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From a broom cupboard: 20 years of rural health at Monash University

Ch 03. External environment

The view from the outside

An important factor in the creation and growth of the School of Rural Health has been its working relationships with key external stakeholders. Here we explore the environment in which the school has operated.

Michael Wooldridge sets the political scene that led to the introduction of key rural health initiatives. In so doing, he dismisses the idea – strongly held within the school – about why it did not receive University Departments of Rural Health funding in the initial round. Bob Wells and Di Wyatt speak from the perspective of Commonwealth and state health departments respectively, about their relationships with the school. The Victorian department funded many projects and provided some core funding that, in the early years, was the life’s blood of the Centre for Rural Health; the Commonwealth’s Rural Clinical Schools Program and University Departments of Rural Health Program are currently the school’s major sources of funds. A perspective of the school and its place within the Faculty of Medicine, Nursing and Health Sciences at Monash is provided by Nick Saunders. Nick was dean of the faculty during a period of significant structural and curricular changes that also coincided with rapid growth for rural health at Monash. The chapter is concluded by Dane Huxley who speaks from his perspective as the chief executive officer at Mildura Base Hospital. Dane was a partner in the establishment of the Mildura Regional Clinical School on the hospital campus and elaborates on its effects.

Political reactions to rural problems

The Hon. Dr Michael Wooldridge

A number of rural health initiatives were introduced during my time as federal Minister for Health, including the John Flynn Scholarship Scheme, University Departments of Rural Health and the Rural Clinical Schools Programs. These initiatives have had a profound impact on medical training, the provision of health services in rural and remote areas, and even the health of rural and regional townships themselves.

The policies have their origin prior to the 1996 election, when we were in opposition. I was of the view that, in a political sense, there had been a very substantial neglect of rural Australia. I believe that this was also a factor in the rise of Pauline Hanson. Following the election, within my portfolio, we set about addressing a number of issues aimed at making a difference to health care in rural Australia.

Our hard work resulted in a very deliberate strategy. In the period from 1975 to 1996, health had been a political graveyard for the coalition – we had been talking about health systems for 20 years and getting hammered. It was time to get the debate off health economics and on to everyday health issues that affect people. One of these issues was the acute shortage of medical practitioners in the country.

In 1996 the medical student intake was roughly 1200 with only 10 per cent of those coming from a rural or regional background; in some universities this was as low as 6 per cent. Research at the time suggested that only 5 per cent of the city origin students would go on to practise in a rural area, compared with 45 per cent of the rural-origin students.

I was also mindful that to spend time in a rural centre, in this era, was akin to committing academic and professional suicide. I wanted to change this dynamic by providing resources to rural areas. Dr Jack Best had performed some important intellectual and conceptual work that supported the view that the absence of rural infrastructure was a major impediment to attracting and retaining academics and professionals. Establishing infrastructure in rural communities also became an important and deliberate part of our strategy.

Our attention was initially caught by the public health unit in Broken Hill. This was small and modest, yet functioned quite well. This unit became the model for an initial proposal of six university departments of rural health. The number six would provide one for each state rather than one for each of the medical schools and was chosen very deliberately. We were not convinced that universities could be trusted to use the funding appropriately, so created some competitive tension. Another caveat was that the funding could not be spent on capital city campuses, to ensure that new buildings were not built on capital city campuses and merely dubbed ‘University Department of Rural Health’.

Monash was initially unsuccessful. The people from Monash felt that they were being disadvantaged for already having the Centre for Rural Health. Although we were concerned that the universities would not take up the concept and merely absorb the funding, the consensus within my department was that the University of Melbourne bid for Shepparton was a better proposition. This decision has been borne out in reviews of achievements at Shepparton. Similarly the University of Queensland missed out when the James Cook University/Deakin University bid for Mt Isa was successful. Neither James Cook nor Deakin had a medical school and the University of Queensland had assumed that they would be successful.

