Rural Health Action Plan 2025-2027

ACEM recognises that emergency departments are staffed by a diverse range of health practitioners. The emergency medicine workforce in regional, rural and remote areas includes the following roles:

• FACEMs
• FACEM trainees
• ACEM Foundational, Intermediate and Advanced Associateships 
• ACEM Associateship in Pre-Hospital Retrieval trainees
• Trainees and specialists of other colleges, such as Fellows of the Australian College of Rural and Remote Medicine (ACRRM), Fellows of the Royal Australian College of General Practitioners (RACGP) and Fellows of the Division of Rural Hospital Medicine in Aotearoa New Zealand of the Royal New Zealand College of General Practitioners (RNZCGP)
• Career medical officers and other medical officers working in hospital emergency departments and other emergency care settings
• Nursing staff, including emergency nurse practitioners
• Allied health practitioners
• Other hospital support and administrative staff.

ACEM is responsible for training emergency physicians and advancing professional standards in emergency medicine across Aotearoa New Zealand and Australia. In recognition of these roles and responsibilities, and to best direct its influence, the RuHAP focuses on:

• ACEM members, including FACEMs, Associateships in Foundational Emergency Medicine, Associateships in Intermediate Emergency Medicine, and Associateships in Advanced Emergency Medicine;
• ACEM trainees; and
• The relationships between ACEM members and its trainee workforce, as well as the broader emergency medicine workforce.

As noted in ACEM’s Position Statement on Rural Emergency Care, multiple classification systems exist for defining hospitals, emergency departments, and geographic locations, both within ACEM and by Australian and Aotearoa New Zealand governments. These definitions are context-specific (for example, training and education, accreditation, emergency department delineation) and consider various factors such as geographic distance, population, and access to tertiary hospitals.

For the purposes of this RuHAP, the term regional, rural and remote includes:

• Within Australia – All locations outside capital cities without access to a tertiary hospital; and
• Within Aotearoa New Zealand – All locations outside greater Auckland, Christchurch, Hamilton, or Wellington. All emergency departments within these metropolitan areas are classified as metropolitan.

The definition is not intended to be exclusive but rather to broadly capture non-metropolitan areas with reduced access to emergency care. It should be interpreted within the context of the RuHAP’s purpose to increase equitable access to healthcare in regional, rural and remote areas. It is important to note that some large regional centres have experienced significant growth and may now function as small urban centres, with increased access to FACEM-led emergency care. As equity improves in these regions, the RuHAP will continue to shift its focus to areas of greatest need, regardless of geographic classification.

ACEM has a longstanding commitment to advancing rural health across Australia and Aotearoa New Zealand. The initial dedicated entity tasked with overseeing this important work was established in 2010, reflecting the College’s recognition of the unique challenges faced by regional, rural and remote communities. Over time, this oversight body has evolved in structure and scope to more effectively address the complex and changing healthcare needs of these populations. The current iteration, the Regional, Rural and Remote Advisory Committee (RRRAC), serves as the principal advisory group guiding the College’s strategic initiatives and policies aimed at improving health equity, workforce distribution, and access to quality emergency care in rural and remote areas.

The RRRAC plays a key role in shaping ACEM policies and guidelines to improve rural health and workforce
distribution in Australia and Aotearoa New Zealand. It leads the development and implementation of the RuHAP, collaborates with College departments to enhance training for rural trainees, and supports workforce planning and governance through representation on key committees. The RRRAC also oversees the National Program’s alignment with rural priorities and advocates for rural health equity externally through partnerships and alliances.

Overall, the RRRAC plays a pivotal role in advancing equitable emergency care across regional, rural and remote communities. Its functions and responsibilities are detailed in its Terms of Reference, which guide the Committee’s efforts to address disparities and promote improved health outcomes in these areas.

ACEM’s Position Statement on Rural Emergency Care was first published in 2012 and is regularly reviewed. It outlines ACEM’s policy positions and key principles for achieving timely, safe and quality emergency care in rural areas.

ACEM’s advocacy is strengthened through its membership in organisations focused on regional, rural and remote healthcare, including:

• Australia’s National Rural Health Alliance.
• Hauora Taiwhenua Rural Health Network, Aotearoa New Zealand.
• the Joint Consultative Committee, in collaboration with the Royal Australian College of General Practitioners (RACGP) and the Australian College of Rural and Remote Medicine (ACRRM), regarding ACEM’s Foundational, Intermediate and Advanced training programs.

