RACMA’s position is that remote, rural and regional health services require high quality and effective medical leadership and management, provided by those specialty-trained in medical administration and addressing the key unique elements of these services.
Around 7 million people, about 28% of the Australian population, live in remote, rural and regional areas (ABS 2017e). These Australians face unique challenges due to their geographic location and often have poorer health outcomes than people living in metropolitan areas. According to the Australia’s health report 2020, data shows that people living in rural and remote areas have higher rates of hospitalisation, death, injury and also have poorer access to, and use of primary health care services, than people living in Major cities.
RACMA through community engagement supports the findings in the Household, Income and Labour Dynamics in Australia (HILDA) survey (Wilkins,2015) that, despite poorer health outcomes for some, Australians living in towns with fewer than 1,000 people generally experienced higher levels of life satisfaction than those in urban areas and major cities (Wilkins 2015).
In New Zealand one in four New Zealanders live in rural areas or small towns, and there is a greater percentage of children, older people, and Māori living in these areas. Ensuring comprehensive, quality services for people living in rural areas is a priority for the New Zealand Government. Funding for rural premiums to support the retention and recruitment of the rural primary health care workforce commenced in 2002.
One of the major causes for the imbalance in health outcomes is the maldistribution of the medical workforce. This extends to Medical Administrators and those who apply Medical Leadership and Management skills as part of their clinical work.
It is often assumed incorrectly that a local doctor, locum or medical trainee can act as the sole resource for Medical Administration in a smaller rural health service; or that a single specialist Medical Administrator can cover a range of roles in rural centres.
Effective Medical Leadership and Management skills provided by those specialty-trained in medical leadership and management will support the attainment of the following key practice elements for remote, rural and regional health services.
In this Statement, RACMA uses the Institute for Healthcare Improvement (IHI) definition for population health based on the definition articulated by David Kendig:
Population health is defined as the health outcomes of groups of individuals, including the distribution of such outcomes within the group. These groups are often geographic populations such as nations or communities, but often can be other groups, such as employees, ethnic groups, disabled persons, prisoners, or any other defined group.
PRACTICE STANDARD 1
Remote, rural and regional health care services in both Australia and New Zealand should embody, in addition to excellent quality clinical care, high levels of education, training and research built on the foundation of population health.
Remote, rural and regional health services should provide excellent quality clinical care with high levels of education, training, research and quality improvement.
Research and quality improvement encompass the continuum from audit and quality improvement projects through to involvement in multi-site clinical trials. Remote, rural and regional health services should not just be “receivers” of research and outreach services. They should be leaders of innovative research given the different nature of the context of care provided, and the unique nature of the workforce and challenges found. This will improve the translatability of research to remote, rural and regional areas and foster a mindset that actively seeks collaboration with larger studies. This involvement will also improve the patient experience and quality of care as connectivity and peer support between urban and non-urban clinicians is fostered during the activities.
Medical education and training should, wherever possible, be locally planned and delivered, and linked to the current and emerging service needs of the community. Trainees and/or Candidates should be aware of the ability to access certain experiences and infrastructure in the rural context. Where possible, there should be participation in networked rotational or other educational support systems.
The remote, rural and regional setting provides a unique opportunity for horizontal and vertical learning and a mandatory term for all medical training in such a setting should be considered.
Effective Medical Leadership and management skills provided by those specialty-trained in medical leadership and management is critical to ensuring that education, training and research, based on a foundation of population health, are provided to a high level to support excellent clinical care.
RACMA Members have acquired specialist knowledge of the medical specialist training college system. In addition, many work with medical schools to establish and support local medical student training as part of building a sustainable medical workforce and assist in developing vocational training programs for rural generalists. RACMA Members are trained in research and able to work to build diverse research capacity.
PRACTICE STANDARD 2
Remote, rural and regional health care services have a close and unique relationship to the communities they serve.
Remote, rural and regional health services have a high level of involvement by community members and are highly scrutinised by the communities they serve, which includes Indigenous communities. There is a real sense of local “ownership” of remote, rural and regional health services that often contributes not just to the health care but also the economic well-being of their communities. This is especially important in regard to the priority of improving the health of Indigenous communities. It also requires a strong focus on population health.
Effective Medical Leadership and management skills provided by those specialty-trained in Medical Leadership and management is necessary to ensure that health services work genuinely with the people they serve to achieve the best individual and population health outcomes possible for their communities. RACMA Members have a focus on reducing inequities that exist not only between rural and metropolitan areas, but also within remote, rural and regional communities themselves.
RACMA Members as Medical Leadership Specialists in a remote, rural or regional setting often come to be seen as leaders in their community. Members engage with and work in coalition with other community leaders, consumers, patients and carers to serve the community and to implement whole of community initiatives for health improvement and population health.
