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Community Affairs References Committee Hansard
Community Affairs References Committee Hansard
Community Affairs References Committee Hansard
Community Affairs References Committee Hansard
Community Affairs References Committee Hansard
Community Affairs References Committee Hansard
Community Affairs References Committee Hansard
Community Affairs References Committee Hansard
Community Affairs References Committee Hansard
Community Affairs References Committee Hansard
Community Affairs References Committee Hansard
Community Affairs References Committee Hansard
Community Affairs References Committee Hansard
Community Affairs References Committee Hansard
Community Affairs References Committee Hansard
Community Affairs References Committee Hansard
Community Affairs References Committee Hansard
Community Affairs References Committee Hansard
Community Affairs References Committee Hansard
Community Affairs References Committee Hansard
Community Affairs References Committee Hansard
Community Affairs References Committee Hansard
Community Affairs References Committee Hansard
Community Affairs References Committee Hansard
Community Affairs References Committee Hansard
Community Affairs References Committee Hansard
Community Affairs References Committee Hansard
Community Affairs References Committee Hansard
Community Affairs References Committee Hansard
Community Affairs References Committee Hansard
Community Affairs References Committee Hansard
Community Affairs References Committee Hansard
Community Affairs References Committee Hansard
Community Affairs References Committee Hansard
Community Affairs References Committee Hansard
Community Affairs References Committee Hansard
Community Affairs References Committee Hansard
Community Affairs References Committee Hansard
Community Affairs References Committee Hansard
Community Affairs References Committee Hansard
Community Affairs References Committee Hansard
Community Affairs References Committee Hansard
Community Affairs References Committee Hansard
Community Affairs References Committee Hansard
Community Affairs References Committee Hansard
Community Affairs References Committee Hansard
Community Affairs References Committee Hansard
Community Affairs References Committee Hansard
Community Affairs References Committee Hansard
Community Affairs References Committee Hansard
Community Affairs References Committee Hansard
Community Affairs References Committee Hansard
Community Affairs References Committee Hansard
Community Affairs References Committee Hansard
Community Affairs References Committee Hansard
Community Affairs References Committee Hansard
Community Affairs References Committee Hansard
Community Affairs References Committee Hansard
Community Affairs References Committee Hansard
Community Affairs References Committee Hansard
Community Affairs References Committee Hansard
Community Affairs References Committee Hansard
Community Affairs References Committee Hansard
Community Affairs References Committee Hansard
Community Affairs References Committee Hansard
Community Affairs References Committee Hansard
Community Affairs References Committee Hansard
Community Affairs References Committee Hansard
Community Affairs References Committee Hansard
Community Affairs References Committee Hansard
Community Affairs References Committee Hansard
Community Affairs References Committee Hansard
Community Affairs References Committee Hansard
Community Affairs References Committee Hansard
Community Affairs References Committee Hansard
Community Affairs References Committee Hansard
Community Affairs References Committee Hansard
Community Affairs References Committee Hansard
Community Affairs References Committee Hansard
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Community Affairs References Committee Hansard

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COMMUNITY AFFAIRS REFERENCES COMMITTEE - …

COMMUNITY AFFAIRS REFERENCES COMMITTEE -
Inquiry into Health services and medical professionals in rural areas

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  • 1. COMMONWEALTH OF AUSTRALIA Official Committee Hansard SENATECOMMUNITY AFFAIRS REFERENCES COMMITTEE Health services and medical professionals in rural areas FRIDAY, 11 MAY 2012 CANBERRA BY AUTHORITY OF THE SENATE
  • 2. INTERNETHansard transcripts of public hearings are made available on the internet when authorised by the committee. The internet address is: http://www.aph.gov.au/hansard To search the parliamentary database, go to: http://parlinfo.aph.gov.au
  • 3. SENATE COMMUNITY AFFAIRS REFERENCES COMMITTEE Friday, 11 May 2012Members in attendance: Senators Di Natale, Fawcett, Moore, Nash and SiewertTerms of reference for the inquiry: To inquire into and report on:The factors affecting the supply and distribution of health services and medical professionals in rural areas, with particularreference to:(a) the factors limiting the supply of health services and medical, nursing and allied health professionals to small regional communities as compared with major regional and metropolitan centres;(b) the effect of the introduction of Medicare Locals on the provision of medical services in rural areas;(c) current incentive programs for recruitment and retention of doctors and dentists, particularly in smaller rural communities, including: (i) their role, structure and effectiveness, (ii) the appropriateness of the delivery model, and (iii) whether the application of the current Australian Standard Geographical Classification – Remoteness Areas classification scheme ensures appropriate distribution of funds and delivers intended outcomes; and(d) any other related matters.
  • 4. WITNESSESANDREATTA, Mr Lou, Assistant Secretary, Department of Health and Ageing .......................................... 68BOLITHO, Dr Leslie Edward, President-Elect, Royal Australasian College of Physicians ........................... 52BOOTH, Mr Mark, First Assistant Secretary, Department of Health and Ageing ......................................... 68CUTTING, Mr Paul, Acting Director, Department of Health and Ageing ...................................................... 68DOUCH, Dr Tom, General Practitioner, Young District Medical Centre ....................................................... 31FLANAGAN, Ms Kerry, Deputy Secretary, Department of Health and Ageing ............................................. 68FRANCIS, Professor Karen, Chair, Rural Nursing and Midwifery Faculty, Royal College of Nursing....... 38GREBE, Mr Sasha, Director, Professional Affairs, HR and Advocacy, Royal Australasian College of Physicians ........................................................................................................................................................... 52GREGORY, Mr Gordon, Executive Director, National Rural Health Alliance .............................................. 23HAMBLETON, Dr Steve, Federal President, Australian Medical Association ............................................... 60HANDLEY, Ms Anne, Policy Adviser, National Rural Health Alliance........................................................... 23HOPKINS, Mrs Helen, Policy Advisor, National Rural Health Alliance ......................................................... 23HOUGH, Mr Warwick, Senior Manager, General Practice, Legal Services and Workplace Policy Department, Australian Medical Association ................................................................................................. 60JOHNSON, Ms Jenny, Chief Executive Officer, Rural Doctors Association of Australia .............................. 13KAY, Mr David, Practice Manager, Young District Medical Centre ............................................................... 31KEANE, Ms Sheila, Board Member, Services for Australian Rural and Remote Allied Health ..................... 1KOCZWARA, Professor Bogda, President, Clinical Oncological Society of Australia .................................. 46MALONE, Ms Gerardine, National Coordinator of Professional Services, CRANAplus .............................. 38MARA, Dr Paul, President, Rural Doctors Association of Australia ................................................................ 13McLAUGHLIN, Ms Kathleen, Deputy CEO, Director, Operations and Professional Services, Royal College of Nursing ........................................................................................................................................................... 38MEAGHER, Dr William, General Practitioner, Young District Medical Centre ........................................... 31MILLS, Dr Jane, Advisory Committee Member, Rural Nursing and Midwifery Faculty, Royal College of Nursing ............................................................................................................................................................... 38NAIRN, Mr Alister, Director, Geography, Australian Bureau of Statistics ....................................................... 7RIVETT, Dr David, Chair, AMA Rural Medical Committee, Australian Medical Association .................... 60SHAKESPEARE, Ms Penny, Acting First Assistant Secretary, Department of Health and Ageing ............. 68VAN HALDEREN, Ms Gemma, Program Manager, Demography, Regional and Social Analysis Branch, Australian Bureau of Statistics ........................................................................................................................... 7WALLACE, Dr Gilbert Hugh Murray, Private capacity .................................................................................. 31WELLINGTON, Mr Rod, Chief Executive Officer, Services for Australian Rural and Remote Allied Health.................................................................................................................................................................... 1
  • 5. Friday, 11 May 2012 Senate Page 1KEANE, Ms Sheila, Board Member, Services for Australian Rural and Remote Allied HealthWELLINGTON, Mr Rod, Chief Executive Officer, Services for Australian Rural and Remote AlliedHealth Evidence from Ms Keane was taken via teleconference—Committee met at 09:45 CHAIR (Senator Siewert): I declare open this public hearing and welcome everyone who is present today.The Senate Community Affairs Reference Committee is inquiring into factors effecting the supply of medicalservices and health professionals in rural areas. Todays hearing is our fourth public hearing for this inquiry. These are public proceedings, although the committee may agree to a request to have evidence heard in cameraor may determine that certain evidence should be held in camera. I remind witnesses that in giving evidence to the committee they are protected by parliamentary privilege. It isunlawful for anyone to threaten or disadvantage a witness on account of evidence given a committee. Such actionmay be treated as a contempt by the senate. It is also a contempt to give false or misleading evidence to acommittee. If a witness wishes to object to answering a question, the witness should state the ground on which theobjection is taken and the committee may determine to insist on an answer, having regard to the ground that isclaimed. If the committee makes such a determination to insist on an answer, the witness can request to have thatanswer taken in camera. Such a request also may be made at any other time. The only other thing is please,everyone turn off their mobiles. Having said that, welcome. I need to double check that information on parliamentary privilege and theprotection of witnesses and evidence has been provided to you? Ms Keane: Yes, it has. CHAIR: I know, you have both done this before. We have your submission. It is number 62. I would like toinvite either one of you or both of you to make an opening statement and then we will ask you some questions. Mr Wellington: Thank you, Senator. I will make some opening comments. I will keep them brief, but first ofall thank you for the opportunity to appear before this committee as a witness. SARRAH was incorporated in1995 and is nationally recognised as a peak body representing rural and remote allied health professionals,working in both the public and private sectors. Our prime objective is to advocate, develop and provide servicesto enable allied health professionals who live and work in rural and remote areas of Australia to confidently andcompetently carry out their professional duties in providing a variety of health services. Our representation is outlined in the submission, so I will not go through that. SARRAH strongly supports theprovision of primary healthcare services in that they should be delivered by multiprofessional healthcare teams.However, our submission focuses on allied health professional. In summary, the factors that impact on the recruitment and retention of the allied health workforce in small,regional communities are the same as that which impact on the medical workforce. Much of the informationcontained in our submission results from the rural allied health workforce survey, which Ms Keane was a lead on;hence, why she is attending by teleconference today. This collaborative research between four universitydepartments of rural health across New South Wales, Tasmania and the NT was coordinated through SARRAHsresearch alliance group. In 2008-09, the research group conducted a survey on the entire rural allied health workforce in New SouthWales, Tasmania and the Northern Territory with follow up focus groups conducted in New South Wales during2009-10. A table of factors for staying in and leaving a position in a rural or remote community identified by thesurvey are outlined in our submission, along with nine recommendations. SARRAHs key message to thiscommittee for its report to government follow. There is a need to develop an allied health evidence database toinform strategies for workforce development, and to reform funding of the collection of allied health workforceand service data, especially in rural and remote areas across Australia. Workforce data must be collected on anational and regular basis using a consistent methodology, including both registered and self-regulated alliedhealth professions, comparing supply with demand. The classification system in the health sector—ASGC-RA—used for the distribution of incentives, must be reviewed, and a key criterion of town size added to the formula. We note that the National Rural Health Alliance will be appearing as a witness before this committee later thismorning. As you may be aware SARRAH is a member of the alliance. The alliance has been developing analternative model to assist government and other stakeholders in determining remoteness, for program eligibility COMMUNITY AFFAIRS REFERENCES COMMITTEE
  • 6. Page 2 Senate Friday, 11 May 2012and incentive payments. Consequently, we defer our comments on this matter to the alliance for discussion at thattime. The current range of programs supporting allied health professionals practising in rural and remote Australiancommunities are welcomed. However, we are concerned over the lack of equity when these strategies arecompared against the range and volume of programs available to doctors and nurses. This must be addressed bygovernment as a matter of urgency. For example, applications for the 2012 intake under the Allied Health ClinicalPlacement Scholarships Scheme, which we administer on behalf of the government, recently closed. For the 150places under the scheme we had 1,046 applicants, of which 864 were eligible. This scheme encompasses all alliedhealth professions and targets settings across rural and remote Australia. So, basically we are saying that there areover 700 eligible applicants who were unable to take up a placement in rural and remote Australia. Given thatthere is a workforce shortage, it is not rocket science to work out one strategy that could be adopted. On thatmatter, in defence of the government, I have raised the point with the minister over recent days. We will see whathappens. A national mentoring program for existing health professionals, as well as those who are new to rural andremote practice, should be developed, funded and implemented as a priority. SARRAH has developed such aprogram proposal and we will be submitting it at an appropriate time, when applications are called for. Currentlythere is no national mentoring program for allied health professionals throughout Australia. Ms Keane: Mr Wellington commented that the factors affecting recoupment and retention are the same forallied health professionals as for doctors and nurses. That is true in matters relevant to personal preferences, suchas a good place to raise children or having a spouse who is a farmer. But there are a number of differences thathave emerged from my research and particularly from the follow-up focus group research to which MrWellington referred. These have not been included in the submission but if you would like to ask questions aboutthat research I would be happy to answer those. CHAIR: Do you want to outline some of those key differences. Ms Keane: Yes. In the first instance, the main concerns of the existing workforce in rural New South Waleswere the workload they had to contend with and, also, there are some issues around access to continuingprofessional development and its relationship to the type of work they do and their career path, which is alsolinked to professional isolation. In terms of workload, that is the same in both the public and private sectors of employment, for differentreasons. In the public sector the workload is largely a result of inadequate and inequitable resource allocationwithin the public sector, combined with very high expectations of service delivery. There was one instance whereone of the focus group participants, who was a speech pathologist of six years experience, indicated that sheintended to leave the profession entirely rather than leave the area. So, it is not only a matter of losing theworkforce distribution, it is also the loss of the workforce supply that is affecting these decisions. In the privatesector the workload is more a matter of having not enough people around. There is not the added issue of resourceallocation. With respect to the workload issue, the governments support schemes for locum backfill are verywelcome. Again, as Mr Wellington said, it would be preferable if that could be enhanced. I would like toacknowledge that the government has been very helpful in that program, and I hope that will continue. In relation to education and access to it, the scholarship program is very welcome. One of the things I havediscovered in my research is that education also serves as a way to remedy professional isolation. Relying ononline programs only may not solve all of the problems. There are opportunities with current technologies to useonline technologies for virtual face-to-face education programs. Those kinds of things could benefit from someinvestment in research about how best to use them. Regarding the relationship of education to type of work, when you are a rural practitioner you see everything.There is no social worker near you so you, as a physio, need to address their problems with Centrelink paymentaccess or with carer support, because, for example, the carer fell down and broke her hip. That leaves the personbeing cared for without a carer for a period of time, and the social worker who would normally deal with that isnot available, so somebody has to cover it. What ends up happening then is that you operate outside of yournormal scope of practice. That has been associated with job dissatisfaction, because people do not feel adequatelyprepared for that extended scope of practice. A recommendation arriving from that would be to acknowledge thefact of extended scope of practice and try to find ways to regulate and prepare the workforce to be able to do that. On the other end of the scope of practice there is an opportunity to defer some of the workload to lesser skilledpeople—the routine aspects of care. I would like to support the development of allied health assistance as a COMMUNITY AFFAIRS REFERENCES COMMITTEE
  • 7. Friday, 11 May 2012 Senate Page 3workforce strategy in rural and remote Australia. A good deal of work will need to be done about establishingcredentialing and regulation of those people. I anticipate that that work is going on and I would like to support it. Finally, I would like to say something about career paths. One of the things I have discovered in this focusgroup research is the tendency for young professionals to come to rural areas for adventure and for an experience.Typically they will stay one or two years and then leave for metropolitan areas because of the opportunities forspecialist career advancement. Those who stay more than two years and up to three years typically then stay for20 years. There is a sort of turning point at which people become embedded in the rural community, like thespeech pathologist I referred to earlier, at which point they are linked to the community and do not want to leave,unless they want to leave their profession because they are so unhappy. If some attention can be paid to thatparticular pivotal moment in a professional career there might be some opportunity to retain youngerprofessionals. A mentoring program would very greatly help with that transition. So I would again support MrWellingtons suggestion about that. Senator MOORE: I did not get your point about the speech pathologist with six years service, who is goingto leave the profession. The second question is for both of you. You both talked about a scholarship scheme. Iwould like to get some more information about how you think it should work. It is all very well to get ascholarship, but other people can do the course without having the scholarship so I am interested as to why youthink the scholarship scheme should be the basis on which we base our process. Could you clarify that point,because you made that point first and I am sure it is important. Ms Keane: That is an exemplar story of a speech pathologist who was working in a regional town and foundher experience in the public sector so unsatisfactory—because of workload, lack of management support forresource allocation, lack of access to continuing professional development and professional isolation—that shecontemplated leaving her profession entirely rather than leaving the area. This points to the strength of influenceof the personal factors that retain people in rural areas, but not necessarily in rural clinical practice. Senator MOORE: It is the kind of process where the public system is letting you down but in the privatesystem itself there is not enough Medicare support to run a private pathology practice by yourself. Is that the pointyou were making? Ms Keane: That is correct. That is in a regional town. It is more of an issue the further out you go into remoteareas. For example, in Broken Hill there are literally no private allied health services. Senator MOORE: And the point about scholarships? Mr Wellington: Briefly, the scholarship program I was referring to was the Allied Health Clinical PlacementScholarship Scheme. That entails students in their third or fourth year going out to a rural and/or remote locationfor up to a maximum of six weeks—an accommodation, travel and sustenance allowance is paid. Generally, thatcosts around about $11,000 per placement. It has been running for two or three years only. Senator MOORE: For allied health professionals? Mr Wellington: Yes. So it is probably a little bit embryonic to come back and say that it is a success. Mycomments refer to the minimal numbers—150 across the country across all the disciplines is insufficient. Senator MOORE: So the basis of that is the proven experience with doctors and nurses in that program. Withextending it to allied health, there is a hope that it will work? Mr Wellington: Correct. Senator MOORE: And you think there should be more of them? Mr Wellington: Correct. Additionally, 700 applicants missed out. CHAIR: So there are people willing. Mr Wellington: Indeed. That is an important point. Senator NASH: I am interested in the point you made earlier on in the submission about the fact that the datais not analysed across the different professions within allied health. It seems to be just in a lumped arrangementrather than just allied health. How do you see that drilling down and working? Have there been any discussionswith the department or the minister about how it is not really appropriate to drill down in that information. Havethere been any discussions around it and how do you see it happening? Once you actually get that depth ofinformation, how do you address those high-priority areas? Mr Wellington: I will respond and then pass over to Ms Keane. Back in 2008 the then minister, MinisterRoxon, released an audit report into the rural workforce. The data used was, from memory, from the ABS. It didnot identify the broad range of allied health professions. In addition to that, within the report the minister COMMUNITY AFFAIRS REFERENCES COMMITTEE
  • 8. Page 4 Senate Friday, 11 May 2012acknowledged that there was a dearth of workforce data for allied health, as compared with doctors and nurses.Ms Keane may wish to add further comments. Ms Keane: Yes, I would. I will give an example of how aggregate data does not serve us well. In my researchin New South Wales with the survey data, the average age of pharmacists was considerably higher than theaggregate age of all allied health professionals. If you were to make some estimation of workforce forwardplanning for retirement, you would have underestimated the need for increasing workforce supply in pharmacyand overestimated the need for that in, for example, dietetics, who have a much younger age profile. The otheraspect of that is what has happened in pharmacy is that, because we have not had access to workforce data, wehave not been able to forward plan and have instead reactively said, Oh dear, there are not enough pharmacists—they are very old; they are about to retire, and opened a whole lot of new programs, and now we are looking at asurplus of pharmacists in workforce supply. So there is some real advantage to having ongoing discipline-specificworkforce data. Senator NASH: Thank you. Can I also ask about the locums. You say in your submission that guidelines needto be reviewed and modified, obviously to increase the uptake of the locums. What is wrong with the guidelines atthe moment and what needs to be done to make it easier for those who need locums to access them? Ms Keane: I think I should refer to Mr Wellington for that as he administers the locum schemes. Mr Wellington: A correction: the locum program is actually administered by a separate organisation. Sincethis submission was written, back in December 2011, there have been some modifications to the locum program. Icould not provide you with figures on how successful that has been in terms of uptake. Senator NASH: Is it a case of waiting to see how that beds in before you go and look at it again to see if itneeds more modification? Mr Wellington: I believe so, Senator, yes. Senator NASH: Ms Keane, I am particularly interested in speech pathology and primary education. Thereseems to be a lack of speech pathologists for primary students and young students in particular. Not being able toget them at an early stage is causing issues. Would you mind providing for the committee any information youhave around that area that might assist us in having a look at that? Ms Keane: Yes. Do you want that now, Senator? Senator NASH: No, if you could take that on notice and provide it for the committee. Ms Keane: Yes, okay. Senator NASH: Thank you very much. Senator DI NATALE: One of the themes that comes through your submission is this question of evaluationand whether it relates to rural student placements or Medicare Locals or incentives for doctors and dentists and soon. Do you think it is a fair comment to say, We are doing a lot of this but we do not have the rigorous evaluationframework in place for some of this investment and we really need to build that across all of those areas? Mr Wellington: I believe so. I think it is a whole-of-government issue, not only for this current governmentbut previous governments, in how they evaluate their programs in terms of how effective they are, whether theybe health programs, employment programs or whatever. I think it is a fundamental issue. But, answering yourquestion, it would make sense to look at and evaluate, if it has not already been done, some of the doctors andnursing programs and then see what works and see if it is applicable to our sector or our workforce. Senator DI NATALE: Looking specifically at the support that is given to rural students in terms ofplacements, I note that one of the outcomes that you are looking at is intention to stay, for example. But, as yousay in your submission, young kids are often very mobile, and intention to stay might not translate to somebodyactually making a decision to stay in a regional area. Has there been much work done on the existing rural alliedhealth workforce, looking retrospectively, particularly at some of the people who have moved there morerecently, to find out what factors have been important and significant in helping them to make that decision torelocate? One of the dangers is that we are investing a significant amount of money in something that does notwork, and there might be a glaring thing that needs to happen that we are ignoring. So what sort of work has beendone in looking at the existing rural workforce? Mr Wellington: I referred earlier to the report released by Minister Roxon in 2008. There is a dearth ofworkforce data on allied health. That is publicly acknowledged. That is the starting point. The second point is wecan always do further investigation, on a national level, into what works and what does not regarding support forstudents. Correct me if I am wrong, Ms Keane, but again I do not believe that has happened on a national level.The point is well made. COMMUNITY AFFAIRS REFERENCES COMMITTEE
  • 9. Friday, 11 May 2012 Senate Page 5 Ms Keane: That is correct. There has been no data analysis or, indeed, data collection on that particular pointon a national level. I will, however, mention that in my research it is my impression that the student placementsare very effective in attracting students to rural placements in the first instance. The problem then becomes how toretain those people once they arrive and I think the factors that affect recruitment are not necessarily the same asthe ones that affect retention. So to say that the rural student placements are not effective—from my limited data,preliminary results indicate that they do not appear to have a strong influence on intention to stay but they doappear to have a strong influence on the recruitment of young people to the area as a start. Senator DI NATALE: One of the things that is agreed, certainly, on the training of doctors is that recruitingpeople who come from a rural area to study is a significant factor. While there might be benchmarks set for thenumber of students who come from a rural area they are not achieving those across a number of universities. Isthe same true in training the allied health workforce? Are we recruiting enough students from rural and regionalareas? Ms Keane: I would say that the answer is no, in particular in the Indigenous population—it is an appallingrate of attraction to the professions. Some of the issues preventing that are probably the same for the medical,nursing and allied health professions in that there are some difficulties with quality of and access to tertiaryeducation in rural and, particularly, remote areas and in the need for some mentoring or bridging educationprograms that would assist with that. In the Indigenous population, in particular, there is also an issue aboutcultural and socioeconomic disadvantage that needs to be addressed. Senator FAWCETT: Ms Keane, I am interested to follow up on your comment about Broken Hill and thefact that there was inadequate work for a thriving private practice. That is what I believe I heard; is that correct? Ms Keane: Yes, that is correct. Senator FAWCETT: That seems quite a stark contrast with South Australia where, for example, there is inPort Lincoln a thriving private practice and very little public service. Do you have any feeling for how variousstate policies affect that mix across the country? As we look at national policy, that variability of the states willmake a huge difference in the viability or business model of allied health professionals. Ms Keane: That is an excellent question. Unfortunately I do not have the data to answer it. CHAIR: So there is no point taking it on notice. Mr Wellington: I do not believe so. Senator MOORE: The department may be able to help. Mr Wellington: I think that is a good point. That would be more of a department role than my secretariat rolewith two people. CHAIR: Remember to ask the department about that. Senator FAWCETT: I will do that. CHAIR: Do you have any more questions? Senator FAWCETT: No. There are a few things I would like to follow up on, but if you do not have the datathen there is no— CHAIR: If we could beg your indulgence—if we get the data we might put some questions on notice, tofollow up some opinions on that. Would that be satisfactory for you, too, Ms Keane? Ms Keane: That would be very satisfactory. Senator FAWCETT: Certainly in South Australia the feeling we are getting is that, unless people canactually be sustained in private practice, there is not enough sufficient public provision of service. And so if theprivate people go out of business for whatever reason—lack of folk taking out extras cover et cetera—then therewill be no service in country towns. Ms Keane: That is correct, and also some of the research that has been done, particularly in Victoria, wherethey are exploring models of combined public and private practice environments, has been very successful. Senator FAWCETT: Are you planning to do any benchmarking of the current status with any impact of thechanges to the Medicare rebate that many pundits are saying will see a reduction in people having extras cover? Ms Keane: That is not part of my future research agenda but it is something that would be a good idea toexplore. Mr Wellington: SARRAH has developed a position paper and provided it to Medicare Australia onrecommendations to the system. We would be happy to provide a copy of that to the committee. COMMUNITY AFFAIRS REFERENCES COMMITTEE
  • 10. Page 6 Senate Friday, 11 May 2012 Senator FAWCETT: That would be great, thank you. Senator MOORE: Does your paper indicate that there is any greater or less uptake of extras cover in regionalareas? Mr Wellington: I would have to revisit the paper, Senator; sorry. Senator MOORE: I just think so. I think it is an issue in terms making a wide statement. CHAIR: I have taken us slightly over time because we started slightly late, so I will thank you very much foryour contributions. We have given you potentially a little bit of homework if we can get the data that we are after.Thank you very much for your time. Ms Keane: Thank you for the opportunity to contribute. COMMUNITY AFFAIRS REFERENCES COMMITTEE
  • 11. Friday, 11 May 2012 Senate Page 7NAIRN, Mr Alister, Director, Geography, Australian Bureau of StatisticsVAN HALDEREN, Ms Gemma, Program Manager, Demography, Regional and Social Analysis Branch,Australian Bureau of Statistics Evidence was taken via teleconference—[10:07] CHAIR: I welcome representatives of the Australia Bureau of Statistics. Can I just clarify that you haveinformation on parliamentary privilege and the protection of witnesses and evidence. Ms Van Halderen: Yes. CHAIR: Thank you. I remind witnesses that the Senate has resolved that an officer of the department of theCommonwealth or of the states shall not be asked to be give opinions on matters of policy and shall be givenreasonable opportunity to refer questions asked of the officer to superior officers or to a minister. This resolutionprohibits only questions asking for opinions on matters of policy and does not preclude questions asking forexplanations of policies or factual questions about when and how policies were adopted. I would like to invite either or both of you to make an opening statement if you wish and then we will go toquestions. Ms Van Halderen: Because we are on the phone, could you just let us know who is in the room? CHAIR: I beg your pardon; sorry. I am Senator Siewert. I am the chair of the committee. Senator MOORE: Senator Moore from Queensland. Senator NASH: Senator Nash from New South Wales. Senator FAWCETT: Senator Fawcett from South Australia. Senator DI NATALE: Senator Di Natale from Victoria. CHAIR: We also have two members of our secretariat. Ms Van Halderen: Wonderful. Thank you very much. I will just make a very brief opening statement andthen hand over to my colleague. Apologies for not being able to physically attend, but we are very pleased to beable to appear before the committee today and answer any questions that you may have relating to the AustralianStandard Geographical Classification remoteness structure. We sent in a submission on Wednesday, 9 May.Hopefully, it has now been received by you. CHAIR: Yes. Ms Van Halderen: That provides an overview of the related structure to assist you in understanding that. Weare very happy to amplify any aspect of that document. I as program manager am happy to take questions. Alisterhere is the director of geography and he is happy to answer questions about our classifications. CHAIR: Mr Nairn, do you want to add anything? Mr Nairn: No. Did you say you had received the submission we sent in? CHAIR: Yes, thank you. It is No. 24. Senator MOORE: Thank you for your submission. I just want to clarify: clearly, the model you put forwardis a model based on geography. Is that right? Mr Nairn: Our classification is a geographically based classification. Senator MOORE: I am unaware of how much you are aware of the other submissions we have received. No-one doubts the accuracy of the geographic model. So there is no sense that the statistical base is being questioned.The question that is being brought up consistently in this inquiry is whether it is the best basis for the provision ofmedical services. That question is the basis of our inquiry. I wonder whether there is any cross-area discussion in the bureau between the geographical branch in whichyou work and the group that does the various statistical returns on medical and socio-economic issues? Mr Nairn: ABS produces a number of different classifications that take into account some of those otherfactors such as SEIFA, but in this case we decided we needed a geographically based classification that split upthe country into different areas of remoteness to produce statistics so that the government could compare differentprograms over those same consistent geographic areas. So the basis of our classification is purely geographic; it ispart of our geographical classification. We do not have another classification that takes into account differentfactors like that that are based on geography and combinations of other socio-economic factors. COMMUNITY AFFAIRS REFERENCES COMMITTEE
