Rural psychiatry

Position statement Last updated: Feb 2022 Published in Australia Reference: PS #65

The RANZCP calls for dedicated strategies and funding to increase the number of psychiatrists working in rural and remote communities.

Purpose

The purpose of this position statement is to draw attention to the continued severe shortage of psychiatrists in rural, remote or regional areas and provide recommendations to governments, health planning authorities and health services to address this issue. The mental health services and support must be improved to deliver better health outcomes for people living rurally in Australia and New Zealand.

Key messages

There is a severe shortage of psychiatrists in rural and remote Australia and in regional areas of New Zealand.
The shortage of psychiatrists and mental health services in rural areas is an equity issue.
Incentives, programs and supports to strategically address the number and distribution of psychiatrists are urgently needed, including for psychiatrists who are currently living and working in rural and regional areas.
Strategies which holistically address inequitable access to mental health care for Māori and Aboriginal and Torres Strait Islander people in rural and remote areas are required..
Improving access to psychiatrists will provide care that is critical to improve mental health outcomes for those living in rural and remote communities.

Background

Australians living in rural and remote areas generally experience poorer health and welfare outcomes than people living in metropolitan areas (1). They have unique factors that impact on their health including reduced access to health services, greater distances to travel for health services, engaging in high-risk occupations such as farming, exposure to hazardous working conditions and environmental adversity such as flood, bushfire and drought (2). Some rural workforces experience mental and physical health co-morbidities, therefore some people have complex presentations (2).

Nearly a million Australians living in rural and remote areas will experience a mental health disorder each year (3). While the prevalence of mental disorders is similar across all geographic locations, some adverse outcomes for mental health, for example, rates of suicide and self-harm, are significantly higher in rural and remote areas, and increase with increasing remoteness (4). Farmers, young men, older people, and Aboriginal and Torres Strait Islander peoples in remote areas are at greatest risk of suicide (4). While initiatives like the Better Access to Mental Health Care have created new methods for accessing Medicare funded mental health services in Australia, these services are not being utilised in rural and remote areas. Rates of use of Medicare-subsidised mental health services decline as remoteness increases (5) with provider availability and securing specialist services often proving challenging in these areas (6).

It is important to understand the differences affecting rural and remote population areas and the impact of remoteness on access to health services and health outcomes.

The mental health needs of Aboriginal and Torres Strait Islander peoples “are significantly higher than those of other Australians” (7). In 2011-12, around one-third of Aboriginal and Torres Strait Islander adults reported high or very high levels of psychological distress – almost three times the rate of non-Indigenous Australians (8). Furthermore, age-standardised death data demonstrates that Aboriginal and Torres Strait Islander peoples aged between 35 and 44 years are 5.7 times more likely to die from mental and behavioural disorders compared to non-Indigenous Australians (9). Discrimination, lack of culturally appropriate policies and services, intergenerational trauma and socioeconomic factors contribute to poor mental health experienced by Aboriginal and Torres Strait Islander peoples (10).

Challenges to mental health care and delivery in rural areas in New Zealand are similar to those found in Australia. A survey in New Zealand conducted between 2003 and 2004 revealed 40 per cent of respondents reported they had experienced a mental illness condition at some time (11). Though there is little difference in the prevalence of mental health conditions between urban and more rural areas, people living in rural areas use mental health services less than their urban counterparts (12). As in Australia, stigma, workforce shortages and distance all play a part in reducing rural communities’ access to mental health services (13).

In many rural areas, Māori comprise a higher proportion of the population than the non-Māori population (14). While Māori have high prevalence rates of mental health conditions they are less likely to be diagnosed (13). Lack of culturally appropriate services, socioeconomic disadvantage and discrimination can affect people’s ability to manage their mental health (15) particularly if services are limited in regional areas. This inequity can have further negative consequences for mental health.

Healthcare services provided in regional, rural and remote areas are often heavily relationship-based with strong networks developing between psychiatrists, GPs, allied health and other specialists to help provide robust local referral pathways and continuity of care to patients.

