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Healthcare in a rural setting
January 2005
Board of Science
Education and training
The challenge of recruiting healthcare professionals to rural areas needs to be approached in numerous ways. Medical students and new medical graduates need to see rural practice as a positive career option and need to be encouraged and appropriately trained to work in a rural area. A report by the World Organisation of Family Doctors (WONCA)e recognises that recruitment can be influenced throughout a student’s medical education. [go to reference 39]
Recruiting students from rural areas
International examples indicate that recruiting medical students from rural areas will increase the likelihood of professionals wanting to work in such areas. [go to reference 39] The Rural Health Initiative in Indiana (in the American midwest) was begun in 1997 because more than a quarter of the 92 counties had a shortage of GPs, despite a general increase in the number of primary care graduates in the state. The initiative involves Indiana State University (ISU) and Indiana University School of Medicine (IUSM), and is administered by the IUSM’s Terre Haute Center for Medical Education. It recruits students from rural areas who have shown a desire to practise medicine in a similar setting. Recruitment efforts focus on students from areas with populations of less than 10,000 or from areas with a shortage of medical practitioners. Admissions are limited to 10 Indiana residents from rural areas per year.
Students are admitted to the undergraduate programme at ISU and have a provisional place at IUSM until this has been completed. Entry into IUSM is dependent on achieving particular grades. Career-related experiences to enhance the likelihood of success in the practise of rural medicine are provided throughout the undergraduate and medical school programmes. To aid recruitment efforts, ISU offers qualified students full-tuition waivers for the undergraduate portion of the degree. [go to reference 40]
In the UK, there is a relative lack of evidence on the beneficial effects of encouraging more students from rural areas to apply to medical schools. A study examining the locations of family home, medical schools and work found a relationship between family home location, medical school, and location of career posts. [go to reference 41]
• Thirty-eight per cent of respondents attended a medical school in the region of their family home.
• Forty-two per cent had a career post in the same region as their medical school.
• Another thirty-eight per cent had a career post in the same region as their family home.
e WONCA is an acronym comprising the first five initials of the World Organisation of National Colleges, Academies and Academic Associations of General Practitioners/Family Physicians. WONCA’s short name is World Organisation of Family Doctors
Although the study does not distinguish between rural and urban areas in each region, it does highlight that there is a relationship between family home and choice of medical school, family home and choice of career post, and medical school and choice of career post. It is worthwhile conducting further research and it is suggested that encouraging students from rural areas to apply to medical schools could be considered as a strategy to boost recruitment and retention of doctors in rural areas.
Secondary school students in rural areas need to be encouraged to consider medicine as a career option and to apply for entry to medical school. Consequently, there is a need for specific programmes that promote medicine to rural secondary schools. [go to reference 39] In the UK work has begun in this area. For example, the IRH runs a long-standing programme to promote medicine to students in the sixth form. Dentistry is also included in the programme. [go to reference 5] RARARI ran a Highlands School Mentor Scheme to encourage pupils to consider medicine as a career. This recognised that Highland communities need to develop doctors who are ‘at home’ in such a community.6 In addition, healthcare professionals are visible role models in rural communities when compared to urban peers. This visibility could be developed and used to encourage school students to enter the caring professions.
Recommendation 1
A broad range of strategies should be implemented to promote medicine to potential students from a rural background and encourage them to apply to medical school. [go to reference 39]
• Programmes for rural secondary school students should be run to promote medicine as a career. Medical schools in partnership with the local authority should implement these as widely as possible.
Undergraduate placements in a rural area
Evidence from other countries strongly supports the need for students to be given the option to undertake a placement in a rural area at undergraduate level. [go to reference 33] Research in New Zealand evaluated the effect of a new undergraduate placement in a rural area developed by the Department of General Practice at Dunedin School of Medicine. [go to reference 42] Students are placed in rural centres during their fifth (penultimate) year, for a period of seven weeks, as part of their training. During this time they are exposed to both rural general practice and rural hospital work. The attitudes of the students to a career in a rural area were measured immediately before and after participation in the placement during 2000 and 2001. Positive changes in students’ attitudes towards rural practice were found (table 4).