A major step was taken in 1998, largely in response to the Pauline Hanson phenomenon. The Prime Minister and others had decided that more effort was required on policies for rural Australia and ministers were invited to put forward suggestions. Around $2 billion per year of suggestions were provided with $300 million available. We had worked hard for two years and were able to refer to the advances made. For instance, there was now a full-time Professor of Medicine and Professor of Surgery located at Broken Hill. The Prime Minister and Deputy Prime Minister eventually decided that, rather than divide the available funds between portfolios, the lot should go to health, much to the chagrin of my colleagues.

My relationship with the universities was much stronger at this stage – they understood what I was on about. It was now time to make sure that every university had a chance to be involved.

Sharman Stone, member for Murray, and Peter McGauran, member for Gippsland deserve special mention. Both provided very strong advocacy for placing rural clinical schools in their regions. In fact, the Rural Clinical Schools initiative was announced in Bairnsdale, part of Peter’s constituency, to highlight our intention to use this funding to place infrastructure directly into rural and regional towns.

My dealings with Monash during this time were primarily with the dean, Nick Saunders. Although I had little to do with Roger Strasser directly, people spoke to me highly of him and his work.

The Rural Clinical Schools Program has had a remarkable effect. Over 30 per cent of medical students are now recruited from rural areas, and a significant amount of the clinical training for medical undergraduates, both of rural and metropolitan origin, now occurs in rural locations. The program has also provided infrastructure and opportunities for joint appointments between health services and the universities that has attracted and retained professionals outside the capital cities. In many instances the clinical schools and their staff have had profound effects on the whole community, reversing lifetime trends.


RACGP training program Gippsland launch 1998: Roger Strasser (left) and Minister for Health, Michael Wooldridge (right).

I take some pride that the rural health initiatives that were introduced during my time as Minister for Health have proved to be significant and enduring. This did not happen by chance – there was no great momentum from around Australia for it to happen, and there was strong competition for the money. It does show how good policy can make an enormous difference. The policies that have changed the face of rural medicine in Australia have taken a very long time from concept to outcome. The challenge now is to apply the same attitude towards policy development to using the wonderful resources now available, to provide more postgraduate medical training outside the capital cities. The aim should be to ensure that our graduates have ahead of them a full range of options that are better integrated into state and regional health services.

A national template

Robert Wells

I first became aware of, and began working with, the Monash University Centre for Rural Health in the early 1990s. I had just taken over as the head of the rural health policy division of the Commonwealth Department of Health and Ageing and, in collaboration with the states and various other bodies, worked on a national rural health strategy. Professor Roger Strasser and the Monash University Centre for Rural Health were heavily involved in this process.

I was impressed that this centre was the only academic unit looking at rural health and access issues from a rural setting, without initial government funding. Monash had set up the centre purely through its own undertaking. The centre was an innovation that provided a model for others to follow or challenge. It trained medical students in rural and primary care settings and, importantly, performed rural health research from a rural location. Monash University Centre for Rural Health was ahead of the game.

In the early 2000s the Rural Clinical School and University Departments of Rural Health Programs were introduced. The Centre for Rural Health in effect provided the template for later aims.

My department’s dealings with the centre, and later school, were always most professional. There was never a shortage of good ideas from Professor Strasser and his colleagues, for which funding was required. In those days innovative thinking was required to tailor existing programs to fund rural concepts. Once funding was made available, the centre invariably succeeded in meeting the desired outcomes and worked openly and professionally with the department.

The early interactions with the Centre for Rural Health developed into an extremely strong and trusting relationship. This was particularly evident with the introduction of the Rural Clinical Schools project. This was an exciting new venture in which both the department and the universities learnt as we went. There was a sense of heading down a river at a quickening pace, not quite knowing what would be encountered round the next bend or where the next waterfall was situated. The relationship with the Monash school was open, positive and trusting; we were confident there were no possible problems being suppressed and did not doubt that the challenging objectives would be met.

The Rural Clinical School and University Departments of Rural Health Programs have been among the most innovative rural health initiatives introduced, not only in Australia but worldwide. These innovations required political vision and courage but can be traced back to the groundbreaking work of the Centre for Rural Health.