Failure to deliver rural services remains an equity and social justice issue for rural and remote communities and clinicians in Australia and New Zealand. The RANZCP has developed the Rural Psychiatry Roadmap 2021–31 to provide a pathway to equitable and sustainable rural mental health services.

Evidence

There is a severe shortage of consultant psychiatrists in rural and remote Australia and in rural areas of New Zealand (16, 17). In the context of current metropolitan based training programs, most trainee psychiatrists also report a continuing inclination to practice in urban centres (18, 19).

Data on the psychiatry workforce shows that major cities in Australia have approximately 15.1 full-time equivalent (FTE) employed psychiatrists per 100,000 population, while that figure was 5.8 for inner regional areas, 3.4 in outer regional areas, 5.0 in remote areas and only 1.4 in very remote areas (16). Generally, the more remote the location, the worse access is to psychiatric services (20).

Although distinguishing between urban and rural areas in New Zealand can be difficult (21), there is a well-recognised geographical maldistribution of psychiatrists in New Zealand. In response, Health Workforce New Zealand runs a Voluntary Bonding Scheme (VBS) to encourage health professionals to work in hard-to-staff communities (22). The VBS provides $50,000 over five years for a new graduate to pursue their career in a regional hospital. Unpublished findings from the Medical Council of New Zealand’s 2016 Workforce Survey provides further details regarding FTE rates of doctors who reported working in psychiatry at their main work sites per 100,000 population. District Health Board (DHB) regions with the highest FTE rates were Auckland (42.2), Capital and Coast (28.0), Waikato (23.3), Canterbury (22.2) and Southern (20.5). Each of these DHB regions contain urban centres as well as surrounding rural areas. In contrast, DHB regions with the lowest FTE rates were South Canterbury (4.6), West Coast (5.6), Wairarapa (6.0) and Tairawhiti (8.7). Geographical isolation and limited career pathways are thought to contribute to these low rates, although further research is required to assess the relevance of other factors.

Generalist rural psychiatrists are required to have broad knowledge and specialist skills across a range of areas of expertise, working with people across all age ranges and treating a wider array of issues than psychiatrists in urban areas. This occurs where there are fewer clinical supports and leads to increased responsibilities and requirements for a diverse range of expertise. It can be more difficult for psychiatrists in rural areas to collaborate with other clinicians due to distance and workload demands. Furthermore, they often have to assume multiple supervisory roles, but still maintain a heavy patient load. This can also impact on the capacity for research activities to be undertaken in areas of rural health and healthcare.

Challenges of rural practice include professional isolation, social and family factors (including difficulties with spouses obtaining employment), limited career and research opportunities, large size of patient base, burden of travel to outreach services, lack of specialist positions at regional hospitals, and remuneration (20, 23, 24). The Medicine in Australia – Balancing Employment and Life (MABEL) survey highlighted professional support as a key factor in career choice and job satisfaction (25). Impacts of professional isolation may include a lack of after hours and sickness cover, peer support and review, access to Continuing Professional Development (CPD), opportunities to train registrars and to have junior medical staff backup, collegiality, and the impact of chronic shortages on sustainable workloads. For Specialist International Medical Graduates (SIMG), the challenges can be all of the above together with the challenge of cultural transition.

Current approaches

For the reasons stated above, rural settings are areas of high unmet need for psychiatry services. Currently, there are several approaches to addressing this situation, some of which need to be expanded and others which offer limited value.

Rural based training

The establishment of rural clinical schools over the past 20 years, amongst other initiatives, has bought about an increase in the number of undergraduate students studying and commencing prevocational work in rural areas (26). However, currently postgraduate options for training and working rurally remain limited due to systemic bias towards programs that are metropolitan based and administered, perpetuating a lack of appropriate placements and opportunities in rural areas (27). The MABEL survey highlights the increase in medical sub-specialisation amongst undergraduates also factors into the numbers of medical professionals available to live and work rurally as graduates looking to specialise must reside in metropolitan areas to undertake training (28). Relocation to metropolitan areas to undertake specialist training is often permanent with few returning to rural or regional practice after training is completed (29). The Rural Psychiatry Roadmap 2021–31 has been designed to enhance Fellowship training to enable trainees to complete all, or nearly all, of their RANZCP Fellowship psychiatry training in rural areas. Funding for additional rural supervisors and support, including dedicated time for supervision, is essential if training opportunities are to be expanded in rural areas.

