Building the Australian Rural Health Workforce

• Introduction
• The Context for Rural Health
  • Population Distribution
  • The Economy
  • Family Structure and Education
  • Health Status of Rural Australians
    
    
• Changes in Rural Health Practice, Public Expectations and Government Policy
  • The Changing Nature of Rural Health Practice
  • The Unique Features of Rural Practice
  • Public Expectations
  • Government Policy
    
    
• Strategies to Build the Rural Health Workforce
  • The Current Situation
  • What Strategies Have Been Shown to be Effective in Building a Rural Health Workforce?
    • Overseas trained doctors
    • Recruiting rural students into academic health courses
    • Retaining rural students in rural careers
    • The undergraduate curriculum
    • Vocational training
    • Recruitment and retention of health professionals in rural and remote areas
      
      
• Conclusion
• Acknowledgements
• Footnotes
• References

Introduction

This paper is in three parts. The first part is a description of some of the key features of the population distribution, economy, family structure, education, and health status of rural Australia. Secondly, we discuss the changing nature of rural health practice and how this relates to the expectations of the rural population and Government policy. Finally, the paper considers some of the strategies needed to build an appropriate rural health workforce. Recruiting, training and retaining adequate numbers of skilled and responsive health professionals are particular issues for rural and remote Australia. ^( a ) . We conclude by suggesting that the rural health workforce may need reconstructing, given the significant impact of specialisation and technology on health care.

The Context for Rural Health

Population Distribution
Australia is one of the least densely populated countries of the world with only 0.8 persons per square kilometre in non-metropolitan areas (compared with 326 persons/km² in metropolitan areas and a national average of 2.3 persons/km²).  ¹   Of the 17.9 million Australians recorded in the 1996 Census, 26.2 percent (4.7 million) live in regional and rural areas, and 3.4 percent (0.6 million) live in remote areas.  ²   Eighty three percent of the population lives within 50 kilometres of the coast.  ¹   Over three-quarters (76.6 percent) of people who live in rural and remote areas, live in scattered small towns and settlements with populations of less than 10,000 people.  ²   This pattern of settlement makes the feasibility and cost of providing health services to rural and remote Australia particularly difficult.  ³  

Although 30% (in 1996) of indigenous people lived in Australian state and territory capital cities, they constituted a higher proportion of the population in rural (3%) and remote areas (13% in remote centres; 26% in other remote areas) compared with the cities (1%).  ⁴   Australia also has one of the highest proportions of residents born overseas of any country in the world (22%). The majority of these people have settled in the major cities but some large regional centres and irrigated agricultural areas do have above average proportions of overseas-born residents.  ¹  

The Economy
In 1997/1998, the rural economy contributed 42 percent of Australia’s exports (agriculture 20%; rural manufacturing 1%; mining 21%), and in 1996/1997 these rural industries directly contributed 12 percent to Gross Domestic Product.  ²   These calculations exclude tourism, which increases the contribution of rural and remote Australia to the economy. In 1995–96, national expenditure by visitors directly contributed 7.4 percent to Gross Domestic Product and accounted directly for 8.4 percent of total employment (694,000 jobs).  ⁵  

Labour force participation is lower on average in the non-metropolitan areas (58.2% in 1996) than in the metropolitan areas (67.1% in 1996) and is dominated by employment in the agricultural, pastoral, mining, and in some areas, tourism industries.  ¹   Mean annual taxable income in non-metropolitan areas was $4,200 less in 1996 than for those resident in the largest cities, although this measure takes no account of assets and masks significant regional variations. For example, regions in Western Australia where mining makes a significant contribution to the economy (eg, the Pilbara and Northern Goldfields) have a lower proportion of low-income families compared with the State average.  ⁶   In 1996, non-metropolitan areas had slightly higher unemployment rates (10.4%) than metropolitan areas (8.5%). Youth are particularly affected with nearly 20 percent of non-metropolitan young people unemployed in 1996, compared with 14.4 percent of their urban counterparts.  ¹  