  • 12. Page 8 Senate Friday, 11 May 2012 Senator MOORE: My last question, because I have read the submission and I think I get it in terms of thegeography but I do not know whether it is the right thing for this area: is there any way you can do a process ofputting the geographic division that you have undertaken and overlaying that with the various other reports thatyou do, so you could actually get a build up. If you took a particular city somewhere, where it fitted in yourgeographic base, and then cross-referenced to see where it fitted in the various other collections that you do. Isthat something that the ABS could do? Ms Van Halderen: The purpose of this one is to be geographically based. I am struggling a bit to understandwhat it is you are asking me, because it would be a very unusual basis to put together a whole range of factorsassociated with, say, a particular area. Alister referred to SEIFA—the socioeconomic indexes for areas—and thatputs together a lot of factors related to a geographical location. That one is based on socio-economic factors thatare collected in the population census. That may be a little bit like what you are talking about, but you would notnecessarily overlay that with a geographical base structure. Senator MOORE: What was the verb that you actually used in that last sentence? Mr Nairn: Overlay. Ms Van Halderen: You would not necessarily overlay the geographically based one with a socio-economicindex. Mr Nairn: I guess the point there is that it would be possible to combine our classification with lots of otherfactors but for what purpose and where would we draw the line?We try and keep those things reasonably separate. We are talking about a geographic classification here whereassome of the other things we do are actually indicators of the data in the area. It would be possible to build up aformula for an area that took a lot of different factors into account, but building that into one product is notsomething that we have looked at doing. CHAIR: I am going to break in for a second because we are all interested in this. I have a couple of othersenators who want to ask questions specifically on this issue, and then I will go back to Senator Moore. Senator DI NATALE: Simply using geographical location might not necessarily be the only important metricthat we need to consider when we are talking about issues like workforce. So the question is: could you providesome sort of weighting to a number of factors—you mention socioeconomic factors, geography and there areother things of course—and produce a metric that potentially weights each of those things and producesessentially a map of Australia that takes all of those things into consideration and is not just based on geography?We understand of course that, when you are doing a classification based on a question like remoteness, that is oneimportant thing, but all we are asking is: is it not possible to weight each of the things that we think are necessarywhen we are talking about planning a rural workforce and then come out with a final metric that reflects that? Mr Nairn: Anything is possible, I suppose, but if the purpose of this is specifically about health policy, thenthat is an issue that is probably better referred to the department of health. But we can provide all of the differentfactors and they could be used. If the department of health wanted to come up with a different formula, it wouldbe possible to take other factors into account. Senator DI NATALE: Thank you. Senator FAWCETT: I am probably asking a very similar question to Senator Di Natale but in a slightlydifferent format. I do not criticise your model at all; it is what it is and it is probably very valid, but the currentapplication in this context sees a great disparity, whereby the same incentives are offered to rural practitioners invery small regional towns in the mid-north of South Australia and large population centres with all kinds offacilities, hospitals and training institutions in Tasmania. Can you suggest a way, on a statistical basis, that thegovernment get a more appropriate guide on how those incentives should be offered? Mr Nairn: Again, that is really a policy issue about what factors should be taken into consideration to meetthose requirements. It is not the role of ABS to offer that sort of advice. I think it is better to refer those questionsto the department of health. We have had discussions with the department of health about the use of thisclassification and some of the problems that have been expressed, but we did not reach a conclusion with themabout anything that would be better—not at this stage. I think you would be aware that there was a reviewundertaken by GISCA within the department of health about possible changes to the model, but I am not surewhere that concluded. At this stage, as I have said, we have had discussions with them about possible changes thatmay improve things but nothing conclusive has come from that. We would have to be mindful also that there areother departments that use this classification for different purposes than just the rural health workforce. It is usedby other departments in terms of education. It is also used for government reporting in terms of government COMMUNITY AFFAIRS REFERENCES COMMITTEE
  • 13. Friday, 11 May 2012 Senate Page 9expenditure into regional areas. So it is a multiuse classification. It is not our role to produce one specific foraddressing medical workforce issues. CHAIR: We now have a slightly related question from Senator Nash. Senator NASH: Just on this geographic: as you say in your submission, it is purely a geographic measure ofremoteness. Remoteness from what? What is the definition? What is it remote from? Mr Nairn: It is our classification. We call is the remoteness structure of the ASGC. It is based on the ARIAgrid produced by the University of Adelaide. That ARIA grid is an accessibility and remoteness index ofAustralia. It is based on access to towns of certain sizes. They make the assumption that small towns have a lesserrange of services than larger towns. It is really remoteness based on access to various sized towns. In the ARIA,they use five different classifications of town sizes, ranging from very small towns that have limited services upto towns of 250,000 and above that are assumed to have all of the services that you would need. It is really aremoteness from available access to services. Senator NASH: If it is remote from access to services and as an example—sorry for my interstatecolleagues—take New South Wales, where there is— Senator MOORE: Just as an example. Senator NASH: the town of Gundagai, four hours from Sydney. Then you have got the town of Wagga,which is probably only another three quarters of an hour away from there. Those two towns—one has apopulation of 3,000 and one has a population about 60,000—are both classified exactly the same in terms ofremoteness, but it could quite well be argued that Wagga provides almost exactly the same services, say, asSydney. When you are talking about remoteness and, as you say, remoteness from services, if the services inWagga are similar to services in Sydney and yet services in that smaller town of Gundagai are virtually non-existent, how can Gundagai and Wagga be classified the same, if it is talking about remoteness from services,when Wagga has those services? Mr Nairn: The next biggest town that is close to Gundagai might be Canberra. Senator NASH: No, it would be Wagga. Mr Nairn: It is Wagga, is it? I was talking about ARIA there. ARIA has 15 different— Senator NASH: Sorry, can I just stop you there too: also, with Canberra it is an issue of interstate; it is notactually in the same state. Senator Moore, wants to add to that. Senator MOORE: Mr Nairn, the other thing is that I have a view—and I would like to see whether you agreeor not—that the particular model is particularly pertinent in New South Wales and Queensland, because of thesize of the states and the size of the regional towns. So that the issue that Senator Nash is putting out is not asrelevant in Western Australia, Tasmania or even in Victoria— CHAIR: They have big towns. Senator MOORE: because of the size of the regional cities. The same point that Senator Nash is making hasbeen made to us very clearly in Queensland. I am not going to name the towns. We have, because of thegeography in Queensland, a large devolved nature of significantly large towns which seem to compete with eachother and smaller towns under this model. Mr Nairn: The point I was trying to make though is we are only grading the remoteness down to four or fivelevels: major cities—there is 68 per cent of the population living in those areas; the inner regional, which hasaround 20 per cent of the population; the outer regional has about nine per cent; and then remote and very remotethat has a very small percentage of the population. We only divide it down—all of the accessibility—into fivelevels. There would be a difference between Gundagai and Wagga when you look at the ARIA scores for them,but, when we are just having to simplify that down to five levels, they might have the same score because there isa range in each of those categories. For instance, we classify all of the places that have ARIA scores of 0.2 to 2.4as inner regional. One place might have a more remote around of 2.3 and some might be 0.3, and they are goingto be group into the same area for our classification. It would be a broad classification, largely for reportingpurposes. It will not answer all of those fine levels of differences between towns that happen to be close to theedges of the remoteness categories. Senator NASH: That is the point that you make very well, because it is a broad classification. It is notnecessarily appropriate for what it is being utilised for in terms of the incentive payments. The other point I wouldmake is that, if the remoteness is remoteness from the provision of services and yet one of those towns likeWagga provides the services, isnt it illogical to say it is remote from services when that town actually providesthe services? COMMUNITY AFFAIRS REFERENCES COMMITTEE
  • 14. Page 10 Senate Friday, 11 May 2012 Mr Nairn: It would not provide the same services as Sydney, though, would it? Senator NASH: But relative to the smaller towns around it, it has 80 per cent more. That is what we are tryingto draw down in the committee—the inequities and the illogical nature of the remoteness from services when a lotof services are being provided in the towns which are being said to be remote from the major cities. Mr Nairn: When you look at the overall national nature of the index, particularly the ARIA 15 score grid, Ithink it does give a reasonable picture. A place with a score of 14 is going to have better access to services than aplace with a score of 15. But you will always have these issues and I understand where you are coming from.Whether it is appropriate to use this for payments is really an issue for the department and we cannot comment onthat. This is not just used for the provision of health services; it is largely a tool that we produce for reporting andstatistical purposes that has been picked up by other departments for different purposes. Whether it is appropriatefor those purposes is really an issue for discussion with those departments. Senator NASH: True. If you were asked to relocate from Canberra, Sydney or wherever you are to eitherWagga or Gundagai and they were going to give you $10,000 in incentive to go to either, would there be anyincentive for you to go to Gundagai? Mr Nairn: That is a personal question. I might like bushwalking or something. Senator NASH: I do not expect you to answer that. That is fine. Senator DI NATALE: Given that one of the issues is obviously that you have to have a cut-off for each ofthose five categories, is there capacity to drill down further and to perhaps double the number of categories andtherefore reflect a bit more of that complexity in the classification? Mr Nairn: That was one of the things that was considered when we chose to use five categories. The reasonwe did it was that we wanted a general break-up, still keeping enough population in each category. We would notwant to break up the very remote and remote areas any more because there are only very small populations inthose areas. The inner regional category has roughly 20 per cent of the population. It would be possible to splitthat up a little bit more, but it only spans 2.2 within the 15-point range in ARIA. So it is not a big range as it is.But, in answer to your question, it would be possible. It would have been possible to have a greater number ofcategories in the classification, but when we consulted most of the users came back and said at that time they feltit met their purposes. Senator DI NATALE: To follow up on that, it is clear that that is the category that causes the most problemsin this area. Technically I imagine it is very straightforward to do that. Mr Nairn: Yes. Senator DI NATALE: To do it, you just need a directive from the department of health. Essentially, youwould just need to break it down a little further, and that might be one way of resolving the issue we have in termsof workforce. Mr Nairn: The department of health does not actually direct the ABS on these classifications. They may havea discussion with us, and we are doing that. If it was agreed and it was stated by the department that they had aposition where they felt we should split one of these into two, or something along those lines, we would then needto go through a consultation process with other users, bearing in mind that any change affects a lot of people.They do not like to see classifications changed too frequently, so we have to weigh up that issue as well and allowenough time for consultation before we continue. Having said that, those sorts of changes would be possible andare the kinds of things we usually look at when from time to time we review classifications to see whether theyare meeting the needs of the people who use them. Senator DI NATALE: Perhaps the issue of directing and so on was not the right phrase. My point is that it ispossible to do it and, if there were agreement that it would be useful, it would not require a huge amount work tobe able to do that. Mr Nairn: No. Technically, it would not be difficult, it is more about making sure that other users and peoplewho use this classification are also happy that that would be it. Senator DI NATALE: Why couldnt you have a model that applies for workforce planning and then otherusers of the existing five classifications continue to use it as it is? Ms Van Halderen: The benefit of having a standard classification in this case is that it can then be used formultiple purposes. Not only could you use this as in this case, for the health workforce, but you could compare itto, say, population numbers and get a profile on the region. You could bring in statistics from the census and youcan bring in statistics from the biophysical aspects of the town, and you could start bringing in a bit of a profile by COMMUNITY AFFAIRS REFERENCES COMMITTEE
  • 15. Friday, 11 May 2012 Senate Page 11using the standard classification. If you start breaking it into a specific classification for workforce and then try tobring up a profile of other things to do with that workforce it is a bit tricky. Senator DI NATALE: Dont you just aggregate the data when you need to analyse it? Ms Van Halderen: You certainly could if you wanted to use it in a different instance. The classification itself,the five groups, is based on ARIA, which is a continuous index between zero and 15. You could, technically, notuse the classification at all, go back to ARIA and use the scores of zero through to 15 on a continuous scale. Thatis another option. Senator FAWCETT: In one of your tables you mention that, as well as population size, you look at distance.Is that distance as the crow flies or does it take into account actual accessibility? Mr Nairn: It is the distance by road? Senator MOORE: Usable roads? Mr Nairn: It does not take into account whether it is a four-lane highway or a one-lane road. Senator FAWCETT: Sure, but, for example, it does not take into account whether pensioners in a particulartown have access to public transport to travel that distance. Mr Nairn: No, it is geographically based purely on distances between places. Senator FAWCETT: So in the case of Port Lincoln it would take into account the eight-hour drive asopposed to the 30-minute flight. Mr Nairn: Yes. CHAIR: On your website you say that, during the development of the ASGCRA, you did not adopt theoriginal classes of remoteness recommended by GISCA and DoHA. Can you explain why you did not adopt themand what were the details of those particular classes of remoteness. Mr Nairn: I am not sure that I can answer that now. I would like to take that question on notice and get backto you. CHAIR: That is fine. If I understand your submission correctly you are saying that there are potential changes,given the recent review of ASGC. Mr Nairn: Yes. CHAIR: Can you articulate a little bit more what they may be? Mr Nairn: Those changes were really about changing a whole lot of other geographical classifications. Youmay be familiar with census collection districts, the smallest area you can get census data from. All of those areasare going to be changed according to some new classifications. It will not affect the remoteness classification inthat we were still proposing releasing it with the same five categories. The unit that we built it up from, instead ofbeing the CD, which was the old census unit, will be the new SA1, which is a replacement unit for census output.We do not expect that those changes will cause a lot of change to the remoteness classification itself, but theremoteness classification is due for update towards the end of this year, the end of 2012, because we do take thenew census data and we produce a new list of all the towns of Australia and all their sizes, and ARIA isrecalculated based on that information. We then take those ARIA values again and overlay them—in this case itwill be with SA1s—to produce the five categories and the new map of remoteness for Australia, which will comeout towards the end of 2012. Senator MOORE: Mr Nairn, is the new SA1 component a smaller component, a more focused component orabout the same as a CD? Mr Nairn: It is a little bit smaller; I think there are around about 65,000 SA1s, whereas there were about38,000 CDs. Senator MOORE: So it is a more focused definition? Mr Nairn: Yes, the SA1s are a little bit more homogeneous in nature. If they are residential, there is not muchmixed residential and industrial and that sort of thing, and they are generally a little bit higher resolution, which ina way probably could improve things. Then again, they are not much smaller perhaps in rural areas, because theyhave a lower population, which limits the criteria for the size of those units. CHAIR: Did I understand correctly that this would probably be done by the end of this year? Mr Nairn: Yes. At the end of this year we anticipate releasing the new version of remoteness. As I said, it isstill the same sort of conceptual product, but the boundaries will change a little bit, based on the fact that the COMMUNITY AFFAIRS REFERENCES COMMITTEE
  • 16. Page 12 Senate Friday, 11 May 2012populations of the centres have changed and that the unit we are using to build them up is the SA1 instead of theCD. Senator MOORE: Mr Nairn, getting back to how different organisations interrelate with each other, is thereany ongoing cross-departmental group that includes Stats and Health and Ageing to continue reviewing thesethings? Ms Van Halderen, this could weld with a question to you. Ms Van Halderen: Yes, that is right, and you asked that question earlier as well. Senator MOORE: No, the question I asked earlier had to do with internally in Stats. My question is nowbetween departments. Senator Nash has already said that, within Education, there are issues between thestatistical basis and the way policy is developed. I want to know whether there is an ongoing interrelationshipbetween Stats and Health and Ageing on the various issues of how you use the model, what the best way of doingit is and what factors are required. Ms Van Halderen: The ABS is in constant contact with the Commonwealth and the state and territorydepartments around these issues. We consult quite extensively, not just with the Department of Health and Ageingbut with the education sector, with FaHCSIA, the users of the classifications. It is an ongoing dialogue. Inparticular we consult very closely at this time when we are reviewing the process. Alister mentioned the releasecoming out later this year. We will be going through a consultation process as part of that development prior torelease. Specifically on this one, we do have an ongoing dialogue with the department of health around the use ofthis between our two institutions. Senator MOORE: Is that with the health workforce or the rural health part of Health and Ageing? We willask the department as well. I am just wondering with whom you dialogue. Ms Van Halderen: I would have to take that on notice and get back to you with which part of the portfoliowe— Senator MOORE: We will ask the department this afternoon as well. I am always interested in this ongoingdiscussion. Mr Nairn: We have had quite a lot of ongoing discussion with Health on this. They have obviously beenconsidering different options and have asked us for different information. We have been continually providingsome information and discussing options with that department. CHAIR: Thank you very much. We have given you some questions on notice. Could we have those backwithin two weeks, if possible. Mr Nairn: Would you be able to send those questions across to us? CHAIR: Yes, we will. Mr Nairn: Thank you. Proceedings suspended from 10:40 to 11:01 COMMUNITY AFFAIRS REFERENCES COMMITTEE
  • 17. Friday, 11 May 2012 Senate Page 13JOHNSON, Ms Jenny, Chief Executive Officer, Rural Doctors Association of AustraliaMARA, Dr Paul, President, Rural Doctors Association of Australia CHAIR: I would like to welcome representatives from the Rural Doctors Association of Australia. Iunderstand the information on parliamentary privilege and the protection of witnesses and evidence has beenprovided to you. We have your submission. It is numbered 67. I would like to invite one of you or both of you tomake an opening statement and then we will ask you some questions. Dr Mara: Thanks very much. We have provided a written opening statement. I would like to read through thatopening statement, just to provide a brief background, and talk to it if possible. First of all, I would like to say thatI have been a rural doctor for 30 years this year in the small town on Gundagai. Senator NASH: I have just been speaking about Gundagai with a previous witness. Dr Mara: My wife when I was coming here said, Just ask them if there is a difference between Gundagai,Cootamundra, Tumut, Cloncurry, Cairns, Coffs Harbour, Hobart and myriad other towns that are in the sameclassification system. I think if any one of you have visited those communities you would know that there is adifference between a small country town such as Gundagai—where we have a main street, a Chinese restaurant, acafe and a war memorial—and major regional centres like Coffs Harbour or Wagga Wagga. That crucialdifference, which I think we all understand inherently, is not being applied in the current system of incentives orgeographical classifications across Australia. The role of the Rural Doctors Association is unarguably an industrial organisation. But, as rural doctors, we seethe application of an appropriate industrial, professional and general working framework as inseparable frombeing able to provide services to our rural communities. The key concern that we as a rural doctors associationhave is that we are seeing the decimation or disintegration of many of these rural communities, in part because ofthe decimation of rural towns and the health services there. There is an increasing frustration level going about for rural doctors. You will have seen recently the issue ofthe incentives being removed from doctors in Moree and other communities, and the level of frustration thereexpressed by the practitioners. I would like to just quote from that frustration level, because we are reallyconcerned that doctors that have out been out there for a long period of time and who are going to be required totrain the next level of doctors coming up as we double the number of medical students and double the numbersgoing into general practice are simply going to walk. That is going to happen very, very rapidly. If I can quote LesWoollard from his report on the 7:30 program: There will be people who will suffer and they will just throw their hands up, as politicians do and say Im sorry we cant getpeople to the bush and theyll say its not their fault.Im saying it damn well is their fault. If youve got a Federal Health Minister—and I do not wish to personalise this to the federal health minister—who cannot see the difference between Townsville, Cairns and Moree, then really they obviously live in some cocoon inCanberra and have no concept of the reality of what life is like in small town rural Australia.I would emphasise that they have no concept of what rural practice is like in regional centres as opposed to that insmall country towns. We cannot see incentives based in isolation. There is no point in having an incentive framework withouthaving a framework that supports the entire professional and industrial aspects of the arrangements under whichrural doctors work. In particular, we believe that the issue of training is very important. To date we haveconcentrated on getting a doctor—any doctor—into these communities and in many circumstances this has led toa downgrading of services as many of those doctors either do not have an interest or do not have the confidence orskills to meet the needs of their communities. So our focus is very much on meeting the health needs in thecommunities as much as possible, and incentives are just one part of what we see as the arrangements that need toapply. First of all, there need to be professional arrangements with an adequate training program that is supported atall levels and reflects the continuum of care that is required in rural practice, from primary care through to generalhospital care or other advanced levels of care, such as Indigenous health. If you do not have that training programand you do not have those opportunities, then people are not going to have the skills and confidence and nonumber of incentives will make a difference. The second area relates to the professional supports that areprovided. It is no longer appropriate that doctors have to work as many of our rural doctors have had to out there,and as we work in our practice. I work with my wife and we are on call seven days a week, 24 hours a day, andthat has been the case for many, many years and often for months at a time. We are just finishing a shift that has COMMUNITY AFFAIRS REFERENCES COMMITTEE
  • 18. Page 14 Senate Friday, 11 May 2012gone on for over 28 days straight. When you are called out to the hospital after hours, after 10 oclock at night, forfour nights a week, that starts to become a burden after 30 years in practice. The third aspect, in terms of thegeneral economics—and this is where the incentives come in—we believe they need to be better targeted, systembased incentives, and we believe we can come up with a solution that would really meet the needs of thosedoctors that is evidence based and meets the needs of the communities. The last area is in terms of infrastructure. I would like to deal with that a little bit as well during our report heretoday. The current infrastructure grants are too small and they are not targeted adequately. We believe you couldleverage that amount of money in a much more effective way by targeting the end output for communities as tohow it could go ahead. I will leave it at that and we can deal with more as we go on to questions, if that is okay. CHAIR: That is fine. Thank you. Ms Johnson, do you have anything further to add? Ms Johnson: I would just emphasise, from where I sit at the office desk, if you like, and from the feedbackthat we get from our members, that this year I have noticed an increasing level of frustration, particularly amongstdoctors who have been in their communities for a number of years. They are really starting to feel as though theyare not being listened to. It is over areas such as the ASGC-RA and the removal of the after-hours practiceincentive program, and also some of the other practice incentives. They are starting to fear for the future of theirgeneral practices. We firmly believe that rural general practice is the most efficient way to deliver services intorural areas. We have already seen a number of doctors saying, I dont know how much longer I can continue this.I may have to leave. We need to keep those doctors there because we have all these medical students comingthrough and they are the doctors who are going to mentor our medical students and the next generation of ruraldoctors. So it is really important that we address not only the long-term scenarios but also the issues that areimpacting on those doctors in the shorter term so we can keep them in their communities for them to provide thetraining to the next generation. Dr Mara: I think this is exemplified by the more recent situation where Dr Maxine Percival—Rural Doctor ofthe Year a couple of years ago, a long-term and highly skilled and highly qualified procedural GP who deliversbabies and has neonatal, intensive care type skills; the whole deal—has said, I can no longer continue to do this.Im out of here. So at the end of the year, in November, she will be leaving Moree. That is a disaster. Aspoliticians, you are well aware that it is often the signals that are sent that make a big impact. When people findout that Maxine Percival will be leaving, that will send a very, very strong signal to a whole range of otherexperienced doctors in the bush that they are not valued, they are not worth while, and there is no light at the endof the tunnel. This is a chief concern for us. The point I would like to make is that we have attempted to engage with the department of health and thegovernment for years on this. We have talked about the ASGC-RA. We had two years before it was implementedand we identified the issues and the key problems with it. Really, what we are seeing now is the fruition of peoplesimply not listening to us on after-hours care, on the ASGC-RA, then not engaging with us in any meaningfulsense or listening to what we have had to say. That is one of our chief complaints. We want to engage and wewant to engage constructively, because we want to do it for our communities. We are open to negotiation. We areopen to a whole range of ideas and attitudes that people may or may not think are appropriate for us to engage in,but we cannot do that if people simply do not listen, and we are no longer in the mood just to keep beating ourheads against a brick wall if that is the case. Senator MOORE: Thank you. There are so many questions, and your submission is very detailed. I knowthat the situation in Moree got media coverage, but it is not peculiar to Moree. Dr Mara: No. Senator MOORE: Can you tell me: what is under threat for a local doctor there? Ms Johnson has spokenabout the increased frustration. The frustration has been there for years, for a long time. But what is the tippingpoint; what has changed; why now? People have been there for a while, and Moree was pretty well serviced;unlike some other regions that cannot get doctors, it has had a few longstanding practices. What is the reason? Dr Mara: The tipping point, I believe, in Moree is the understanding that people coming through the systemnow who are forced out to the bush in the general practice training programs through the moratorium on overseastrained doctors simply are not interested in continuing on with that continuum of care which includes theprocedural based care. Moree being an isolated area, as you reduce the number of doctors with the skills inanaesthetics, obstetrics—and they are high-level skills that those doctors have to have—and surgery, people aredoing harder and harder rosters. It simply becomes unsafe and they simply become burnt out because they cannotcontinue to do that. If you start seeing, for 10 years or 12 years, a succession of doctors coming through in a rural COMMUNITY AFFAIRS REFERENCES COMMITTEE
  • 19. Friday, 11 May 2012 Senate Page 15training stream because they cannot get in any other training stream, and they have no inclination to become aprocedurally based rural doctor and support that, then that is what is happening. As I say, it is not just Moree. In Young there is another issue around in this, where the number of doctors withthe procedural skills has simply deteriorated and declined to a point where the rosters are simply no longer viable.In Tumut, which now has 10 doctors for a town of over 6,000, a large number of those doctors are now underprovisional registration requiring supervision and are refusing to do after hours at the hospital. This is the tipping point we are seeing. We have lost obstetrics. We have lost anaesthetics. How are we goingto lose after-hours care and emergency care? And that is what is happening. When I first moved to Gundagai,there were six doctors in Tumut who all had anaesthetics and obstetrics experience, and I contributed with myanaesthetics and obstetrics experience. Now there is one anaesthetics doctor there and two with obstetricsexperience, one of whom is under formal supervisory arrangements. You cannot keep going and provide a safe,effective service in those sorts of circumstances. Senator MOORE: So numbers alone are not the issue? Dr Mara: Numbers alone are not the issue. It is what we talked about. It is having the doctors with the skillsand training, qualifications, confidence and desire to meet the needs of their population. Why is it, for example,that we have an area-of-need system developed under a district-of-workforce-shortage arrangement where doctorsare put into that area of need under a commercial basis but they are not fulfilling the need because they arerefusing to go to the hospital and they are refusing to provide after-hours services? Those doctors should not begiven area-of-need positions. Senator MOORE: Unless they are prepared— Dr Mara: Unless they are prepared to— Senator MOORE: Is there some form of contractual arrangement that should be set out before people are sentthere? Dr Mara: I think we need to review all these issues of DWS. If I may provide you with evidence in Gundagai,we have Barbara Cameron, who is a young, second-year-out doctor. She has been a bonded medical placementscholar, so she is committed to six years minimum in the bush. Senator MOORE: That was the system that was brought in to get people out there? Dr Mara: Yes. That, from my point of view, is a good stream, and this is where the future lies. But she getsinto Gundagai as a trainee doing a PGPPP year, which is a prevocational training year, and she wants to come toGundagai when she finishes her training, but she discovers that Gundagai is not a district of workforce shortageso she is not eligible, but the Tuggeranong Valley in Canberra is eligible. The beauty about the DWS is that itchanges every three months. So last year, when Barbara came, it was not a DWS, but because I was off sick andhad a major operation in June last year and was off for six months, all of a sudden it has become a DWS againbecause of the way in which the figures are adjusted. You cannot have that degree of uncertainty with thesepeople. Will it be a DWS in the next six months? Probably not, because I am back at work. Senator MOORE: So from that situation, for long-term training and placement, you cannot be certain thatthat would continue because the rating changes; is that right? Dr Mara: Because of the way in which it is designed and changes, and the same thing applies to the ASGC-RA classification. Why would a doctor come to Gundagai when they have to do after hours and maybe collect the$12,000 incentive payment, when they can pick up the $12,000 in Wagga, Coffs Harbour or Hobart or any ofthose other major centres which have far more facilities than just the local swimming pool? Why would they gothere? And that is what we are seeing. Senator MOORE: Dr Mara, do you want to table that so that we have a copy? Dr Mara: If I could. I have a number of copies there for people. Not only does it identify the issues thatBarbara has faced— Senator MOORE: It personalises it. Dr Mara: it personalises it, but it also shows you what the Gundagai Independent is all about, compared withthe Coffs Harbour review or the Hobart Mercury or anything else. These towns are different. The services andskills that we provide are different. It is a continuum of care. If we lose that continuum of care, what is going tohappen to the patients in Gundagai after hours? They are going to have to hop on an ambulance and gosomewhere, like they do in West Wyalong. At the moment, West Wyalong cannot guarantee after-hours services,and that is 60 kilometres from Temora. Temora cannot guarantee it. Young sometimes cannot guarantee obstetricsservices, and people are shuffled to Cootamundra and Wagga. These are the things that concern us. That is why I COMMUNITY AFFAIRS REFERENCES COMMITTEE