Regional training hubs are a recent important initiative promoting postgraduate specialisation in regional areas (29). Enabling postgraduate specialist medical training to occur in rural and regional areas encourages medical professionals to remain in these locations after their training is complete, helping to build a local, sustainable health workforce for rural and remote communities. Investing in regional training hubs is an important means to keeping regional, rural and remote areas connected, promoting sustainability and independence, whilst limiting the reliance on metropolitan based solutions such as fly-in fly out locums or telehealth services who may not be ideally placed to understand the needs and cultures of local regional, rural and remote communities.

International Medical Graduates

In Australia, another approach to meet workforce need in rural and remote areas, is to recruit International Medical Graduates (IMG), who are incentivised to work in rural areas by obtaining permanent Australian residency or Australian citizenship. While this can provide urgently needed care, there is a risk of amplifying problems of professional and social isolation for practitioners who have not trained in Australia and do not have the professional networks that training in Australia provides. Furthermore, they may have limited knowledge of the context of the Australian health and community systems. There are potentially also cultural and language issues, which can further increase professional and community isolation. New Zealand also recruits internationally trained medical professionals to address access issues to medical care with higher numbers of international medical graduates practicing in rural areas (54.5 per cent) than urban areas (37.8 per cent) (30). A focus on selecting medical students with a rural background, who are more likely to return to live and work in rural areas, has been promoted as another alternative to reliance on IMGs. However, as previously noted, the increasing propensity for sub-specialisation among medical graduates can limit opportunities to live and train in rural areas (28), reducing the propensity for graduates with a rural background to return to rural areas after specialist training is complete.

Rural Generalists

The establishment of a Rural Generalist pathway has been proposed as a means of addressing the inequity to health services faced by those living in rural and remote areas. A Rural Generalist is a medical practitioner who trains to meet the diverse range of healthcare needs of those living in rural and remote Australia, providing general practice, emergency care and other components of medical specialist care including psychiatry (31). However this pathway does not formally exist for specialist medical graduates including psychiatrists.

Technological initiatives

Technology is another potentially useful approach to patient assessment and consultation as well as training and supervision for rural psychiatrists who would ordinarily be isolated and hard-to-reach. The RANZCP supports the use of telepsychiatry in augmenting the delivery of local mental health services and notes its practical application in reaching people in rural and remote areas. Studies have demonstrated that telepsychiatry can be as effective as face-to-face consultations in achieving improved health outcomes (32, 33). However, telepsychiatry should not be seen as a stand-alone service for rural and remote communities; the implementation of telepsychiatry requires a planned and coordinated approach built on a foundation of local services and providers. For psychiatric emergencies, the telepsychiatry practice should work in coordination with local services, and these services should be resourced and available at equivalent and proportionate rates as available in metropolitan areas and should not be resourced to the detriment of often underfunded local services. Telepsychiatry can also be used to support the use of multidisciplinary teams in assessment and treatment, allowing those in rural and remote areas to access care from a central regional hub (34). Virtual multidisciplinary teams (VMT) can be used to identify and treat complex comorbidities over large distances using common technology such as text messages (35). However, the use of technology to support health services to people in rural and remote areas may also diminish locally-based care and coordination as specialists in rural areas are effectively ‘priced out’ from providing services locally, due to competing costs with metropolitan-based telehealth providers. Localising telehealth services can be beneficial as it strengthens the economy of regional and rural communities (36).

Technology can provide opportunities supporting education, training and networking for psychiatrists in regional, rural and remote areas, for example, providing webinar-style training and supervision which might be difficult to access in person. Improving digital health infrastructure, including high speed internet, in rural and remote areas, is urgently needed (37) to facilitate the use of technology for health professionals and patients within regions.

