Draft proposal 10.3

Financial incentives vs practical experience for health professionals in rural or remote areas

The NRHN recognises that there are currently programs that are both ‘incentive-driven’ and ‘coercive’ approaches for education and training or service delivery in rural and remote areas.  The NRHN membership comprises of many students who are recipients of varying scholarships including the John Flynn Scholarships (JFSS) and the Medical Rural Bonded Scholarship (MRBS) Scheme.  The NRHN is in support of the Government’s plans to research and implement varying initiatives to help increase Australia’s health workforce in rural and remote Australia.  A relatively new initiative (commenced in 2001) the MRBS scheme provided a small group of approximately 15 graduates at the conclusion of 2004 with the majority of MRB scholarship holders graduating at the completion of 2005 and 2006.   As such, the NRHN supports the Government’s plans in the coming years to assess and reasonably track bonded and non bonded scholarship and non scholarship graduates versus the benefits they will provide in health care to communities in rural and remote Australia.

Statistics provided in table 10.1 indicate that the larger number of health workers in rural and remote Australia are nurses who do not have the opportunity to receive financial incentives such as the John Flynn Scholarship or Medical Bonded scholarships currently available to medical students. With this in mind, the NRHN questions whether only financial incentives are the answer.  The opportunity for career advancement, career development and education (eg. Surgery, specialist education etc) may be key reasons for doctors staying in major urban areas given the lack of opportunity for such advancement in rural and remote areas. However, nurses have the opportunity to advance their careers by working as nurse practitioners in rural and remote areas.  This is not a financial incentive but rather a practical experience incentive.  The NRHN recommends that such incentives are reviewed in conjunction with financial incentives for medical, allied health and nursing disciplines. 

General comments on the Australia’s Health Workforce paper

Advisory health workforce improvement agency

The NRHN supports draft proposal 4.1 for the establishment of an advisory health workforce improvement agency to evaluate and facilitate major health workforce innovations on a national, systemic and timetabled basis.  The NRHN recommends that a representative from the NRHN Council should be a member of the proposed agency to provide a voice for current students who will be the future of Australia’s health workforce in rural and remote Australia.

Single national accreditation agency for university-based and postgraduate health workforce education and training

The NRHN supports draft proposal 6.1 for the establishment of a single national accreditation agency for university-based and postgraduate health workforce education and training.  The NRHN supports the goal for the development of uniform national standards upon which professional registration would be based.

Nurse practitioner model 

The NRHN is in support of nurse and other allied health professional practitioners in rural and remote areas given that in the current climate this extension of practise would benefit community health and create career advancements for people working in rural and remote Australia.  The NRHN is unable to provide a position statement addressing this issue at this stage, however the NRHN nursing subgroup WINNOWS does support the advanced rural and remote nursing practise as a first line contact in the health care service. 

The NRHN does recommend that flexibility is needed for the provision of nurses and allied health professionals in rural settings.  This is particularly due to the fact that rural and remote areas depend, in particular, on nurses to provide primary health care and clinical services within a nursing framework and in collaboration with other health professionals. In many smaller towns and communities the nurse is supported only by on-call or part-time medical officers and allied health staff. The NRHN recognises that the role of the nurse practitioner is only available to nurses with expert experience gained over a long period of time and that education and competency development is crucial to the role.  However, the NRHN believes that stringent requirements need to be implemented including the need to seek advice and guidance from a medical practitioner via tele-medicine or telephone when no other options for treatment are available.

Further and improved access to tele-medicine

While it is acknowledged that in many cases, resident medical specialists are not a viable option in most rural and remote areas, improvement of access to specialist care for individuals must be considered and ultimately improved.  There are a variety of avenues that can achieve this inclusive of, but not restricted to, Tele- / videoconferencing and “fly in, fly out” type visits.

Summary

The NRHN supports many of the draft proposals outlined in the Commission’s report as they have the potential to increase the health workforce in Australia, aid in the break down of barriers for the provision of health services, particularly in rural and remote areas, and provide greater integration.  The NRHN highlights that some proposals will require stringent control and thorough planning and discussion with key health representatives nationally prior to implementation and that the commission will encounter opposition to the implementation of some of the recommendations.  Regardless of this however, the NRHN is in support of any initiatives that can better improve the working environment of Australia’s health workforce and importantly, that lead to a betterment of services provided to Australia’s community particularly within rural and remote areas.