ACEM also collaborates and consults with a range of medical colleges, government bodies, health authorities, and other organisations involved in regional, rural and remote healthcare.

ACEM is one of several medical colleges that allow trainees to be based in regional areas, requiring them to rotate to a metropolitan centre only for their six-month Major Referral training. The College’s introduction of a six-month Regional, Rural and Remote Training Requirement, commencing in 2027, ensures that all trainees gain experience in regional, rural and remote emergency departments. This initiative necessitates accrediting additional sites to provide sufficient training placements for all trainees. Not only will this requirement offer a more comprehensive training experience, but it will also benefit regional, rural and remote patients by increasing their access to FACEMs and trainee-provided emergency care.

ACEM manages the following projects and initiatives under its National Program, funded by Australian Government grants, which aim to develop, strengthen, and support a skilled and confident workforce of emergency medicine physicians in regional, rural and remote areas.

• Associateship Training Programs in Emergency Medicine (Foundational, Intermediate and Advanced)
• Special Skills Placement
• Emergency Medicine Education and Training Program (EMET Program)
• Integrated Rural Training Pipeline (IRTP)
• Specialist Training Placements and Support Program (STPS Program)
• Blended Supervision Pilot Project
• Accredited Training Networks Project

The sustainability of the emergency medicine workforce across Australia and Aotearoa New Zealand is influenced by factors such as increasing workloads, workplace culture, health system pressures, emergency physician burnout, and employment status issues.

ACEM’s Guidelines on Constructing a Sustainable Emergency Department Medical Workforce (G23 Guidelines) recommend minimum staffing levels necessary to provide quality patient care. Compared with metropolitan emergency departments, an even smaller proportion of emergency departments in regional, rural and remote areas meet these benchmarks for FACEMs and senior decision-makers, resulting in inequitable access to local specialist emergency care.

In 2023, across Australia and Aotearoa New Zealand, the majority of FACEMs working in hospital settings (70.1% in Australia and 68.2% in Aotearoa New Zealand) were employed in metropolitan public hospitals as their primary workplaces. Just under one-quarter (24.2%) of all FACEMs worked in a regional or rural area, with 23.2% in Australia and 31.8% in Aotearoa New Zealand based in these locations as their primary workplaces (Figure 1).³

More than half (55%) of new FACEMs (six to twelve months post-Fellowship) worked exclusively in metropolitan areas, 22% worked only in regional, rural or remote areas, and 16% worked across both metropolitan and regional, rural or remote settings.⁴ This represents an increase from 2014, when only 12.9% of new FACEMs were working in regional or rural areas. The main factors influencing new FACEMs to work in regional, rural or remote areas were an appreciation for the rural lifestyle and greater job availability and security.

In 2023, only 18.2% of trainees in Australia were based in regional or rural localities as their permanent workplaces, a figure similar to that in Aotearoa New Zealand (17.8%) (Figure 2).⁵
 

Figure 1. Distribution of FACEMs’ primary workplace, by region and remoteness (n = 3470)

Figure 2. Distribution of FACEM trainees’ placement workplace, by region and remoteness (n = 1805)

In 2024, only 5.3% of emergency departments in Aotearoa New Zealand and 18.9% of emergency departments in Australia met the minimum FACEM staffing levels recommended in ACEM’s G23 Guidelines.

At the time of reporting, just over one-third (40.7%) of ACEM-accredited major hospital emergency departments in metropolitan Australia met the G23 Guidelines. In contrast, none (0%) of the metropolitan (Urban 1) hospital emergency departments in Aotearoa New Zealand met the recommended minimum staffing levels.

No emergency departments in the Australian Capital Territory or the Northern Territory met the G23 Guidelines. In regional hospitals in Australia, two emergency departments (13.3%) met the G23 Guidelines, but no rural or remote hospitals in Australia, nor Urban 2 hospitals in Aotearoa New Zealand, met the minimum FACEM requirements.⁶

In addition:

• ACEM-accredited rural and remote (1:0.5) and private (1:0.3) hospitals in Australia had the lowest ratio of emergency medicine specialists to FACEM trainees compared with larger hospital peer groups.
• Regionally located ACEM-accredited emergency departments in Australia and Aotearoa New Zealand were more likely to report unfilled FACEM FTE positions. In Australia, 60.0% of regional and 66.7% of rural and remote hospitals reported unfilled FACEM FTE, compared with 29.6% of major referral hospitals and 45.8% of non-major referral metropolitan hospitals. In Aotearoa New Zealand, 55.6% of Urban 2 hospitals reported unfilled FTE, compared with 36.4% of Urban 1/specialist hospitals.