  • 20. Page 16 Senate Friday, 11 May 2012say that we are an industrial body but we are the people that live and work in and meet our communities everysingle day, and they are the issues that occur as a result of the ASGC-RA. Senator MOORE: Dr Mara, has there ever been a workable system? Dr Mara: I think there has been a workable system. Senator MOORE: In the past? Dr Mara: In the past, what we found was that, when I moved into rural practice, probably 25 per cent of mycohort in university moved into rural practice. I accept that there are changes. I accept that there is a different— Senator MOORE: Without being too directional, what era was that? Dr Mara: Sorry? Senator MOORE: Without being too directional and breaching privacy et cetera, what era of medical practicewas that? Dr Mara: I started medicine in 1972 and I graduated in 1978, and we spent— Senator MOORE: So late seventies or early eighties? Dr Mara: It was the early eighties. We spent five years to train to become rural doctors. Senator MOORE: And you are saying that 25 per cent of the graduating class would do that? Dr Mara: Yes. They moved into towns. They moved into Young. They moved into the Gilgandras, theymoved into the Griffiths and they moved into the communities out there. Now I am probably one of the last menstanding on the scene. They moved there because they were enticed by the whole concept of cradle-to-the-gravemedicine by gaining and being able to utilise additional skills and by having the confidence when they had thoseskills that they could actually make a difference in those communities. That is the reason we moved into ruralpractice. Senator MOORE: Were there financial incentives under that system? Dr Mara: No, there were not at that stage. Senator MOORE: There was no financial incentive; it was a life choice that doctors made in the earlyeighties? Dr Mara: No, it was a choice. It was a commercial decision. We paid a lot of money to buy into a practice.The incentive was that in those days probably there was a higher level of income that you could get as a ruraldoctor by dint of the extended work and the extended skills that you had. That has been removed to a large extentunder the current Medicare arrangements where turnover is valued more than comprehensive arrangements. Having said that, for us it was not about the money. We always had this notion that, if you moved into ruralpractice and did a good job, the money would follow as a result of that. When Neal Blewett removed the after-hours loadings as a result of various things, I think way back in 1979 or the eighties—it was 1982 or somethinglike that—that led to the rural doctors dispute in New South Wales and then we were able to negotiate a verygood package for doctors in New South Wales around the hospital payment arrangements. Senator MOORE: That was the state government though? Dr Mara: With the state government. That package has been maintained and supported, and I think it hasbeen helped along by the fact that we have been able to engage at a committee level, the Rural Doctors SettlementPackage committee, which must be one of the longest standing committees going that still goes and still has very,very positive impacts. More recently, with the New South Wales government, we are negotiating around theintroduction of a generalist training pathway. In relation to that: we have lost the concept of generalism inmedicine as being a vital thing. I think Richard Murray, the ACRRM representative, discussed this with you, andI agree with Richard. We simply cannot afford to have an ever-increasing superspecialisation, because it is goingto cost the government and it is going to cost the taxpayer too much. At the end of the day, we have to startputting some investment into people who can do basic things very, very well in a comprehensive sense. Senator MOORE: I do not want to be too directional, but some of the push towards the subspecialties andspecialties has come from the colleges. Dr Mara: I appreciate that. Senator MOORE: There has been that focus from the profession to go down that track. How do you balancethe right of the profession to develop their focus and to attract people, as to the evidence that you have providedand also we got in Townsville on exactly the same point? We are actually competing for a range of medicalstudents. They have come on. How do you actually balance the role of government as intruding on that stuff? You COMMUNITY AFFAIRS REFERENCES COMMITTEE
  • 21. Friday, 11 May 2012 Senate Page 17would understand. You portrayed your own group as an industrial group. How far should government intrude insaying what you can and cannot do? Dr Mara: I think at the end of the day it comes down to a quality agenda. Part of the superspecialisation or thesubspecialisations agenda is the individual specialists or doctors—because GPs are subspecialising now—feelingcomfortable within a domain of practice. They do not get that full gamut. So I think it has to take into account thatcomfort level. It has to take into account the quality agenda. Clearly, there is a higher level of quality involvednow even in repairing a fractured ankle or a fractured scaphoid that requires a more specialised approach andgives a better result at the end of the day. It is the result at the end of the day that is important. But, when it comesdown to people in rural areas, a caesarean section on a low-risk patient or a normal delivery on a low-risk patientis just as appropriately undertaken in Moree as it might be in John Hunter Hospital. What it comes down to is thatthere are horses for courses. It is about patients election and patient requirements. The other thing we have to take into account is that there are limits to growth in medicine at the end of the day.I often have this argument about 95-year-old patients having a hip replacement. There is clearly an indicationwhere some of those people would benefit greatly from a hip replacement and the lives of others of them wouldnot benefit from that arrangement. Part of my counselling at the moment with my patients is to really make surethat they have an understanding of what the benefits of these things are, because the system will give them thatopportunity to have it forever. Does the government have a role in that? I do not know. I think ultimately it comesdown to the doctor and the patient, and the government has to say, Were going to fund these things. Certainlythe rationing is where the government comes in. But a patient at the age of 80 who requires a hip replacementshould not be waiting two years if they are going to get a benefit out of that hip replacement. Ms Johnson: I think also, from the experience that has been shown in Queensland—and no doubt you haveheard all this—that what we are calling the advanced rural training pathway, or this move towards a designatedtraining pathway that promotes rural generalism, is really one of the ways that we can address this trend towardssubspecialisation because it actually gives people— Senator Moore interjecting— Ms Johnson: Well, it is, but it is far more a generalist form of practice. Dr Mara: And the important thing about that is that it is founded on the basis of primary care with acontinuation into the secondary level care. Primary care, of course, involves preventative medicine and a range ofother strategies, working with the community and working with other health providers, to prevent the need forthat superspecialisation down the track. I think that is an important thing as well. Senator FAWCETT: Looking at the whole supply chain, if you like, of the rural health workforce, youobviously have the training in the universities, and there are implications of federal funding and universitypolicies. You then have the training in hospitals that often happens after that, the intern years, and then all thethings we are talking about here in terms of incentives for people to go to the country. South Australia has donesome modelling recently looking at the number of people who need to go through that intern year placement.There are about 246 places available in state funded hospitals in metropolitan areas but only six available incountry areas. The modelling says we need about 53 just to sustain the workforce. In South Australia, because ofthe dint of our population distribution and the retraction of state government funded hospitals with training places,in 2013 they are looking at trialling interns working with GPS to provide that training in country. Do you thinkthat is likely to be a successful model? Would that have application more broadly across Australia? Would thatimpose a higher workload on a group of GPs who are already struggling under significant workload pressures? Dr Mara: The first point is that training is longitudinal and making sure there are linkages across thatlongitude from the medical school to the intern year to the prevocational training to the registrar position is veryimportant, and we still have disconnects in that way. The Rural Doctors Association has published a set ofnational principles on the pathway for advanced training. That set of principles clearly identifies that there is anissue in some states for the availability of training positions that are required to do rural medicine and that otherstates may have to be brought in to provide some of that access. It is the same with the Northern Territory, forexample, where we do not have the number of public hospitals required. So we believe that doctors should be ableto move within that pathway into those other areas as the training simply may not be available in some of thesmaller states. It may have to be provided by other areas with more regional hospitals. I personally, in my practice, would not be able to take on an intern in their vocational training year. Theregistration requirements, the risk requirements and the other arrangements for their training are very difficult tosupervise. But I know that some practices are geared up to do it and they do it very effectively and very well. Wefind that the prevocational general practice training program is one of the best things that we have had, even better COMMUNITY AFFAIRS REFERENCES COMMITTEE
  • 22. Page 18 Senate Friday, 11 May 2012than the registrar training program, because by and large the quality of the doctors coming through that PGPPPprogram are of far higher quality than some of the registrars that we have had. It is simply because those doctorshave been in the Australian training system and they have a good understanding of that arrangement. To answeryour question, you simply may not have the training places available required to provide that continuum of carebut there should be capacity at the federal level to be able to work on the other states to provide those places.Simply providing extra money to some of the hospitals in South Australia will not necessarily do it because youcannot create an artificial training place without having a service component to that trading place. Senator FAWCETT: You said your practice would not be placed to do that. What would the federalgovernment need to provide to a GP practice in order to (a) encourage them and (b) enable them to provide thatlevel of training? Dr Mara: We need doctors. It is all about workforce. Build the capacity to have practices that are self-sustaining and viable which can provide the range of services. To us that is the model. The town of Gundagai has3,000 people. At the moment there are two fully qualified doctors working there 24 hours a day, seven days aweek, so we are under staffed. We have another two doctors who require full supervision and that is a burden initself to provide. Senator MOORE: Are they going through some kind of program? Dr Mara: Yes. There is a PGPPP doctor, Barbara, who is exceptional but still requires supervision andsupport, and we have an overseas trained doctor registrar who requires the full level of supervision and support.We have 3,000 patients and we are on a 24/7 on-call roster. We need doctors. If we doubled the number ofdoctors in Gundagai then that would effectively mean that we would not get as much income in our Medicare fee-for-service during the day but it would mean that we would be able to provide the afterhours service in a moreviable arrangement and would be able to provide the teaching. If we were to get to 5 full-time doctors then wewould get a system that would become self-sustaining and become a rapid support for some of the other areas.When Dr Charles Louis Gabriel moved to Gundy in the late 1880s he complained that there were too manydoctors in Gundagai, because there were five—without the other two—so we have not made great leaps andbounds over that period. This whole thing is about workforce. Senator NASH: As you said earlier, ASGC-RA issues are just part of it. It really is a jigsaw puzzle, isnt it,trying to get all the pieces together to make the picture look far better than it now looks? One thing that strikes meis the different way in which GPs are treated, in particular rural GPs, compared to specialists or even rural GPscompared to city GPs. Do we need to think outside the square and perhaps treat rural GPs entirely different insome way—I do not have the answer; this is very much just a question—in the fact that it is a social group,because the economy of scale is not providing those doctors in the regions? That social group is needed with thatprovision. Is there a way of treating them differently because, at the moment, GPs in Sydney and GPS in ruralareas, apart from the obvious bits of funding, by and large, are seen as GPs. Is there any benefit in giving somethought to changing the structure completely so they are somehow entirely different? Dr Mara: I think we have done that in a number of different ways. We believe that there has to be anadvanced training program and now the profession has endorsed our key principles, which effectively are sayingthat you require advanced training for rural practice. That has the endorsement of the entire profession, thecollege of GPs. It is not about just the FRACGP; it is about having a higher qualification of the AustralianCollege of Rural and Remote Medicine or the advanced diploma of the college of GPs in that area. So we havedifferentiated that to say there is differential training. We know that there is a differential work pattern that isoccurring there and that it is all about that continuum of care. One of our concerns is that people do not see it as a continuum of care. They are more and more now saying,Ill be a locum GP anaesthetist, and not do that continuum of care. That is not good enough, from my point ofview. Doctors have to have good training in the gamut of general practice: they have to be able to apply thoseskills into that next stage, the advanced levels. So they are different. The department does not recognise thatdifference. The government, to date, has not recognised that difference. The difference is there. We do it everyday but, until we get that recognition, it will not come home. Professor John Humphreys, when he looked at theASGCRA—and I presume you have seen this article—he shows that the difference in practice relates to the sizeof the town and the availability of hospitals. He targets the incentive of structure here clearly to what thecommunity needs and what the issues are with practising in rural areas, rather than the ASGCRA which targets itat some distance from a major centre type thing. We need to look at a couple of changes. I would like to table that paper, if that is possible. To us, this is the onemodel we should be going to. It is evidence based around what the differences are. It reflects very well thosedifferences and the problems that the doctors in those communities are facing. COMMUNITY AFFAIRS REFERENCES COMMITTEE
  • 23. Friday, 11 May 2012 Senate Page 19 Senator NASH: You make the point that GPs in the bush are really specialists in rural general practice, insuch a way that it is not just being a GP; it is all those extra services. As you have been saying, they need to haveall of those capabilities to provide a whole medical provision for people in regional areas. Having identified thatthat is the problem, that we need them to be able to be proceduralists, how do you address that? The questionfrom us sitting on this side of the table is: what is it that you want to see from government that would help youaddress skilling those GPs to be able to do the procedural aspects and also give them the incentive to want to doit? Dr Mara: Firstly, we have to recognise that difference at the government level and recognise that the currentgeographical structures and incentive arrangements simply do not cut it. We have to get that recognition first.Having done that, we have to recognise that just simply taking doctors from overseas, ripping the intellectualproperty out of countries overseas as a matter of policy and putting them on a train to Bourke or Gulargambone orwherever, and saying, Go for it, without supervision, without training, without adequate support for them or theirfamilies and without even allowing them access to Medicare for themselves and then forcing them to stay there assome sort of Kanaka labour is totally inappropriate. It is not a short-term solution; it is not even a long-termsolution. Over 30 per cent of the overseas trained doctors moving into practice are going through the AustralianGeneral Practice Training program. It is not a short-term solution; they have to do the same training as our graduates. Doctors who are out therewithout support and supervision are spending years before they are able to meet their own qualificationrequirements to get full qualifications. They are not getting the procedural training and the other training that isavailable to Australian graduates. I am not opposed to bringing doctors from overseas. We have a migratoryculture in Australia, and doctors should be part of that migratory culture but they should not be forced and weshould not as a matter of policy be importing those doctors to solve our needs because it has not. We have seenthe wind-down in hospitals and the procedural things as a result of that. I can show you something on the trainingpathway, which I think is very illustrative. You asked me a second question: how should we target the incentives? The incentives at the present time arewhy the government came into play and said, We are all of a sudden going to give doctors in Cairns, Townsville,Coffs Harbour, Wagga and Tamworth—where there is a natural shift of doctors as you fill up to bucket, so whyare we giving them between $12,000 and $18,000, getting no bang for their buck and the same being paid to theguys in Moree that are out of bed 24 hours a day seven days a week? I do not get it. I am not saying that doctors in general practice are not worth more money; they are. But as a targeted means ofattracting doctors to places where you do not have to attract them to, why give doctors in Wagga $12,000 for eachESQ it is. Are you on after hours as a result of this? Not necessarily. Is Wagga underserviced? They have got adson the TV, they have got big ads in the paper and they have got cars driving around with their medical centrewritten all over it. That does not say to me that the town is underserviced. What bang for your buck are yougetting out of that? What I would be saying to the people is that we believe and the evidence shows through the viable modelsproject that you need to target where Medicare is the main system, you need to target the incentives that theMedicare level. Our preferred option is to have a separate item number which is non-rebatable, which is capped tocontrol your investment, which is gradually implemented in areas of greatest needs where, every time a doctorprovides a service in general practice in order to encourage that continuity, they get an extra incentive paymentautomatically paid. Ideally, after a period of time, say, five years they are able to carry that incentive if they wantto go back to the city. That would provide a very, very visual transparent, explicit incentive, and they can take thatback with them. So if they are in Gundagai for five years, they take that incentive back with them at the end ofthat five years for five years into wherever they want to practise after that. That is what we need. At the moment the incentives are not explicit. They are not linked to providing a continuum of care. They arenot even targeted adequately into areas of greatest need because of the ASGC-RA arrangement, and we have thissituation where right across these training pathways, programs, you have got very, very high levels of overseastrained doctors who are there only because of the moratorium. So the incentives have not driven people into thoseareas; they have driven them to the coast, and these figures clearly show that in our areas. Senator NASH: That payment that is attached to payment that you are talking about, I think, is a very goodidea. When you say carry the incentive back to the city, are you saying that if somebody was prepared to comeout and do five years in the bush, they get the incentive payment for the five years as a recognition, I guess, of thefact that they were prepared to do that. When they moved back to the city, do they still get the incentive paymentfor a period of time? Dr Mara: For the time which they have spent in the bush. COMMUNITY AFFAIRS REFERENCES COMMITTEE
  • 24. Page 20 Senate Friday, 11 May 2012 Senator NASH: So commensurate. So if you are going to do five years, you get five years and the city; yougo and do 10, you get 10 years in the city. Dr Mara: And you have a cut-off point at which it comes in so that in Gundagai, for example, which isarguably closer to major centres and different to Hay, then after two years you are there. The other thing is that the incentives at the moment are going to doctors that are unsupervised. They areunsupported and not fully qualified or trained. You target those people that are trained, fully qualified andsupported so it gives them some incentive to actually go and do the things that are required. You only give thoseincentives to the doctors that are providing the continuum of services. The de facto arrangement of that is theafter-hours hospital based care but it may be Indigenous communitys Indigenous based care. If they are providingthat continuum of service, then they get that incentive. To us, when Tony Abbott bought in the Medicare rebate incentive payment for bulk-billing, it stopped thedecline in bulk-billing overnight. We believe that a similar sort of payment would be a very, very explicitincentive. If a doctor is working in a totally salaried position then you do not provide these incentives in that way;you provide it through the salary arrangement. But because the main game in town is still Medicare fee-for-service, you target the incentive at a fee-for-service arrangement. You can have arguments about whether itshould be the main game in town or not, but the reality is that it is there at the present time. So that incentive andthe ability to carry that for a certain period of time back to your city environment, if you do want to go back there,means that people start to make decisions. Ms Johnson : There used to be in Queensland almost a tacit agreement that, if a doctor had spent some time inrural service, they were given almost preferential entry into a specialist training program. That was alsorecognition of the breadth of experience that doctors got in rural areas, so a lot of the colleges recognised that thatexperience was valuable and would stand them in good stead when they actually entered into the specialisttraining program. That does not happen anymore, for a whole variety of reasons, but I think it is worth looking atsystems like that, where rural service is recognized and valued. On a little bit of a different tangent, I have heardabout this from rural specialists and from some of the medical students—and this is not something thegovernment can do anything about; it is a professional issue. I think one of our challenges is to improve the statusof rural medicine, so people say, Rural doctors do really good stuff and you can get really good services in ruralareas. There seems to sometimes be an assumption with city based professionals that the services and the peoplewho provide those services in rural areas are not of the same calibre, which is patently untrue. Dr Mara: The issue is not about more money for individual doctors. From our perspective it is about buildingcapacity within communities to provide that continuum of service and that means that you have to fund extranumbers of doctors. What such an incentive would do is say: We expect that you will go on to a one-in-fourroster, which we believe is an appropriate and reasonable arrangement for after-hours care. If you do that one-in-four roster, the next day—when you have been out of bed at two oclock in the morning—you have got theeconomic capacity to be able to take half the next day off or the full next day off. You have got the economiccapacity to be able to provide educational services for medical students and PGPPPs and GP registrars. So it is notjust about more money as a money grab for the individual doctors. I think that is the important thing that we needto stress here. Senator DI NATALE: I have got some specific questions. I do not think that anyone on the committee woulddoubt that the rural classification system has problems. I have some specific questions about how we fix it. Doyou think the existing classification system is a good basis upon which to improve or do you think we need tostart again from scratch? Dr Mara: I would ideally see that we start again from scratch, but I am also a realist in the system and I thinkthe evidence from John Humphreys clearly shows that when you get to the higher levels of classification in theASGC-RA they are probably fairly appropriate. The issues exist with the RA2s and the RA3s to a large extent,and also the differential payment arrangements between those. So you have a huge continuum in the RA2sbetween very small communities and doctors providing a high level service and those doctors providing what wecall standard office based general practitioner services. Senator DI NATALE: It would be feasible to put some additional filter over the top of that, particularlywithin that banding or potentially subcategories within those groups, to try and get a more appropriateclassification system that addresses some of the anomalies that we see. Dr Mara: And I think John Humphreyss paper is evidence based and it would fulfil probably 95 per cent ofthe requirements as we would see it. COMMUNITY AFFAIRS REFERENCES COMMITTEE
  • 25. Friday, 11 May 2012 Senate Page 21 Senator DI NATALE: I am someone who was a fellow of the College of Rural and Remote Medicine. One ofthe big problems—and I think Ms Johnson mentioned it earlier—is that the status of rural and remote medicinesimply does not exist within the medical profession, let alone within the broader community. The issue thenbecomes: how do we ensure that people who have specialist skills in that area are recognised? And we are talkingabout incentives. So we have fee-for-service, for example. Specifically, by providing incentives for GPs workingin regional areas through a fee-for-service mechanism, we are still not recognising those people who have specialskills and have trained through a particular pathway. In other words, you can be a GP working in the city and nothave been through an accredited regional pathway. Should those people still get access, too, if we have anincentive system through fee-for-service? Does that make sense? So what I am asking is: should that loadingapply just to people who have been through the pathway, or should it apply to all GPs working in a regionalcommunity? Dr Mara: Ultimately I believe it should only be those people who have got demonstrated capacity throughtheir fellowship qualifications and through their credentialling at various hospital arrangements and are providingthe services. So you have got to have the qualifications and skills. You have got to be providing the services inorder to get the incentive component. Ms Johnson: We have also proposed that another option could be, as well as that service component, acomponent that recognises the isolation or the area in which those services are taking place. So, in other words,you are the right doctor; you have got the right qualifications; you are providing the right services—which isafter-hours, procedural, primary care; as Paul says, the continuum—and you are providing it in the rightcommunities, the communities that need it most. Dr Mara: I think that is important, Richard, because you may have doctors working in remote areas who arenot providing that advanced level skill, for whatever reason—it might be childbirth, or reaching retirement. Thefact that they are working in an area and fulfilling a need imposes some burden that should be compensated. Thatis why we divide it into two. Senator DI NATALE: Does that not then put another barrier in, for those people, for example, who may notnecessarily have the skills? Say you are a GP working in town and you decide, Okay, thats it—were packing upthe family and were going to Tennant Creek. What that means is that that GP would need to obtain an additionalset of skills prior to accessing those incentive payments. Isnt that potentially a barrier to those people moving— Dr Mara: Under our schema they would be entitled to the isolation component. If they desired to move onand provide the complexity component, then they would be required to have the skills and to be utilising thosewithin the community. We have to be very cautious here because there has been a commercial involution intothese communities whereby doctors do not have the skills and are not required to do the after-hours or whatever,and they are putting more financial pressure on the established practices that are providing those levels ofservices. In fact, the financial pressure is such that practices are saying to us: We can no longer afford to take GPregistrars; its affecting our viability, because, clearly, while you are off at the hospital and someone else is takingall the cream off the cake, then it becomes very, very difficult, and there are commercial groups that are doingthat, in what some would say is a cynical practice. Senator DI NATALE: So what you are saying is: you have a fee that recognises (a) skills, (b) the servicesthat are provided and (c) just the fact that they are there. In that way you may attract new people who might notnecessarily have the skills but who develop them over time, but you actually provide some reason for people towant to do that training in the first place. I think that is one of the issues here. In know from my own experiencethat is was, So what? I became a fellow of the college, but that did not mean anything in practice. Dr Mara: And what we would be saying is that those area-of-need positions should be available only to thosepeople who have a demonstrated capacity and an interest in fulfilling the need. There is no point in havingsomeone coming in and working 9-to-5 in Moree. That is just not on any more. Senator DI NATALE: I have just been asked to wind it up so I will ask just one last question. One of thethings that has come up—and this is a much more long-term solution—is training of students from ruralbackgrounds. We know we are going to get more doctors in rural areas if we recruit them from rural areas to train.A lot of universities are not fulfilling the quotas that are required of them in terms of how many. Do you thinkthat is an issue? And what do you think we should be doing about it? Dr Mara: I think that if the universities are getting paid the money to put people out there, they should berequired to do it. There is no doubt in our mind that the provision of students from rural areas—giving themopportunities to do medicine in regional and rural areas, and having that regional and rural training—is probablythe most effective strategy we have for the longer term or for the medium term to do this, and the universities COMMUNITY AFFAIRS REFERENCES COMMITTEE
  • 26. Page 22 Senate Friday, 11 May 2012should be put on notice. Take Wagga, for example. It introduced a regional clinical school and then, all of asudden, there were about 10 professorships given to specialists in that area but not one went to a GP. That signalsto me that they still have not got it in terms of rural areas. General practice is not just about teaching generalpractice. We teach basic medical, surgical—a range of advanced skills in these satellite posts out there. Thereshould be some recognition of GPs providing that level of training. Senator DI NATALE: You dont have to convince me. It is why I changed jobs. Senator NASH: Is the lack of support networks in terms of things like specialists a disincentive for doctorswho are possibly looking at moving to rural areas? If you are a GP in the city and you do not know what is goingon, you have at your fingertips myriad specialists to refer patients to. Is this a barrier for doctors who might wantto move out of the city but think it is a bit scary out there because they will have no support network in terms ofspecialists? Ms Johnson: You have to take on more. Patients expect you to take on more. With the policies that havecome over the last 20 years, we are getting better services in regional centres, as opposed to the rural centres. So Ido not believe that is as much of a problem anymore. The concern I have is that people are coming to the doctorand it is beyond the doctors capacity or it is going to take too much time, so they are given a letter to go tocasualty in the regional centre 100 kilometres away. To me, that is a major problem. We should be able to take onthose skills and have confidence. I think we get enough support. At the end of the day, you have got to accept thatyou are practising in isolation. You just do it. You learn about it. Senator MOORE: I read about why you do not want Medicare Locals to take over the after-hours service. Iwould like more information on that. I need to know exactly what that will mean and how people could lose out. Ialso need a bit more convincing about why people should keep the added component when they leave the regionalarea. I can totally grasp the idea of them getting it while they are there. But I cannot see it benefiting someonewho is going to stay there for 20 years, as we hope they will, if someone who stays there for five years can get themoney for 10. It would be great if I could get a bit more information on notice as to why that would be a goodidea. CHAIR: Thank you very much. We have given you some homework. Ms Johnson: There is our opening submission to be tabled. There is also a letter that we sent to the ministerregarding the situation in Moree. CHAIR: Fantastic. Thank you. Senator MOORE: When did you send the letter? Ms Johnson: It was sent probably three weeks ago. CHAIR: When it became public. Ms Johnson: Yes. Dr Mara: Can I just put on the record our thanks to the committee for your questions and your interest in this.I know you have got a job to do on this matter. I think the crucial thing is that, if we can get engagement with thegovernment through the department of health, we can solve a lot of these problems very, very rapidly. But, todate, we have not been able to get engagement. CHAIR: Thank you very much. COMMUNITY AFFAIRS REFERENCES COMMITTEE
  • 27. Friday, 11 May 2012 Senate Page 23GREGORY, Mr Gordon, Executive Director, National Rural Health AllianceHANDLEY, Ms Anne, Policy Adviser, National Rural Health AllianceHOPKINS, Mrs Helen, Policy Advisor, National Rural Health Alliance[11.54] CHAIR: I understand information on parliamentary privilege and the protection of witnesses and evidence hasbeen provided to you. We have your submission; it is No. 95. I invite you to make an opening statement, and thenwe will ask you some questions. Mr Gregory: Thank you for inviting the National Rural Health Alliance to appear before the committee. Thetopic of this inquiry is absolute core business for the alliance. The first part of the terms of reference could pass asa synopsis of the alliances very purpose:(a) the factors limiting the supply of health services and medical, nursing and allied health professionals to small regionalcommunities as compared with major regional and metropolitan centres;We therefore want to thank you for initiating this inquiry and for the energy you continue to display, including atthe public hearings you have held in Alice Springs, Darwin and Townsville. At those public hearings, members ofthe committee heard directly from organisations and researchers with detailed knowledge of the challenges ofproviding health services in remote areas. Today in Canberra you are speaking separately with some of the alliances member bodies. In a supplementarysubmission which we hope you will accept, we emphasis high-level or strategic points and also, because we thinkit incumbent upon us, given that this is our core business, to produce some specific recommendations, we haveattached to that supplementary submission a document modestly entitled The NRHAs 20-Point Plan forimproving health services and health workforce in rural and remote areas. May I formally table thesupplementary submission, Chair? CHAIR: Yes; thank you. Mr Gregory: The six strategic issues in that document are: (1) the importance of being faithful to the terms ofreference and recognising the full range of health professionals providing front-line services in rural and remotecommunities, (2) the urgent need to obtain the datasets needed for overcoming the factors limiting supply ofhealth services and health professionals in rural and remote communities, (3) improving on the ASGC-RAclassification system, (4) the pros and cons of a universal health service obligation, (5) the role of rural andremote health and medical research in informing and implementing health policy reforms in rural and remotecommunities and (6) the relationship of your inquiry with other activity. The first issue is greater equivalence of support for all front-line health professionals. Among the distinctivefeatures of the best health service delivery in rural areas is a team approach to care. GPs and other healthprofessionals do not want to work alone in rural areas; they prefer to have peers with whom responsibilities canbe shared and a range of other health professionals with whom they can work. In many areas, general practitionersare the coordinators of care for individual patients, and they are frequently the leaders of action related to thehealth of the local community. The rural and remote health workforce relies heavily on nurses on the front line,including where doctors are scarce. Multidisciplinary or, better still, interdisciplinary teams—often broughttogether by phone or video, or by driving in—become more important for health service provision as thepopulation becomes more sparse. The terms of reference for this inquiry speak, properly, of the supply of health services and medical, nursingand allied health professionals. To these could be added Aboriginal health workers, pharmacists, dentists,paramedics, midwives, chiropractors and health and aged-care service managers. We are confident that, in itsreport, the committee will include whatever recommendations are necessary to ensure that the inquiry makes asignificant contribution to health service and health professional availability across the board in rural and remoteareas. The second strategic issue is data. For too long there has been uncertainty about the actual full-time equivalentsupply of doctors to rural areas and the number of doctors in practice compared with the number needed for fairaccess. There have also been a variety of understandings of rural and remote. Thanks to our friends at theAustralian Institute of Health and Welfare and Health Workforce Australia, and the work of the Australian HealthProfessionals Registration Authority, we are closer to being able to report accurate figures for the numbers anddistribution of doctors. We may soon have better information for nurses and allied health professionals as well,but the historic data is not clear cut for nurses and has been highly deficient for allied health. Given the closerelationship between the numbers of professionals and the supply of health services in any particular area, it will COMMUNITY AFFAIRS REFERENCES COMMITTEE