Family Structure and Education
Children in rural and remote communities experience a number of disadvantages. Children raised in single parent families are more likely to be raised in poverty than children in two parent families. Whereas in 1996 there were only minor differences in the proportion of single parent families in non-metropolitan (10.1%) and metropolitan (9.7%) communities, the numbers of single parent families increased more dramatically in non-metropolitan centres between 1991 and 1996 (26.7% compared with 19.2% in metropolitan centres). Not surprisingly, more children under 15 years of age in non-metropolitan areas (28.3%, compared with 22.5% in metropolitan areas) lived in families in 1996 who were receiving some form of government benefit.  ¹   Children also have poorer access to educational opportunities in rural areas compared with children in the cities. In 1996, 75.8 percent of 16-year-olds attended school in non-metropolitan areas compared with 82.9 percent of those in metropolitan centres, and attendance decreased with increasing remoteness. This does not take into account those children from rural and remote communities who attend school in the cities.  ¹  

Health Status of Rural Australians
Given the relatively poor geographic access to health services, lower socio-economic status and employment levels, and exposure to comparatively harsh environments and occupational hazards, it is not surprising that the health status of those people living in rural and remote Australia is worse than those living in cities on a number of measures.  ³   Indigenous Australians continue to experience a higher burden of illness and die at a younger age than other Australians. Rural and remote Australians have shorter life expectancy and higher incidence of and mortality rates from injury and coronary heart disease compared with those living in Australian state and territory capital cities.  ⁴   There is some evidence from New South Wales, in respect of coronary heart disease mortality in men aged 40–64, that inequality between metropolitan Sydney and coastal areas on the one hand, and inland small towns and rural areas on the other has increased between the 1969–1973 and the 1990–1994 periods.  ⁷   Infant mortality and the incidence of respiratory diseases increase with increasing remoteness.  ¹   Indifferent attitudes towards illness, poor uptake of health promotion and self-care messages, and a higher prevalence of risky behaviours have also been blamed for the health inequalities of rural Australians.  ³  

Changes in Rural Health Practice, Public Expectations and Government Policy

The Changing Nature of Rural Health Practice
In 1900, doctors knew almost everything they had to, or could know, about the diagnosis of medical problems and the limited forms of treatment available. Everything needed for total patient care could be packed into a doctor’s black leather bag and taken to the patient’s home.  ⁸   In 2000, doctors are single members of a team of professionals which includes nurses, allied health professionals, health managers, economists and epidemiologists. These health professionals collectively focus on population health, the care of patients in a range of settings, and the management of the health sector. That sector is one of the highest cost areas of government spending.

Medical research has led to an escalation of complex diagnostic and treatment technologies that are far beyond the capacity of one human being to apply to patient care. Whereas in the twentieth century great weight was placed on the skilled use of the scalpel, in this century the skilled use of the computer is likely to achieve pre-eminence. Medical treatment is replacing surgery in the management of many diseases (eg, peptic ulcer disease and abnormal uterine bleeding). Other operations that were once routinely performed by generalist rural surgeons are now the province of highly trained specialist surgeons (eg, laparoscopic cholecystectomy).

The computer provides essential access to patients and other health professionals, and to databases to assess the best evidence for interventions. In the management of chronic diseases, information gathered in episodic consultations is likely to be replaced by recurrent information acquired in the course of patients’ daily lives and transmitted electronically.  ⁹   Electronic medical records can not only improve clinical decision making  ¹⁰   and the co-ordination of care,  ³   but with appropriate safeguards to protect privacy and address consumer concerns,  ¹¹   allow more productive epidemiological and health services research.  ¹⁰   Patients’ access to their own records, and, in fact, sharing in the compilation of their records, can be achieved more readily, particularly with improved interface approaches for accessing this information such as voice navigation and control systems and touch screens.  ¹²  

The computer is also making an increasingly important contribution to pathology. For example, in cervical screening programmes, liquid preparation techniques with computer analysis of cells present enables automatic screening of slides so that cytologists are required to confirm abnormalities in only a fraction of the specimens.  ¹³   Microminiaturisation of analytical clinical pathology procedures may lead to complicated assays being performed near the patient either in the patient’s home or the doctor’s surgery.  ¹³   Telepathology and teleradiology allow anatomical pathology and imaging to be undertaken at a distance.  ¹⁴   Robotics allows some surgical procedures to be undertaken at a distance. Generating the data for diagnosing and managing diseases will become easier, but its application to the patient will become more complex necessitating highly skilled multidisciplinary teams, which could be virtual, and in which rural health practitioners could participate as equal partners.