Regionally located emergency departments are more likely to employ locums. In Australia, 76.2% of emergency departments in rural and remote areas and 53.3% of emergency departments in regional areas employ locums, compared with 8% of major and non-major referral emergency departments in metropolitan areas. In Aotearoa New Zealand, the opposite trend is observed: only 22.2% of Urban 2 emergency departments reported employing locums, compared with 45.5% of departments in Urban 1 areas.⁷

Geographic maldistribution of the emergency department workforce has an amplified impact on Māori in Aotearoa New Zealand, as a greater proportion of Māori attend emergency departments located outside metropolitan areas compared with non-Māori. In 2017–2018, 69% of Māori emergency department patients attended regional hospitals, compared with 51% of non-Māori patients.⁸ As of August 2025, these figures have not been updated by the New Zealand Ministry of Health.

This maldistribution also has a distinct impact on Aboriginal and Torres Strait Islander peoples in Australia, as a higher proportion of this population resides in regional, rural and remote areas compared with metropolitan areas. Aboriginal and Torres Strait Islander people represent 1.9% of the population in major cities, increasing to 32% in remote and very remote areas.⁹

In 2024, Aboriginal and Torres Strait Islander peoples accounted for a higher proportion of emergency department presentations in regional (15.2%) and rural and remote (17.7%) hospitals, compared with 5.2% in major referral hospitals.¹⁰ Across all ACEM-accredited emergency departments, Aboriginal and Torres Strait Islander patients were over-represented relative to their proportion of the general population.¹¹

Inequitable access to ACEM-trained emergency care reflects the broader challenge of unequal access to healthcare services. Individuals residing in regional, rural and remote areas frequently encounter barriers such as extended waiting times for treatment, limited choice of healthcare providers, and reduced availability of specialist services. For patients, this may manifest as:

• Not having a regular general practitioner (GP) or usual place of care.¹²
• Needing to present to an emergency department due to the unavailability of a GP when required.¹³
• Travelling long distances and experiencing extended stays away from home to access health services.¹⁴
• Experiencing delays in diagnosis, transfer and treatment.¹⁵
• Encountering difficulties in self-managing chronic conditions.¹⁶
• Compromised ongoing recovery after returning home, contributing to a ‘vicious cycle’ of worsening health.¹⁷

The effects of inequitable access to healthcare are reflected in the poorer health outcomes of people living in regional, rural and remote areas compared with those in metropolitan areas. For example:

• In Australia in 2023, 48% of deaths of people aged under 75 were potentially avoidable. For both males and females, the rate increased with remoteness. The rate of potentially avoidable deaths in very remote areas was 2.8 times higher than in major cities.¹⁸
• In Australia in 2018, the burden of disease in remote and very remote areas was 1.4 times higher than in major cities.¹⁹
• In 2023, Australians living in very remote areas were more than twice as likely to die by suicide compared with Australians in major cities.²⁰ In Aotearoa New Zealand, the suicide rate is also higher for those living in rural areas than in urban areas.²¹
• In Aotearoa New Zealand, people living in rural towns have a lower life expectancy than those living in cities or surrounding rural areas.²²

In general, Māori experience significantly worse health outcomes than non-Māori across Aotearoa New Zealand. Although progress has been made over the past 30 years to improve Māori health, substantial disparities persist. These include poorer outcomes across a range of measures, greater exposure to the determinants of ill-health, limited health system responsiveness, and under-representation of Māori in the health workforce. Māori have higher rates than non-Māori for many health conditions and chronic diseases, including cancer, diabetes, cardiovascular disease and asthma. They also experience higher disability rates, shorter life expectancy, higher suicide rates (particularly among young Māori), and higher smoking rates.²³

Māori are over-represented among those accessing mental health and addiction services, comprising 27.7% of users compared with 15.4% of their proportion in the general population.²⁴ Similarly, Māori account for 20-21% of presentations to emergency departments.²⁵ However, there is a gap in data regarding how many of these emergency department presentations by Māori are related to mental health.