  • 28. Page 24 Senate Friday, 11 May 2012be critical for your report to make recommendations on what might be called the health data system, in whichthose three agencies and a number of others are involved. Those others including in the COAG Reform Counciland the National Health Performance Authority. The alliance would like Health Workforce Australia to fund the Australian Institute of Health and Welfare forsome particular projects that relate closely to your terms of reference. These projects could include better andmore regular reporting for allied health and joint projects between Medicare, PBS and the AIHW to compare ratesof utilisation of NBS and PBS services across areas by remoteness. We believe there is still a need for moredetailed analysis of full-time equivalent doctors and other health professionals by geographic location. The third strategic issue is ASGC-RA. The Australian Standard Geographical Classification or RemotenessAreas classification system should not be used on its own for the identification of rurality, for the distribution offinancial incentives or for the return of service to rural or remote areas under various student bondingarrangements. There should be one simple approach to the assessment of health workforce shortages, which couldin the long term help provide greater equivalents of support across the professions. The alliance has been working on a composite measure, which would include three criteria for any particularplace. It is ASGC-RA classification, it is population size and an index reflecting its success in the past inrecruiting and retaining health professionals. This last is a proxy for the range of variables which results in aparticular place being one to which it is easy or difficult to attract and retain staff. Many of the alliances memberbodies have approved this approach, while some others with particular interests in the matter have sought furtherconceptual work, modelling and more time prior to any public promotion by the alliance of the final measuresystem. Four, universal health service obligation: we note from Hansards record of your earlier public hearings thatthere is some enthusiasm for the notion of a universal health service obligation approach to the planning anddelivery of health services, described more colloquially as an agreed basket of services appropriate for differentcommunities. In our supplementary submission, we place on record the reasons why the alliance believe this to bean impractical approach. We seek an appropriate balance of local core services, supported by outreach, telehealthand patients travel assistance, but effective primary or community care services in rural and remote areas can andshould take many shapes. Fifth, health research: we have already made the point that there are data problems relating to your inquirysterms of reference. For instance, little is currently certain about the impact of the introduction of Medicare Localson the provision of health services. This weeks budget announcement about incentives for dentists to relocate torural and remote areas is very welcome, but little if anything is known about the specific issues which mightaffect the mobility of dentists, let alone retaining their services in rural and remote locations. The McKeon review will hopefully conclude, among other things, that there needs to be greater research efforton rural and remote aspects of the national health system and that it should include more upstream research on thesocial determinants of health and more downstream research on health service systems and approaches. As anation, we need it to apply an evidence base to choices made between policy options just as we have and need anevidence base on illness and disease. Six, relationship of your inquiry with other parliamentary and governmental activity—that is the heading. Iwant to make the point that the subject matter of this inquiry overlaps with a number of other pieces of workrecently completed or currently in train. In particular, the recommendation from your colleagues in the otherplace, relating to overseas trained doctors, should be integrated with your own considerations. The Department of Health and Ageing is beginning another review of its workforce programs. HealthWorkforce Australia is engaged, as you know, on a number of fronts that are relevant to your inquiry. Thealliance for which we work has a considerable number of relevant documents about these matters on its website. Ithink that is the point where I should apologise, possibly to your secretariat, for the weight of our submission,because we provided a great deal of documentation for your inquiry but that reflects only the fact that, as I havesaid, it is core business for the alliance. CHAIR: I should say that our committee gets a lot of documentation, so we have pretty high benchmarks forweight of documentation. Mr Gregory: Thank you so much. That is splendid. As to the 20 steps to equal health—this is in summary andthe detail of these points is in the supplementary submission which we tabled—the 20 points are: (1) getting morerural students into health professions; (2) getting more health students to undertake rural placements while intraining; (3) getting more Aboriginal and Torres Strait Islander people into the health workforce; (4) ensuringpositive modelling and leadership on rural practice for tertiary students; (5) promoting knowledge of the various COMMUNITY AFFAIRS REFERENCES COMMITTEE
  • 29. Friday, 11 May 2012 Senate Page 25rural incentives available, and of the positive elements of rural practice, to late-year undergraduates and newgraduates; (6) creating a greater proportion of supported placements for new health graduates that can beundertaken in rural and remote areas; (7) increasing the proportion of vocational training for health professionalsthat is undertaken in rural and remote areas; (8) enhancing the capacity of existing practitioners in rural areas toaccommodate, mentor and supervise new graduates and vocational trainees; (9) extending the coverage ofuniversity departments of rural health; (10) balancing incentives for health professionals to train for generalistrather than specialist practice; (11) targeted infrastructure and human resources programs to maximise theopportunities for use of information technology in health, including as back-up to training and mentoring ofhealth professionals in rural areas; (12) enhanced support for the role and capacity of rural workforce agencies;(13) national leadership on work to ensure health practitioners are able to work collaboratively and maximizetheir individual contributions within their full scope of practice; (14) refurbishment of the whole recruitment andretention program for health professionals to ensure its effectiveness for places in particular need and for the newgeneration of practitioners; (15) ensuring that the funding and governance of Medicare Locals equips them fortheir role in the identification of service gaps and provides them with the wherewithal to fill those gaps; (16)greater involvement of governments in special cost-sharing arrangements for salaried staff in areas of veryparticular need; (17) working with professional colleges to ensure that mature-age clinicians willing to work part-time as mentors and preceptors are able to do so; (18) improvement of national data collection and analyses; (19)increased emphasis on health service system research for rural and remote areas; and (20) continued nationalcommitment to building universal schemes for dental care and disability. Senator DI NATALE: I am interested in the Medicare Locals issue, just following on from Senator Moore,because I know there is some concern from the Rural Doctors that the Medicare Locals might act as fund holdersand regarding the role of GPs on the boards and so on. They have expressed a number of concerns aroundMedicare Locals regarding accountability and so on. What is the alliances view of the potential for MedicareLocals in regional Australia? Mr Gregory: There are, as we said, major expectations of them, but we believe that they are real, they arewith us, they are happening, and we should be taking every opportunity to make it work in rural areas. There are alot of issues—not only those you have identified which come particularly from the doctors. There are issuesrelating to size, for instance. The whole of the north of Western Australia is one Medicare Local, as you know,and the whole of Tasmania is one. There are lots of issues but we, the alliance, take the view that this is, if youlike, the focal point now of all the effort that has been put into health reform over the last three to five years andwe want to make every effort to make it work best for people in rural and remote areas. We had a workshop abouttwo weeks ago jointly with the Australian Healthcare and Hospitals Association on this very subject, and I wouldcommend to you the report from that workshop, which will be out in a week or two. Ms Handley: It was also a wonderful opportunity that we have not had before for some cross-border issues tobe resolved. For instance, Finley, Jerilderie, Berrigan and Tocumwal are in one Medicare Local that is sharedwith and feeding through Goulburn Valley Health, and that has always been the natural flow. It has always gonesouth. So even though Berrigan, Finley, Tocumwal, Jerilderie and, to a point, Urana and Deniliquin were feedinghospitals geographically when they were Greater Southern or Murrumbidgee, or whatever we were last, the givenhospitals were Griffith and Wagga, but neither the ambulances nor the patients wanted to go there, so the generalflow was south. That is a real opportunity around this cross-border— Mr Gregory: So it is across the river. You get the point, I am sure. They go to Victoria. Senator DI NATALE: Yes, it is a very frustrating situation. Mrs Hopkins: And, more generally, it is just to get that involvement of local people in what local healthservice needs are and what the solutions might be so that they will work. Senator DI NATALE: Do you have concerns about them essentially becoming just rebranded divisions ofgeneral practice? Mr Gregory: We trust they will not, because the very essence of their success will be that they are muchbroader than general practice. That is one of the main challenges, as you perhaps indicated through your question.We have to make this work. We are concerned, I think, about high order issues like the relationship betweenMedicare Locals and local hospital networks in rural areas. It seemed to us initially to be a bit strange toinstitutionalise the difference between acute care and primary care given that, especially in more remote areas,you have the same clinicians working in both sectors. But we accept the logic that it is to make sure that thehospitals do not gobble up all the resources—put crudely. Senator DI NATALE: You mentioned in point No. 20 you are committed to universal dental care. COMMUNITY AFFAIRS REFERENCES COMMITTEE
  • 30. Page 26 Senate Friday, 11 May 2012 Mr Gregory: Yes. Senator DI NATALE: I am very pleased to see that as one of your recommendations. Recently a package ofmeasures was announced, one of which included some relocation grants. I think the target was 300 dentists toregional Australia. Is there anything else you think could be done as a short-term measure to increase the numberof dentists to regional Australia? I think the obvious immediate policy lever is incentive payments. Is thereanything else that could have been included as part of that? Ms Handley: It is very expensive equipment. I will go back to the example of Berrigan. There is a publichealth dentist there for, I think, one day a month, and they are always booked out years in advance. The dentistthere said to me that he would be much better off having a mobile van and moving around, like the old schoolprogram did, to give more people access and not duplicate the very expensive tools of trade that they have. Mr Gregory: As well, we see no reason why HECS reimbursement should not be available to students ofdentistry, and indeed allied health and nursing, as well as medicine. Senator NASH: Just on Medicare Locals, the Rural Doctors Association raised in their submission—and wedid not have a chance to ask about this—that the incentive payment available in the PIP After Hours Incentivewill now be redirected through Medicare Locals. They had some concerns about Medicare Locals administeringthe funding. Is that a concern that you share or are you comfortable with the fact that administration of thefunding will now go through Medicare Locals? Mr Gregory: Our broad view is that, given one of the key expectations of Medicare Locals is that they willidentify gaps in service and then move on to fill by whatever means there is, the alliance broadly approves of thepossibility that funds might be held by Medicare Locals in some circumstances. As you can tell, I am being fairlynuanced because the organisation you mentioned is one of the member bodies in the alliance. If we are seriousabout Medicare Locals, as I hope we are about Medicare Locals identifying gaps in service and filling them, Iwould have thought the health consumer would be pleased if that is done by whatever means, irrespective of whoholds the funds, where they come from, how they flow. Lets meet the need. As Helen said, lets identify the localneed and meet it by whatever means. Senator NASH: Would it be fair to say that for Medicare Locals at the moment there is a lack of a clearpicture? With the questions we have asked in the past there has been a lack of a clear picture of exactly how theyare going to work. If it all goes well, it is going to be terrific; but there is a possibility that it may go pear shapedand will not be as good as it possibly could be, and that we are all just hoping it will work really well. Ms Handley: One of the biggest things that one particular person and one doctor brought up was that we havejust disbanded 15 or 20 years of goodwill between the divisions of general practice, so if it does not work it isgoing to be bigger than Ben Hur. Senator NASH: It is high risk, really, isnt it? Ms Handley: It is very high risk. The other thing is that if you talk to the different members on the boards ofdifferent Medicare Locals and ask them questions, the actual make-up and the set-up of how they are organised isvery different. There does not seem to be a uniform scaffolding that everybody sits on. To me, that is the mostworrying thing. Mr Gregory: I think it is likely in five years time when we look across the Medicare Locals that we will findthere is just the range of effectiveness and noneffectiveness, as there was with the divisions. With the divisions ofgeneral practice, some of them were good and some of them were not so good. Some of them were not so good atall. Senator NASH: Does that lack of a template, for want of a better word, give too much autonomy to theMedicare Locals to set things up and run things how they want or would that have a benefit in giving them a bit ofa blank page to have a look locally at what needs to be done and purpose build that for themselves? Ms Handley: I think it all depends on what sort of information there is. I have had a lot of GPs ask me what Iknow about the Medicare Locals. For instance, at the moment they might have a diabetes nurse in their clinic whois the only one in the town. Will they lose that person and have that resource taken away from them because thisis a more attractive thing that is going on than in the GP clinic? If we have only a given number ofphysiotherapists, allied health people, psychologists et cetera, are they all now going to be torn between too manyplaces? That is also a fear of GPs—the competition to attract what you need. Mrs Hopkins: One of the principles that we had in developing Medicare Locals was that it would be veryimportant that they nurtured the people who were already on the ground and worked with them to developsolutions that would keep as many people involved as possible. With the gap in information about how it is all COMMUNITY AFFAIRS REFERENCES COMMITTEE
  • 31. Friday, 11 May 2012 Senate Page 27going to unfold it is a nervous time. We, the alliance, are also looking to see how we can play a part with theMedicare Locals, particularly those which might encompass quite large rural areas as well as the city areas, towork out that balance. One reassuring thing is that we will have the healthy communities reports starting to giveus some transparency about how it is all unfolding on the ground, remembering that it is a work in progress andthat we will have opportunities to come back and say, This is not working; we need different solutions. Senator MOORE: Ms Handley, I do not understand your last point. If you have a diabetes nurse or apsychologist already in a region, why would a Medicare Locals process make that worse? Ms Handley: This is just feeding off what the GPs have said to me. If in the gap analysis it was decided thatyou needed this particular service around psychology or diabetes management and that service was put outside ofthe GP practice where it is located now and that was the only person in the region would they be losing all thegains they have made by incorporating that person into their primary health care to another part of anorganisation? Senator MOORE: I do not think there is any ability within Medicare Locals to take resources and movethem. Ms Handley: But the GPs do not understand that. Senator MOORE: A Medicare Local is looking at identifying gaps and what is needed to fill those gaps. Ifthey are saying, We have a diabetes nurse in our practice and someone is going to take that diabetes nurse out ofour practice and give it to somewhere else, there is no power for that. Ms Handley: No, there is not, but these are the conversations they are having. That is how much lack ofunderstanding is out there because of the way perhaps in particular areas it is being delivered to them as GPs. Theconcepts, formats or understanding of the education around what is happening now that the divisions of generalpractice— Senator MOORE: So it is the communication process? Ms Handley: Yes, it is a communication problem. Senator MOORE: So it is a build-up of fear about, What am I going to lose? Ms Handley: Yes. Senator MOORE: I am very interested in the issue of the ASGC. Are any of you aware of any model that hasever worked in this area of how you define need and remoteness? Mr Gregory: No, but we, the alliance, think that it should be agreed that the current system on its own doesnot work and that we should move on and build a new one. You have heard from RDAA that they support theJohn Humphreys model. What we are proposing is very close to that. Senator MOORE: So yours is very close to that of Mr Humphreys? You are not going off on a different— Mr Gregory: No. Senator MOORE: Okay. Good. Mr Gregory: We have ASGC-RA and population size of the place, which is basically what John Humphreyshas got, and then we are adding a third one which is a proxy for whatever it is that makes a particular placeattractive or not attractive, because it is a measure of how they have done historically. Senator MOORE: Cairns versus Gundagai? Mr Gregory: You would look at the evidence for Cairns and Gundagais respective success over the last—choose a number—15 years, and that would necessarily, almost by definition, be a proxy for everything thatmakes Cairns and Gundagai differentially attractive. So we have this consolidated thing which we think couldapply to the measurement of the need for doctors or, indeed, potentially any other health professional if you havethe data. Senator MOORE: It is in terms of the need for everything, which is important. Do you think that can work?We were talking about stats earlier this morning. It was about trying to find out whether you can combinedifferent datasets to come up with an outcome. It seems to me that you should be able to. Do you think that, withthe range of knowledge you have and with all the component membership which covers everybody in this field, itcould work? Mr Gregory: We have drafted a look-up sheet, which would be the equivalent thing to what is currently onDoctor Connect. It would enable you to look up your place and, according to the three criteria that I mentioned,you would get a ranking and a weighting. It is entirely possible—of course it is. COMMUNITY AFFAIRS REFERENCES COMMITTEE
  • 32. Page 28 Senate Friday, 11 May 2012 Senator MOORE: As we saw with RRMA, there was always a place that was on the border. With yourproposal, would there also be those places that are just on the border of being able to be defined in the way theywant to be defined? Mr Gregory: I am sure there would theoretically still be border issues but not so much, because we aretalking about a discrete place. The border issues would relate to Gundagais shire bordering on— Senator MOORE: I am not talking about a physical border. I am desperately trying to remember one thatMichael Forshaw used to come to every estimates with. It was somewhere in New South Wales. This was acommunity that, under RRMA, just missed out. The world was going to end because this community did not fitthe RRMA qualifications, and it was probably true. Under your process, because you are setting a defined area,there still could be a place that misses out? Mr Gregory: Yes—border issues. Mrs Hopkins: I think that the addition of the historical ability to maintain an appropriate workforce helps torationalise that. It helps peoples understanding because it means that there is a little bit of flexibility built into itso that you can make a case for a changing situation and a little stability built into it so that it does not change theday you appoint somebody. We think there are some possibilities to make it all seem more rational to those whoare at borders. CHAIR: What you are saying is that you would build into the criteria something that has a bit more flexibilityto deal with the outliers? Is that what I understand you to be saying? If you have a border issue, you could look atthat particular criterion and say, When you look at it in this light, there is actually an issue here and it should infact be in that classification? Is that what you are saying? Mr Gregory: As your Senate colleague said, there are always going to be border issues. Lets say you haveDubbo there and you draw some lines—whether that is Dubbo City or Dubbo shire; I have no idea—but outsidethat will be some other shire and the definition of need for that other place will be done according to its ASGC, itspopulation size and its history, and the definition of need in Dubbo will be done according to those three criteriafor Dubbo. On the boundary between those two places you have somebody on this side and somebody on thatside. Border issues will necessarily relate to any geographic system such as this. Senator MOORE: There has to be flexibility. Now it is: you are either in or out. Senator NASH: There should be some sort of process of appeal for border issues. CHAIR: Yes. Then you would have a degree of flexibility and you could say, We could reassess thisparticular situation. Mr Gregory: But we believe there should not be as much flexibility as there currently is in the area of needscheme, whereby it can be done, as we understand it, by a state minister at four oclock in the afternoon to make aparticular place an area of need. Senator MOORE: Or something could change, Mr Gregory! I mean, we heard in the previous evidence that adefinition for a region could change with one person no longer being available—that if you have it based on thenumbers of appropriate people being in a place, if you have someone who has the skills not being there, it couldchange overnight in terms of people who could go there. That is because we are working on such a very tightarea. Mr Gregory: I think it is worth highlighting what Helen said. If you have a place which is in need andtherefore has incentives, and somebody goes, you have this dynamic issue about whether this place is still deemedto be in need. Senator MOORE: That is right. If someone who is married turns up, there suddenly two people in the area. Interms of incentives, you have looked at a lot of them. Do you have anything that you think would be anappropriate range of incentives to encourage people in all medical professions? What would be an effectivemechanism to get people into rural areas? Mrs Hopkins: That is our 20 points. Mr Gregory: Yes, we have. We have gone to some lengths to talk about the various things which areresponsible for successful recruitment and retention. As you know, they relate to not only remuneration, but scopeof practice, family matters, education, infrastructure in the town—all these sorts of things. Senator MOORE: Housing. Mr Gregory: Yes. What we are suggesting is that the whole system should be what we call refurbished. Thatis for two reasons: firstly, because we are clearly not doing it right for those places where it is particularly hard to COMMUNITY AFFAIRS REFERENCES COMMITTEE
  • 33. Friday, 11 May 2012 Senate Page 29recruit to; and, secondly, because we have a new generation of health professionals. At the moment, we are usingsuch evidence as we have as to what it is that used to attract and retain the old cohort. We have got new people. Ido not know what generation they are—gen Y or something. So we need to look again at all the workforceprograms. But I think you are right in alluding to the fact that it is not just the professional things; it is the familythings, the business things, connectivity with broadband—everything. Ms Handley: It is working well somewhere though—the relationship that Monash-Churchill has withparticular hospitals in South Gippsland. David Eisner is a general procedural practitioner who does caesars and awhole gamut of things. He is one of the last of those great procedural GPs. Monash approached him before heretired and said, We need to make sure that youre sharing your skill with our students. So they deliberately got ascheme going down on the south coast, where the best of the procedural GPs take on fifth-year students, registrarsand other people. Some of them are overseas trained but most of them are straight out of the universities—and itdoes work well. He put in for a grant—I do not know whether he got it; I have not been in contact with him for 12months or so—to put in lecture theatres. Senator MOORE: In the regional centres? Ms Handley: No, in the actual GP clinic area, where he had three flats for the rotating students and a lecturetheatre. Senator MOORE: His proposal was to build a place like this? Ms Handley: Yes. Senator MOORE: I was thinking that, if he had one of those, we could go and look at it. Ms Handley: He did put in for a grant. It is all there. I do not know where he is up to with it. It is anexceptional program and it works really well. It is a town with fewer than 2,500 people. They have a visitingneurologist, obstetrician and gynaecologist. They do case managed birthing. They have caesar capability—planned and unplanned, low risk—and myriad other things. They have 10 part-time GPs—because they all havesuch fabulous lives— Senator MOORE: On the Gippsland coast. Ms Handley: Yes. Senator MOORE: Ms Handley, have you got any information you send us, or can you send us a link? Ms Handley: Sure. Senator MOORE: I do not think we have seen any submission that picks that up. One of the things we foundin our Queensland evidence was that kind of idea—that you would have someone with the skills who would thenwork with people in the region. They talked about accommodation. They also talked about appropriate trainingfacilities—because many of the surgeries did not have that. This seems to pick up on that. If you have got a linkwe could have, that would be fabulous. Ms Handley: Sure. I think that probably he would give me the whole document. CHAIR: That would be great. If you could send that through, that would be good. Mr Gregory: I want to commend to you our 20-point plan, because we have done some special work on this.In presenting evidence to you today, because you are meeting directly with several member bodies in the allianceyou know much better and more detail—as you have just seen from RDAA—we thought the alliances proper rolefor you today was to be strategic and talk about the things like research, which maybe our individual memberbodies would not want to. But then we realised in doing that we were missing the opportunity to synthesiseeverything we do. I say again, this is our absolutely central core business for the alliance: your terms of reference.We have put considerable effort since four oclock this morning into producing a brand new set of 20recommendations. So we have tried to sum up all of the positions the alliance has based on the views of 33national organisations. We have tried synthesise them in such a way as they are specific enough to be someonesresponsibility. They are not high-cost, but we are quite sure that if you were to recommend even half of these 20and half of that half were to be picked up, there would be significant progress made. I read 20 statements very,very quickly, but I would commend those 20 to your committee. Thank you. Senator MOORE: Shame we have not put cost input in this committee. Four oclock tomorrow morning,okay? Mrs Hopkins: It is what departments are for. COMMUNITY AFFAIRS REFERENCES COMMITTEE
  • 34. Page 30 Senate Friday, 11 May 2012 CHAIR: Yes. We know to ask the department that. Thank you very much. Your oral evidence, your writtenevidence and your supplementary submission are very valuable and the 20 points will be very useful for us.Thank you very much. Mr Gregory: Thanks so much. CHAIR: We will suspend and restart the hearing at 1:30, but do not forget we have a private meeting at 1:15. COMMUNITY AFFAIRS REFERENCES COMMITTEE
  • 35. Friday, 11 May 2012 Senate Page 31DOUCH, Dr Tom, General Practitioner, Young District Medical CentreKAY, Mr David, Practice Manager, Young District Medical CentreMEAGHER, Dr William, General Practitioner, Young District Medical CentreWALLACE, Dr Gilbert Hugh Murray, Private capacityEvidence from Dr Douch, Mr Kay and Dr Meagher was taken via teleconference—[13:39] CHAIR: Welcome. Do you have any comment to make on the capacity in which you appear before thecommittee? Dr Wallace: I am a general practitioner in the country and I am here to speak to you about encouragingdoctors to go to the country. Dr Douch: I am a GP-anaesthetist in Young. I would like to give a rural viewpoint, particularly with regard toprocedural doctors. CHAIR: I understand information on parliamentary privilege and the protections of witnesses and evidencehas been provided to you. We have your submissions, which are submission Nos. 23 and 37. Obviously, becauseyou are coming from different areas, you will all want to make opening statements. I will invite Dr Wallace to gofirst, then Mr Kay, Dr Meagher and finally Dr Douch, if you would like to make opening statements, and then wewill go to questions. Dr Wallace: I just want to make several points that I have made in the submission. Firstly, that I feel ourspecialist colleagues in the cities tend to regard those in country practices, both specialists and GPs, as inferior tothose who work in the cities. I offer a method of helping with that by sending the country people to find out thelatest in medical practice by working in the city for, say, two weeks twice a year, which is about what I have donein the past, arranging it myself. Secondly, another obstacle to country practice is the education of doctors children. I feel this is done better inQueensland than it is here. I do not think that children should go to a private school necessarily—which is whatyou might think from my submission—but if the education of the children were paid for, perhaps in a hostel neara good public school, it would be just as good. I think that is what happens in Queensland. Thirdly, another factorthat deters doctors from practising in the country is the feeling of inadequacy, particularly for women doctors,when they are faced with emergencies. That can be helped by what I have mentioned before—that is, by going tothe city frequently. There is one more point that I would make in regard to (c)(iii). Money is valuable, but it is not the main thing. Isuggest that the appropriateness of the delivery model which you are questioning is wrong. You should never tryto attract a person to a single doctor, or solo, practice. If a town is too small for two doctors, it is too small forany. People should not practise on their own. That is about all I had to say. Mr Kay: I will give the opening statement, if I may. Thank you for giving the practitioners equal opportunityto speak via teleconference. Unfortunately, they were unable to attend in person due to patient commitments, butDr Meagher and Dr Douch are here for the teleconference. The members of Young District Medical Centre believe that policy makers do not fully understand how themedical workforce in rural areas provides medical services to the community. Rural areas such as Young aresmaller country shires outside a city classification. The shire has approximately 13,000 people and is two hoursfrom any major base hospital: the nearest are Wagga, Bathurst, Orange and Canberra. Young has a strongeconomic foundation and is serviced by two medical practices, a district hospital, a rehabilitation facility and twoaged-care facilities. Young also services patients from the surrounding shires of Boorowa, Weddin and Harden.Many would say that Young is well serviced by medical professionals in comparison to a lot of rural areas. Today we hope to give you an insight into how medical practitioners provide medical services to theircommunities and show you what a fragile position those medical services are in—a view from the coalface, if youwill. We can only speak from own situation, but believe our experiences would be largely replicated for a numberof rural areas. The problems are real and need to be addressed now. We understand the necessity to plan for 2020and beyond, but there is a need to address the short-term position with immediate action. The biggest problem issustainability. Medical services in Young are accessed mostly by patients through local general practice, that is,private practice, the local hospital or community health. The question of who provides medical services at theselocations is paramount. At the core of health services in Young are the GP services provided by eight GPs andthree registrars. Young district hospital is currently serviced by four of the GPs, who undertake procedural work COMMUNITY AFFAIRS REFERENCES COMMITTEE
  • 36. Page 32 Senate Friday, 11 May 2012covering obstetrics, surgery, anaesthetics and emergency medicine. At one stage all of the eight GPs providedservices to the hospital, but as time has gone on only four remain. In addition to the GPs, Young hospital usespaid locums to cover emergencies, during business hours and at other times when one of the four GPs is notavailable. A second anaesthetic doctor is available to Young hospital under contract but does not provide anyother routine services. None of the three registrars, who are the future, provided from Coast City Country Ltdrural pathway training, provide services to the hospital. The question is: why? Our projections reveal that in five years only one or perhaps two GPs will be available for limited on-callhospital work. The implications are that the obstetrics service, currently delivering around 200 babies a year bynormal birth, assisted birthing or caesarean, will not be available to continue. This is at a time when the majorregional hospitals are also struggling to maintain services with ever-increasing demand. Bed block is quitecommon. With only one or two doctors, emergency coverage at Young hospital will be dependent entirely onlocum doctors. This would be extremely expensive compared to the current way of staffing. The factors affecting the supply of health services and medical professionals in rural areas that we wish to talkabout are: recognising the tension between providing patient care in rural hospitals and conducting a privatemedical practice, rural classifications such as the Australian Standard of Geographical Classification -Remoteness Area, training pathways supporting rural generalist training and proceduralist training, a moratoriumon overseas trained doctors, innovative practice ownership and management, incentives for rural doctors,specifically for those who provide hospital services, and mental health. Thank you for this opportunity. DrMeagher, Dr Douch and I will address your questions and are happy to expand on the above points. Senator NASH: Gentlemen, thank you very much for giving us your time today. This whole process isbecoming ever more useful. You mentioned at the outset, Mr Kay, the lack of understanding from the governmentand the department of how regional medicine works. Could you expand on what impact that is having and whatcould be done to try and resolve it. Senator MOORE: And is it longstanding? Mr Kay: Dr Meagher might be in the best position to answer that. Dr Meagher: The first is the demands on running a private practice and servicing the public through thehospital emergency services. I do not think the hospital services understand what is required to run a privatepractice. Our general practice is a private business. We run at only marginal profit here. We can give you figureson that later if you like. We have a minimum of 55 per cent running costs before the individual doctors look attheir own indemnity, their own running costs, equipment, superannuation and all of those things so it is only just aviable proposition. If we are not here working full time then it is not a viable proposition. The demands of the hospital for the four of us doing that work is not only aligned to the time that we are oncall for emergency or for obstetrics or for anaesthetics when we may get calls but also when we need to do roundsin the morning to follow-up patients. We can be up there for two to three hours in the morning. We receivenumerous phone calls during the day about patients who are in-patients, which disrupts the services here, and thenwe receive emergency calls during the day to assist Caesareans or emergency airways or anything during thattime. On weekends when we are second on call we cannot go away. This has big effects on spouses and families.All of these things interact. Doing one or either of those jobs would be easy but doing both is very difficult and isnot well remunerated. I think that is one of the main reasons why these young registrars will not take on bothopportunities to work at the hospital and in the private practice. It is not to say it is not rewarding. I think it is veryrewarding work but the stresses there probably far outweigh any remuneration or interest. Senator NASH: In essence, as a private entity you are also providing a public good. Dr Meagher: We do believe that we are. But at some stage there is a differential. We are running this practiceand the costs are ours. Senator NASH: Senator Moore just asked if that lack of understanding is long standing? Dr Meagher: Very much so it is long standing. It is a difficult thing. How do you look at it? Dr Douch cantalk about some innovative measures on how to reduce the cost of running the private practice—or what you sayis a semi public practice in lots of ways—but that is probably going to involve governments at federal, state andlocal level and perhaps the new Medicare Locals. We have been very disappointed with the support we have hadso far from Medicare Locals. Senator SIEWERT: Did you say disappointed? Dr Meagher: Yes, I said disappointed. COMMUNITY AFFAIRS REFERENCES COMMITTEE
