OPINION: If the key to reducing the health inequalities experienced by rural communities lies in better access to health care, then the federal government is treading a very delicate path.
With universal access to primary health services still in question, the proposed higher education reforms also threaten to undermine years of initiatives aimed at addressing the rural health workforce shortage and the equitable provision of health care in rural Australia.
Obstacles are already placed in front of potential doctors who come from rural areas — such as lower average household incomes and educational disadvantage — and it is not only future doctors, but rural communities, who are set to suffer.
Evidence and our own experience at the University of NSW Rural Clinical School has demonstrated that doctors who grew up and went to school in rural areas are more likely to practise in rural and remote areas.
I was one of them. After completing all of my schooling in Wagga Wagga, the UNSW Rural Student Entry Scheme allowed me the opportunity to study medicine, which I would not have been able to do through the mainstream entry process. But the cost associated with this opportunity in terms of travel and living away from home was significant.
Fortunately, UNSW opened the Wagga Wagga campus of the Rural Clinical School, which allowed me to complete the final 3 years of my medical degree in my home town.
Studying in my home town developed my interest in rural health care and consequently I have remained practising in rural areas for more than 10 years.
The ability to study medicine in my home town also meant my family could afford to support my younger siblings through their university degrees.
Future students may not be so fortunate. The proposed deregulation of higher education will significantly increase the cost of studying medicine. With average incomes being lower in rural areas compared with metropolitan areas, higher costs represent a significant disincentive for potential future rural medical students.
When the Rural Clinical School surveyed medical applicants it revealed they felt most negative about supporting themselves financially during university and about the overall cost of a medicine program.
Perhaps as a consequence, this year the number of students who applied for our Rural Entry Scheme has been the lowest ever.
Our students are worried, not just about the immediate costs of their degree, but about their long-term career prospects and gaining postgraduate fellowship training positions.
The federal government has rightly increased general practice training places, indicating the importance of primary health in the bush. But with the average income of GPs significantly lower than that of other specialities, there will be a disincentive to pursuing general practice training for medical graduates who have significantly larger education debts needing to be repaid.
General practice is still the only specialist training pathway available to doctors which can be completed entirely in the bush, and this is of significant concern to the rural students I talk to.
The specialist colleges have not followed suit to increase fellowship training positions to match the increase in the number of medical students. We know that those who do go on to specialist training in the city are unlikely to return to the bush. By the time they have qualified they are married, their children are in school, and the incentive to relocate to a rural area has long passed.
To address rural health inequalities, rural Australia needs doctors who are committed to working in rural and remote areas. We need doctors who have grown up in rural areas and understand the issues that impact rural communities. We need to attract doctors who are able to relate to and support people living in these areas.
Whatever reforms the federal government introduces, it must ensure that primary health care delivered by doctors trained in rural medicine is not affected.
We must all be cognisant of the impact these government reforms could have, and work to ensure our students are kept interested in rural medicine, that they continue to be offered rural scholarships, and that attractive postgraduate rural training opportunities are available.
The practice of rural medicine is one of our best-kept secrets. There are few other jobs in medicine that provide the hands-on experience, the variety and the sense of collegiality that we enjoy in the bush.
Universities have the essential responsibility of selecting and training future rural doctors and the federal government needs to ensure there is no disincentive for young rural Australians who aspire to being a doctor working in rural and remote communities.
Dr Damien Limberger is the head of the Griffith Campus, Rural Clinical School UNSW.
This opinion piece was first published in the Medical Journal of Australia.