Time to end the drought in the bush

Rural and remote communities in Australia experience disproportionate difficulties in accessing mental health services compared to metropolitan populations. Despite presenting with a mental health burden equivalent to metropolitan populations, rural and remote communities experience higher rates of suicide, increased levels of acuity and are uniquely affected by environmental challenges including drought, fires and climate change.^1–4 With respect to the psychiatric workforce in rural communities, the situation has been in perpetual crisis; however, solutions may now be starting to crystallize.

Rural and remote areas have less access to psychiatrists as compared to metropolitan areas. ⁵ , ⁶ Indeed, the Royal Australian and New Zealand College of Psychiatrists (RANZCP) recognizes there is a ‘severe shortage of psychiatrists in rural Australia and in provincial areas of New Zealand, due to most people exercising a strong preference to live and work in major cities’. ⁷ Data on the psychiatry workforce show that major cities in Australia have approximately 15.1 full-time equivalent (FTE) employed psychiatrists per 100,000 population, while that figure was 5.8 for inner regional areas, 3.4 in outer regional areas, 5.0 in remote areas and only 1.4 in very remote areas. ⁶ The postgraduate specialist training system throughout Australia has perpetuated, if not created, this bias of specialists to reside and train in metropolitan centres.

Over the past decade, medical schools throughout Australia have been challenged to train doctors who are willing and able to practise in areas of poverty and workforce need. ⁸ Substantial Commonwealth funding of Rural Clinical Schools (RCS) across the country has accomplished substantial ends: graduates of these schools are working rurally at significantly higher rates than their urban-trained peers.^9–12 The known relationship between rural background and rural employment works synergistically for these graduates. ¹¹ Urban-background graduates are also positively impacted. ¹³ In addition, new medical schools which offer an entire medical degree in regional settings have made significant contributions to the rural generalist medical workforce. ¹⁴

It is increasingly clear that the impact of RCS is independent and additive. Both rural- and urban-background students entering medical school with rural intent, but who did not participate in RCS, are significantly less likely to enter the rural workforce than RCS participants,^15,16 indicating that funding for prevocational RCS accomplishes a significant additive workforce end relative to rural student recruitment alone.

The sum of these data has led to associated policy initiatives being accepted and adopted as a preferred framework to address medical workforce maldistribution from an undergraduate perspective. In contrast, there has been a striking lack of engagement in strategically developing postgraduate medical specialist training. Workforce data suggest rural internship and specialty training places would further increase the rural medical workforce, given that residents trained in a rural/remote area are more likely to remain there. ¹⁷ , ¹⁸

Existing postgraduate studies are largely focussed on the discipline of general practice: in Australia, ¹⁹ , ²⁰ and in the USA, ²¹ Canada, ²² South Africa ²³ and Finland. ²⁴ With respect to specialist areas in medicine, although there are some ²⁵ suggestive data that rural undergraduate exposure increases rural work in some medical specialties (Australia, ²⁶ Canada ²⁷ ), in general, there has been a dearth of studies looking specifically at the outcomes of postgraduate specialist training in rural locations. ²⁸

In the absence of specific training initiatives, all existing data suggest that medical specialties, including psychiatry, have low entry into rural work. ²⁵ The lack of opportunities for those seeking specialist postgraduate training rural opportunities is notable. Specialist medical postgraduate training pathways remain metropolitan-centric, with trainee selection, allocation and administration occurring from, and to, predominately capital cities, arguments for this being one of ensuring adequate supervision and training experiences. Thus the status quo of a metropolitan-based workforce is perpetuated.

To further complicate the acceptability of rural training pathways, contemporary trainee experiences of rural training may reflect current organizational issues, rather than actual learning opportunities. Despite the RANZCP removal of mandatory rural rotations, some health service jurisdictions still require them. Mandated short-term experiences for trainees can be disruptive, personally costly and may rupture the social supports required during postgraduate training. For obvious reasons, this forced approach of ‘rural experiences’ has not resulted in lasting workforce recruitment and retention.

Not all prospective trainees will want to live, train and work rurally. ¹³ However, with the increase in selection of rural students to medical schools, and a comparatively small number of trainee opportunities available rurally compared with cities, the numbers required to develop and sustain a rural training workforce are not large or insurmountable.

Initiatives such as the New South Wales Rural Psychiatry Project provide a glimpse into the advantages of rurally based programmes, with locality being a strong driver of trainee satisfaction and choice. Having a rurally based training coordinator, dedicated rural training activities, support in supervision and financial support when accessing metropolitan-based experiences were important components of the initiative. However, systemic bias towards ‘city-centric’ training regulations and demanding service requirements in overstretched rural services were seen as barriers to rural fellowship training. ²⁹ A lack of subspecialty advanced training opportunities and difficulty accessing formal aspects of training remain as structural deterrents for some aspects of training; however, the generalist approach to fellowship in rural locations was considered well suited. ³⁰

In keeping with recent changes to undergraduate medical training, specialist colleges are now being called upon by governments to provide medical education at regional levels to ensure rural programmes ‘support long term community outcomes’. ³¹ The Integrated Rural Training Pipeline and Specialist Training Programs are evidence of this shift. ³² With future evaluation of this funding model, the rural generalist pathway may prove to offer specific, as yet unidentified advanced skills in psychiatry, unique to the rural training environment. However, one of the challenges for these programmes will be in identifying and developing supervisors, in addition to developing new innovative supervision models. ¹⁰ Initial structural training support from the RANZCP and metropolitan-based fellows and supervisors will be required until critical rural supervisor numbers are realised for programmes to become self-sustaining.

The foremost question when considering the disproportionate circumstances that rural and remote communities face in accessing mental health services remains: will the disadvantage continue unnecessarily over the next decade? Or is it time for the drought to be broken? Dedicated rural training programmes may just provide the workforce relief that is needed.