  • 37. Friday, 11 May 2012 Senate Page 33 Senator NASH: What is the disappointment with Medicare Locals? We have had a bit of discussion aboutthis so we are interested in your viewpoint. Dr Meagher: Primarily their first interest was in after hours and we believed it. The health minister said thatshould be one of their first goals. Their interest in what they call after hours is supplying services. They said theywould pay for staff between five oclock in the evening and eight oclock in the evening and that is where themoney will go so that we can offer an after-hours service. To us that is more a convenience service. There are alsohospital staff working at that time. Really, the after hours that we need help with is the 24-hours a day,particularly those antisocial hours. Senator NASH: That is a very good point. You said also that only four of the doctors remain in the practicethat are providing the service to the hospital. Why is that? Why is there a decrease? Dr Meagher: I think there is burnout from the overwork—the stress of trying to run the two jobs. With theregistrars that are coming in, it is probably because of a lack of training in procedural skills. That is why wewould be behind any support for the advanced rural training program. Again, that is probably a long-term thing,and our issue is how we are going to sustain the infrastructure and keep what we have going until some of theseproposals come through. Senator NASH: In terms of the proceduralist GPs, what do you see as the barriers? This has come up quitesignificantly as a path we need to go down. We need GPs who can actually do these procedures, but the trend isgoing in the other direction. What are the barriers to having the proceduralist GPs? Are they things like indemnityfor GP obstetricians? I am trying to get a sense for the committee of the barriers that are in place to stop us gettingGPs who perform myriad functions. Dr Douch: There are probably a few barriers. The first one might be a traditional barrier. A lot of theprocedural training appears to have been an add-on to training GPs. If you take my own case, I was a littleunusual in that I did my anaesthetics training before going out into rural GP practice, so I arrived skilled andtrained to perform an anaesthetic. The usual routine in the past was to make that procedural training occurred atthe end of your time. It meant that you were getting GP trainees moving out to the country who had no proceduralskills. They were more or less committing to a line of work and a pathway of development, with familycircumstances et cetera. To pick up and leave all that to go back and do procedural training was difficult. The other point that we are really trying to stress is as follows. If you are going to undertake proceduraltraining, which we see as critical for any rural practitioner, it means that you work at the hospital. You then feelthe tension between providing essentially a public service and conducting a private business. We see that as a bigturn-off, if you will, for new people coming through. We see a light on the hill with the ideas being pushed aboutgeneralist pathway training—training people in a more fulsome sense for practice in the country. That wouldincorporate, I would expect, some form of procedural training rather than having it as an add-on. That may be ahope for the future but, as Dr Meagher pointed out, that will be a long-term solution rather than a short-termsolution. Senator NASH: Are you aware, in Young or any other rural towns, of a GP who wanted visiting rights to thehospital but was denied? Dr Douch: No, I am not aware of anything like that. Dr Wallace: That was in Cooma, and I probably did not say that I was from Cooma. I spent most of myworking life in Cooma, but in order to practise in the country, which I always wanted to do, I had to be au faitwith obstetric emergencies. That is why I have a fellowship of the College of Obstetricians and Gynaecologists.The person who was not allowed to go to the hospital was in Cooma. Cooma has been popular with doctors fromthe time I have been there because it is quite an unusual place and it is quite close to Canberra, but there were justtoo many. As I said in my submission, I think obstetrics should be reserved for big hospitals. I would muchsooner see the money spent on obstetrics in hospitals near large hospitals. Obstetrics has become so complicatedlately and it is so open to suing and so forth that I think it should be done in the best places if at all possible,although I do think that doctors in isolated places ought to be able to do a normal confinement. Senator NASH: You raise a very interesting point. My mother was a GP for 50 years and she used to say that90 per cent of obstetrics was easy and the other 10 per cent was very, very complicated. I think when you put theoverlay of rural onto that, it is a very interesting point you raise. Thank you for your submission, you raise somereally good points, Dr Wallace. I am also very interested in your second point about the education of children. Myother hat is the shadow parl sec for regional education. The marrying the sustainability of rural communities—there is a whole range of things from health and education. So if this sort of model was set up, would you see itbreaking down a real barrier for some doctors— COMMUNITY AFFAIRS REFERENCES COMMITTEE
  • 38. Page 34 Senate Friday, 11 May 2012 Dr Wallace: Yes. Senator NASH: if there was assistance in some way, shape or form for that education for children of medicosmoving out to the bush? Dr Wallace: I think it is now generally realised the latest work on children in teaching that I have read is thatbrilliant children are stimulated children. There is no question. We have several years where they are brilliant andyears where they are not. I went to a private school but I do not think there was any reason. If I had my way, theywould not receive any subsidy at all. I, for instance, would have done just as well at North Sydney Boys HighSchool, which you will note in the Australian is the second-best school. Senator MOORE: You picked a good one; it is a very good one. Dr Wallace: I passed for that school. It was the cleverer ones went to high school, whereas I went to Shore,which I never really fitted in with, I think. I think I would have done just as well. I would like to see a hospitalnear a good school for those children who want stimulation from each other. Senator NASH: That is a very interesting point. Senator MOORE: Dr Wallace, I will start with you. The same questions—any one can jump in as well. DrWallaces submission, his first point is about training and professional development. Would that be right? Dr Wallace: Yes. Senator MOORE: Your suggestion is there needs to be some exchange and ongoing training for doctors whoare working in rural areas. Dr Wallace: Yes. Senator MOORE: You suggest it through exchange and you said that you have actually arranged that foryourself. Did you get any support to do that? Dr Wallace: No. Senator MOORE: So you had to find a place? Dr Wallace: I practised in Cooma most of my life, as I have said but I am now working part time in Bombala,which is rather more isolated than in Cooma. Yes, I had to pay for it. I had to pay $2,000, for instance, when I wasgoing to work in Port Hedland to do ultrasound—this was at Canberra Hospital. It was a matter of taking a locumin England. I would get up to the point. I had to arrange another one to look after premature babies—that wasdone in Canberra. Again, there was no subsidy for it. Senator MOORE: There seems to be a focus on the work that is being looked at now of taking people fromthe city to regional and rural areas. I am interested whether anyone wants to say something about the point DrWallace has made about that needs to be a bit of a two-way street that people who are currently workingregionally may benefit from some process of having further training in larger areas, be they major cities. DrDouch or Dr Meagher, do you have any view on that? Dr Douch: Yes, we like to make a point about that. While we respect the view that has just been made,training is always an issue. It is always a challenge, but there are a lot of opportunities these days. For example,registered proceduralists get financial support to travel to accredited training on various things, includingultrasound. So there are some attempts being made at that. The difficulty is that you have got a time absence— Senator MOORE: From your own practice. Dr Douch: time away with your other associates so that the practice is not left short. That is the challenge. Wealso have had in the past a reasonably good number of specialists visiting from major centres to update us, as DrWallace suggests. In fact, this afternoon one of our colleagues is in Canberra learning how to undertakecaesareans as part of our plan for the future. She is doing that at time to the practice and so on. We do undertakethose things but we think that the real message here is not that there is a lack of training. There may be a possiblyto enhance it to a degree, but there are good programs in place at the moment for people who are registered asprocedural. The challenge is to get more people trained as procedural so they can partake in those programs. Senator MOORE: I have a follow-up question from what you were saying in your answers to Senator Nash.Dr Wallace, you can jump in as well if you want. There is a tension when you are working in the kinds of citiesyou are working in, where you have a hospital and the expectation of servicing. My understanding is that up untilrecently, anyway, the Medicare component operated in your private practice, but when you were doing work atthe hospital it became a state government process. Is that right? Dr Douch: Yes. COMMUNITY AFFAIRS REFERENCES COMMITTEE
  • 39. Friday, 11 May 2012 Senate Page 35 Senator MOORE: I will have to check with the department, but my understanding of the health reforms isthat that may be changing. Is that what you think? Dr Douch: There is certainly some investigation going on by the local health and hospital district at themoment into the role Medicare can play in smaller hospitals. There are rules and regulations, of course, and theyare being looked at in our area. The point that we are trying to make here is that we are paid when we go up to thehospital, but often the type of service that you provide is lengthy, for which the remuneration is not particularlygood— Senator MOORE: It does not match. Dr Douch: in terms of the expenditures and costs you are incurring keeping your practice open while you areaway. For example, I am on call for anaesthetics at the moment. I am fully booked out this week and at the dropof a hat I could be called up there to provide an emergency airway, which has happened in the past. Thatimmediately means that my patients have to be rebooked. My waiting list at the moment is something like four tosix weeks out, depending upon the urgency. So you can see the compounding effect not only on the conduct of thebusiness but on, I guess you could say, customer satisfaction with the service that we try to provide. Although Ithink most people in town do recognise the stresses and strains, at any given time there are a number of peoplewho are dissatisfied with their ability to access immediate medical review. Senator MOORE: This is in a town which you describe from the outside as one that looks pretty wellserviced. Dr Douch: Yes. Senator MOORE: Senator Nash would be able to name many in New South Wales which I do not know thatwould not have the same number. Dr Douch: I suspect that we are representative. If you look at us today, we do look all right. But, as theopening statement said, if you look ahead five years there is no-one coming through. Senator MOORE: Dr Wallace, do you have the same experience with providing services to hospitals? I wasjust wondering because of your background. Dr Wallace: I would disagree a little bit. I suppose I am retired, but I think I am quite well paid in Bombala. Itis nice to get a cheque when you do not expect it. I do three nights. Nobody will do nights, but I do not minddoing nights. Senator MOORE: This is the extra hours process? Dr Wallace: Yes. Dr Meagher: I want to make one comment, to go back to what Dr Wallace said about obstetrics services. Ihope he is not talking about not offering obstetrics services in a town this size. I think one of the reasons we arehere is that we believe that rural people deserve comparable services to city people. Two hundred deliveries herea year means 200 women who should not be going elsewhere if we can give them a good, comparable servicewith good backup. I think that that is a really important issue. I do not think we should be looking at sending thesesorts of things away when people can be trained to provide these services. What we have to look at is getting theright training initially, and then you have your ongoing training. We need to make sure that the incentives to getpeople to the bush are there. Senator MOORE: That is one of the strongest messages we get. That is the message I get in Queensland.Regional communities have hospitals that used to provide obstetric services but now, because of the concernabout appropriate training and fear of being sued, no longer offer obstetrics. So women are leaving their hometowns to go hundreds of kilometres away to have their children. It could be the fourth generation from a town andthe first generation of kids not to be born at home. It is extraordinarily painful and it is all over the state. So it is abig issue. In fact, Dr Wallace—I will say it because we have raised it—you are the first witness we have had whohas reinforced the point that some of the governments have made. We have taken your evidence because you gaveyour reasons for it—the complexities of some births and the possibility of legal action. Senator NASH: If I could add to that, the point that Dr Wallace makes is also valid. It is great if everything isgoing well, but for those women who have no choice, where the level is not as high as it needs to be and theyhave to go away, there is no support when they go. I think that is the point Dr Wallace is making. When you haveto leave, there is no support. CHAIR: Dr Wallace was just about to speak. Dr Wallace : There is another point: the high caesarean rate. There are two obstetricians in Canberra who aretrying to bring it down believe it or not by knowing exactly where a babys head is. There are many caesarean COMMUNITY AFFAIRS REFERENCES COMMITTEE
  • 40. Page 36 Senate Friday, 11 May 2012sections that are done because of transverse arrest where the babys head does not rotate. It takes a lot of skill tolearn how to do that. Not only does it take a lot to learn but to practice it all the time. They are making sure theywill get the patients where they can do the manual rotation or whatever they are doing. There are instruments todo it with, and you have to have constant practice at it, otherwise you do a caesarean section. We are just nowrealising the complications following caesarean section. They are more likely to have a placenta praevia—that isdown below—and a placenta praevia accreta, which is a very difficult thing when the placenta will not comeaway and is more common after caesarean section. Caesarean sections should be reduced. They are attempting todo this. It is something I suppose I was good at and I had plenty of practice at it. I would like to see normaldeliveries done or let s say, not quite normal but with a little help. Senator MOORE: I do not know which one of you was trying to speak. CHAIR: Whoever was trying to speak before—do you want to go now? Dr Meagher: There was a question earlier about indemnity and whether that was a threat. For obstetrics in ouremergency services in New South Wales rural hospitals, if we wish, most of us are covered by, the TreasuryManagement Fund at a state level so that is not a big issue at stopping people from practising. Dr Wallace : I would say a point there if I may: you would still get sued and to be sued is really a terriblething. I have only been sued once and that was enough. If you are associated with somebody suing, you will befeeling just the same—completely lost. CHAIR: I have one question, which could take us the rest of the afternoon. It is about the ASGC-RA. Couldyou just give us some thoughts on what you think of the effectiveness of the current system. Also there are lotsand lots of people who have recommended changes, and we have been discussing this morning whether we havethe data and how you could use the various sets of data to make the system more flexible and have betteroutcomes. Have you got some thoughts—I am sure you have? Mr Kay: Our experience has been that the overseas trained doctors—they are the usual applicants—becauseof the provider number moratorium and the need to obtain a section 19ab from the Department of Health andAgeing, they prefer to go to the larger towns. They seem to be very interested in the monetary assistance that isavailable through things like a classification. They nearly always have families in capital cities and they do notreally have interest in working on the hospital rosters as they return to their families on the weekends. You haveprobably already got all the information about Townsville, Cairns, Wagga and Bathurst and how they are biggercentres. We have got to have some sort of competitive edge to compete against those bigger cities, because that iswhere the registrars and overseas trained doctors are dragged to. Dr Douch just wanted to say something also. Dr Douch: In effect Senators, we are classified the same as Wagga and Townsville, and it does not makesense. We have scratched our heads about it here, because we would not want to give the impression that all wedo is whinge. We are trying to find a solution. Senator NASH: Not for a second! Dr Douch: We did wonder whether one of the ways to look at this is that, certainly, you need to recognisegeographical factors, where places are located, but perhaps also some of the functional factors that occur withinthose areas. Again, with our core idea of trying to create a sustainable system in terms of procedural doctors out inthe bush, you might say that a place like Young, for example, is a classification of RA2 geographically but thatthere are various individuals within that town who deserve a different classification because of their function.They provide more than just in-private-rooms practise; they also provide hospital services and more advancedservices. Some sort of combined model might be worth looking at and certainly has attracted some favourablecomment amongst the colleagues down here. CHAIR: Thank you. Dr Wallace, did you want to add anything to that? Dr Wallace: No, I do not think I could. That was very good. I have found that I am just amazed at the number,for instance, of Egyptian doctors around Wagga Wagga. There are a large number and I do not think they areadequately trained. Perhaps that should not be taken down. CHAIR: It has been already, sorry. Dr Wallace: I worked in Tumbarumba for a while and I had to correct several treatments that could have beenserious. Senator MOORE: I have one question to the practice at Young. Do you have practice nurses or specialistnurses who are linked to your practice? Dr Douch: This is one of the areas we would like to see pursued. It is one of the areas we think is badly done.We talked about innovate practice management. We did have a nurse incentive payment for several Medicare COMMUNITY AFFAIRS REFERENCES COMMITTEE
  • 41. Friday, 11 May 2012 Senate Page 37items that was taken away recently by the government in favour of a lump sum payment. We think it is the wrongapproach. What we need to be able to do is utilise our nurses more fully. We have some excellent nurses here whoclinically are very well trained and who could operate independently but within the network of the practice. Weare talking about things such as aged care, outreach services, follow-up care and so on. You could name a wholerange of things, but rather than operating as independent nurse practitioners in their own practice, if they operateas part of our practice, where we can use them in a more independent fashion for which they get a Medicarerebate, then that would allow good continuity of care and would take away the current requirement for doctors tohave to face-to-face every patient who comes through in order to attract a Medicare payment. I think it wouldallow a better utilisation of trained clinicians and a better prioritisation of who sees the doctor versus who needsto see someone else for other sorts of services. So we need to look at the use of practice nurses far more closelybut steer clear of the idea of independent nurse practitioners. We do not support that because we feel that isleading towards fractured care rather than continuity of care. Senator MOORE: Do you now have nurses on staff within your practice? Dr Douch: We do. We have three registered nurses and two enrolled nurses. Our three registered nurses arevery, very experienced and, if given the go ahead, I could use them in a very full way tomorrow. But at themoment my hands are basically restricted by the Medicare rules. Senator MOORE: Thank you. CHAIR: Thank you all very much. COMMUNITY AFFAIRS REFERENCES COMMITTEE
  • 42. Page 38 Senate Friday, 11 May 2012FRANCIS, Professor Karen, Chair, Rural Nursing and Midwifery Faculty, Royal College of NursingMcLAUGHLIN, Ms Kathleen, Deputy CEO, Director, Operations and Professional Services, Royal Collegeof NursingMILLS, Dr Jane, Advisory Committee Member, Rural Nursing and Midwifery Faculty, Royal College ofNursingMALONE, Ms Gerardine, National Coordinator of Professional Services, CRANAplus[14:18] CHAIR: I welcome representatives of the Royal College of Nursing and CRANAplus. CHAIR: I understand you have all had information on parliamentary privilege and the protection of witnessesand evidence. Is there anything you would like to add about the capacity in which you appear today? Prof. Francis: I am Professor of Nursing at Charles Sturt University, and I am here in my capacity as chair ofthe Royal College of Nursing Australia Rural Nursing and Midwifery Faculty. Ms Mills: I am here as deputy chair of the Rural Nursing and Midwifery Faculty of the RCNA. Ms Malone: I am here representing CRANAplus and I am the national coordinator of professional services,based here in Canberra. CHAIR: We have your submissions, numbered 82 and 26. I would like to invite whoever wants to to make anopening statement and then we will ask you some questions. Prof. Francis: Thank you for allowing us to speak. Speaking from a professional nursing perspective in thisopening statement I will summarise the issues that we would like to emphasise to the committee in relation tofactors affecting the supply of health services in rural areas. There are professional, social and economic as wellas health system factors limiting the supply of health services and nursing and midwifery professionals to smallregional communities. These limiting factors are interconnected and there is no single solution to overcomingthem. The Royal College of Nursing Australia strongly argues that a comprehensive and overarching framework, inthe form of a national nursing and midwifery workforce strategy, must be in place to steer the future direction ofthe professions and to ensure the supply of nurses and midwives into the future. As the peak representative bodyfor nurses and midwives working and living in rural areas, RCNA is continually advised that the rural nursing andmidwifery workforces are under great pressure in the professional environment and also experience many socialand economic challenges. Looking first at the overarching professional issues, there are now mandatory national registrationrequirements for demonstrating recency of practice and for maintaining continuing professional development,which of course we support. Meeting these requirements, however, is proving to be a significant challenge formany rural nurses and midwives. Poor access to continuing professional development programs and limitedopportunities to obtain adequate and timely leave from employment, as well as financial and social barriers, aremajor concerns for the development and retention of the nurse and midwifery workforces in rural areas. Of particular concern is the supply of dual registrants—that is, registered nurses who are also registeredmidwives. It is becoming increasingly difficult for dual registrants to maintain recency of practice specifically inmidwifery. Due to low population demand for maternity services in some health services, dual registrants in thesefacilities are facing serious obstacles to accruing the requisite clinical practice hours to comply with the recencyof practice standards. This presents a risk to the supply of midwives in rural areas and to maternity services ingeneral. RCNA highlights that there are few career or financial incentives to attract and retain rural nurses andmidwives. There is no structured career pathway for rural nurses and midwives to aspire to, and no nationalfinancial incentive schemes to attract the best possible workforce to smaller regional communities. In relation tothis, RCNA notes the great inequities between the level of national investment in the development of the ruralmedical workforce and that in the nursing and midwifery workforces. Given that we represent 60 per cent of theworkforce, I think those inequities are not sustainable and should not be sustained. These professional challenges are compounded by social and economic circumstances in rural areas. Otherinhibitors to nurse and midwifery workforce development and effective supply include isolation, financialpressure, limited family supports and/or employment opportunities for partners, difficulties in transportation and alack of access to technology. Inadequate professional development opportunities and supports also present COMMUNITY AFFAIRS REFERENCES COMMITTEE
  • 43. Friday, 11 May 2012 Senate Page 39challenges. We would like to highlight our concerns that the recently released Health Workforce Australia report,Health Workforce 2025: doctors, nurses and midwives, does not adequately examine current and future risks tothe sustainability of the rural nurse and midwifery workforces. Given the information in this report will informand underpin planning for our future workforces, it is important we note that the future geographic spread anddistribution of the workforces need further analysis. It will be important to explore the potential impact onworkforce geographic spread should shortages in metropolitan areas result in a workforce drain from rural areas.It is foreseeable that metropolitan nurse workforce attraction strategies could in future draw nurses out of smallerregional communities, thus increasing the workforce shortfall. This is particularly pertinent given that the nurseand midwifery workforces in rural areas are ageing and that comprehensive analysis of the skill mix of theemerging workforce is currently not available. Turning now to health service delivery, flexible funding arrangements are required to improve the supply ofhealth services in rural areas to give the community easier and greater access to a range of healthcareprofessionals. The decision to provide nurse practitioners and eligible midwives access to the Medicare BenefitsSchedule and the Pharmaceutical Benefits Scheme has been a strong step in this direction but does not go farenough. These MBS and PBS arrangements for nurses and midwives should not be limited by regulations that tienurses and midwives to medical practitioners or any other unnecessary restrictions that potentially limit publicaccess to their services, particularly in rural areas. In relation to Medicare Locals, it is acknowledged that their introduction is at various levels of implementation.At this point it is too early to determine the effect they will have on the provision of health services in rural areas.RCNA continues to endorse Medicare Local partnerships, inclusive membership and skill based corporategovernance arrangements and engagement with health service users. Achieving the goals of improving Australiasprimary healthcare infrastructure and better integrating service delivery requires broad engagement with healthprofessionals working in the sector. Given the centrality and potential of nurses within primary health care in ruralcommunities, it is paramount that nurses are actively and positively engaged with Medicare Locals at all levels,and that is at the practice nurse as well as the nurse practitioner levels. To ensure a sustainable rural nurse and midwifery workforce into the future, the issues I have outlined must beaddressed through a nationally coordinated approach supported by substantial funding investment. RCNArecommends that the Australian government action the following recommendations: that funding be allocated forthe development of a national nursing and midwifery workforce strategy; that funding be allocated for a nationalrural nursing and midwifery work environments and lifestyles assessment; that incentive packages and tax reliefarrangements be developed to attract and retain rural nurses and midwives; that research be commissioned toexplore structured, specialist-generalist career pathways for nurses and midwives; that financial schemes beurgently implemented to support rural nurses and midwives meet mandatory registration requirements; thatfunding incentives be provided to establish an increased number of specialist advanced practice nurse and nursepractitioner positions in smaller regional communities; that undergraduate clinical placements in small regionalcommunities be promoted and financially supported as a key nurse and midwifery workforce attraction strategy;that resources be allocated to provide structured, flexible and dedicated mentoring support mechanisms forgraduates and early career nurses and midwives in smaller regional communities; that a national funding initiativebe developed exclusively for nursing and midwifery research; and that funding be allocated to scope theestablishment of a national research repository for the nursing and midwifery professions. Thank you. CHAIR: Thank you. Ms Malone, do you have a statement? Ms Malone: Yes, a short one. As the peak body for remote health we would like to clarify our position withregard to the nature of this inquiry. As we acknowledged in our submission, the terms of reference focused on therural sector, but it is incumbent on us to ensure that the remote sector is considered in any deliberations. Whilstthere is some overlap from rural to remote and they are often considered in tandem, the remote sector is unique inits particular challenges: specifically, in the first instance, the nature of the communities themselves, the modelsof health service delivery and the health professionals who comprise a significant majority of the healthworkforce. These remote health services are staffed predominantly by Aboriginal health workers and remote areanurses. Some communities have permanent medical officers, but more commonly they have the fly-in, fly-outvariety, such as is provided by the Royal Flying Doctor Service, and we know this trend of fly-in, fly-out isincreasing at perhaps an alarming rate. The implication for supporting the health professionals and the opportunities to build on models of health carethat are not in the tradition of GP models need to be considered in the best interests of these remote communities.We would like these models to receive greater acknowledgement as they work well, with highly skilled staff who COMMUNITY AFFAIRS REFERENCES COMMITTEE
  • 44. Page 40 Senate Friday, 11 May 2012work collaboratively with their health professional colleagues through telephone and video communication inspite of the fact of being inequitably supported. We welcome the opportunity to appear before you and we are happy to expand on any issues raised. CHAIR: Thank you. We will go to questions now. Senator NASH: Just to start, Ms Malone, I think the title being rural certainly did not exclude remote. Weprobably should have thought of that. When we looked at rural it was about being non-urban and so everywherefalling in that non-urban zone. Ms Malone: We always feel the need to clarify that. Senator NASH: Point made. CHAIR: We should also say we have already been up to Alice Springs and Darwin and had some reallyvaluable evidence. Senator NASH: Point well made and well taken. Can I start with the issue about freeing up of the fundingarrangements to give the community easier and greater access to healthcare professionals. How does it work now?What sort of flexibility do you want to see that is going to improve the situation? Prof. Francis: I am happy to start. What happens at least at the primary care level is that we have the generalpractitioners offering services, community health and public sector funded, and a range of NGOs. I think the issueis that there is such demand on services that are at no cost, so no fee for service, that they become so stretchedthey cannot service the communities properly. I do not think there is effective networking between what servicesare out there. I know part of the brief of Medicare Locals is to make those networks happen a little bit easier. I amnot seeing evidence of that as yet but, as we stated, it is early days. One of the things is that there seems to be ad hoc development of services rather than any real planning aroundwhat should we do and how do we work? I guess some of the clinical placement networking stuff that ishappening through HWA may make the networks develop over time. But I think it is about adhocness, the accessof the communities to it and the whole strategy of supporting at-risk services for people at risk. I think what thathas actually done is stigmatise people to the point that those people that really need access to the services do notaccess them because they have become so highly visible, particularly in rural communities where everyone ishighly visible. Senator MOORE: For example? Prof. Francis: Mental health services is the one that is in my mind at the moment. If you have a mental healthproblem and you are identified as at risk—let us say through school systems or you might have had some call togo to an ED or something like that—as soon as you become visible and people see you going into services, thenyou just do not access them. Given that we have such a high mental health problem in rural Australia, we cannotafford that. The other one that is in my mind is around maternity care services, antenatal and postnatal care particularly,where we have at-risk clinics for women who might be substance abusers, that sort of thing. The people that wereally want to go into the services and use them go away from them because all of a sudden they become inlimelight for having mandatory reporting occur, the removal of your children and all that kind of stuff. That thencreates an even greater risk. When we had a system that was much more about publicly funded services beingavailable to everyone and no prioritising—and I know the problems around that—the maternal-child healthservices were on basically every corner of each town, everybody went through and there was none of that stigmathat is attached to it. So I think we have actually lost the plot a little bit. And I think it is even more problematicwith our Indigenous populations, particularly in communities where the Indigenous population is probably asmaller proportion than the non-Indigenous. Senator NASH: Imagine that you are the health minister and that tomorrow you get the chance to do whateveryou want to improve, I guess, the sustainability of nurses and midwives and improve the future for them. Whatwould be the priority? Prof. Francis: I think the real problem is about how to provide a career structure for nurses and midwives thatkeeps them in the system. Senator NASH: This is the structured specialist and generalised pathways you were talking about? Prof. Francis: Yes. Let us look at the career advancement pathways for nurses: there has always been anadministrative pathway, there is an academic pathway and there is an extremely limited clinical pathway. If youcouple that with the fact that it is a female dominated workforce, it is a part-time workforce—we know that from COMMUNITY AFFAIRS REFERENCES COMMITTEE