Other activities (especially the management of chronic conditions) that are currently undertaken by physicians will be taken over by other health professionals who, with the aid of clinical guidelines, can provide equivalent outcomes and at a lower cost.  ^{9  ,   12}   The National Health and Medical Research Council (NH&MRC) has indicated that such guidelines are designed "to improve the quality of patient care, to reduce the use of unnecessary, ineffective or harmful interventions, and to facilitate the treatment of patients with the maximum chance of benefit, with minimum risk of harm, and at an acceptable cost."  ¹⁵   The NH&MRC has developed nine principles that should underpin guideline development. These include (1) that guidelines should be flexible and capable of adapting to varying local conditions, and (2) that they should be developed with resource constraints in mind. An assessment of the impact of guidelines on the US rural health workforce found that adherence to the guidelines for the management of Type-II diabetes in Medicare recipients 65 years and older would be associated with a 1.3– 2.4 percent increase in the number of primary care physicians and a 1.0–6.6 percent increase in the number of ophthalmologists.  ¹⁶   These findings suggest that in meeting the NH&MRC principles, impacts on the rural health workforce must be carefully considered in terms of the feasibility of implementing the guidelines without placing demands on the workforce that are unlikely to be met.

The Unique Features of Rural Practice
There are some unique features of rural practice that mean that rural health professionals should be well placed to respond to the changing nature of rural practice, the changing burden of disease and evolving government policy. Rural and remote health practice is unique in that it encompasses the following mix of approaches, foci, and challenges.  ¹⁷  

Rural and remote health workers, whether they are allied health professionals, Aboriginal health workers, nurses, doctors, or public health specialists, are likely to be comfortable and skilled at working in multidisciplinary teams, using a primary health care approach. They are generalists, and they need multiple skills. They focus on the community and need to respond to the social dimensions of health and illness. In their every day work, they are challenged to set priorities, allocate resources efficiently and to use technology appropriately. Rural and remote health workers are patient/client focussed and have a significant role to play both in promoting their patients’ or clients’ good health and in all episodes of their patient’s health care, including health emergencies. The competencies developed by health professionals from working in rural health services should allow them to make a significant contribution to health service delivery in any setting, and to health sector development.

Public Expectations
Many recent changes in medical practice and rural health care do not fit well with public expectations. What a rural population wants is a local GP, preferably one with appropriate skills and an adequate understanding of the health needs and expectations of their community. Geographical access, waiting times, affordability and acceptability are secondary to having a doctor in the first place.  ^{18  ,   19}   In small community-based studies, GPs have been rated as the most important part of the health care system.  ¹⁹   That does not mean that rural communities will necessarily take what they are given. Young rural women particularly want access to a doctor with whom they feel "comfortable".  ²⁰   A significant proportion of health and medical services are accessed outside a person’s residential area, because of inability to provide the service locally, but also because of choice.  ^{18  ,   21}  

Government Policy
Part of the context for rural health care is the Commonwealth Government’s overall policy for the health sector, which includes patient-centred health services, improving value for money in health service delivery, improving quality of health care, collecting and using high quality information, and focussing on high priority areas.  ³   The measures taken by the Government to improve value for money are particularly relevant to rural health care. These include modifying "fee-for-service" by rewarding "best practice", controlling on the basis of efficacy and cost-effectiveness the list of services and pharmaceuticals that are publicly subsidised, and attempting to ensure the health workforce "...is of the right size and composition, is properly trained and equipped to do the job, and is appropriately located in relation to those making demands on the system."  ³  

Within this overarching policy, the National Rural Health Strategy was endorsed by the Australian Health Ministers’ Conference in 1994,  ²²   and updated in 1996.  ²³   Healthy Horizons: A Framework for Improving the Health of Rural, Regional and Remote Australians was released in 1999.  ²   A vital component of the Government’s rural health policy has been the rural health workforce. The release in 1994 of A National Framework for Education and Training Arrangements for Rural Health Services was an important milestone.  ²⁴  