Table 4: influence of a seven-week rural placement on the percentage of Dunedin School of Medicine students indicating that they would or probably would enter rural general practice
 | Before the placement (%) | After the placement (%) |
| Students from a rural background | 6 | 22 |
| | |
| Students from an urban background | 1.1 | 13 |
Source: adapted from data in Williamson et al [go to reference 42] (2003).
The results show that a rural placement can produce attitude changes in students from both a rural and an urban background. Medical schools need to provide the opportunity to undertake a rural placement at undergraduate level as this encourages students to consider rural general practice as a career. The report found that 50 per cent of students had decided on a career path earlier than the fifth year of their undergraduate degree and it may be that placements could have a more beneficial effect if run earlier in the degree.
Many medical schools in Canada, Australia and the USA have separate rural health faculties. [go to reference 38] The concept of rural medical education and the significance of new rural-oriented medical schools is discussed by Hays (2003). [go to reference 43] It is suggested that the main distinguishing attribute of rural schools may lie in their greater ‘social accountability’ or orientation to the needs and opinions of their closely connected communities. The significant workforce and programme developments in medical education in Australia, partly in response to the recruitment difficulties facing rural areas, are detailed in Prideaux (2001). [go to reference 44]
Case study – Promoting rural practice throughout the medical curriculum: Indiana State University (USA)
The Rural Health Initiative, involving Indiana State University and the Indiana University School of Medicine promotes rural healthcare throughout the undergraduate curriculum. Students begin to study rural medicine early in the undergraduate curriculum and have mentoring opportunities and contact with active rural healthcare providers. They have the opportunity to work alongside rural GPs, participate in summer placements at rural clinics, take part in a rural health seminar series, and gain patient experience during placements with rural hospitals or clinics in the third and fourth years. [go to reference 40]
Case study – Promoting rural practice throughout the medical curriculum: Flinders University Rural Clinical School (Australia)
Rural healthcare issues are included at all levels throughout the four year Graduate Entry Medical Programme at Flinders University Rural Clinical School. In year one, students complete a weekend-long cultural awareness programme, learning about Aboriginal, medical and rural culture and how they interact. Students are encouraged to consider the merits of working in a rural, remote, Aboriginal or multicultural environment at some stage of their career. Students work in small groups with local rural GPs to gain a better understanding of healthcare provision within a rural setting. In year two, students undergo a one-week rural programme. During the week students complete a community-based research project and the findings are fed back to the relevant community. [go to reference 45]
In year three, students showing an interest in rural practice have the chance to move to rural regions for the academic year and follow the Parallel Rural Community Curriculum Programme. The students live and learn in a rural general practice, but do not learn only about rural practice and are expected to attend clinical activities related to all areas of medicine. Instead of studying these disciplines in rotation as their university-based peers do, students learn about them in an integrated way throughout the year. Patients encountered in general practice are followed through primary care and secondary care. Students also become actively involved in community projects. [go to reference 45] The third year Parallel Rural Community Curriculum Programme follows from a successful pilot programme, detailed in Worley (2000). [go to reference 46]
Finally, in year four, students are expected to spend a six-week placement in a rural healthcare setting. [go to reference 45]
Although the evidence just discussed comes from other countries, it seems likely that placing students in a rural area for a period of their study can have generalisable educational benefits. Medical education in the rural primary and secondary care environment provides important opportunities for medical students to understand the context of illness and gain a holistic view of health in communities where many of the illnesses and social issues are more visible [go to reference 42] (key issues 4).
Key issues 4: advantages of placements in a rural healthcare setting
• Introduces students to rural healthcare and culture and dispels misconceptions.
• Promotes the status of rural healthcare within the training programme.
• Maintains contact with rural communities for students orientated towards rural practice.
• Provides students with a wider range of experiences than urban placements can always provide.