The Aotearoa New Zealand Health and Disability System Review found that, although data is limited, there are indications that poorer health outcomes for people living in rural towns are further accentuated for rural Māori.²⁶ A 2010 report by the National Health Committee found that life expectancy for rural Māori may be slightly lower than that for urban Māori.²⁷

Multiple classification systems exist for defining hospitals, emergency departments, and geographic locations, both within ACEM and by the Australian and Aotearoa New Zealand governments. These definitions are context-specific (for example, training and education, accreditation, and emergency department delineation) and consider factors such as geographic distance, population, and access to tertiary hospitals.

For programs funded under the Commonwealth Government’s Specialist Training Program, the Modified Monash Model (MM) classification system ²⁸ is used to determine rurality. The MM categorises metropolitan, regional, rural and remote areas based on both geographical remoteness and town size. It was developed to address the challenges of attracting health workers to smaller and more remote communities. The MM is based on the Australian Statistical Geography Standard – Remoteness Area²⁹(ASGS RA) and further differentiates areas within Inner and Outer Regional Australia according to local town size.

Table 1. Modified Monash Model classifications

MM 1	Metropolitan areas	Major cities accounting for 70% of Australia’s population. All areas categorised ASGS-RA 1.
MM 2	Regional centres	Areas categorised ASGS-RA 2 and ASGS-RA 3 that are in, or within 20km road distance, of a town with a population greater than 50,000.
MM 3	Large rural towns	Areas categorised ASGS-RA 2 and ASGS-RA 3 that are not in MM 2 and are in, or within 15km road distance, of a town with a population between 15,000 and 50,000.
MM 4	Medium rural towns	Areas categorised ASGS-RA 2 and ASGS-RA 3 that are not in MM 2 or MM 3 and are in, or within 10km road distance, of a town with a population between 5,000 and 15,000.
MM 5	Small rural towns	All other areas in ASGS-RA 2 and 3.
MM 6	Remote communities	All areas categorised ASGS-RA 4 and islands that are separated from the mainland in the ABS geography and are less than 5km offshore. Islands that have an MM 5 classification with a population of less than 1,000 without bridges to the mainland (2019 Modified Monash Model classification only).
MM 7	Very remote communities	All other areas that are categorised ASGS-RA 5 and populated islands separated from the mainland in the ABS geography that are more than 5km offshore.

In Aotearoa New Zealand, rural and regional areas are classified using the Functional Urban Area (FUA) system.³⁰ The FUA framework identifies small urban areas and rural areas that are integrated with major, large, and medium urban centres to form FUAs. It uses the Urban Rural (UR) geography to define urban areas, Statistical Area 1 (SA1) units to delineate the surrounding commuting zone (hinterland) within FUAs, and rural or water areas outside FUAs.

Table 2. Functional Urban Area classifications

​FUA	Inclusions
U1	Metropolitan area	More than 100,000 residents living in the urban core.
U2	Large regional centre	Urban core population 30,000–99,999.
R1	Medium regional centre	Urban core population 10,000–29,999.
R2	Small regional centre	Urban core population 5,000–9,999.
R3	Area outside functional urban area

As a minimum requirement, a hospital must meet one of the delineation levels specified in ACEM’s Statement on the role delineation of emergency departments and other hospital-based emergency care services (S12) to be considered for emergency department accreditation. For geographic location, sites accredited for FACEM training are classified as Major Referral, Urban District, or Rural/Regional, in accordance with relevant jurisdictional systems.

As previously noted, ACEM also manages several projects and initiatives under the National Program, funded by Australian Government grants. These projects primarily use the ASGS-RA classifications.

ACEM’s Annual Site Census uses the following Australian Institute of Health and Welfare (AIHW) classifications:

• Major metropolitan
• Large metropolitan
• Medium metropolitan
• Major regional
• Large regional
• Medium regional
• Private hospital

For ACEM’s Aotearoa New Zealand hospital remoteness classification, emergency departments are considered metropolitan if they are located in greater Auckland, Christchurch, Hamilton or Wellington. All other emergency departments outside these cities are classified as regional.

1.    Australian Bureau of Statistics. Snapshot of Australia [Internet]. Canberra: ABS; 2021 [cited 2025 Aug 7].

2.    Stats NZ. 2023 Census population counts (by ethnic group, age and Māori decent) and dwelling counts [Internet]. Auckland: Stats NZ; 2024 [cited 2025 Aug 7].

3.    Australasian College for Emergency Medicine. 2023 FACEM and FACEM Trainee Demographic and Workforce Report [Internet]. Melbourne: ACEM; 2024 [cited 2025 Aug 13].