RACMA Members as Medical Leadership specialists will promote full ongoing participation with Aboriginal, Torres Strait Islander and Māori in decision making, service planning, design and implementation of policies supporting their health and wellbeing. They will work to ensure equity in health outcomes for Aboriginal, Torres Strait Islander and Māori individuals, their families and communities.
PRACTICE STANDARD 3
Remote, rural and regional health care services require Medical Leadership and governance, underpinned by population health, that integrates a holistic approach so that primary health care aligns with all levels of hospital care.
Remote, rural and regional services are unique in the way that primary care interacts with secondary and tertiary levels of care. Primary care practitioners provide hospital care and population health services as well as individual patient care across a range of specialty areas.
Effective Medical Leadership and management skills provided by those specialty-trained in Medical Leadership and Management is to ensure a true integration of service delivery across the continuum of care. Remote, rural and regional health care services are leaders in integrated care and may be able to inform system change in other areas of the health system.
RACMA members have specialist knowledge of how to integrate effectively and efficiently the numerous component parts of a health system to ensure optimal functioning. This is particularly critical in remote, rural and regional settings where health resource stewardship is fundamental to innovation in models of care to serve a diverse community.
PRACTICE STANDARD 4
Remote, rural and regional health care services require a medical workforce that is wherever practicable locally resident and provides genuine continuity of clinical care and cultural safety to patients and population health services to Australian and New Zealand communities.
Strategic medical workforce development and deployment for remote, rural and regional health services should be led by those who are specialty-trained in medical leadership and management who will:
- Lead the strategic development of a rural medical workforce that is fit for purpose and contextualised to the local Clinical Services Framework and future projections of their region’s health care needs.
- Ensure that the workforce composition matches that of the local population including the Indigenous community.
- Build robust relationships with key stakeholders to drive a shared vision of a rural medical training “pipeline”, with particular reference to rural generalist training matched to the local community need.
- Advocate for recruitment and retention strategies that support the resident workforce, inclusive of the capacity to participate in quality activities, research and education.
- Analyse the barriers for remote, rural or regional sites to recruit to medical positions and develop innovative strategies for addressing these barriers.
- Ensure that the locum medical workforce operates within a framework that ensures continuity of care for patients, support for resident clinicians, and an expectation that locums will engage in training, and patient safety and quality initiatives.
- Set the standard for medical governance that actively fosters a workforce culture that is focused on patient safety and consumer engagement.
- Develop culturally safe and appropriate models of care that are enabled by innovative workforce solutions in challenging remote, rural and remote environments to enable equity of access to health care.
- Analyse the cost and revenue drivers impacting on medical workforce establishments to ensure a sustainable workforce is developed with a balance of skill mix and seniority.
- Actively support workforce strategies that foster Indigenous employment aligned with principles endorsed by appropriate indigenous organisations.
- Facilitate succession planning for key medical roles in their region, including their own.
RACMA membership provides an appropriate standard for the rural generalist to attain skills in Medical Leadership and Management. Effective medical leadership and management skills, provided by those specialty-trained in Medical Leadership and Management, is necessary to ensure remote, rural and regional health services have a highly skilled medical workforce.
RACMA Members in remote, rural, and regional Australia and New Zealand combine specialist Medical Leadership and Management knowledge with personal investment in, and commitment to, their local community. This promotes engagement with and support for peer medical specialists, both of which are factors contributing to attracting and retaining a high-quality medical specialist workforce.
PRACTICE STANDARD 5
Remote, rural and regional health services require a holistic clinical governance model informed by population health involving genuine engagement between managers and clinicians.
In rural and regional health care services a close partnership of all clinicians is central to achieving good governance in the areas of pro-active assessment of care; research linked to population health which includes Indigenous people, community and patient centred care; training and supervision; performance reporting and transparency; and workforce capability, planning and performance.
Effective Medical Leadership and Management skills provided by those specialty-trained in Medical Leadership and Management will ensure appropriate clinical governance and engagement that will deliver the highest quality care for patients and their communities.
RACMA Members have specialist medical knowledge in clinical governance. These skills are particularly useful in implementing a robust yet nuanced clinical governance approach in a remote, rural or regional setting where clinical governance stakeholders are often high-profile members of a local community and Indigenous people.
RACMA Members are skilled to shape rigorous clinical governance in remote, rural or regional settings while preserving the privacy of patients and staff (risks to which sometimes deter clinical governance actions).
 Wilkins R 2015. The Household, Income and Labour Dynamics in Australia Survey: selected findings from waves 1 to 12. Melbourne: Melbourne Institute of Applied Economic and Social Research.