• Helps students to understand the context of illness including transport and emergency care issues.
• Allows students to observe a holistic model of healthcare for individuals and communities, and observe medical leadership within small communities.
• Has the potential to widen understanding of international rural health issues and the care of indigenous communities on other continents.
• Gives an understanding of the balance between access and quality of health services.
Sources: Buckley [go to reference 33] (2003), Williamson et al [go to reference 42] (2003).
Although further research is required in relation to UK rural placements, it is suggested that valuable advantages for the development of a student’s medical education can be gained from placements in different types of area. Although most UK medical schools now recognise the value of providing the opportunity of a placement in a rural area, in medical schools in predominantly urban areas the majority of placements are urban-based. For example, the University of Liverpool places some students in rural GP practices in the Morecambe Bay area and Llandudno, although the majority of placements are urban-based for most of the course. The locations of UK medical schools are shown in figure 2.
Figure 2: location of medical schools in the UK (based on UCAS listings)
Some medical schools do have significant rural connections and can place a significant number of students in rural areas. Examples are given in key issues 5.
Key issues 5: medical schools with significant rural placements
• The University of East Anglia places students in a primary care setting one day per week from year one to year five. The majority of the placements are in small towns or villages. All students gain experience in practices in Norwich and in rural practices over the five years. Planning is under way to ensure that all students have experience of working in a community hospital, most of which are in rural areas.
• Peninsula Medical School places students throughout Devon and Cornwall from year two to year five. Many of these placements are rural in nature. In addition, Special Study Units allow students to experience remote and isolated environments.
• Hull York Medical School operates a travel-time rule in year one and two so that students do not travel for more than half an hour to reach their placement. Current year one placements include village practices with a rural catchment area. It is intended that year three and four students will experience primary care in both rural and urban areas, while year five students will travel more widely for placements and continue to build upon their experience of rural areas.
• The University of Aberdeen places approximately two-thirds of its students in rural/remote areas in years four and five. In the fourth year just over 50 per cent of placements are in rural areas, mainly rural towns. In the fifth year around 90 per cent are in rural areas, with some in the remote island areas.
• The University of Dundee has rural/remote placements in year five only, amounting to 50 per cent of the total placements in that year. In addition, 6 per cent of year five students may elect to do a three-month extended placement in a rural practice.
• The University of Edinburgh places students in a rural (but not remote) practice in year four only, which accounts for around 50 per cent of placements in that year, although they are actively looking to increase the number of rural placements.
However, even when there are opportunities for rural placements, there may be access difficulties. Rural placements can be expensive for students and universities, with significant travel and accommodation costs. Funding for rural placements would help to address these issues. An example of a funding scheme is in place in Australia, where scholarships are administered on behalf of the government to sponsor students in rural areas and encourage medical schools to undertake rural teaching. [go to reference 47] Students may also feel isolated from their peers and local-networking structures need to be established.
Recommendation 2
It is desirable that all medical students have the opportunity to choose a rural placement. The opportunity should be seen as a positive contribution to a student’s medical development. Placing students in a rural area could promote working in a rural area as a positive career choice.
• Appropriate funding should be provided to cover any additional costs of travel and accommodation that are incurred by rural placements. The costs incurred by the practice providing the training must also be considered.
Postgraduate training
Rural and remote practices can provide a broader range of services than those in urban areas. Research in Australia has found that, in general, the proportion of GPs providing a broader range of services increases with increasing rurality or remoteness. [go to reference 48] Rural GPs are often the first port of call for a wide range of health needs, and may be exposed to health problems for which they may not have received sufficient training and support. Those health problems that practitioners in rural/remote areas may need experience and knowledge of are highlighted below in key issues 6.