The state connection

Di Wyatt

I first met Roger Strasser and became acquainted with the Monash University Centre for Rural Health in the early 1990s. Roger and I, in my capacity as manager of the Victorian Department of Human Services’ rural health unit, were part of a national rural health strategy advisory group. The Centre for Rural Health was very new but was one of the key players and stakeholders in this field.

At the time there was a strong movement aimed at pressuring governments to address rural and remote health issues, and Roger and his centre were at the forefront. Significant time and effort was given to raising ideas, working with stakeholders, identifying issues and then developing policies and programs to deal with them. Headed by the world’s first Professor of Rural Health, the Centre for Rural Health was uniquely placed to be a key contributor.

I recall that Professor John Humphreys was working with the Commonwealth, writing the Rural Health Strategy around this time, prior to joining the Centre for Rural Health. Many of the policies and programs emanating from this sector devolved to my department at state level, for implementation in partnership with the Centre for Rural Health. The relationship between the Victorian Department of Human Services – and in particular my boss, Ralph McLean – and the centre became crucial. Ralph relied upon and supported the centre. Funding was provided for many projects and some core funding was provided as well at this stage.

Roger Strasser’s drive and persistence were undeniable. He never tired of promoting rural health programs and ideas. For instance, his efforts were fundamental to the formation of the Coordinating Unit for Rural Health Education in Victoria program and the Rural Doctors Association of Victoria. Roger and the centre played important roles on many committees set up to implement government programs. Often they would come up with the ideas and implement them as well – all they needed was the funding! There is little doubt that the momentum built largely by Roger Strasser and the Centre for Rural Health provided the impetus for important federal programs such as the rural clinical schools and the university departments of rural health.

The Centre for Rural Health was also influential worldwide, particularly through its involvement with Wonca (the World Organization of National Colleges, Academies and Academic Associations of General Practitioners/Family Physicians). Roger served a term as chair of the working party on rural practice, a group that is still active to this day. Other universities around the world have since picked up the agenda, and centres for rural health have been formed based on the Centre for Rural Health and Roger Strasser’s vision.

The Centre for Rural Health was a critical driver in the 1990s for gaining recognition of rural health issues and setting the national and international rural health agendas that are bearing fruit today.

Wonca conference Melbourne 2002: Di Wyatt addresses the delegates.

 

Juggling expectations

Emeritus Professor Nicholas Saunders, AO

The end of the twentieth and the beginning of the twenty-first centuries were good years in which to be a dean of medicine interested in rural health, thanks to the policies and programs developed during that period by Dr Michael Wooldridge, the federal Minister for Health and Ageing, and his wily advisor, Jack Best.

Those two men were passionate about reducing disadvantage and improving the health of rural Australians. In large part, it was they who created the opportunity for medical schools and health faculties around the nation to create university departments of rural health and rural clinical schools, and to increase the proportion of medical students who came from rural and regional backgrounds. Generous funding provided by the federal government, for capital works and recurrent operating expenses, permitted the rapid expansion of teaching and research facilities, student accommodation, and clinical placements in rural and regional Australia. Substantial scholarship funds were also made available to support students who were willing to commit to spending at least the early part of their medical career in the bush.

When deans have plentiful resources at their disposal, effecting change is made much easier! Clearly, some politics were involved as the schemes were rolled out. Why, for example, was the Monash rural clinical school officially named the Bairnsdale Rural Clinical School and launched in that delightful East Gippsland town by Minister Wooldridge, when most of the school’s activities were to be located elsewhere in Victoria, if not to bolster the local member’s electoral prospects? And it was burdensome having to keep university department of rural health and rural clinical school funding strictly siloed because of the needs of the Canberra bureaucracy. But the programs that Michael Wooldridge and Jack Best initiated have been a resounding success overall, as judged by the large number of students who have gained a meaningful rural experience as part of their undergraduate program, the resultant internationally significant innovation in teaching programs, and the growth of high quality rural clinical services over the last two decades.