4.    Ibid. 2024 New FACEMs Early Career Survey [Internet]. Melbourne: ACEM; 2025 Feb [cited 2025 Aug 13].

5.    Ibid. 2023 FACEM and FACEM Trainee Demographic and Workforce Report [Internet]. Melbourne: ACEM; 2024 [cited 2025 Aug 13].

6.    Ibid. Annual site census [Internet]. Melbourne: ACEM; 2024 [cited 2025 Aug 13].

7.    Ibid.

8.    Ministry of Health. Emergency department use 2014/15 [Internet]. Wellington: Ministry of Health – Manatū Hauora; 2016 [cited 2025 Aug 13].

9.    Australian Institute of Health and Welfare. Rural and remote health [Internet]. Canberra: Australian Institute of Health and Welfare; 2024 [cited 2025 Aug 13].

10.  Australasian College for Emergency Medicine. Annual site census [Internet]. Melbourne: ACEM; 2024 [cited 2025 Aug 13].

11.  Australasian College for Emergency Medicine. Aboriginal and Torres Strait Islander and non-Indigenous presentations to Australian emergency departments: May 2018 [Internet]. Melbourne: ACEM; 2018 [cited 2025 Aug 13].

12.  Australian Institute of Health and Welfare. Survey of Health Care: selected findings for rural and remote Australians [Internet]. Canberra: Australian Institute of Health and Welfare; 2018 [cited 2025 Aug 13].

13.  Ibid.

14.  National Rural Health Alliance. Rural health in Australia snapshot 2025 [Internet]. Canberra: National Rural Health Alliance; 2025 [cited 2025 Aug 13].

15.  Harrison R, Walton M, Manias E. Evidence Check: Patients’ experiences in Australian hospitals [Internet]. Sydney: The Sax Institute for the Australian Commission on Safety and Quality in Health Care; 2015 [cited 2025 Aug 13].

16.  National Rural Health Alliance. Rural health in Australia snapshot 2025 [Internet]. Canberra: National Rural Health Alliance; 2025 [cited 2025 Aug 13].

17.  Ibid.

18.  Australian Institute of Health and Welfare. Deaths in Australia [Internet]. Canberra: Australian Institute of Health and Welfare; 2025 [cited 2025 Aug 13].

19.  Ibid. Rural and remote health [Internet]. Canberra: Australian Institute of Health and Welfare; 2024 [cited 2025 Aug 13].

20. Ibid. Suicide & self-harm monitoring [Internet]. Canberra: Australian Institute of Health and Welfare; 2025 [cited 2025 Aug 13].

21.  Health and Disability System Review. Health and disability system review – final report – Pūrongo whakamutunga [Internet]. Wellington: Health and Disability System Review; 2020 Jun 16 [cited 2025 Aug 13].

22.  Ibid.

23.  Australian College for Emergency Medicine. Te Rautaki Manaaki Mana: Excellence in Emergency Care for Māori 2022–2025 [Internet]. Melbourne: ACEM; 2022 [cited 2025 Aug 13].

24.  Australian College for Emergency Medicine. Mental health service use: A New Zealand context [Internet]. Melbourne: ACEM; 2019 [cited 2025 Aug 13].

25.  New Zealand Ministry of Health. Annual update of key results 2023/24: New Zealand Health Survey [Internet]. Wellington: Ministry of Health – Manatū Hauora; 2024 Nov 19 [cited 2025 Aug 13].

26.  Health and Disability System Review. Health and disability system review – final report – Pūrongo whakamutunga [Internet]. Wellington: Health and Disability System Review; 2020 Jun 16 [cited 2025 Aug 13].

27.  Ibid.

28.  Australian Government Department of Health, Disability and Ageing. (2025). Canberra: Australian Government Department of Health, Disability and Ageing. Incentives and support for GPs and general practices in MM locations (MM 1 to MM 7 facts sheets) [Internet]. Canberra: Australian Government Department of Health, Disability and Ageing, 2025 [cited 2025 Aug 13].

29.  Ibid. Australian Statistical Geography Standard – Remoteness Area [Internet]. Canberra: Australian Government Department of Health, Disability and Ageing, 2025 [cited 2025 Aug 29].

30.  Statistics New Zealand. Functional urban areas – methodology and classification [internet]. Wellington: Stats NZ; 2021 Feb 21 [cited 2025 Aug 29].