Key issues 6: healthcare aspects common in rural practice
• Emergency and trauma care: practitioners need to be prepared to deal with day-to-day trauma and a rotation through accident and emergency (A&E) as part of vocational training is an enormous benefit. Rural practitioners should also be prepared to deal with the pre-hospital management of trauma patients where there may be problems of access and absence of A&E equipment. [go to reference 49] The British Association for Immediate Care (BASICS) provides
courses in dealing with emergencies that are strongly recommended for rural practitioners. [go to reference 37]
The need for rural practitioners to be prepared for dealing with emergencies and the problem of skill decay have recently been identified as important issues for educational research and policy development.
• Mental health: some mental health problems are more prevalent in certain rural/remote populations. A RARARI report identified that there is not always the infrastructure in rural/remote areas to ensure that acutely distressed mentally unwell people have access to specialist care. [go to reference 50]
• Chronic disease: the higher proportion of elderly people in rural/remote areas leads to a higher incidence of chronic disease.
Sources: Cox [go to reference 49] (1999), Gillies [go to reference 37] (1998), Kerr [go to reference 50] (2003) and Sim [go to reference 35] (2001).
In addition, patients in rural areas may present practitioners with health problems that are particular to rural areas or more prevalent in rural areas. For example, certain health problems are more prevalent in farming communities (key issues 7).
Key issues 7: health problems that are more prevalent in the farming community
• Anxiety, depression and suicide.
• Farm-related accidents.
• Zoonotic diseases (infections passed to humans from animals) such as food poisoning, rabies, tuberculosis, and infections with ringworm, orf and cowpox.
• Risks associated with use of chemicals.
Sources: Mungall [go to reference 51] (1999), Burnett and Mort [go to reference 52] (2001) and the Rural Mental Health Working Group [go to reference 53] (1998/1999).
In the secondary sector, there is a similar need for consultants working in such areas to provide a broader range of services. The surgical skills needed by surgeons in rural areas may vary with location. For example, consultants in Shetland and Orkney need to carry out caesarean sections, while those in Fort William need skills in mountain trauma. [go to reference 35] Surgeons also need generalist skills to deal with a complex case mix.
Healthcare professionals in rural/remote areas therefore need to develop a greater range of skills than those in urban areas. RARARI in conjunction with Skills for Health has recently explored the skills used by rural healthcare professionals and these are discussed in key issues 8.
Key issues 8: skills for rural healthcare teams
In the UK, RARARI has worked with Skills for Health, the Scottish Executive and relevant NHS health boards and organisations to provide an improved understanding of the activities that make up healthcare in rural communities. Skills for Health has categorised the skills and competencies that are needed by rural healthcare teams. Identifying these skills will assist workforce planning and inform the education and training of staff at all stages of their career.
The project has identified:
Skills that appear to be specific to rural/remote healthcare
• Maintain confidentiality and respect professional boundaries in small closely-knit communities.
• Undertake roles that in other communities would be undertaken by other practitioners (for example dispensing as well as prescribing drugs with its implications for practice income).
Skills that are often needed by rural/remote healthcare teams that may not be needed in urban areas
• Emergency care, including an active role in road traffic injuries and major incidents; stabilising patients prior to hospitalisation; dealing with obstetric emergencies.
Issues that might need greater emphasis in rural/remote communities
• Mechanisms to deal with travel difficulties and distance from specialist care.
• Effective prioritising and planning of workload.
• Effective team working for dispersed population and small communities.
Source: Skills for Health. [go to reference 54]
Postgraduate training programmes should be provided which reflect the generalist skills required in rural areas by different healthcare professionals. This would help to provide professionals with the confidence and encouragement to choose rural practice. Primary and secondary care in rural areas can provide opportunities to expose trainees to a variety of situations and experiences, and thereby increase knowledge of generalist skills.
A period spent in general practice would give all trainee specialists experience of the holistic, generalist and continuous care delivered in general practice. Most patients treated in hospital are referred from general practice, most return to a community setting, and 80 to 90 per cent of all healthcare episodes are dealt with in general practice. An improved mutual understanding of the skills, knowledge, experience and roles of GPs and other specialists would be helpful. Modernising Medical Careers offers the opportunity to broaden the experience of trainees within the general practice setting. The second foundation year (the equivalent of the current senior house officer training) will focus on the management of acutely ill patients as well as the acquisition of key generic skills. One aim of this training period is to foster a better understanding of the relationship between primary and secondary care, by providing a greater number of experiences in, and knowledge of, general practice. [go to reference 55] It is desirable that the choice to spend time in a rural practice as part of this training should be offered and encouraged.