As with telepsychiatry, the use of fly in, fly out psychiatrists can assist with supporting mental health service provision in rural and remote areas, particularly if coordinated with local regional services and undertaken with robust processes to limit discontinuity of care (38). Metropolitan based multidisciplinary teams visiting rural and remote areas can also help improve access to specialist services especially if adequate primary care services exist locally (39). However, while the use of alternative methods, such as the use of fly in, fly out psychiatrists, have a role to play in delivering mental health services to rural and remote areas, increasing the number of, and supporting, psychiatrists currently living and working in regional, rural and remote areas should remain a priority

The RANZCP acknowledges the importance of telehealth and other technology-based services in providing choice for people in regional, rural and remote areas seeking to access mental health services although the focus should ultimately be placed on supporting local services in regional areas. In order to achieve this, funding must be allocated to building the capacity of regional communities and health care systems to provide localised, sustainable care to surrounding rural and remote areas.

Workforce programs

A range of projects directed to rural workforce development include the New South Wales Rural Psychiatry Project, Commonwealth Government initiatives such as the Specialist Training Program and the Integrated Rural Training Pipeline and the delivery of undergraduate medical education through rurally-based medical schools. These programs are demonstrating results. However, to date, there is little impact on recruitment of psychiatrists to rural areas due to the lack of recruitment and retention incentives, the small number of psychiatric positions available in rural areas and the lack of career pathways for rural psychiatrists. The New Zealand Government has highlighted a commitment to undertake measures to improve mental health services in rural areas (40). However, it is important that support and incentives are offered to those currently practicing in rural and regional areas as well as designed to attract new practitioners.

Within Australia, there is the opportunity for Primary Health Networks (PHNs) to commission psychiatrist services and build locally relevant, sustainable psychiatric care throughout regional and rural areas in Australia. This also has the potential to support working relationships with GPs and other health professionals.

In response to the evidence around the shortage of mental health specialists, an Australian Inquiry recommended that the Commonwealth Minister for Health work with health professional colleges to develop strategies for the immediate improvement of professional supports and clinical supervision for registered health practitioners working in rural and remote locations (41).

Recommendations

In order to address the inequities in access to health care services in rural and remote areas of Australia and New Zealand, the RANZCP recommends the following actions:

Australian Government

Provide dedicated funding for psychiatrist positions in regional and rural areas with associated targets agreed in the National Partnership Agreement on Health Services with the States and Territories. Such positions should be available, as a minimum, at rates at least proportionate with metropolitan areas per capita of the population.
Fund the Rural Psychiatry Roadmap 2021–31.
Establish enrolment targets and weighting of enrolment criteria in favour of regional/rural students to increase the numbers of medical students with a rural background.
Invest in integrated rural psychiatry training centres and programs to facilitate more trainees undertaking their psychiatry training entirely in (or from) regional and rural locations.
Provide funding to the development of ongoing additional supports for rural psychiatrists including CPD, networking, mentoring and managing stress and burnout.
Provide opportunities and incentives for rural psychiatrists to undertake individual research or as a research career pathway.
Improve data collection and reporting across services to assist in better delivery and continuous improvement.

New Zealand Government

Invest in integrated rural psychiatry training centres and programs to facilitate more trainees undertaking their psychiatry training in regional and rural locations.
Increase the number of training positions and availability of longer rural clinical placements for trainees to improve the capability of rural mental health services to accept psychiatry trainees.
Improve data collection and reporting across services to assist in better delivery and continuous improvement.
Provide funding to the development of ongoing additional supports for rural psychiatrists including CPD, networking, mentoring and managing stress and burnout.
Ensure rural psychiatrists can access reliable connectivity and technological infrastructure to develop and provide regionally based telepsychiatry and virtual multidisciplinary teams.