In respect of the health workforce, the Commonwealth Government has implemented a number of strategies to achieve its policy intent. The ’Rural Health Support, Education and Training Program’ has provided grants to a range of allied health and nursing projects which contribute to the education, training and professional development of rural health professionals. In the 1992 budget, the Commonwealth Government announced the ’Rural Incentives Program’ to improve access to GP services in rural areas.  ²⁵   Ten percent of this programme was set aside to assist medical schools in encouraging medical students to pursue a career in rural practice. Other grants under this programme include those for relocation, working in remote areas, continuing medical education and locums.  ¹⁸   In 1996, the Commonwealth Government called for tenders from university medical schools wishing to form a University Department of Rural Health. Seven departments have been set up in each state and territory (of which the Combined Universities Centre for Rural Health in Western Australia is one example) with the exception of the Australian Capital Territory. The principal objective of these departments is to improve access by rural and remote communities to appropriate services through the promotion of professional support, education and training of rural and remote health workers, and for those city based health care professionals interested in furthering their training and practising their clinical skills in a rural and remote setting.  ¹⁷   In the 1999 budget, the Government introduced retention payments for long-serving GPs in rural and remote areas and a contribution to the establishment of regional medical schools. State governments, in partnership with the Commonwealth Government, have been devising policies that allow for the recognition of overseas qualifications.  ²   Scholarships to assist rural medical students meet their accommodation and support costs have been extended as has support for first-line emergency-care courses to remote area nurses. The Bush Crisis Line, which provides crisis support and counselling for job related trauma among isolated rural and remote health workers and their families has been extended and upgraded.  ²⁶  

The states deliver hospital, community health and public health services to rural communities. They have a major role in the recruitment, retention and development of the nursing and allied health workforce.

Many universities have active Aboriginal studies centres that support Indigenous students, and offer courses leading to degrees, diplomas and certificates in subjects of relevance to Aboriginal health. Aboriginal health workers are also trained through accredited programmes in community-controlled organisations,  ¹⁷   and in state-funded training agencies.

Further evolution of government policy is likely as Healthy Horizons: A Framework For Improving the Health of Rural, Regional and Remote Australians  ²   is implemented.

Strategies to Build the Rural Health Workforce

The Current Situation
Given the unique features of rural health practice, it would be expected that health professionals would flock to work in rural areas to enjoy the professional satisfaction of responding to exciting professional challenges. The reality is, of course, very different, both in Australia and overseas.  ^{2  ,   27  ,   28  ,   29  ,   30}   The reasons for the difficulties in recruiting and retaining a skilled and responsive health workforce have been well documented. Although GPs in rural and remote areas in Australia manage more diverse case-loads  ¹⁸   and enjoy undertaking procedural work and hospital access,  ^{31  ,   32}   they (together with their rural general surgical colleagues)  ³³   work significantly longer hours, are rostered on-call more often and experience more call-outs than their metropolitan colleagues.  ¹⁸   Rural practitioners lack locum relief  ^{18  ,   28  ,   33}   and GPs lack access to backup, specialist services  ¹⁸   and continuing medical education.  ³²   At times they experience stress,  ¹⁸   lack of privacy  ³³   and feel isolated.  ^{28  ,   32}   Their spouses and family also bear the costs of rural practice, which, in addition to the high workload, include lack of employment opportunities for spouses,  ³³   and inadequate educational opportunities for children.  ^{31  ,   33}  

As a result of these experiences in rural practice, it is not surprising that the nearly 30 percent of the Australian population who live in rural areas are served by only 20 percent of the country’s GPs and 10 percent of the medical specialists.  ²⁵   Less than one-quarter of these GPs are women and two-thirds of women working in rural general practices work part-time.  ²⁰   The turnover of rural doctors is about 20 percent every five years or about 200 doctors per year, and a similar number are usually required to fill vacancies.  ²⁵   This means that if Australia were to become self-sufficient in the supply of medical graduates, up to 30 percent of medical graduates would be required as rural doctors.  ²⁵  

The recruitment situation for other health professionals to rural areas does not appear as serious as that for doctors, although there is inadequate information on the distribution of most allied health professionals nationally. In 1996, employment of nurses per 100,000 people in large rural centres (1,705), small rural centres (1,363) and remote centres (1,220) exceeded that of capital cities (1,183). However, around 30 percent of nurses employed in rural centres and other rural and remote areas (except for large centres) were enrolled nurses. ^( b )  In Australian state and territory capital cities, only 17.1 percent of employed nurses were enrolled nurses.  ³⁴   The distribution of pharmacists is related to the distribution of GPs because the demand for and financial viability of pharmacy practice is related to the average per person Medicare consultations with GPs. In 1995, the full-time equivalent provision of pharmacists per person in large and small rural centres (69.6 pharmacists per 100,000 population) in most States was similar to or exceeded that in non-capital city metropolitan areas, but declined (to around 51 per 100,000) in other rural and remote areas.  ³⁵  

What Strategies Have Been Shown to be Effective in Building a Rural Health Workforce?
Most of the research on effective strategies to build the rural health workforce has been done on the rural medical workforce. As with many programmes, much of the research has not sought to disaggregate and measure the effect of one intervention in isolation from the overall programme. A comprehensive programme is needed if the rural health workforce is to be built in a sustainable way.