  • 45. Friday, 11 May 2012 Senate Page 41around 25 to 45 it remains part time, probably around 0.4 FTE. Think about how many nurses and midwives weneed just to cover the ordinary full-time equivalent workforce. CHAIR: You need double, dont you. Prof. Francis: Three times, actually, by the time you cover shifts. What are we doing that keeps people there?We are not doing much. Even for stuff around providing a more flexible workplace for people with youngchildren et cetera: some places do that all right; others do not address it at all. It is not something we are going toget away from. The workforce will remain female, I think. If it had a better career structure we might get a bettergender balance than we currently have—it is currently 91 per cent female and nine per cent male. I am mostconcerned about the clinical pathway. In midwifery it is even worse; there is hardly anywhere to go. Senator NASH: When you say clinical pathway, what do you mean and how would that look? If I am ayoung woman in a regional area and I am a part-time nurse, what is the clinical pathway now and how should itlook? Prof. Francis: When registered nurses come through the system there is a graded salary until about year eight,I think. You get a minimal wage rise. If you stay as a clinical nurse and do nothing else that is it. You can expect awage rise other than CPI for eight years. Senator NASH: Regardless of where you work. Prof. Francis: Regardless. You could decide that you want to take on a more managerial role, so you mightdecide to aim towards becoming a nurse unit manager or an assistant nurse unit manager, whatever they arecalled. You can step up that pathway, but you get to a point after nurse unit manager where the next role isassistant director of nursing or director of nursing, or something like that—a supervisory role of somedescription—but there are not many of them, and you have taken the clinical nurse away from the clinical work.That is one of the things we have not done well. Partly, that is the professions fault, because we have not pushedit. The medical profession set up a pathway for the progression of every student that they bring through thesystem—about how they will pass through. We do not do that with nursing or with midwifery. Senator NASH: Would they pick a stream or a strand of the path they want to head down, whether it be intothe bureaucracy or the actual clinical work? Prof. Francis: Do they actually pick it? I think some people do, but, on the whole, most people do not. Thecareer pathway is not something that is really talked about and there are basically no options. In rural nursing it iseven more complicated, because even though we are in a workforce shortage, the most stable workforce out thereis nursing. That is basically because it comprises women, they are usually married, they have a family and theytend to stay in the same places. But that is not taking us forward in planning for the future for a progressive,innovative health-care system that is responsive and thinks about what is going to happen with the populationover time. One of the concerns we have is about the future workforce. How do we get the best and the brightest?How do we make a career pathway that is attractive and that keeps them in it, so that they are responsive and arelooking forward and create new ways of managing population health? Senator NASH: What are the barriers for people looking to go into nursing in a rural area? What are thethings that stop them choosing that as a career? Prof. Francis: A career pathway. I have worked in rural universities most of my academic life, and Jane hastoo. Most of our students, when you talk to them about where they are thinking about going as they move throughtheir career, and once they register, say, I am going to Sydney—or Melbourne or somewhere—because that iswhere all the action is. That is where the big intensivist opportunities are and that is where the career pathwaysare for the advanced practice nurse et cetera. In rural areas, other than in the regional hospitals, which havelimited opportunities for specialist practice, there is very little out there. So that whole idea of valuing being ageneralist—we do not do that. In medicine they do not do it either. Ms Mills: Well, they do in Queensland now. And I think that the Rural Generalist Pathway that they haveestablished in Queensland is actually a very good model. It probably could provide some sort of pathway fornursing to go down as well, but of course that would require external funding because it is outside of stategovernment remit. Prof. Francis: I think it is even worse for midwives in rural practice. We know there has been an absolutedownturn in maternity service across the board because of the issue about women being at risk. But even for anexperienced, very competent, midwife it is becoming increasingly difficult to maintain their currency, andtherefore their registration, under our current system. In fact, with this round of registrants that is just goingthrough the board, we will be waiting to see how many of the rural midwives drop off the register. I am expectinga significant number. Even though the hospitals that they might be working at, or the services that they might be COMMUNITY AFFAIRS REFERENCES COMMITTEE
  • 46. Page 42 Senate Friday, 11 May 2012working at, may not have birthing services, they do provide ante-and postnatal care. As soon as there are nomidwives to do that, what then happens to that service? It goes. Ms Mills: They also do emergency obstetrics, and that is also problematic if they are not registered asmidwives any longer and somebody comes to the door. Senator NASH: Yes, what do you do? It is interesting. It really reflects the GP concern that we have had thismorning where we have got the doctors going through university in Sydney and they see the bright lights of beinga specialist as what they want, as that is where all the dollars are and where all the opportunities are—comparethat to being a rural GP in the bush! What you are saying, if I am right, is that it is a similar structure for nursing. Prof. Francis: It is. CHAIR: Except they have not got so much of an ability to do the specialties. Ms Mills: There is also a real dearth of graduate programs in rural Australia. Obviously, we both teach atuniversity and so we are quite concerned with what happens to first year graduate nurses. There are very fewgraduate programs in rural Australia. A lot of that is around cost and cost-cutting by state governments. But that isalso not attracting students to go back out into country Australia. Many of our students come from countryAustralia and that is why they are enrolled in regional universities. But if they are looking for a graduate program,for us, they will often end up going to Brisbane; for Karen, it would be Sydney. Senator NASH: Can I just ask where you are all from? Ms Malone: I am currently working in Canberra, but I have worked predominantly in remote Australia inflying doctor services and as a midwife. Ms Mills: James Cook University in Cairns. Prof. Francis: Wagga. Ms McLaughlin: I am Canberra-based. Prof. Francis: I was listening to the medicos who were talking before when they were talking about locumrelief. One of the things that we know is happening in rural and remote services is the increasing use of—andneed for—locum support. In some ways that is great, it is a gap-filler and that is all it is. But if our hospitals andother services are only being supported by locum services, then I think there is a real issue for the communities,because the lifeblood of a lot of communities is their health services. It is a real issue. I know at Wagga BaseHospital, which is a fairly large regional hospital provider, the need to fill the nursing and midwifery vacancieswith locum staff is increasing all the time. And that is with a university on the doorstep that puts out 1,700undergraduate nurses per year and they still cannot staff it. CHAIR: How do they find locums? Are there people who are already in the community who are employed aslocums or who choose to be locums? Ms Malone: In the nursing world we have always been called agencies, rather than locums. Locum tends to bea medical term but it is the same thing really. Generally they are flown in from more populated areas. Prof. Francis: From the cities. CHAIR: Like fly-in fly-out? Ms Malone: For a period of time, yes. With NAHRLS, which is the latest Commonwealth initiative in termsof supplying nursing and allied health to rural services, again, it is the same. Although they say they have a bit ofa commitment to using locums, if you like, who have experience in rural and remote, but that is not the norm withagencies. So, as Karen said, it has huge implications for communities. Just recently we heard about staff goinginto remote who have no context, particularly culturally, and the impact that has on the community. It also has abig impact on the Aboriginal health workers, who are the real core to those communities. Unfortunately, there isnot a good understanding by people who do not work in these areas of the absolutely pivotal role, the essentialrole, that Aboriginal health workers have. So they are feeling even more disengaged through a lot of theseprocesses. It is becoming more common. Prof. Francis: And a level of resentment from communities when they get the fly-in fly-outs, because there isno continuity. CHAIR: No-one knows them or their history— Ms Mills: Especially when they come from overseas. I know that in Cape York Peninsula, which is obviouslyin my backyard, a lot of them are New Zealand locums. Senator MOORE: Massive problem. COMMUNITY AFFAIRS REFERENCES COMMITTEE
  • 47. Friday, 11 May 2012 Senate Page 43 Ms Mills: I really support Gerrys statement about the cultural inappropriateness of the nursing care provided.The lack of ability to provide mental health care is also a really big issue in an awful lot of those communities,and there is no service provision because of that. Senator MOORE: I am interested to hear what you thought of the evidence of the previous witness about thenurses in the young practice and how he could use his nurses better if the system were different. Ms Mills: Interestingly both Karen and I are very active researchers in the area of general practice nursing.We have a lot of publications between us about that, so we know a lot about it. The big issue is the funding modelin general practice. While the funding model continues to be a small business model where general practitionershave to generate income out of item numbers, nurses will continue to be inappropriately utilised and their scopeof practice will continue to be constrained. That comment is quite common. I think the sad bit is that a lot of thetime they do not actually realise what the general scope of practice of a registered nurse is. Certainly the way theMedicare item numbers used to be set up—and of course the PIP payments—there is still this belief that doctorshave to sight every single patient and, in many ways double-dip. Senator MOORE: It is just really sad that the understanding is not there. Prof. Francis: And I think that is the big issue. I am currently doing some work and all the practice I havebeen involved in there is that misunderstanding that that is how they have to operate the payment system.Regarding that whole notion of not having a nurse practitioner; they are not supportive, there are models wherethat actually works really well; it divides the work up and they provide a much better service to the community. Itis just turf war. Ms Malone: Unfortunately there is a lack of understanding in the medical community about the role. They usethe phrase independent nurse practitioners almost as this notion they are going to be off doing their own thing,which is really far from the truth and absolutely against the whole notion of it. I dont know what you guys think,but I think there is real lack of good understanding by the medical profession of what nurse practitioners do.There are a lot of myths out there, and that is really unfortunate because there are some great models of nursepractitioners in general practice. CHAIR: Can you give us some examples where it is working well? Prof. Francis: There is a practice in Cootamundra, with a very innovative medico as their practice principal. Ithink that practice stands out as an exemplar. I think it is a whole-team approach, and everybody on the team, thenurses included—I cant remember if the nurse practitioner is endorsed yet or still in train—provide acomprehensive service, a much better arrangement than other practices that I know of. Senator MOORE: And accessing Medicare to its full extent? Prof. Francis: Yes. A solid understanding of it. Ms Mills: Ironically, general practitioners have been working with community nurses for years. Communitynurses work to the full scope of the registered nurse practice. They happily go out and visit people in their homes.They undertake dressings, they deliver care, they make decisions, they case manage and they case managepalliative care clients—all of those things GPs have worked in a team operation with for a long time. But, as soonas you put a practice nurse into their practice and they are responsible for paying their salary, it changes thedynamic. Senator MOORE: And it changes the relationship as well. Ms Mills: Totally. Senator MOORE: They are used to a relationship. Ms Mills: They are. Senator MOORE: Has the issue around careers changed? You are identifying all the issues about the lack ofcareer opportunity in rural areas at the moment being a disincentive. Was it different 10 or 20 years ago? Prof. Francis: Was it different? I would probably have to say no. Senator MOORE: That is my view. Prof. Francis: Having said there are no career structures, there are but they are limited—which is the point.We are seeing more nurses as CEOs than we saw in the past. But that is the whole argument though—it is anadministrative pathway. If you are trying to career advance, there is not the clinical type of pathway. The nursepractitioner, advance practice nurse scenario was the way forward but there is a big gap between the registerednurse and the nurse practitioner. We do have clinical nurse specialists and clinical nurse consultants—although COMMUNITY AFFAIRS REFERENCES COMMITTEE
  • 48. Page 44 Senate Friday, 11 May 2012the consultant is a more administrative leader type person. There is just not anything that fills the ladder—thesteps up. Senator MOORE: There never has been. Prof. Francis: No. Underpinning all that, you need to have some strategies that support people to be able tomove through that, recognising that the majority of the workforce is part time. So the structures have to actuallytake that into account as well. Ms Malone: It has been there informally for a long time, if we think about the advance nurse practice role.Many different words have been used for that. I think it is there but it has not actually ever been well or formallyacknowledged. Senator MOORE: Or paid. Ms Malone: Yes, or paid or supported in terms of education, although we have made some big inroads in that.In the remote sector, remote area nurses certainly are in positions of advance nurse practice—not all of thembecause, again, there are levels within that. We have some really good opportunities in that vein for clinicalpathways and as a bit of a stepping stone to get to nurse practitioner. There are opportunities but we have not beenvery good at advancing that until now. Ms Mills: I think it would support the diversity of service provision in rural and remote areas of Australia ifthere was a stronger career pathway for nurses, if there was a stepping stone somewhere between a registerednurse and a nurse practitioner. You could then look at nurse-led clinics and nurse-led models of care withsomebody who has undertaken a structured pathway of education and training and to gear them up to be able todeliver that. Senator MOORE: There has been a lot of talk in most of the conditions-specific organisations about thewonderful work that could be done by having nurse-led teams or a nurse-only team in regional areas witharthritis, Alzheimers, heart and diabetes, for example—and breast nurses of course which get a lot of publicity. Iknow that in regional towns sometimes a nurse with one of those guises, through specialist funding often—whichis not government—could well be the centre point of lots of community care anyway. They may have the titlebreast care nurse but everybody knows her and, if they have got other medical problems, they are more likely tochat to her than they would be to anyone else. Do they fit within the system that you are describing—that kind ofspecialist care? Prof. Francis: Yes, absolutely. Whilst we recognise that chronic and complex care are the major issues facingthe population at the moment, I like to think that the difference between nursing and maybe a medical practice isthat we have always used a wellness framework. It is about maintaining optimal health and working from apreventative rather than intervention perspective. That is how I see nursing complements especially generalmedical practice, which is really interventionist. I know they do not think it is, but I think it is. The work that wedo is about maintaining and promoting wellness and working with allied health people around how to work withpeople that require cardiac rehabilitation—or even before that—in order to keep them at a level where they arefunctioning and can live independently. That is where I think there is scope for advancement and new roles fornurses that will add value. Senator MOORE: This committee is also working on palliative care Prof. Francis: Absolutely. Senator MOORE: It certainly has come out that it is often the nurse community that is working with peoplethrough that process, and the community organisations are focused on that. Prof. Francis: Absolutely. CHAIR: They were talking about the need for a case manager and there were a number of suggestions sayingit would be better— Prof. Francis: I can give you an example of a really good response by a small MPS, not in this jurisdiction—Imean not in New South Wales. This happens quite regularly It is a small service. It does not have any localmedical officers at all, so it is serviced by a medical officer from another town who comes in once or twice aweek. The local service identified a number of people coming through their A&E department, which is basically anurse-led department, with various stages of cancer and no localised support—so people were having to travel100 kilometres to the nearest oncology services. What the nursing staff at the MPS did was set up a roster forpeople to go out into the community and provide in-home support for palliative care—off the roster. That isstaffing an MPS, which is a very small acute care, and a very large aged-care, service. Senator MOORE: They were doing their own community nursing. COMMUNITY AFFAIRS REFERENCES COMMITTEE
  • 49. Friday, 11 May 2012 Senate Page 45 Prof. Francis: Basically, yes—but they were actually ward staff, not community nurses. It was in response tothe community need. I think that is an indication of the innovation that is out there if we can somehow provide thesupport that allows them to do it and recognition through career pathway options. Senator MOORE: And this is an option for them. Prof. Francis: Yes. Senator MOORE: Do all the graduates of both your schools get employed? Prof. Francis: Yes, but every nurse gets employed. Ms Mills: Actually, I have to say we did not end up with all our graduates gaining employment inQueensland. We had quite a lot of our graduates having to leave regional Far North Queensland and head down toSydney and Melbourne to get jobs. Prof. Francis: When I said they all get work, I did not necessarily mean they all got work in surroundingareas. They got jobs, but whether they got a graduate placement is another question. Senator MOORE: That is the dichotomy. That is what I have heard: we have now built up nursing schoolsthroughout the country which are highly regarded, and places are taken every year. That is my understanding aswell, but I have heard over the last couple of years that in Queensland people do all that work and graduate, butthere is no work. I would have thought that would be the worst result. Ms Mills: It has only been in the last two years, and I think it is a result of the GFC. That really did putpressure on Queensland Health from reduced retirements; that is my understanding. Senator MOORE: With the superannuation figure, yes. Ms Mills: Yes. That was what happened, and the squeeze was on. Queensland Health, to give them their due,have offered fractional appointments, so a lot of our graduates got employed at 0.7 of 0.8 of full-time and endedup picking up casual shifts to fill up to a full-time salary. It is not ideal, but still— Senator MOORE: The same thing has been recorded in Toowoomba and also some of the other colleges. Ms Malone: One of the issues about graduate placements—I think Jane mentioned it—is that often,unfortunately, a lot of rural and remote programs do not offer graduate placements. That is really about lack ofresources and lack support to do it. There is a willingness there for a lot of the remote and regional centres to dothat, but unfortunately there is not much support, either financially for the students to undertake those placementsor for the health services themselves to have the resources to be able to support and supervise graduate roles well. Senator MOORE: They want people with more experience. Ms Malone: They often go for people with more experience. It is a bit of a catch-22. We all support the factthat you can have a really good graduate program in a rural or even, we might argue, a remote area, but it is aboutthe lack of support and resources they have to provide that, if that makes sense. There are some very good modelsin the medical world where they do that support very well, which are funded. There are some good lessons to belearnt there, but unfortunately we do not have those at the moment. I think we would then get more nurses inundergraduate studies in regional areas who would like to do those placements in those places, but unfortunatelythe support and the structure is not there to allow that to happen. CHAIR: Okay. Thank you. We are on 3:00. I do not think we gave you any homework, did we? No. You arelucky. Get out while the going is good, before we dream something up! Thank you very much for your time. COMMUNITY AFFAIRS REFERENCES COMMITTEE
  • 50. Page 46 Senate Friday, 11 May 2012KOCZWARA, Professor Bogda, President, Clinical Oncological Society of Australia[15:00] CHAIR: Welcome. I understand you have been given information on parliamentary privilege and theprotection of witnesses and evidence. Prof. Koczwara: Yes. That is correct. CHAIR: We have your submission. It is number 27. I invite you to make an opening statement and then wewill ask you questions. Prof. Koczwara: Thank you for the opportunity to present our position on behalf of the Clinical OncologicalSociety of Australia. I will refer to the organisation as COSA from now on. We are a member organisation ofsome 1,600 members, representing a variety of disciplines in cancer management, including epidemiology, cancerprevention, cancer treatment surgery, chemotherapy, pharmacy, nursing and allied health. Pretty much anybodywho is a healthcare professional and is involved in cancer care can become one of our members. Our mission is toimprove the care of Australians affected by cancer. The subject of your inquiry is really an issue of greatimportance for us. Currently the rural healthcare workforce is a priority for COSA. There are a number of reasonsfor it. One is that we know that the rates of cancer are increasing as the population ages. We know that the burdenof cancer is increasing as well, because cancer treatments are getting better and so patients live longer. Theyendure more treatments, they are often older and have co-morbidities. I would expect that the actual cancer, whileit is the main healthcare burden in Australia already, will become a greater burden with time. At the same time, we know that the outcomes for rural Australians when it comes to cancer are worse than forthose in metropolitan areas. There are a number of reasons for it. I am sure that the submissions to your inquiryhave alluded to them, so I am not going to go through them in detail. But this is really a major problem inAustralia. In addition to that, we are waiting for the new rural cancer centres to open. As you know, the federalgovernment has invested $560 million into infrastructure for the centres. Some of those centres will be openingvery, very soon. That is very exciting, but, in order for that investment to be realised, we really need to see theworkforce, the structure and the processes that drive the care delivery through those centres. We have notreceived a lot of information in that area. Our organisation has a lot of interest and a lot of anxieties about what isgoing to happen when the doors open. We want to put that money to the best use. This is occurring at a time where there is already a significant shortage of cancer workforce, both in Australiaand overseas. We cannot expect that we are going to get healthcare professionals from elsewhere to fill ourvacancies, which we already have. That is only going to get worse. Estimates made by the American Society ofClinical Oncology, in around 2006, indicated that over the next 15 years demand for cancer services wouldincrease by about 50 per cent, but supply would increase by about 15 per cent. That means that the gap betweenwhat we have and what we have to have is going to progressively get greater. The shortages of workforce in ruralAustralia in some ways is a reflection of workforce shortages in Australia as a whole. It is really, again, an issuethat affects all the disciplines and professions that we represent and will have impact on how we deliver careacross the board. Before I get into what we consider priorities in terms of solutions, I just want to highlight some of the issues ofcancer care delivery that are probably unique to cancer rather than other areas of care, but not entirely in isolation.First is the distinction between rural and remote, which really relates to population density. In designing servicesin rural areas on the eastern seaboard, you might have a population density that allows you to develop a fullyintegrated, multidisciplinary service. In areas of low population density, in remote areas—and that representsmost of Western Australia, South Australia, the Northern Territory—the volume of population density and thevolume of clinical cases is such that it is very hard to deliver services on site and maintain the volume of workthat is required for robust service delivery. To make it more complex, cancer care is multidisciplinary—very rarely do we deliver care by one professional.You often need surgery, chemotherapy, radiotherapy, allied health care staff, supportive care not to mentionprevention and so on. Senator MOORE: Dieticians— Prof. Koczwara: Exactly, which really means that for one patient you may need to have a number of healthprofessionals to come together to deliver care. So in terms of pure mathematics it is a more cost-effective serviceif you have a somewhat higher volume of operation. We also have good data in oncology that the quality and outcomes of care are better if there is a higher volume.I think there was a paper in the Medical Journal of Australia last week talking about surgical volume and COMMUNITY AFFAIRS REFERENCES COMMITTEE
  • 51. Friday, 11 May 2012 Senate Page 47pancreatic cancer indicating that your surgical outcomes are better if you do more surgery. Of course, there issafety. In order to train staff to really know what they are doing in terms of, let us say, chemotherapy delivery,they need to do it often enough to have the required expertise and know-how and sense of judgment to reallydeliver safe care. A lot of what we do in oncology is potentially quite risky. Giving chemotherapy is lifethreatening and as it happens that life-threatening time often comes seven to 10 days after the fly in, fly outoncologist has left the town. There is a relationship between safety and quality and outcome and volume. But that also means that indelivering services there is always going to be a tension between safety and quality and high volume on one sideand the desire for convenience and proximity to home and delivering care on site. We really need to have a veryrational but also fair approach to how we are going to address those tensions. They are always going to remain butI think there needs to be some sense and wisdom in how we make those decisions. They are not easy decisions.The paradox is that it is going to be the sickest and most complex patient in the rural area that would want to betreated there. The person who is has very straightforward care is usually quite fit to get into the metro area fortheir relatively straightforward treatment. So those tensions are the sort of moral underpinning of this area ofwork. How do we solve the problems? I really think that you can group the solutions in two categories. One is wereally need to use the resources we have optimally at the moment. That relates to knowing what it is that we have,and there are some gaps in information. We need to be clear of what our needs are. We need to know what ouroutcomes are and how the resources that we invest relate to the needs and relate to the outcomes. As it happens,that information comes from many different jurisdictions. The Medicare Locals and communities can tell youwhat they need, the often metropolitan services deliver services and resource allocation might be in a completelydifferent pocket altogether. There are a lot of good ideas and a lot of projects happening around Australia today, but we often do not knowwhat they are because there isnt really a format or a system of sharing that information and disseminating whatworks. What often works is really funded by small projects or pilot grants that the moment that the project iscompleted do not have any funding left for the dissemination. So a lot of good work spends its time on the shelvesof various libraries but does not necessarily get translated into practice in the long run. We really need to make sure that the care that we design is designed based on evidence and that we have someagreed standards of what we can do that have a realistic reflection of what our resources might be. To do that weneed to invest some resources into research into health service delivery and health economics. That is not the typeof research that is funded by corporate, industrial funding; this is where we actually need government investmentto drive that area of research in the areas of priority. That will assist us in knowing where we are and making the most of what the resources are already on theground. But we need to plan for the future and in doing so we cant only create more positions, although we wantmore positions. But creating an additional position is not going to be an answer because there will be nobody tofill it, given there are shortages of staff. We have to be quite innovative about how we go about it. We have toprovide incentives that are not just monetary and we should really be careful not to put a single person into anisolated position, because isolation is a recipe for demoralising, and people leave eventually when they get burntout from being on call every day for the entire year. I have been listening to the previous speakers and I havereflected on a number of cases of healthcare professionals in rural areas who work solo as doctors or nurses.When you are working alone, there is a great danger that you may never have an opportunity to develop a break.You develop a very focused area of work and you do not have a lot of time in your daily work to develop ordiversify your career or even compare your knowledge with anybody elses. I think isolation is not good forpractice and it is not good for sustainability. We need to be innovative in how we deliver care. Maybe we need to move away from craft based workforcedevelopment and look at skill based workforce development. The same skills could be developed through anumber of craft groups, depending on need and interest. One craft group that could be utilised in cancer servicesmuch more is general practitioners. I do not think GPs would routinely see cancer care as their core business.They see palliative care as their core business but cancer is a slightly different area. I think there is a lot of cancerwork that fits very well into the GP area. But I think there needs to be facilities for training and education, andrecognition that cancer is a core business for general practice education. We need to invest in technology. We can deliver care through e-health, through telemedicine. We do not haveto do fly in, fly out all the time; there are actually other ways of doing that. But that requires resources and itrequires addressing the very basics—somebody to organise a phone call, something to bring the case notes. It isoften the weakest link that deserves most attention. 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  • 52. Page 48 Senate Friday, 11 May 2012 Finally, that approach requires a very broad way of looking at cancer care. It is not just acute care, specialtycare, chemotherapy or radiotherapy. It ranges from cancer prevention to treatment, to rehabilitation—from simpleto complex—from cancer vaccines to bone marrow transplantation. That means many healthcare professionalswill be involved in cancer care delivery—from nurses, to GPs, to specialists, to a social worker who might assistin funding for travel et cetera. They will be delivering that care in person, via phone, via email and viavideoconferencing. The challenge for us in planning services is to make sure that that diversity of service delivery is really done ina coordinated fashion despite the fact that it comes from different jurisdictions, different funding models and, veryoften, different geography. Thank you. CHAIR: Thank you. Senator Nash. Senator NASH: I am very interested in the point you made about the nexus between provision of service atthe optimal level and the desire of people in rural areas to have their treatment close to home. Is there any workbeing done on how to resolve that and what the optimum point is? Putting the emotion to one side, what economyof scale does your sector think is enough to deliver the care that is needed? Is there work done on that? Prof Koczwara: I do not think there is a simple answer. There is some work done on that. For at least someareas—it is a little bit easier to do for surgical outcomes, for example—you could provide data on outcomes,depending on the volume of work. In a way, this is a matter of judgment. To some degree, you need patientfeedback on what is more important for them—best possible chance of survival versus the desire to be close tohome but with a certain inconvenience. In oncology, that is a very common issue that you juggle and present—therisks and benefits of treatment. And I think this is the issue of the risks and the benefits of treatment. A commonexample is a woman who says she will forgo radiotherapy for her breast cancer and have more radical surgerybecause the inconvenience of travel is undesirable to her. But that is a personal choice. In order for us to informpatients, we need to have the data to provide that information. Some of the data exists, but it does not exist foreverything. One of our biggest challenges is that we need to have data on what are the patterns of care and whatare the outcomes, so we can then have information to present to our patients. If you were to have that information,you can translate it into what resources would be required. At one extreme you could potentially delivereverything to every patient close to home, but there will be a certain resource in terms of human resources andtravel et cetera to do that. We just need to ask ourselves whether that is a cost that we can afford and prefer andwhat we would not get instead. But in order to make those decisions you have to have information and quite a lotof information on what is the relationship between care and outcomes. That information is difficult to obtain notonly in many areas of cancer care but probably in other areas of healthcare delivery as well. Senator NASH: I suppose for rural areas it is quite complex, isnt it, because it is a bit of a chicken and eggsituation. If you are going to set up infrastructure that will deliver this kind of care, you need to know roughly thequantum of people who are going to utilise it because, by the time they get to the point of utilising it, you have notgot time to then create the infrastructure that will deliver it. Prof. Koczwara: You can start that process because we know what the incidence of cancer is. So you couldsay that it is a particular cancer centre that captures a particular area and caters to a population base. Then youcould say in that community or in that population area there will be X number of cancer X—and those figuresalready exist—and we would predict that, out of 100 patients with that cancer, 50 of them would requirechemotherapy, 60 of them would require surgery et cetera. So in the period X we would expect that theintervention Y would be delivered that number of times. That means it would require that much of a clinicalprovider to deliver a care and then you may find that if a particularly rare cancer occurs in that community onlytwice a year, then it would not be a terribly cost-effective investment to appoint somebody to actually providesurgical treatment for that cancer. It would be much wiser to say that this particular cancer would need to bemanaged in a larger centre where there will be a greater concentration of care. But that means that we need torealise that there is that sort of dilemma and that tension. We need to be honest as we are talking to patients aboutwhat is a reasonable expectation. I would advise patients that bone marrow transplants will be given in large metropolitan areas forever becausethe complexity of care and the frequency of need is such that we are going to have much better outcomes if we doit in that area. It would just be too expensive to do it in small community areas. It is a little bit different for othercancer types and maybe not as clear-cut. But we are beginning to recognise that, if we really want to have the bestoutcomes and often the most cost-effective care delivery, we need to triage, so to speak, the work that we aredoing. Some work will be done in highly specialised areas. Some cancer types might require one centre for theentire country. At the other end of the spectrum there will be a type of care that should be delivered close to homepretty much under most circumstances or all circumstances. The frustrating thing, though, is that sometimes that COMMUNITY AFFAIRS REFERENCES COMMITTEE
