Analysis to synergy: Why coordination of rural initiatives at metropolitan universities is important and timely

The article by Lyle et al.1 analysing the University of Sydney's rural recruiting/workforce and educational initiatives illustrates how a leading metropolitan academic institution has or has not developed a synthetic strategy that optimises its response to the Australian rural health workforce shortage. The problems that the authors have identified: lack of dedicated staffing and resources aimed at rural educational issues, and lack of resource coordination, result from historical growth. Lack of strategic planning, in this instance regarding university rural clinical education, is typical of government and academic structures funded by small initiatives that are, de facto, siloed in university departments. Furthermore, small add-on programs with independent funding come with accountability requirements for reporting that tax the small number of staff allocated to the job. The authors raise the issue of small bits of rural initiative in many places. Thus, the study highlights the problem of creating critical mass when dealing with a broadly important, but thinly resourced issue. First, let us ask the question, how important is the 'rural workforce issue'? Should metropolitan universities dedicate themselves to rural curriculum, staff, infrastructure and resourcing when so many pressure points exist in an already, arguably, under funded educational system? The mortality statistics from rural Australia and the data available regarding metropolitan use of health resources argue 'yes'. Rural Australian men's mortality rates are 10% higher than their metropolitan counterparts.2 Conversely, metropolitan Melbournians see their GP an average of 7.4 times per year compared with 4.7 consults per year for rural Victorians.3 One could argue what the appropriate rate of consultation is, but an equity gap clearly exists. Alternatively, one could argue that Australia's economy is crucially dependent on a healthy, thriving rural community because 42% of Australia's primary producing capability comes from the rural sector.2 If the crux of the 'rural problem' still lies with workforce initiatives rather than education, should universities be trying to solve a workforce problem and how might universities tackle the issues identified in this study? Although part of the agenda is to address workforce issues, universities do not exist to address workforce issues per se, but rather to provide high-quality educational experience for their students and thus competent and well-prepared graduates for the workforce. In Australia, public funding of education for health professionals has resulted in a system that has not necessarily matched graduates to workforce, despite attempts to do so. Technically, about 30% of the Australian populace resides outside capital cities, but only 7% of medical doctors, for example, live in these areas.4 The strategies and resources in the education sector needed to address the gap must, by nature, come first as recruitment, second as educational policies that encourage rural curriculum and exposure and third as infrastructure and support for students. Most universities across Australia, but also in Europe, the USA and Canada, are struggling with similar workforce issues. One of the first steps, as shown in this study, is to gather correct data. It is likely that rural students are disadvantaged in their ability to gain entry to highly competitive universities, especially in the health professions. Furthermore, even if an equitable proportion of rural students are gaining entry into programs, many datasets for tracking rural students depend on high school postcode and such methods miss bright or rural background students who attend metropolitan boarding schools (with metro postcodes) in an effort to 'make the grade.' Getting the datasets right, and getting admissions policies right is crucial to top universities. It might be that students who grew up in the country would still go back to that place, even if they had attended boarding school. Thus, although rural recruitment and understanding the successes from that strategy are important, rural needs will never be met completely by rural students. If we assume that coordination of resources is good and necessary, but perhaps not enough, what other models exist? Large rural academic outposts with infrastructure and staff must be weighed against funding or establishing rural universities who do have the rural agenda as their raison d'etre. Outposts of prestigious universities can be and are successful across Australia, but they struggle for capable staff as outstanding staff are often lured to more prestigious city jobs. Even the government's larger programs, such as the University Departments of Rural Health and Rural Clinical Schools programs, implemented at the local level of each university in rural communities, struggle with the tyranny of distance and go largely unnoticed in thehurly-burly of academic life. Rural coordination imperatives pale in comparison to national initiatives (such as the Research Quality Framework) that are attempting to identify, coordinate and strategically allocate funding to research; with the risk of cutting off funding to small rural departments. The major risk to rural programs is the fragility of their potential so early in the game. Rural initiatives must still be protected from significant weeding and competitive natural selection in this early period of growth and innovation. The authors identify that little rural curriculum exists in their institution. Is the need for 'rural curriculum' really an issue or is it a political myth? Rural health professionals will certainly encounter snakebites more often, but is there a broader agenda? A rural agenda can be worth more than it appears at first blush. For example, specialty colleges have identified a lack of rural proceduralists as a significant issue and, even in metro, most would agree that the balance of specialists to generalists is a problem. A recent study in the USA notes that generalists do only half of the procedures that they did 20 years ago, but that rural doctors maintain their skills in this area and only 23% of rural doctors do procedures.5 Specialists cost more and take less responsibility for the whole patient in an era when concerns about health professionals' communication about patient issues is still of concern, with a recent review showing that only 11% of discharge letters and 25% of discharge summaries reach primary care doctors.6 Finally, is this worth a university-wide initiative? The health workforce is critically dependent upon jobs in other sectors for doctors' partners and issues such as lack of child care and educational opportunities in rural areas. Thus, joint faculty initiatives in rural areas, such as the cross-faculty rural campuses at the University of Melbourne's School of Rural Health in Shepparton and Dookie (Land and Food Resources) enrich the lives of students and staff by providing the critical mass of academic and cultural experience as well as university services. The 605 new university medical undergraduate places announced in 2006 are partly targeted at rural shortages and most of these new students will be training in rural and regional areas, thus the time is ripe for analysis and planning. At the end of the day, large metropolitan universities struggle to prioritise rural issues when bigger pressures such as traditional academic research recognition, research funding and Commonwealth educational funding are so much more critical to their survival. For such behemoths, recognition and coordination of a key 'minority' issue (e.g. rural health, women's health and indigenous health) must come from the top and be highly visible. Even this editorial, published in a rural health journal, will arguably be far from the attention of Vice Chancellors. However, the first steps, getting the data and knowing the lay of the land enables advocates to take a reasoned argument to the leaders who need to understand the critical nature of the rural problem before they can make an informed choice to take up the mantle or, perhaps at their peril, to ignore the problem.

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