Overseas trained doctors
A short-term solution to the unmet need for rural doctors has been the recruitment of overseas-trained doctors. Overseas-trained doctors have always been an important contribution to the supply of medical practitioners in Australia, making up 20.4 percent of the Australian medical workforce in 1997.  ³⁶   In 1997, 23.5 percent of rural and remote medical practitioners gained their initial qualification overseas, and overseas-trained doctors made up 30.6 percent of the doctors in remote practice. Government regulations on recruiting overseas-trained doctors can make the recruitment process challenging and expensive for small communities,  ²¹   but steps taken recently to allow appropriately qualified overseas-trained doctors to gain vocational registration in rural and remote Australia may ease the situation. The evaluations of the effectiveness of using overseas-trained doctors in under-serviced rural areas have focussed on whether or not the unmet need in the country to which these doctors migrate has been met, rather than whether the loss of doctors from the originating country generate need in that country. The US experience is similar to Australia. Overseas medical graduates constitute a greater proportion of the US primary care physician workforce in rural, under-serviced areas even though there is much interstate variation.  ³⁷  


Recruiting rural students into academic health courses
The impact of a rural upbringing on the likelihood of doctors practising in a rural community has been known for some time.  ²⁵   Recent research which analysed the impact of a 22-year-long US programme (Pennsylvania) to increase the number of family physicians in rural and under-serviced areas demonstrated that selectively admitting students on the basis of their rural background is the most powerful independent variable contributing to a positive outcome, followed by commitment to rural practice at admission to the programme.  ³⁸  

To be selected for a health career, students have to apply for entry to a health course. To apply, they need an appropriate academic record in school and they need to express interest in a health career. The educational disadvantages of rural children have already been raised in this paper. In Western Australia, 23 percent of the population aged 17 to 24 years lives outside the metropolitan area and yet only 15 percent of offers for university places for 1999 were to country residents.  ³⁹   For those school students who achieved high tertiary entrance examination results, in 1998 only 9 percent of West Australian country students in this category applied to study medicine at the University of Western Australia compared with 28 percent of their urban peers (personal communication, Viv James, 17 June 1999). A study of the primary care-oriented practices in medical school admissions and the practice intention of matriculants (drawn from the Association of American Medical Colleges’ databases) found that there was greater interest in primary care and rural practice at schools with recruitment activities that targeted future generalists before the application stage.  ⁴⁰  

For these reasons, initiatives have been undertaken in Australian country high schools to promote health careers  ¹⁷   and to provide vacation revision and skill development courses for senior students.  ⁴¹   In South Australia, financial support has been provided on a competitive basis to students to attend these courses. In the same state, school principals and career counsellors have been asked to identify senior students (years 10–12) with the career aspirations and the capability of becoming medical students. These students and their parents have been provided with medical careers information personally and at careers nights.  ⁴¹   Reports of overseas evaluations of similar measures suggest that these are effective means of increasing applications and admissions of rural students to medical courses.  ⁴²  

The selection process also needs scrutiny. Many universities are moving away from using matriculation marks as the predominant method of selecting medical students in order to select the students who are likely to become the sort of doctors society needs.  ⁴²   The University of Western Australia now uses a written selection test (Undergraduate Medicine and Health Sciences Admission Test or UMAT), a structured interview and academic performance. These three methods are scored, standardised and weighted equally. UMAT is designed to assess logical reasoning, critical thinking, problem solving and decision-making. The purpose of the interview is to assess motivation and commitment to the chosen career, ability to assist and work with others, ability to think critically and to manage oneself, and communication skills. There is also a quota for rural applicants and these applicants are offered financial assistance to attend the selection process. A detailed statistical analysis of all data relating to the new selection process is being undertaken.  ⁴³  


Retaining rural students in rural careers
Once rural students are in academic health courses that can lead to rural health careers, a further set of strategies must focus on retaining their commitment. Anecdotal evidence from South Australia suggests that country students may under-perform academically in their first year because of difficulties coping with the double transition – from school to university on the one hand, and from the bush to city life on the other.  ⁴¹   Australian strategies include financial support (scholarships), personal support and mentoring and student clubs, which can also act as agents for change to improve rural content of curricula.  ^{41  ,   44}   The successful ‘Pennsylvania Physician Shortage Area Program’, graduates of which account for 21 percent of family physicians practising in rural Pennsylvania even though they represent only 1 percent of all Pennsylvania medical graduates, includes family physician faculty advisors for students.  ³⁰   Amongst graduates of one medical school in Pennsylvania, a high level of debt was inversely related to rural practice,  ³⁸   which should sound a warning on the cost of undergraduate education in health courses borne by the student and their family, and the levels of debt incurred through student loan schemes in Australia and New Zealand.