Health planning authorities (eg. State and territory health departments in Australia and the Ministry for Health in New Zealand)

Increase the availability of longer regional and rural clinical placements for junior medical officers and psychiatry trainees, and improve the capability and capacity of regional and rural mental health services to supervise and train rurally located psychiatry trainees.
Improve support provided to trainees working in rural settings including local information to assist settlement, peer support, supervision and mentoring, access to continuing professional development and educational materials, support for relocation (including partners) and increased opportunities for advanced training in psychiatry, for example, child and adolescent psychiatry.
Increase incentives to psychiatrists through competitive salary packages (and relocation costs), access to locum services, access to continuing professional development including travel and accommodation, and career development including management and leadership skills.
Provide targeted support to SIMG working in regional, rural and remote areas to understand the rural health and community context and to support their professional practice including directed mentoring and professional networking.

Health services

Provide dedicated regional and rural psychiatrist training positions and ensure they are adequately funded.
Ensure access and uptake of supervision and peer networking including site visits.
Ensure access to locums for psychiatrist leave cover including professional development and networking.
Ensure that all psychiatrists and trainees receive training in cultural safety and the specific mental health risk factors for Māori and Aboriginal and Torres Strait Islander people.
• Assist in finding housing for new psychiatrist recruits and their families, and employment for a psychiatrist’s partner to enable couples to be recruited and retained in regional, rural and remote locations.

Definitions

Rural and remote areas are defined and classified by various methods. In Australia, the Modified Monash Model (MMM) has been recently developed and is used by the Department of Health to address the maldistribution of medical services across Australia. The MMM draws on up-to-date population data and uses seven categories (1, major cities through to 7, very remote). In New Zealand, Stats NZ also uses seven categories (1, main urban area through to 7, highly rural/remote), based on different criteria.