Case study – Promoting rural practice through postgraduate training: The Australian College of Rural and Remote Medicine (Australia)
The Australian College of Rural and Remote Medicine has developed a Rural and Remote Area Placement Program (RRAPP) to offer junior doctors 10 to 13-week placements in rural practices as part of their clinical rotations. RRAPP trainees receive high quality training in procedural and other practice skills in a wide range and depth of clinical situations. The aims of the RRAPP are to:
• assist state and regional bodies to establish up to 20 training sites and 100 posts throughout Australia for postgraduate students during years 2000-03
• help to establish postgraduate training sites in small rural/remote towns (and in larger provincial towns, with special justification)
• increase the number of doctors experiencing postgraduate rural practice/rural community experience
• increase the length of exposure to postgraduate rural practice
• provide a high quality learning experience – both clinical and social – in a setting other than a major teaching or provincial hospital. [go to reference 56]
Recommendation 3
Postgraduate training programmes should use the opportunities provided in rural primary and secondary care to teach generalist skills to healthcare professionals (including surgeons) during their basic training.
• It would be desirable to provide all doctors with the opportunity to spend time in general practice as part of their postgraduate training, and the option to spend time in a rural practice should be encouraged.
• Small rural hospitals provide an excellent opportunity for postgraduate medical education. It is desirable that rotations proposed in Modernising Medical Careers for the foundation years should include the option of rural placements as part of generalist training.
• Funding should be available to support such placements.
Continuing professional development (CPD)
Due to the heterogeneity of rural areas, specific skills are needed for certain locations. Maintaining high standards across this broad range of services poses special educational challenges. [go to reference 33] There is a need to provide healthcare professionals with opportunities for individual learning and training. Programmes should maintain the breadth of competencies required in rural areas and the individual should identify his/her specific educational needs according to the needs of their particular practice. High quality CPD can improve/maintain confidence, increase job satisfaction and reduce professional isolation (thereby aiding retention). [go to reference 33] Professional isolation can be reduced by initiatives such as interprofessional learning, where a wide range of healthcare professionals are involved in continuing education. [go to reference 57] Such initiatives encourage partnership and closer working with colleagues. (Also see interprofessional working). Practitioners need to know that a rural post will provide appropriate opportunities for professional development. [go to reference 14]
Centres of expertise, that provide training in the specific skills that rural healthcare professionals require, could usefully be established. In one example, an affiliation between the IRH and the School of Postgraduate Medical and Dental Education of the University of Wales College of Medicine, has led to the creation of the Welsh Rural Postgraduate Unit. The unit has particular expertise in postgraduate training and continuing professional development for those working in rural Wales. The scope of activities is multidisciplinary and covers all rural health practitioners in Wales. [go to reference 5]
Recommendation 4
Continuing professional development should be flexible and responsive to the range of needs found in rural/remote medical practice and tailored to the educational needs identified by the individual. [go to reference 58]
Workforce planning
One of the great difficulties is that while staff may be encouraged to pursue training, access to available opportunities may be limited by staff constraints, patient overload and financial constraints (key issues 9). It is therefore important that rural practices assess their workforce planning in a rigorous and proactive manner so that staff can be supported in their professional development.
Key issues 9: difficulties associated with access to CPD opportunities in rural areas
• Lack of adequate staff cover due, for example, to the difficulty and/or expense of obtaining locum cover.
• CPD opportunities may be available in urban centres only, leading to difficulties in accessibility.
• Budget constraints, for example, the high costs of travelling.
Sources: Niven [go to reference 59], Servers & Crane [go to reference 57] (2000).