The undergraduate curriculum
As part of their strategies to improve the rural workforce problem, many countries have reviewed their undergraduate health curricula with a view to improving the length of time allocated to rural health, the quality of the learning experience and the delivery mechanisms, so that more of the course is either delivered in regional centres, through distance learning and/or in rural clinical attachments.  ^{29  ,   30  ,   41  ,   45}   Rural attachments can make an important contribution to training students in procedural skills.  ⁴⁶   Students find the educational experience of rural attachments to be better than comparable time spent in city practice, and as well as the benefits from training in procedural skills, they also see a more diverse range of health and medical conditions.  ⁴⁷  


Vocational training
The particular needs of rural practice have been recognised in vocational training programmes, particularly general practice and surgery. Unfortunately the results are not very promising. The Royal Australian College of General Practitioners (RACGP) has provided a rural training programme since 1995. A commitment to rural practice counts for 15 percent of the scoring system for selection. The number of entrants to the RACGP has been limited to 400 per year. In 1999, 110 were admitted to the rural training programme. The available data suggest that 94 trainees have left the rural training programme prior to completion since its inception. Nationwide, only 35 RACGP graduates have entered rural practice since the beginning of 1997. The programme provides for a fourth year for the development of advanced rural skills. In 1999, 49 students undertook this option. Of the 53 graduates of this programme to date, 19 (36%) are practising in metropolitan areas.  ⁴⁸   The results of the RACGP training programme are consistent with the unexpected finding in a small Australian study of the 1996 outcomes of the 1986 intentions of 91 rural doctors. A statistically significant variable in a univariate analysis was that those who had left rural practice were more likely to have completed a rural internship.  ³²   These poor results may be due to the quality of the programmes and/or because the graduates had not been exposed to an integrated undergraduate and postgraduate rural curriculum. A review of the Rural Physician Action Plan, Alberta, Canada, which does have an integrated curriculum, suggested that whereas there was no evidence that the plan had materially increased recruitment and retention rates in Alberta, without the plan there would have been a net loss of rural doctors.  ²⁹  


Recruitment and retention of health professionals in rural and remote areas
Recruitment and retention of health professionals in rural areas requires a different set of strategies, many of which have been discussed previously. Practice issues appear more important in retention than background variables.  ³⁸   There is also evidence that similar issues are the most important factors in the recruitment and retention of nurses to rural hospitals.  ⁴⁹   Those who stay in rural practice feel that they are doing "...a special job which made a difference to the community."  ³²   Country doctors rate professional satisfaction in whole patient/whole family community care and continuity of care more highly than their urban colleagues.  ¹⁸   Workforce agencies have been established in the states to respond to the reality of rural medical practice and arrange locum cover, assist with recruitment and strengthen access to continuing medical education for doctors.  ⁵⁰   The ’General Practice Rural Incentives Program’ now includes rural retention payments to assist with the economic issues. Given that rural GPs value procedural work, it has been suggested that reducing access to hospital beds would "severely undermine any other positive efforts to retain GPs."  ³¹   A small Australian study has cited the downgrading of hospital facilities as one of the reasons for leaving rural practice.  ³²  

Conclusion

There is clearly a dissonance between the changing nature of rural practice and the workforce needed for the future on the one hand, and the factors that currently contribute to the retention of the rural medical workforce, particularly the procedural work, and the expectations of rural communities, on the other. This dissonance suggests that the rural health workforce needs to be reconstructed rather than simply being built to provide more of what is currently delivered. The challenge is to achieve a smooth reconstruction around multidisciplinary specialist health teams to service rural communities using the developments in technology that can support those teams. In achieving this reconstruction, it is essential to ensure that communities and the workforce participate in and feel part of the process, so that communities consider their needs are being met and retention of the rural health workforce does not deteriorate.

Acknowledgements

The authors would like to thank Ann Larson for her thoughtful and constructive comments on this paper.

Footnotes

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