During this time Monash’s Faculty of Medicine, Nursing and Health Sciences also benefited from initiatives implemented in rural Victoria by the Kennett and Bracks governments. Particularly noteworthy events for Monash were the opening of the Latrobe Regional Hospital and a significant expansion and upgrade of Bendigo Health Care Group. This investment by the Victorian Government greatly improved the opportunity for a broadly-based clinical education in rural Victoria and made the prospect of a rural career in the health professions much more attractive.

The substantial increase in resources for medical schools to build their rural programs during the late 1990s and early 2000s allowed the recruitment of talented staff from around the world. For example, the head of Monash’s School of Rural Health, Professor Geoff Solarsh, was recruited from the University of Natal in South Africa, and the director of the University of Melbourne’s program in Shepparton, Professor Dawn de Witt, was recruited from the University of Washington in the United States. People like Geoff and Dawn brought their experience and new ideas to rural and regional Australia which benefited our students and enriched the community.

As might be expected in any organisation during a time of rapid expansion, the new federal University Department of Rural Health and Rural Clinical School Programs caused some ‘growing pains’ in the faculty.

Outside the School of Rural Health, some staff were envious of the very generous funding provided by the federal health department for rurally-based medical education; on a per capita basis, it was roughly four times greater than the funding provided by the federal education department! Some staff were upset that rural clinical school funding was strictly tied to medical students and could not be used to support nursing and allied health students in rural settings, especially as the funding of these disciplines was already far less than that of medicine. Others, particularly those in the biological sciences, expressed concern that the teaching focus of funding might diminish the faculty’s research reputation through the appointment of staff without a strong track record in research. A significant number wondered aloud whether the quality of teaching and the student experience in a rural setting would match that in the city and particularly, whether experience heavily based in general practice would be as effective as specialty-based tertiary referral hospital experience. Concerns were also expressed about being able to adequately support a widely distributed faculty, notwithstanding recent developments in electronic communication.

My job as dean was to listen carefully to these concerns, assist the leadership of the School of Rural Health to formulate strategies to address them, communicate with the faculty leadership about the intended approach, and support the school in its efforts.

Inside the School of Rural Health, there was a sense of great excitement and an urgency to grasp the opportunities brought by a major increase in resources. However, the growth and diversification of staffing and the expansion of activities outside Gippsland also created challenges. The Centre for Rural Health had suddenly become the School of Rural Health and, as a consequence, expectations of its performance in teaching and research had increased considerably. Many staff were not adequately prepared to meet these new expectations, particularly in research. The school’s centre of gravity was seen by some members as having shifted too far north-west, with attendant anxiety about the fate of the Gippsland site. The need to expand the numbers of medically qualified staff in the school brought the problems of recruitment to rural Australia into sharp focus and was seen by some members as a threat to the multidisciplinary culture of the previous centre. There was also concern that the growth of specialist staff numbers might threaten the centre’s strong commitment to primary care.

Here, my job was to work with the staff of the school to build their belief and confidence that change would bring rewards to them, individually and collectively, and to Monash and the community. The recruitment of several senior academic leaders from a variety of disciplines including, importantly, the social sciences, greatly assisted the transition.

The successful resolution of these significant challenges demonstrates the willingness of staff at Monash to work together and to be innovative in their approach to solving problems. It also points to the faculty’s strong commitment to equity for disadvantaged groups, in education and health, and to excellence in teaching, research and community service. As the Centre for Rural Health has grown and diversified to become a fully fledged school within a vibrant faculty, it has made a very real contribution to the lives of rural Victorians and to the multidisciplinary scholarship of rural health, nationally and internationally.

It was a great privilege to serve as dean of the Faculty of Medicine, Nursing and Health Sciences at Monash between 1998 and 2003. The opportunity to assist in the development of the School of Rural Health provided me with one of the most rewarding experiences of my professional life.


Nick Saunders, dean of faculty, opens the new facilities at Latrobe Regional Hospital, Traralgon 1998.