  • 53. Friday, 11 May 2012 Senate Page 49type of care is delivered in the metropolitan area because the providers and patients often do not have informationthat it should be done differently. But, again, healthcare professionals are often not trained in the field of design ofhealthcare services. They sometimes get it; they sometimes dont. So there is a need for more detailed planningthat is based on evidence. That may mean that the initial phase of that planning will identify what are the gaps ofevidence and what would be required to get the evidence. Senator NASH: From the governments perspective, what would you say is the priority for them to consider atthe moment in terms of effective oncology care in rural areas? Prof. Koczwara: We really need to have a way of having a uniform rural care plan for the country as a whole,not a series of different plans that occur in different states, partly because we can actually learn from experiencesof different states. Rather than each state reinventing its own structure we can borrow from next door and use theknowledge that has already been created. Senator NASH: Do not reinvent the wheel. Prof. Koczwara: We do not need to reinvent the wheel. It is actually a very costly exercise and there is someof that going on at the moment, because we simply do not know what is out there. The other thing is that I thinkthat society can reasonably expect that there will be similar standards across the board. You should not think thatyour standard of care in Western Australia will be different to the one in Victoria just because we do not talk toeach other. I think the standard should be the same. At the moment we have different jurisdictions dealing withdifferent areas. Cancer Australia deals with the standards of care delivery. Health Workforce Australia deals withthe workforce and employment. The infrastructure is provided through a federal approach. The employment ofstaff is done on a state level. These are completely different jurisdictions, and of course general practice is privateenterprise and sits outside of it altogether. This means that the care is delivered through a variety of differentsectors and there is no way of pulling it together at the moment. So what COSA will be doing at the beginning of August is trying to bring together the people who are involvedin care delivery, both from the government perspective at the state level and nationally and from the perspectiveof healthcare providers, so we can hear what happens everywhere. What are the gaps across the area and what canwe learn from each other? At the moment there is not a lot of information. I think that will be the first step. The next step is that we need to have more data as a matter of routine, not just when we are opening a newseries of cancer centres. It will be nice to have some kind of rural cancer plan or monitoring system that looks atwhat happens and brings that information together from different jurisdictions on a regular basis. It could matchcancer outcomes and the human resources that go into service delivery, because the majority of costs in servicedelivery actually rest within human resources. So I think that will be a priority and those are the things that Iwould really like to see as soon as possible. We are certainly prepared to invest our energy and our commitmentto make it happen. Senator MOORE: Two of the things you talk about in your submission are things this committee has done alot of work on. One is the cancer registry, which you mentioned, and the other is patient assisted travel. Both ofthose things are critical to getting good results in this area and helping people. It is in your submission, but isthere anything you want to talk about? You have already mentioned the registry a bit, but is there anything youwant to add about those two things? They are areas that I know are close to our hearts. Prof. Koczwara: It is important that we mention the area of patient assisted travel because it is a given thatnot every patient will receive care at the place of residence. The other thing that is probably worth highlighting isthat cancer is not a one-off event. It is not equivalent to surgery for appendicitis— Senator MOORE: A broken leg. Prof. Koczwara: or a broken leg. It is not that you discover it, you fix it and then you can go back to your life.Most cancer patients require multiple visits to multiple providers, and the sad reality is that the patient mightcome on Monday to see one person, on Tuesday to see the next person, on Wednesday to see the next person, andthe next week they do it all again. If I sound like I am passionate about it, I can tell you that my interest in rural care developed from my work asa medical oncologist in Adelaide. I would see women with breast cancer travelling from Mount Gambier. That is5½ hours of travel one way and 5½ hours the other, and the chemotherapy takes half an hour. They would do thisevery three weeks for six months. Senator MOORE: The radiography takes two minutes, but you still have to go all the way. Prof. Koczwara: That is right. I think we need to accept that there are times when commuting to the metroarea is the best way of delivering the best care, and patients understand that very well. But the fundamental issue COMMUNITY AFFAIRS REFERENCES COMMITTEE
  • 54. Page 50 Senate Friday, 11 May 2012is that we need to recognise that there is a real cost to it. What the patient subsidy covers at the moment is verymodest anyway, but we need to recognise that travel is a problem. The other issue is that there is a great need for coordination of the variety of things that go into care. I knowthis is only slightly related to travel, but it gives me an opportunity to highlight that there is a great need for us toensure that we coordinate cancer care, because it is complex. The comfort of care and the ease of care is asignificant determinant of how patients perceive their care. I think it can potentially make care more efficient andcost effective for patients, and yet the involvement of cancer care coordinators around the country is very variableand resources allocated to that are very variable. That is an example of a nursing role with a significant clinicalcomponent that can make a lot of difference—connecting to the previous speakers. Senator MOORE: Yes, we talked about the specialist nurses— Prof. Koczwara: That is right. Senator MOORE: and their particular need in regional centres. Prof. Koczwara: Absolutely, and they can do a lot. Certainly from COSAs perspective many oncologists inour organisations have worked with nurse practitioners and physicians assistants in the United States, where theroles are very well developed, so we are all for it. We want it. We want to see more of it. But that requires someresourcing and some planning for the roles. There are great challenges in creating cancer coordinator positionsbecause they often sit in one discipline. They are often quite isolated. If you become a cancer coordinator forbowel cancer, for palliative care, and you suddenly wish to change disciplines, you may find that there is notanother role. If you want to change jobs, there may not be another role in palliative care in your town or even inyour state. Senator MOORE: Currently, more than likely. Prof. Koczwara: That is right. And you may not have the skills of being a cancer coordinator for bowelcancer. Doctors are lucky that they seem to be trained with a kind of allowance for some portfolio of skills, so ifone skill is not as needed you can expand on the others. In nursing there is a much greater sort of precision ofwhat is being done, but that also limits the career opportunities, even when the clinical job is badly needed. Senator MOORE: I have just one other question on the issue of research which you have touched on and alsodata— Prof. Koczwara: Yes. Senator MOORE: and effective use of data. In terms of Cancer Australia and the specialist allocation ofgrants they have there for research, and also the NHMRC, are there things with rural situations that you thinkshould have some focus in that research? Prof. Koczwara: There are a number of things. One thing is that there is good evidence that participation inclinical trials is associated with good care, so we want cancer patients in the rural area to have access to clinicaltrials just as much as patients in metro areas. In some ways I think that participation in clinical trials, access toclinical trials, potentially can be an indicator of success or functionality of cancer centres but it requires someresourcing, and a lot of clinical trials in Australia currently are run by very limited and very softly fundedresources. So I would like to highlight that there is a need for access to clinical trials in their current form in ruralcentres. There is a need for research that focuses on how health care is delivered. Cancer Australia has been very goodin driving priorities in cancer care. That has actually changed what type of research is being done and it hasdirected research funding into areas that have previously not been funded, whether supportive care or psycho-oncology. Recognising something as a priority area does impact on how researchers apply for research and howresearch is shaped, and I think it would be nice to see more of it. It would be really good to see research that looksat health economics and health service delivery as a priority area both for Cancer Australia and for NHMRC. Senator MOORE: Thank you. CHAIR: I have one follow-up question. You made a comment about the cancer centres that you do not knowquite what is going on. Have you sought an opportunity to get more information, or what has been the level ofconsultation with your organisation? Prof. Koczwara: We are doing that at the moment. We are going to clinicians on the ground, our members, toguide us but we are also approaching state governments in each state and territory and asking them. Theworkshop at the beginning of August will be an opportunity for them to present their major achievements andtheir major needs. We are developing a discussion paper that will be available for circulation before our meetingthat really is designed to identify where we are at the moment and also what the main priorities are for our work. COMMUNITY AFFAIRS REFERENCES COMMITTEE
  • 55. Friday, 11 May 2012 Senate Page 51 COSA had done a similar type of work a few years ago when we looked at the level of rural healthcare deliveryfor cancer around Australia, using a very similar model where we asked our members who provides care, howcare is delivered and how many chemotherapies are given. I think that that information has contributed to thedevelopment of rural cancer infrastructure and the investment that we see today. Our priority now is to take the next step and really look at not just workforce but also how the services aredelivered. We do not want to seek rural cancer centres to be functioning totally in isolation, because patients donot receive care in isolation either; they often move between rural and metro and they move between public andprivate, so there really needs to be an integration of the services across the board. So we are using the samemethodology and we hope to have a fairly detailed document available, hopefully at the beginning of July. Senator MOORE: With these rural cancer centres there were a series of announcements. There is federalmoney in there as well? Prof. Koczwara: Yes. Senator MOORE: It is more or less COAG, isnt it? Prof. Koczwara: The federal government has allocated $560 million to rural centres and there are 20 of them.In addition to that, state governments have committed to a variable amount of money, depending on the state— Senator MOORE: And they all have. Prof. Koczwara: to create additional centres, and there are certain conditions attached to it. The conditionswere that there will be a workforce strategy for the centres. I will use the example of South Australia, my home state, because I can provide a little bit of detail. In SouthAustralia I believe that the majority of the federal money has been allocated to the Whyalla cancer centre, whichwill be a large centre with radiotherapy and with comprehensive service provision. In addition there are 10additional centres that will provide chemotherapy service delivery throughout different sites in South Australia,and that is very welcome. However, I have some anxieties—and that is probably my personal view rather than necessarily a view ofCOSA. If you do simple mathematics, currently we have funding, I think, for rural service provisions for amedical oncologist of one position. Either you can divide that one position into 11 sites—and it does not take a lotof effort to imagine how effective that would be—or you could divide that one position between three majormetropolitan hospitals and say, Were going to give you 0.3 each and you can just service all those other centres.But the reality is that you are not going to be able to achieve a lot with that resource and that many sites. It wouldbe wonderful, and people across South Australia who live in those centres are really looking forward to usdelivering services, and we as oncologists want to deliver good services, but it is going to be very hard when weare going to just have an additional 11 sites to service. Senator MOORE: With one specialist staffer allocated. Prof. Koczwara: That is right. At the moment, all we can do is just add it to our existing work, and most of usdo not have a lot of capacity to add anything else to our existing work. The challenge is that most of us if not allof us went to oncology because we were really committed to doing a good job here. We are passionate about thequality of care that we do. We are proud of what we do. We want to do well and we are interested in the welfareof our patients. But we are worried that we are setting ourselves up for not being able to fulfil our aspirations. Weneed some help here. CHAIR: Thank you very much. Prof. Koczwara: Thank you. Proceedings suspended from 15:33 to 15:46 COMMUNITY AFFAIRS REFERENCES COMMITTEE
  • 56. Page 52 Senate Friday, 11 May 2012BOLITHO, Dr Leslie Edward, President-Elect, Royal Australasian College of PhysiciansGREBE, Mr Sasha, Director, Professional Affairs, HR and Advocacy, Royal Australasian College ofPhysicians CHAIR: Welcome. Have you been given information on parliamentary privilege and the protection ofwitnesses and evidence? Mr Grebe: Yes. CHAIR: I know it is not the first time you have appeared before a committee. Is there anything you wouldlike to add about the capacity in which you appear today? Dr Bolitho: I am a consultant physician in rural Victoria, so this is a passion of mine. CHAIR: We have your submission, numbered 76. I would like to invite one or both of you to make anopening statement, and then we will ask you some questions. Dr Bolitho: Thank you for the opportunity to contribute to this important inquiry. The Royal AustralasianCollege of Physicians, which I am representing today, congratulates the Senate for establishing this inquiry intothe factors affecting the supply of health services and medical professionals in rural areas. We also congratulatethe Commonwealth for establishing Health Workforce Australia with which the college is working to developincreased understanding of the medical specialist workforce requirements in rural and remote areas andexamining ways to provide extra specialist training posts. As the committee well knows, people in rural areas have poorer health status than their counterparts inmetropolitan communities and in major regional communities, with an excess of chronic disease, an increase inall-cause mortality and with reduced access to health services. The social determinants of health and wellbeingcan be clearly seen in the rural setting as there is often poorer housing, limited schooling choices, limitedshopping for appropriate dietary requirements and limited work opportunities. These are influential factorsreflected in the consensus report published recently by the Australasian Faculty of Occupational andEnvironmental Medicine with the college, Realising the health benefits of work, which presents compellinginternational and Australasian evidence that work is generally good for health and wellbeing and that long-termwork absence, work disability and unemployment generally have a negative impact on health and wellbeing. However, particular to this inquiry, and significant in the interaction with other rural, social and economicpressures, is the limited access for rural populations to appropriate health services for their community needs,commonly described as the right care at the right time for the right illness in the right location by the rightpractitioner. I am sure the committee is aware of the information about Australias rural and regional healthworkforce which was provided for the first time in the Australian government report on the audit of the healthworkforce which was published in 2008. That report showed that, despite a range of Commonwealth and stategovernment programs aimed at increasing the health workforce in rural and regional Australia, medical workforceshortages persisted, particularly in general practice and the specialty services, and that the supply and distributionof health professionals in these areas largely correspond with the distribution of state and territory funded orcontrolled hospitals. This is not surprising, as opportunities for a comprehensive medical practice rely on accessto in-patient services, other professional colleagues and other clinical support services. As smaller regionalcommunities often comprise small centres, with dispersed populations across large surrounding catchments, thecapacity to attract and retain health professionals is compromised if there is not reasonable access to a public orprivate in-patient facility. The audit also found that a higher proportion of rural medical workforce was made up of overseas traineddoctors; a direct outcome of a significant Commonwealth program that requires overseas trained practitioners,both GPs and specialists, to practise in areas of workforce shortage for a period of up to 10 years prior to beingeligible to practise more broadly. That program is based on the Australian Standard Geographical Classificationscheme and directly correlates to the time restriction to the remoteness of the area of the workforce shortage. Whilst my college has not directly assessed the effectiveness of these arrangements, there is evidence that theireffectiveness in the provision of a specialist medical workforce for rural and regional areas is limited. TheAustralian Institute of Health and Welfare has shown that, in 2007, the rate of specialists in major cities was twiceas high as the rate as in inner regional areas, three times the rate in outer regional areas and four times the rate inremote and very remote areas respectively. Whilst this is some time ago there is no indication of any significantchange occurring. A particular investment by the Commonwealth, which has been increasingly significant incontributing to medical population in these areas, are the rural clinical schools and the university departments ofrural health. COMMUNITY AFFAIRS REFERENCES COMMITTEE
  • 57. Friday, 11 May 2012 Senate Page 53 These have provided education and training opportunities in regional communities for some years and haveenabled senior professionals to engage in supporting the teaching and training of local or temporary residents andtrainees and is a win for both the professional community, the general community and the students who wish tostudy, work or live in a community in which they have grown up in. The Royal Australasian College of Physicians is a training college for medical specialists in adult andpaediatric medicine. There are associated faculties, chapters and specialist societies. There are 13,500 physiciansand currently 5,000 trainees in Australia and New Zealand. There are 67 training programs and 35 medicalspecialties within the college. The college is working in conjunction with the rural clinical schools to ensure thatmedical graduates can train not just in the communities in which the schools are established but in trainingpathways supported by these schools across wider and less sparsely populated catchment areas. There are earlyprograms established, such as the Murray to Mountains Program in north-east Victoria where intern training isentirely in the rural setting. This program will be expanded in the future. Whilst learning and working in rural communities is likely to contribute to the recruitment and retention ofhealth professionals in these communities, this is not likely to be sufficient to develop an adequate specialisedmedical workforce. And by adequate we mean a workforce that meets the particular health requirements of ruralcommunities noting, as I have said earlier, the higher levels of chronic disease in these communities. The RACPrecognises that education and skills mix needs to be tailored to the needs of the community, and to the aspirationsof the health professionals who could be encouraged to work in these communities. The RACP has been working with government bodies—the Commonwealth and state governments and HealthWorkforce Australia—to promote and develop new and integrated models of service delivery and to expand ourability to train physicians. There is increasing recognition of the need for the health system overall to haveadditional general physicians with expertise and diagnosis and management of patients with multiple chronic andmultisystem disease. General physicians or general medical specialists encompass the breadth of expertise to deal withundifferentiated complex presentations and coordinate and manage illnesses affecting more than one organsystem. In addition, dual training providing some physicians with an additional specialty will enable a broaderrange of expertise to be provided with a smaller workforce to be committed to smaller populations. RACP is working to encourage the development of a robust general physician workforce to improve services inrural and remote regions. General physicians with dual training would provide skills in the management anddiagnosis of these complex conditions and enhance the scope of treatment provided regionally and would work incollaboration with the metropolitan and tertiary referral centres. The college urges this committee to recognise the compelling need to encourage more general physicians anddual trained physicians to live and work in rural and regional areas. Not all regional or rural hospitals will be ableto have a full complement of specialist physicians. General physicians are able to cover many of these areas toprovide services for the more complex patients and are able to liaise with the major centres for collaborativeclinical care as required. The model of dual trained physicians has been in place in New Zealand for over a decadewith that countrys district health boards employing general physicians who are dual trained to provide servicesthroughout New Zealand. This model of service delivery requires additional resources to ensure there is astructured career pathway which will attract quality trainees and enable them to be provided with skills to dealwith chronic and complex patients. The RACP is working with all governments to develop training positions for this model and acknowledges theincreased capacity to train in nonmetropolitan areas as provided by the Commonwealth funded Specialist TrainingProgram. The RACP is involved with the administration of this and applauds this initiative but encourages theprovision of increased funding to allow additional training places to be established. Rural-based specialist trainingwould encourage trainees to remain in the country. There is a need to support physician teachers, supervisors,mentors and to ensure that the trainee is nurtured and will return to the rural setting for long-term gain in themedical specialist workforce. The college would encourage the establishment of centres of excellence in rural medical education inconjunction with the rural clinical schools to provide a continuing postgraduate training and education,particularly in the early years of graduation from medical school. We also encourage an inquiry into the earlyeducation requirements after medical school graduation. There is a significant degree of commonality across allthe colleges in the first three years post-graduation. An entrance examination for advanced training could be heldat the end of the first three years of training, with the award of an intermediate certificate to acknowledge thelearning process, and then acceptance into advanced training for all medical colleges would ensure a highlyskilled and educated workforce. The infrastructure to assist training and retention of medical specialists could COMMUNITY AFFAIRS REFERENCES COMMITTEE
  • 58. Page 54 Senate Friday, 11 May 2012include a specialist practice incentive program. This would be similar to the GP Practice Incentives Program andwould ensure there is adequate funding for installation and upgrade of IT equipment, preferably connected to theNBN, to ensure adequate and timely communication with general practitioners, hospitals and ambulatoryhealthcare services. The ability for IT communication across various platforms is essential to provide informationaccess between pathology services, medical imaging services and private and public hospital facilities. The college cautiously welcomes the introduction of Medicare locals and looks forward to the maturationprocess. Medical specialists work closely with primary and ambulatory care services, as well as with acuteservices in and outside hospitals. Medicare locals should be inclusive and embrace Medicares specialist servicesto enable the active shared management and support of patients, particularly between the smaller workforces insmaller rural and regional communities. Currently the provision of additional medical service specialists is via MSOAP, Medical Specialty OutreachAccess Program, and associate programs in Indigenous health and other areas. This has enabled medical specialtyservices to be provided to patients in rural and remote areas. There should be an expansion of these programs,which would increase services to rural and remote patients. These services can be delivered in various ways,including fly in, fly out, fly in, stay, fly out and various driving in, drive out facilities. We would also encouragethis inquiry to examine the possibility of encouraging the nations major metropolitan and large regional hospitalsto be responsible for provision of specialist services in designated rural and regional catchment regions. Thiscould also provide a platform for coordination between Medicare locals, local hospital networks and privatepractitioners. The provision of medical specialties services in rural and remote regions ensures patients receive the right careat the right time, in the right location, by the right provider. Facilitating the growth of accessible medicalspecialist services in small communities could lead to reduced hospital admissions, improved quality of life forpatients through reduced interactions with the healthcare system and the development of system-wide savingsover time. One of these savings could be the reduced cost of patient transfers and travel to metropolitan settings.We note the recent increase in budget in several states to cover the assistance required for patients travelling toaccess health services in the metropolitan areas. The Commonwealth should be encouraged to examine the cost benefit of provision of services in localsettings—that is, work with the states and territories to review the benefit of financially assisting patients to travelto necessary specialist services, compared with the opportunities to financially support the provision of specialistservices to entire communities through expansion and redevelopment of programs such as MSOAP. In summary,the Royal Australasian College of Physicians encourages the inquiry to examine not just the factors influencingsupply of health service and medical professions in rural areas but to consider innovative options to enable thehealth workforce to learn and work locally, to fly in or drive in and drive out and to develop dual skills to enablethe necessary smaller workforces in regional hospitals to provide comprehensive specialist and multidisciplinaryhealthcare to smaller communities. Senator NASH: It strikes me listening to that, which is eminently sensible—we are hearing a lot of eminentlysensible views about what can address the problems for regional health delivery, yet we are hearing of long-termdecline when there are such practical, good ideas. Why is there a disconnect to making them happen? Dr Bolitho: If we look at the number of Commonwealth funded programs for general practitioners and thenumber of specialty programs we see there is one for specialist medical care, the STP, apart from me with locumsfor obstetricians. This is something which has not been integrated and Medicare locals do not mention medicalspecialist services of any description. There is a total disconnect and local hospital and health networks also donot mention any specialty services. Between 70 per cent and 80 per cent of medical specialists provide services inprivate outside the public hospital setting and 57 per cent of surgery is carried on in the private hospital setting. Senator NASH: Is that across the board or just regional? Dr Bolitho: It is across the board, in regional centres as well as metropolitan centres. Senator MOORE: And the same figures for regional? Dr Bolitho: As far as I am aware it is the same figures, so that more surgery and more services are deliveredoutside the public health system than in it at this stage. Certainly the metropolitan is concentrated. We have greatdifficulty attracting specialists to the rural setting. The MSOAP has certainly been influential in providingservices to our smaller communities and we are directly involved with it. I should say that I have been involvedon the MSOAP board for the last 10 years until it was recently re-formed, both for Victoria and for our localregion. Looking at the services provided is essential. With the involvement of the metropolitan tertiary centrestaking responsibility for doing these services, it seems logical that if you take a specialist to a region and they can COMMUNITY AFFAIRS REFERENCES COMMITTEE
  • 59. Friday, 11 May 2012 Senate Page 55see 15 or 20 patients it is far more cost-effective than having to provide assistance for 15 or 20 patients to travel tothe centre. Senator NASH: Are you suggesting a fly in, fly out model? How would it work? Dr Bolitho: We would prefer them to be regionally based. We would certainly encourage people to live andwork regionally. In our system we have six general physicians in Wangaratta. We have all undertaken to visit upto 100 kilometres from the centre at least one day a week. So we all go to regional centres and cover 100,000patients in about a 100 kilometre radius from Wangaratta, including one of our fellows flying to Echuca everyTuesday. Senator MOORE: A sizeable chunk of Victoria. Dr Bolitho: It is a sizeable chunk of northern Victoria. Senator NASH: Is that sort of model replicated anywhere else? Dr Bolitho: No, and I have not written it up yet—in my spare time occupation! I have been encouraged towrite the model. We have had to attract three overseas trained doctors to help us with that. Senator NASH: Even when you do get the time to write the model up, if you could would you provide it tothe committee—whenever that might be? It would be very useful. You were saying in your opening remarks thatthe hospital should be responsible for doing that. What is the mechanism for making them do it? In a perfectworld, if you were going to say to a larger hospital: You are responsible for providing X amount of specialists outinto the rural communities, what would be the process or the mechanism to make them actually do that? Or is itsomething that they cannot be made to do, that they have to be led to the trough to drink? Dr Bolitho: The college covers both Australia and New Zealand. The process in New Zealand is a totallydifferent one. There they are employed as dual-trained physicians and are expected to provide services in the localregional communities. It is part of their employment contract. I do not think that is in the Australian vernacular atall. I see that we have interns coming up from the Royal Melbourne, St Vincents, the Austin, Monash and theAlfred in Victoria—from all the major centres—and they all go out to areas. They say, That is our catchmentregion. We are saying, Why dont you come down and actually see the patients and see what is going on? Wehave developed a very good relationship with our tertiary centres, so, as general physicians, we provide the followup. I was listening to the evidence from oncology services. We have rural and regional oncology service in Albury-Wodonga. We have their specialist come down one day a week to Wangaratta. We have delivery of regionaltreatment in Wangaratta. I supervise the oncology on day to day. These patients have multisystem disease. Theydo not just have cancer; they have diabetes and heart disease. That is where I come in. The oncologist tells uswhat they are going to have and supervises that. But as soon as they end up with pneumonia or their diabetes isout of control or their heart disease has been right, they end up being coordinated. The integration of care in theregional services or across rural and remote is a role specifically for general physicians, because we have thatbroad ability to integrate care. Senator NASH: To do a whole heap of things. I think it was the previous witness who said that they wouldlike to see a rural health plan instead of it being so ad hoc. Is there a way of having some kind of plan that sets outthe requirement for the major hospitals to utilise their specialists—they would have a regional requirement aroundthe type of model that you have in Wangaratta? Dr Bolitho: I am not aware of one in the Department of Health in Victoria. I cannot comment on the others. Senator NASH: I am not asking about existing, sorry. I am asking whether it would be possible to have theworld look like that? Mr Grebe: I think one of the big opportunities here is having the arrangement between the Medicare Localsand the local hospital networks. You touched before on why these things have not been addressed to date. Someof those legacy issues relate to having essentially a dual-track system. You have the Commonwealth looking afterone setting and the states looking after another. For a lot of these patients, you end up having siloed care beingdelivered. We are talking about getting greater fluidity, where patients really do not know what they areaccessing, whether it is Commonwealth or whether it is state, but they are getting is the right care that they need.The opportunity there is also is for more of those state based services to be delivered in a different setting, whichcould be outside of the hospital as well. We are also looking at having those people with the right skills around multidisciplinary care and coordinatedcare. In particular, we are looking at the opportunity for our fellows to play a role in that, particularly for generalphysicians, with their broad based skills, to deal with chronic illnesses and co-morbidities. There are changing COMMUNITY AFFAIRS REFERENCES COMMITTEE
  • 60. Page 56 Senate Friday, 11 May 2012patterns of illness occurring and there is also that running up against what is often a very hospital-centric carearrangement—I think Australia has one of the highest hospitalisation rates in the OECD. We need to reduce a lotof those unnecessary and avoidable hospital admissions. There is a change that needs to occur and, potentially aframework with the health reforms to adapt to that. Senator NASH: I was just going to ask about the New Zealand contracts that have a requirement for doctor todo regional work. Would it be possible to provide a copy of that type of contract for the committee or direct uswhere to go to? Mr Grebe: They do not have states is there issue there—in terms of that dual tack. Senator NASH: But, as far as you can— Dr Bolitho: We could see if we could find the model. Senator MOORE: The AMA have been really keen on contracts with doctors. Mr Grebe: Yes, I will probably leave that one to them. I would just point out that in New Zealand you start asa generalist and then pick up something else. That gives much greater flexibility for the allocation of resources. Dr Bolitho: With the integration of care, we looked at the national health reforms as a marvellous opportunityto improve services. Ambulatory and primary care extend through all the medical specialty. It is where wemanage the patients before they get to hospital as well as after they have been in hospital and with ourappointment in-hospital—if we need tertiary services, coronary artery disease, coronary angiogram, with orwithout surgery, and then they come back. But the majority of our services in rural and remote regions areprovided outside the hospital system, particularly in Victoria. Nobody has actually seen that from a governmentdepartment point of view—that is to say that a significant amount of Commonwealth money is expended forambulatory care by specialists and it is not recognised in any of the documents that have come out today. Thereneeds to be a rethink so that specialist services are integrated more closely with primary care and generalpractitioners. Our role is ensuring that the communication is there. That is where we talk about thecommunication across all our regional communication, which is electronic. We have set it up with the generalpractitioners for the 100 kilometre radius so that all communication is electronic and the letters are integrated intothe general practitioners program. This leads me to the difficulties envisioned with the introduction of PCEHR, the personally controlledelectronic health record, where the person who puts the information in is the GP. If you have somebody under anoncologist who is having their breast cancer treatment, which may require weekly or fortnightly or so visits to thespecialist, none of that is going to be put in until they go back in three or six months to the general practitioner, ifit is done elsewhere than in a public hospital, where the discharge summary will be incorporated. So there will beno capture until they go back to their general practitioner if we as specialists cannot put the information in or thechange in medication in. So, the PCEHR is potentially going to be only as good as when they have gone back inthree or six months time to their general practitioner, who then has to put in a huge amount of information. Senator MOORE: We thought that was still under discussion. Dr Bolitho: I would like to emphasise that it is a real concern. Senator MOORE: The other issue is the view of the AMA and the GPs that they are the single portal for thisinformation. From someone who is not in the medical profession one of the things that constantly comes up inthese discussion is the different views of the various people in the medical profession. Dr Bolitho: I am sure the AMA will provide you with the general practice view. I will not say any more. Senator MOORE: On the issue about the area of acute care and ambulatory care—primary care—beingdominated by GPs, and also the electronic health stuff, it is because the GPs are promoting their ownership of it.Where is the discussion between the various medical areas about it? In previous evidence it was said thatspecialists do a lot of the—what was the term you were referring to? It was in the areas where the GPs do ownit—the discussion and the promotion of it. Dr Bolitho: They have been bequeathed it. They do not own it. For the complex patient— Senator MOORE: It is a matter of trying to get agreement between you guys. That would be good. Dr Bolitho: We see complex patients. We see the diabetes, the heart disease, the heart failures, the kidneyfailures, the lung disease, smokers. All of those come through when the general practitioner either requiresadditional assistance or it is chronic and complex or it is integrated care. With our population now getting older—average lifespan for women is 87 and for men 79 to 83—no longer is 70 considered the end of the line, I am verypleased to say. We are now aiming for everybody to get to their mid-80s. So management of care is across theboard and we are managing with, and deferring to, the general practitioners. COMMUNITY AFFAIRS REFERENCES COMMITTEE