References

Australian Institute of Health and Welfare. Rural and remote health: Web report. Canberra: Australian Institute of Health and Welfare 2017.
Accident Compensation Corporation. Farmers’ mental health. 2014.
Garvan Research Foundation. Medical research and rural health: Garvan report 2015. Darlinghurst; 2015.
Harrison J, Henley G. Suicide and hospitalised self-harm in Australia: trends and analysis. Injury research and statistics series no. 93. Canberra; 2014. Report No.: Cat. no. INJCAT 169.
Australian institute of Health and Welfare. Mental health services in Australia 2019 [Available from: https://www.aihw.gov.au/reports/mental-health-services/mental-health-services-in-australia/report-contents/medicare-subsidised-mental-health-specific-services.
Meadows GN, Enticott JC, Inder B, Russell GM, Gurr R. Better access to mental health care and the failure of the Medicare principle of universality. Medical Journal of Australia. 2015;202(4).
National Mental Health Commission. The national review of mental health programmes and services. Sydney; 2014.
Australian Bureau of Statistics. Australian Aboriginal and Torres Strait Islander Health Survey: First results, 2012–13. Canberra; 2014. Contract No.: ABS cat. no. 4727.0.55.001.
Australian Institute of Health and Welfare. Aboriginal and Torres Strait Islander health performance framework 2014 report: Detailed analyses. Canberra; 2015. Contract No.: Cat. no. IHW 167.
Dudgeon P, Walker R, Scrine C, Shepherd C, Calma T, Ring I. Closing the Gap Clearinghouse: Effective strategies to strengthen the mental health and wellbeing of Aboriginal and Torres Strait Islander people. 2014 November 2014.
New Zealand Guidelines Group. Identification of Common Mental Disorders and Management of Depression in Primary Care: An Evidence-based Best Practice Guideline. Wellington; 2008.
New Zealand Ministry of Health. Urban–Rural Health Comparisons: Key results of the 2002/03 New Zealand Health Survey. Wellington; 2007.
New Zealand Government Inquiry into Mental Health and Addiction. He Ara Oranga: Report of the Government Inquiry into Mental Health and Addiction. 2018 November 2018.
New Zealand Ministry of Health. Mātātuhi Tuawhenua: Health of Rural Māori 2012. Wellington; 2012.
Best Practice Advocacy Centre. Recognising and managing mental health disorders in Māori. Best Practice Journal. 2010;28.
National Medical Training Advisory Network. Australia’s Future Health Workforce – Psychiatry. Canberra; 2016.
New Zealand Ministry of Health. Health of the Health Workforce 2015: A report by Health Workforce New Zealand. Wellington; 2015.
Royal Australian and New Zealand College of Psychiatrists. Report on the Admission to Fell
Royal Australian and New Zealand College of Psychiatrists. Report on the Trends in Admission to Fellowship Survey 2011–2013. 2014.
Health Workforce Australia. Health Workforce 2025 – Volume 3 – Medical Specialities. Adelaide; 2012.
Statistics New Zealand. New Zealand: An Urban/Rural Profile. 2004.
New Zealand Ministry of Health. Voluntary Bonding Scheme – 2018 intake information 2018 [Available from: Voluntary Bonding Scheme | Ministry of Health NZ.]
Department of Health and Ageing. Report on the Audit of Health Workforce in Rural and Regional Australia. Canberra; 2008.
Paliadelis P, Parmenter G, Parker V, Giles M, Higgins I. The challenges confronting clinicians in rural acute care settings: a participatory research project. Rural Remote Health. 2012;12.
Joyce CM, Schurer S, Scott A, Humphreys J, Kalb G. Australian doctors’ satisfaction with their work: results from the MABEL longitudinal survey of doctors. Medical Journal of Australia. 2011;194(1).
.Geffen L. A brief history of medical education and training in Australia. Medical Journal of Australia. 2014;201(1):S19-S22.
Coleman M, Playford D. Time to end the drought in the bush. Australasian Psychiatry. 2019;24(4):366-8.
McGrail M, O'Sullivan B, Russell D, Scott A. Solving Australia’s rural medical workforce shortage: Policy Brief. Melbourne Institute of Applied Economic and Social Research, The University of Melbourne; 2017.
Monash University. Rural Health: About the hubs n.d [Available from: https://www.monash.edu/medicine/srh/hubs/about-us.
Medical Council of New Zealand. New Zealand Medical Workforce in 2015. 2018.
National Rural Health Commissioner. National Rural Generalist Taskforce: Advice to the National Rural Health Commissioner on the Development of the National Rural Generalist Pathway. 2018 December 2018.
García Lizana F, Muñoz Mayorga I. What About Telepsychiatry? A Systematic Review. Primary Care Companion to the Journal of Clinical Psychiatry. 2010;12(2).
Deslich S, Stec B, Tomblin S, Coustasse A. Telepsychiatry in the 21st Century: Transforming Healthcare with Technology. Perspectives in Health Information Management. 2013;Summer.
Tso J, Farinpour R, Chui H, Liu C. A Multidiciplinary Model of Dementia Care in an Underserved Retirement Community. Frontiers in neurology. 2016;7(25).
Munro A, Swartzman S. What is a virtual multidisciplinary team (vMDT)? Bristish Journal of Cancer. 2013;108:2433-41.
Graham M. The Broader Benefits: Telehealth as an Instrument to Improve Human Security in Remote and Northern Canada. Queen's Policy Review. 2017;8(1):86-104.
Communique - CouncilFest 2019. [press release]. National Rural Health Alliance2019.
Stokes B. Review of the admission or referral to and the discharge and transfer practices of public mental health facilities/services in Western Australia. 2012.
Wakerman J, McEldowney R. Fly in/fly out health services: the panacea or the problem? [Editoral]. Rural and Remote Health. 2012;12(2).
New Zealand Government. Tackling rural health workforce issues. 2018.
Senate Community Affairs References Committee. Accessibility and quality of mental health services in rural and remote Australia. 2018.

Disclaimer: This information is intended to provide general guidance to practitioners, and should not be relied on as a substitute for proper assessment with respect to the merits of each case and the needs of the patient. The RANZCP endeavours to ensure that information is accurate and current at the time of preparation, but takes no responsibility for matters arising from changed circumstances, information or material that may have become subsequently available.