 

Working together for mutual benefit

Dane Huxley

The turn of the century was a time of great change at Mildura Base Hospital. As part of the sweeping reforms introduced by the Kennett state government we had become Victoria’s second privately owned public hospital. We operated from a brand new hospital built on a greenfield site. The infrastructure was owned by the Motor Trades Association of Australia and the service was provided by Ramsay Healthcare. This made for a complicated three-way contract agreement between the state government’s Department of Human Services, the Motor Traders Association and Ramsay Health Care.

I first became aware that Monash University was considering placing a clinical school in Mildura when I was approached by its dean of medicine, Professor Nick Saunders. We were enthusiastic about the prospect and believed that recognition as a teaching hospital would enhance our reputation and standing. It appeared that the project would be of mutual benefit to our respective organisations. Nick was very impressive and his amicable style quickly moved negotiations onto a heads of agreement.

It was agreed that Monash would build the clinical school – consisting of teaching rooms, academic and administration offices and accommodation for students – on the hospital campus. The clinical school buildings would become part of the hospital buildings on completion. The Department of Human Services and the other parties to the contract were all in agreement, so the decision was made to start the construction while it was left to the lawyers to work through the contractual arrangements. The smoothness of the original negotiations and agreement with Nick Saunders was a stark contrast to the difficulties encountered with the contract variations. The buildings were complete and in use for many months before the contracts were finalised. Yet even through this episode, the trusting relationship between Mildura Base Hospital and Monash was maintained as both organisations were determined to make it work and to be as good as their word.

The relationship developed further as the clinical school became established and the students commenced. The clinical school director, Dr John Russell, was a pleasure to work with. The mutual trust that had developed, and still exists, meant that there have been very few issues between our organisations, and when any have arisen they have been resolved without fuss.

The presence of the students around the hospital has had a noticeable effect. The patients enjoy them and their interest in the patients’ health, while the hospital staff have also reacted positively. A state of enhanced learning and sharing of knowledge has resulted and benefited both staff and students. I know that some of the students placed in Mildura in the early days had academic and social concerns. I also know that the vast majority of students have completed their placements and returned to Melbourne with glowing reports of their experiences, both clinical and social.

The facilities that the clinical school has built are excellent and have become a resource for the hospital and staff. The meeting and lecture rooms, complete with audiovisual equipment, are available for hospital use, while the state-of-art clinical simulation centre is a boon for all health professionals in the region.

While the presence of the clinical school has not made a quantifiable difference to the recruitment of health professionals to the region, it has had more subtle effects. A number of past and present clinical school staff have held joint appointments with the hospital and other health service organisations in the region. In fact, John Russell worked for many years as director of emergency services at the hospital in concert with his Monash role. The school provides the opportunity for doctors and other health professionals to teach or mentor students, which can be a welcome distraction from full-time clinical service.

The opportunity exists for further joint appointments between the clinical school and hospital in Mildura. In the future all the hospital’s training could occur at the clinical school. Jointly appointed positions would centralise training that has previously been performed sporadically across both organisations and provide exciting career options for those with the appropriate skills.

From the point of view of the Mildura Base Hospital, the establishment of a Mildura Regional Clinical School has been an unqualified success. Monash has always been a delight to deal with. This has been exemplified in the past by Nick Saunders and John Russell, and presently by Associate Professor Fiona Wright, the current director. They have nurtured the relationship that has seen our organisations work together for mutual benefit.

Inspecting the progress of construction in Mildura 2003: left to right – Robert Clough, Elaine Duffy, John Russell.

Wooldridge, Michael, Wells, Robert, Wyatt, Di, Saunders, Nicholas, and Huxley, Dane. 2012. ‘External environment: The view from the outside’, in From a Broom Cupboard: 20 Years of Rural Health at Monash University, edited by Clough, Robert. Melbourne: Monash University Publishing. Pp. 35–48.

From a broom cupboard: 20 years of rural health at Monash University

   by Robert Clough, editor