CPD training could be provided locally and at a distance from a main university campus, to reduce the substantial costs and extended periods away from practice. For example, the Department of Nursing and Midwifery, based at the University of Stirling, provides a wide range of CPD courses for nurses and midwives. Many of these courses are delivered in satellite campuses closer to rural areas. [go to reference 59] A road show approach can also be taken, [go to reference 33] in which mobile facilities provide skills development and training. Secondary care services in rural/remote areas could be linked with hospitals in urban areas, to ensure provision of cover for study leave and to allow CPD. A sabbatical or secondment that allows doctors from rural areas to spend time with their peers in urban facilities would be very beneficial, and could be delivered as part of the flexible employment opportunities available to all healthcare professionals (also see flexible employment opportunities).
The NHSU, the corporate university for the NHS, has been set up to provide everyone who works in health and social care with opportunities to learn and develop, [go to reference 60] and acquire the skills they need to work effectively. These opportunities will be delivered in a variety of ways. Most learning will take place in the workplace but there will be an emphasis on electronic learning (e-learning). The NHSU have suggested that they will prioritise programmes for areas that will have the biggest impact on patients’ experiences. [go to reference 60] In the present context, the NHSU could help to widen access to training for rural healthcare professionals and so bring great benefit to their patients. It will be of great interest to see whether the NHSU addresses the specific training requirements of professionals in rural areas.f
E-learning
E-learning involves education using the Internet or specific computer programmes. An e-learning approach could offset the limited access to professional development opportunities faced by rural practitioners. E-learning has several advantages. For example, each learner can organise an individual time-schedule, images and data can be worked upon easily, groups of learners can be pooled to determine educational need, and distance poses no problems as educational providers can be sourced from far afield including other countries where appropriate.
However, technology often lags behind expectation and is expensive in capital investment and implementation. E-learning also has the potential to increase rather than lessen personal isolation if it is viewed as a means of reducing costs and avoiding attendance at courses, which have the benefit of peer interaction. Many experienced rural practitioners view the social element of courses as just as beneficial as the educational content. E-Learning should be seen as one of many educational tools and it is important that its use is driven by educational principles, rather than the technology driving the education.
f It was announced in December 2004 that the NHSU will merge with the Modernisation Agency to create a new NHS Institute of Learning, Skills and Innovation.
Case study – Bringing managers together using an e-learning approach to CPD (Australia)
An e-learning approach is in place for health service managers in Western Australia, where distance and geographical isolation can limit many rural practitioners’ access to CPD opportunities. The Electronic Advanced Learning Set provides the flexibility and efficiency of e-learning, along with limited face-to-face meetings, for a group of managers from various health service backgrounds. This provides a forum for them to work together on locally relevant programmes, encourages networking, decreases isolation and develops organisational and management skills. Videoconferencing, telephone conference calls, an electronic bulletin board, email networking and limited face-to-face workshops are used.
Time is a major limiting factor and health service regions must demonstrate commitment to CPD by contributing funding for participation and so enable time out for work-based learning. Common problems to be overcome include the need for access to videotechnology and the Internet, and training in the use of videoconferencing. [go to references 61,62] Initial financial expenditure on equipment is also a limiting factor.
Recommendation 5
Workforce planning must consider CPD training needs. A wide range of CPD opportunities should be developed so that staff from various types of rural practice have access to training.
• CPD training can be carried out away from the main university campus and taken out to rural practitioners.
• Secondary care services in rural/remote areas should be linked with hospitals in urban areas, to provide cover for study leave and facilitate CPD. CPD should involve professionals from rural areas spending time with their peers in urban facilities.
• CPD should include opportunities for isolated practitioners to learn with and have contact with colleagues.
• Appropriate funding from the primary care organisation should be provided to enable staff cover, the purchase of computers or other equipment, and to underpin CPD programmes.
• E-learning must be available and should use appropriate electronic media so that those with only limited access can take part. Training in using the equipment is necessary and broadband will need to be made available in all rural areas.