  • 61. Friday, 11 May 2012 Senate Page 57 Mr Grebe: That has been the other change, too. In shifting to saying it is the Medicare Locals instead of theGP Networks is a recognition that it is a setting and who provides which care in which setting should depend onwhat the patient needs. So more specialist care in that primary or ambulatory setting can be delivered. A goodexample of that at the moment which is encouraging development was the agreement between theCommonwealth and the New South Wales State government for the clinic in Raymond Terrace which is a 50-50joint venture and has all the GP, allied health and specialist services being provided by all levels of government inone place. So we think that is the sort of arrangement when it does not matter to the patient: they just arrive andsay they need to see X and that person is there and available for them. Dr Bolitho: Multidisciplinary team care is a specialty of general physicians as well so that we integrate thecare. Our problem on the ambulatory care side of it is that we cannot access the allied health requirements withoutsending the patient back to the general practitioner with a recommendation that they need to see a physio, apodiatrist, an ophthalmologist or a psychologist. We have to send them back. The rehabilitation specialists areparticularly keen to try and broker that they can access it. But it is across the board in the rural setting. It seemsironic that we can see a patient and recommend that they go to cardiac rehabilitation after they have had theirmyocardial infarct, but we have got to send them back to the GP to access and do the paperwork. Thecommunication is there. The letter goes back to the general practitioner. As a specialist I do not own a patient; Ilook after them with you and the general practitioner. Mr Grebe: But a lot of these additional steps are fine when you are talking about going one suburb to anotherin a metro setting. If you happen to move around long distances. Again, just listening to the previous presentation,some recent papers have been published in the Internal Medicine Journal of the college about the treatment ratesfor female cancer patients in rural areas—the impost of that trip and then putting their family first in getting thefollow-up care. So in a lot of these situations people are diagnosed with the problem. It is the management of theillness. You touched before about the broken leg versus a chronic illness. We are very much geared up for thoseprocedural, episodic treatments and yet the shifting pattern of care now is towards chronic illness, which ismanagement and ongoing care. Senator NASH: For life. Mr Grebe: That is exactly right. Dr Bolitho: The other patients particularly affected are people like dialysis patients. If we can look after thedialysis for them in the regional setting. We now have one and a new nephrologist for the whole region based inAlbury-Wodonga so that we provide services in the smaller centres for these people so they are closer to home.Three times a week they have got to come in. It is really a huge impost and the services required— Mr Grebe: How far is Wangaratta from Albury? Dr Bolitho: An hours travel is the easiest way to say it. We are gradually attracting services to come down toWangaratta and see the patients there. Mr Grebe: Our working principles in developing a dual training pathway is that we want to look at increasingthe number of patients who can be dealt with in the local setting, whilst recognising that there are going to be, asothers have said, occasions where people are going to have to go to a tertiary setting. But how many more couldwe do locally and how many more treatments could be provided? That is where we believe, in particular, thatgeneral physicians with their broad array of skills—so they can, based on the scope of practice through theirtraining—look at all of the specialty areas. We have 30-odd. Dr Bolitho is able to look at most conditions that arepresented in that setting. So you get the additional benefit of having that sort of specialist—again, recognising thatyou are not going to have one of everybody at every hospital. If you are not going to do that, the other issue is: how are those specialists, even those with dual training,allocated? What is the pattern of distribution? One of the things we are looking at is trying to get an alignment inthose additional areas of specialty to cover the chronic illnesses. What the college has put forward in its currentproposal is that if you took, say, Dubbo, Orange and Bathurst, and we had dual trained physicians with a specialtyin the relevant areas, how many more patients could be dealt with in that area without them needing to travelelsewhere? The other beauty of that model—and it is picked up in a few of the submissions—is that what we are talkingabout here is creating an environment where those specialists want to stay in that setting as well. So it is not justabout recruiting them; it is about getting them to stay. If they can see a rewarding career, then it becomes moreattractive. Of course we are interested in ensuring that the training experience they have is positive, but if they cansee a future where they will be able to network with their peers and be supported professionally in theirdevelopment without always having to go off for CPD—you know, that ongoing vocational training—then it COMMUNITY AFFAIRS REFERENCES COMMITTEE
  • 62. Page 58 Senate Friday, 11 May 2012starts to become a more attractive and more sustainable workforce model without relying on top-ups, incentivesand all those sorts of arrangements. Senator NASH: What is that proposal? Mr Grebe: It is a discussion paper that we have out at the moment. We are working with Health WorkforceAustralia and a number of state governments on trying to get to a model that has a dual trained general physicianin this additional area in that hospital and then a dual trained physician with a complementary additional specialtyto treat more patients with chronic illness in the other local area. Senator NASH: Could you provide a copy of that to the committee? That would be really useful. Mr Grebe: Absolutely. Senator MOORE: Dubbo-Orange is a pretty dynamic health area, isnt it? Mr Grebe: Yes, and there is a good general practice network there as well. Senator MOORE: Yes, and they are very proactive. Dr Bolitho: It is similar in the Hume region. If we could coordinate Shepparton, Albury-Wodonga andWangaratta, we would cover nearly half a million patients. But we do not have the services of a Geelong oranything like that available regionally. We have got the cancer centre and radiotherapy up there, and the newbuilding is going ahead for the new oncology centre at Albury. But the other services are certainly still veryrudimentary. The other thing with the integration of care is the upskilling of nursing and allied health staff in the region. Soit is not just a matter of bringing the doctors in; we need the skilled staff to support us, to improve hospital careand to ensure that we have models of care that are sustainable across the whole hospital base and also out in thecommunity. Mr Grebe: That is a benefit also to the GP. A great study has recently come out from an endocrinologistoperating out of Toowoomba Hospital. The evaluation was that the local GPs gained significantly from havingthat specialist come into their general practice to treat those patients. Putting aside all the obvious patient benefits,the GPs gained an insight into the treatment and there was better continuity of care. Rather than being seen as animpost on them, it was actually seen as a benefit. Senator NASH: It is really interesting. If you are a GP in the city, you send your patient to a specialist andyou do not have that connectivity. But to actually have them come in— Mr Grebe: Yes. A lot of the submissions picked up that one of the retention issues is access to specialistservices for GPs. Senator NASH: Yes, very much so. I think you expressed cautious support for Medicare Locals. It seems thatthat is a bit across the board. It is a blank piece of paper at the moment: if it goes the way of the good, it is goingto be fantastic; if it goes the way of the bad, it is going to be a nightmare. Underneath that, in your submission youtalked about the reintroduction of general physicians. That implies that they were there but now they have gone.Could you elaborate on that for us? Mr Grebe: If you look back historically at the number of those places that may have been available, somestates, as supposed to others, took the view that more specialty areas were the way to go—and you see that termthe subspecialisation—and that general physicians were less required. I think it would be fair to say that there hasbeen a bit of a turnaround and a bit of a shift in thinking in recent times and it is recognised that, unfortunately fora lot of area health services, there are not the generalists there anymore to get the trainees. We have significantinterest from trainees in doing general medicine now, so they are in a way driving the changes as well. There hasbeen a shift back. Dr Bolitho: Our most populated state managed to remove all general medical training units from their publichospitals just prior to the Olympics, a few years ago. I will not tell you which state. They totally deconstructedthem and said they were no longer required and they only needed subspecialists, subologists. Senator NASH: What was the rationale behind that? Particularly for a regional area, you may have a doctor,one specialist, with a patient where (a) the GP does not have a clue or (b) there is a multilayered presentation ofdifferent things. What they are saying is that the GP has to pick what the problem is before they send the patientoff to the specialist. Is that correct? Mr Grebe: That is right. Senator NASH: And if you have more than one, you go to four or five, buddy. COMMUNITY AFFAIRS REFERENCES COMMITTEE
  • 63. Friday, 11 May 2012 Senate Page 59 Dr Bolitho: We have some wonderful letters from people who go to metropolitan centres and see five, six orseven specialists. They come back and we then have to untangle it all and reassemble them because they do notunderstand what organ is not talking to the other. They ask, How does that happen? Whereas we say, Youre aperson. Lets get you improved. Senator NASH: That is very interesting. Mr Grebe: You might also look at some of the state budgets, as Dr Bolitho touched on in his openingstatement, around the significant blowouts in recent allocations for patient transfers. Some of those states mightnow be relooking at some of their decisions in light of the doubling of those budgets. Dr Bolitho: Emergency transfer is particularly expensive; it is a minimum of $6,000 per transfer. If we needto send somebody acutely off to a tertiary centre it is a very expensive business. The ambulance service has learntto create everybody into category 1, so they then charge the hospital system. With or without a medicalrequirement for it, there is an additional hidden cost in there. Senator NASH: Would you please take on notice for us where to go to source some information on theremoval of those generalist positions out of the equation for that state? Mr Grebe: We will do some analysis for you and come back to you on that. Senator NASH: Thank you very much. That would be great. CHAIR: We have given you some homework. If we could have that back within two weeks, that would befantastic. Senator NASH: Obviously, if any of that is detailed you may need a little bit longer. Mr Grebe: We expect to be able to comply with that. CHAIR: That would be fantastic. We look forward to seeing your discussion paper. That will be really handy.Thank you for your time. COMMUNITY AFFAIRS REFERENCES COMMITTEE
  • 64. Page 60 Senate Friday, 11 May 2012HAMBLETON, Dr Steve, Federal President, Australian Medical AssociationHOUGH, Mr Warwick, Senior Manager, General Practice, Legal Services and Workplace PolicyDepartment, Australian Medical AssociationRIVETT, Dr David, Chair, AMA Rural Medical Committee, Australian Medical Association Evidence from Dr Hambleton was taken via teleconference—[16:29] CHAIR: Welcome to witnesses from the Australian Medical Association. Before we start, have you hadinformation provided to you on parliamentary privilege and the protection of witnesses and evidence? Dr Hambleton: Yes, I have. Mr Hough: Yes. Dr Rivett: Yes. CHAIR: We have your written submission, which is submission No. 42. I invite you each to make an openingstatement and then we will ask you some questions. Dr Hambleton: I would like to thank the committee for providing the AMA with an opportunity to presentfurther evidence to this inquiry. The AMA has a very strong interest in rural medical health and supportinginitiatives that encourage doctors to practise in regional and rural areas and in ensuring that Australians living inthe bush have access to high-quality medical care. We know there are no easy solutions in this area, and certainlyno one size fits all. Our submission to your inquiry does, however, look at these issues strategically and broadly.It proposes a range of initiatives and solutions that would provide more incentives for doctors to consider workingin rural and regional areas. As you may be aware, the AMA releases position statements on a range of health and medical issues. Theseposition statements are updated periodically, particularly when issues need further policy attention. In recognitionof the imperative to improve rural and regional healthcare and support for health practitioners working in thebush, the AMA recently updated its position statement on regional and rural workforce initiatives 2012. Thisreplaces the 2005 position statement. I would be happy to arrange for the updated position statement to be tabledto this committee. Quite a lot of the content is in our submission, but we can provide that to the committee. CHAIR: That would be helpful. Dr Hambleton: I will hand over to my colleague Dr David Rivett, who chairs the AMA Rural MedicalCommittee and who himself is a doctor practising in a regional area, to outline the key issues the AMA believesare crucial to the supply of health services and medical professionals in rural areas. Before I do, what I have beensaying publicly and am happy to say to the committee is that I often hear governments asking, Whats the onething we can do to fix the problem? In this circumstance, really there are a range of things that we need to do.That is why we tried to put all of that information in the submission to the committee to really help thedeliberation. There are a whole lot of things that make a difference. If we can build all those in, we can actuallymake a difference. Dr Rivett: Thank you, Steve. I reiterate our thanks to the committee for providing this opportunity to addressit today. Since I graduated I have practised in Batemans Bay, on the South Coast, which I am sure you are allfamiliar with. The population has grown in that time from about 1,700 to 17,000 and we now have five nursinghomes in town. We are not pulling in new doctors, so people at the end of their working lives, like me, are beingforced to work harder and harder, which is just not tenable. This is not the situation just on the South Coast; thisapplies all around Australia. We have to get robust systems in place to attract more doctors to go rural. At themoment government is putting substantial funds into facilities. We are seeing good training facilities for studentsand better generalist training in Queensland, and that is going to spread around Australia, by the look of it. Soresources are being spent. Facilities and training are being addressed, but we are not seeing incentives to get them there. You have justbeen talking to somebody about general physicians, which is a really gaping hole in trying to staff regionalhospitals. Our rural medical committee does not look just at the tiny hospitals the RDA represents; we are lookingat regional hospitals as well. We have a spread of doctors on the committee from throughout Australia; all statesare represented. Some of the big regional hospitals are having a lot of trouble getting generalist staff. Generalphysicians in New South Wales are just about extinct—or are extinct, I think you have just been told. Generalsurgeons are not coming through the scheme. There is more and more subspecialisation. Some of this is driven by COMMUNITY AFFAIRS REFERENCES COMMITTEE
  • 65. Friday, 11 May 2012 Senate Page 61Medicare differentials; there are higher incomes to be made in subspecialisation at times. So there are lots offactors that have to be fixed, not one or two. Over the years I do not know how many meetings I have been to about planning for rural health, andeverybody listens and takes the attitude that it is all too hard. They feel absolved from guilt by saying: Its toohard. Lets just sweep it under the table and admit we cant win. I think you have got to have a damn good go at it.That has not been happening in the past. So I am very enthused that there is a Senate committee actually lookingat this and hopefully going to bring forward some robust solutions. There are a lot of robust solutions, fromdifferent areas of approaching the problem, in this paper that has been presented to you by the AMA. Currently, I am three doctors down in my practice. I am trying to go through an area of need process, which Ican assure you is an absolute morass of red tape. I have been told I can apply for one doctor at most. You cannotget three area of need positions, even though I need three people desperately. All the doctors in my practice areover 60 and hanging on, wanting to get out and just slow down. But they feel they cannot do that, because theywant to provide a community service. The younger doctors coming into town do not have real incentives toprovide after-hours care. They want to have a life as well as be a GP—which is totally sensible and admirable.There have got to be core numbers to support this into the future. You cannot say, Were going to get a doctor to atown. There have got to be core numbers, so that that doctor has a good lifestyle there, he has got good access toeducation and ongoing training and he can look after his patients but also have time to look after his family andhis other interests. The old days of dinosaurs like me trying to do everything at once and working crazy hours are long gone. If welook back to that old model and say that it is going to happen again, we are losing the plot altogether. We need aseries of robust solutions to get doctors back to rural practice and enjoying it—not doctors drafted in, not IMGsdrafted in because they cannot work somewhere else. We have got enough medical graduates coming through inAustralia now that we can solve the problem. But it is going to mean some dollars spent by government to getpeople there in core numbers, so that they have a good lifestyle and provide a good service to those ruralpopulations. Again, the paper enunciates most of the areas that need addressing, in a very clear format. I will not go throughit bit by bit now, but it is a real crisis and it is getting worse, because the people with the experience, and most ofthe proceduralists like me, are over 60 now. They are not going to be around for much longer. We need to getrobust systems to get younger doctors into the loop now, while the older guys are still there to show them around.It has got to happen in a hurry, not in 10 years time. It will be all over then. There will be more and more peoplegetting flown out expensively, as there are now. At Batemans Bay, we have a helicopter just about every daynow, sometimes several times a day. Facilities are getting wound back. We need more robust facilities, withspecialists and GPs. It is not just a GP issue. We need general specialists to bolster those big regional hospitalsright throughout rural Australia. It does not matter what state you go to, we need more generalists. They need tobe well paid and to have decent rosters so it is an attractive working life. Thank you. Mr Hough: I have nothing to add. Senator NASH: I will start off with a question I started with for the last witness. We have seen a lot of reallygood ideas. There are some terrific proposals. There are some incredibly intelligent people on the ground,involved in the sector, that actually have the answers to how we improve health delivery out in the bush and in theregions. Yet there is this disconnect. We have got the situation as it currently is—and, as you say, Dr Rivett,getting worse—and these fantastic ideas. Why is there such a disconnect? Why cant we get some of these ideasand proposals actually implemented? What is the block? Dr Rivett: When we take it to the health bureaucracy, we get the too hard or too expensive answers all thetime. Also, you have got a federal system battling with a state system, so there is buck-passing going on. Who isresponsible? Is the state responsible or is the federal government responsible for solving the rural workforcecrisis? They have both got different parts of the pie and they have both responsibility for different parts of thesolution. Again, they can buck-pass from one bureaucracy to another. There needs to be a single body that isempowered to put solutions in place. These are multifactorial solutions that cannot just be done by the stategovernment or the federal government alone. They need to be working in sync and they need to have a strongdesire to actually solve the problem. I think that is lacking badly. The AMA has taken forward, with the RDAA,the rural rescue package for the last four or five years, without getting any traction on that. That should be a sexypackage to any government. It has got a sexy title: rural rescue package. It is not madly expensive. Of the fundingit does cost—we have costed it at $300 to $400 million a year—you are going to claw probably half of that backin tax receipts anyway. It has two key incentives. The first is to get people to go to more and more remote areaswhere there is the loading on the patients fees they garner from Medicare and a second loading to encourage them COMMUNITY AFFAIRS REFERENCES COMMITTEE
  • 66. Page 62 Senate Friday, 11 May 2012to be on call at the hospital, whether it is in A&E, anaesthetics or obstetrics. It is a broad system. It is not just forGPs. It is for specialists outside the cities. It is for registrars training outside the cities so they get a higher level ofpay. It gives a real incentive. You guys have the levers on it. If you put in too much money and the country is flooded—heaven forbid!—then you can pull back the lever and say, We will make that incentive slightly less. Or if there are not enoughdoctors you can push the lever forward and say, We need to put in more incentives there. You are in control of it.It is not a blank spend where you are throwing money around willy-nilly. It is a package that has been wellworked out by the RDAA and the AMA, but it has not garnered any traction. Senator NASH: What has been the response? When you brought this up to bureaucracy and government,what was the response to the package? Dr Rivett: Usually we are told it is too hard. The usual answer is, We are broke. We do not have any fundingto do anything. Dr Hambleton: David has hit the nail on the head. It is the state government-federal government interface thatis a huge problem. We have to look at funding in real terms. When you get the tax receipts from doctors going tothe bush and have a look at the net cost it is across two portfolios. That is always very hard for government. The other major reason that this has not happened is, just as I said in my opening address, that governmentstend to say, Tell me the one solution that will solve the problem. What they have used is the 10-year moratorium.What that effectively did was stop people solving the problem. For a number of years we have had an unhealthyreliance on our international colleagues to save the day. We have not put these systems in place. We have notforced governments to sit in the one room and nut it out and send up the white smoke when they have a solution.We have relied on our colleagues from overseas and put them in one of the most difficult places to work in ourcountry. I would hate to think of myself working in some of the countries these doctors come from withoutappropriate support, and they are without the ability to demonstrate to Australia that they are reaching the samestandards as our local doctors and they do not even have access to Medicare or public schooling. We have saidthat the 10-year moratorium should be scrapped because it would force us to look for the real solutions. This isthe one solution that has delayed the real solutions. Senator NASH: It is a band-aid. That is very useful. Just on the generalism issue, you talked about elevatingthe status of generalism. It sounds good, but how do you actually do it? Dr Rivett: I think most colleges are now looking at this. The College of Physicians has recently announcedthat they are going to have a double training scheme where physicians will come through with two skills in theirkitbag, which will be good for big regional hospitals and for providing an on-call roster. Also general surgeryneeds to be boosted. There need to be better payments for general surgeons providing on-call services in thecountry and also in the cities. Most of your hospitals in the city need a generalist on call who can man theemergency department and take somebody to theatre in the middle of the night. They have to be lifted in theesteem of the medical profession, so the deans have some responsibility. Medicare benefits need to be looked at tosee if they are giving the right incentives. At the moment, if you are a subspecialist doing a lot of procedures youcan certainly earn a higher income and your chances of being called in the middle of the night are much smaller.This needs to be wound back to some degree. There has to be a balance. I am not saying we do not needsubspecialists. They are vital if we are going to give top-quality care to the Australian populace. But there needsto be a balance. The wheel seems to have turned too far. Dr Hambleton: In relation to generalism, I think David outlined some of the issues about elevating the status.The status of someone who says, I am prepared to accept all comers, is very important because that is the essenceof a general practitioner. A specialist general practitioner is quite prepared to see whatever problems come acrosshis desk, not just tailored into a specific area. That quality is— CHAIR: I am having a little bit of trouble hearing you. Could you speak up a little bit? Dr Hambleton: Yes, sure. CHAIR: That is better. Thank you. Dr Hambleton: I was just saying that the quality of an individual, be it a general physician, a general surgeonor a specialist general practitioner who has indicated they are prepared to see all patients no matter what theircondition, is what we need to applaud because that is the essence of a general practitioner or a general specialist.They are prepared to see a range of conditions and not simply tie themselves to a small part of medicine. I thinkthat it is an attitudinal change. Something the colleges have got to pick up, something the AMA has got to pickup, something the government has got to recognise in remuneration, or at least in rebates is that those who offerthemselves across the board are valuable to our health system. COMMUNITY AFFAIRS REFERENCES COMMITTEE
  • 67. Friday, 11 May 2012 Senate Page 63 CHAIR: When you are talking about the training, we heard earlier from the College of Physicians that one ofthe states, which was not specifically named but which we worked out—New South Wales—had cancelled itsgeneral programs about 10 years ago and was— Dr Rivett: It was general physicians which have been wound right back. CHAIR: Yes. I presume that means that to do this you need to wind that back up again. Dr Rivett: You would do. It would have to be a substantial change because there are not a lot of generalphysicians left to train those coming through. Senator NASH: Who made that decision? Who decided that that would happen? Dr Rivett: I could not answer that. I am not aware of that information. Dr Hambleton: So many of these decisions are made in isolation. Never before have we had an entity take abirds eye view of the profession in a comprehensive way. Health Workforce Australia recently delivered thereport Health Workforce 2025 to look at the nursing profession and the medical profession, and to look at, withsome sensitivity analyses: if we do this, that and the other right through until 2025, where will we be? We allknow that the major concern is the number of students coming through. The question we have to ask healthministers is: Is our target to be self-sufficient? because, if it is, we are not going to get there under the currentsetting. How many specialists do we need in what area? That work is yet to be done. Health Workforce Australianeeds to do it. The Medical Training Review Panel needs to be part of that process. A birds eye view needs to betaken so we know how many general physicians we need and how many general surgeons we need, whereas astate may make a decision at a state level, ignorant to the impact of that on the workforce 10 or 15 years down thetrack. The pipeline is a long one in medicine. It is going to take until 2015-2016 until the real crunch comes in termsof training positions for those young men and women now in our medical schools who will be in our hospitals inthe next few years. We absolutely need a birds eye view, a national view, about the pipeline from the start—atmedical schools through those prevocational years, through vocational training and into where these specialistsare going to work. Unless we have that, we are not going to have the ability to manage our workforce. Thewarning from Health Workforce 2025 is that the settings that are currently dialled up will not render us self-sufficient. We are going to be relying on our international colleagues right up until then. We simply have not gotthe capacity to train one more student properly under the current settings and we need to really think about that. Senator NASH: On the generalist issue, as part of the recommendation you say:... improve the level of remuneration for generalists to encourage generalist practice, including the removal of anomalies inthe MBS that reward sub-specialisation over generalism.What are those anomalies? Can you expand on that for us? Dr Rivett: We can give some clear-cut examples of anomalies. Mr Hough: Yes. I think at the end of the day there is a consensus that the MBS generally speaking rewardssubspecialty, as Dr Rivett said earlier on, particularly in the procedural areas. Senator NASH: How does it do that? What is the reward? What actually— Mr Hough: Through higher rebates for those particular item numbers. Whereas the thinking doctors, such asthe generalist physicians, generally speaking are not looked after as well. There certainly does need to be a reviewof those particular areas to try and restore some of the balance. So, ultimately, if you have got young graduateslooking at careers in these areas they will see that if they want to go into generalism financially they will notsuffer as a result compared to some of the other specialties. Senator NASH: That is a good point. Dr Rivett: I think Steves point about needing national blueprints is a really big one. I think you need to workout numbers—and a demographer could easily do that—and look at the populations in the big regional cities andsay, So this town has got 30,000, or 100,000 people or whatever it is. What will we need to staff that centralhospital there? How many general physicians will we need? How many emergency physicians will we need? Howmany anaesthetists will we need? How many obstetricians will we need? Then you collate the national data andtry and move your training targets to meet what the demographer says you are going to need in so many yearstime. That is fairly simple, I think, and it would set some fairly realistic targets. Sure, they are going to change.Some towns are going to go downhill if they have their water supply cut off in the Murray River basin, forexample, and some towns are going to grow faster when they find a huge mother lode of coal or something. Thatis going to give you a baseline so you can get the colleges to work towards producing the right numbers. This is along-term thing, but firstly you need a plan and you need to start counting some numbers as to what you are going COMMUNITY AFFAIRS REFERENCES COMMITTEE
  • 68. Page 64 Senate Friday, 11 May 2012to need, what Australia needs now and what people will need in 10 or 20 years time because there is a long flow-through, as Steve said. But without a plan, and there is no national plan at the moment, you are not going toachieve your goals. Putting a bandaid here and a bandaid there, like we have been doing since I have beeninvolved in medical politics, is not the answer. We need a robust solution that we work towards, and it has got tobe malleable and changeable so it keeps abreast of the times. Senator MOORE: Dr Rivett, has it always been this bad? I am interested in the fact that for GPs, and inparticular specialists, if you are living in certain parts of Australia there have never been specialist services. Dr Rivett: Some years ago we had a lot of overseas doctors come in from South Africa and the UnitedKingdom with a broad range of skills and good training in those countries and they held rural Australia togetherfor a long time, but they are not coming any longer. Senator MOORE: That is right. And it was nothing to do with special incentive payments or anything likethat. Dr Rivett: They enjoyed rural Australia from the time they got there, but they are not there anymore so youare not going to look to them for a solution. You have got to look at the modern generation doctor and say,Whats going to attract him to rural Australia? You have got to have the numbers so that he can do the otherthings in his life that he wants to do or you are not going to win. You cannot conscript people into rural Australiaand make them work there. That is not going to happen. They are not going to be happy. They are not going tolook after their patients and enjoy their work. Senator MOORE: And they will not stay. Dr Rivett: They will not stay. As soon as their conscription period is over they will be out of there or they willavoid the conscription by working overseas. There is a big international medical market and Australian graduatesare very well trained. It needs to be a robust solution and a plan has got to be part of it. As Steve said, you havegot to plan what you need and tell the colleges you need so many generalists because they have got to staff basehospitals and outer urban hospitals so you have got the right on-call numbers 24 hours a day. Senator MOORE: So where have the specialists for your regions come from in the past? For specialisttreatment have people from Batemans Bay come to Canberra? Dr Rivett: Most of the care needed comes to Canberra and if it is too complicated for Canberra it goes toSydney—or if Canberra is full or if the highway is blocked, as it was the other day. Senator MOORE: But in terms of someone who needs a specialist? Say they have seen you or someone elseat Batemans Bay and something has been identified for specialist care. Traditionally it has always been Canberra. Dr Rivett: Yes. We do have visiting specialists. Senator MOORE: So they do come down, dont they? Dr Rivett: So you do have your schemes in place to encourage them, and there are excellent schemes and theyencourage more specialists to go rural, so they have been a great success. Senator NASH: Would you mind taking it on notice and providing to the committee how those schemeswork? Dr Rivett: Certainly. Senator NASH: Thank you. Senator MOORE: The AMA submission naturally spends a fair bit of time on the remoteness classificationissue. I am interested to see whether anyone wants to add anything to what is in your submission because it hascaused a lot of discussion with witnesses and with people who have given submissions to us. So is there anythingyou would like to add as to this constant struggle that governments—and I say governments—seem to have hadgoing back a long time in defining remoteness and regions and all those things? Dr Rivett: The current scheme is a nonsense. When it first came in everyone thought it was going to be animprovement on RRMA but it is actually worse than RRMA. I am a doctor who provides on-call service to thehospital on one in three days. Our hospital is run by GPs. There is no specialist help there virtually at all. I get thesame government incentive to work there as somebody living in Hobart does. The way it is being done at themoment is just plainly idiotic. They will bring out lots of excuses and say, This parameter is different to thatparameter and youve got to look at the road distances instead of a common-sense approach. Senator MOORE: Where is road distance from, for you? Is it Canberra or Sydney? Dr Rivett: Most of our tertiary care comes to Canberra. Senator MOORE: So on the scheme, is that under— COMMUNITY AFFAIRS REFERENCES COMMITTEE
  • 69. Friday, 11 May 2012 Senate Page 65 CHAIR: Would that be the measurement point? Dr Rivett: That is the most vital measurement in their classifications now. Senator MOORE: You are counted as coming to Canberra. You are in band 2. Where were you in RRMA? Dr Rivett: We were RRMA 5. Senator MOORE: So you actually had the highest rating under RRMA. Dr Rivett: No. It goes to RRMA 7. Senator MOORE: In terms of your allocation in RRMA, you were considered more needy under RRMA thanyou are under this? Dr Rivett: These other areas did not get benefits until the new scheme came in. A lot more doctors werecovered under the new scheme, including the whole of Tasmania. Dr Hambleton: The AMA has a solution in its submission. It recommends that we review the divisions and itsays, Lets make us continuous. Then at least there would not be this gaming between RA2 and RA3, where wehave got most of our problems. It has been done. It has been introduced. If not, let us have a more granularstructure. Senator MOORE: Yes. It is one of the huge issues. We have heard it in every place we have been, except theNorthern Territory, which was all the top one. The other issue is the payment process. The AMAs submissionrecommends that we have a standard rural payment that is put on for all doctors, the rural— Dr Rivett: Loading. Senator MOORE: The rural loading. Have you given any thought to what level of loading that would be? Itsays there should be a loading. Dr Rivett: Yes. The suggested percentage loading is in that attachment to the paper. They are onlysuggestions. The levers will need to be tweaked to see how successful it is. That came as an attachment to theAMA paper. Senator MOORE: I am sorry. Sometimes the attachments do not come through. Dr Rivett: The good thing about the loading is that it drives people to work longer hours also. It encouragesthem to see more patients because it is a per patient episode loading. It is not a weekly payment or an annualpayment where you can see a small number of patients and still collect the same incentive. If you work harder,you will get a bigger payment. We certainly want to see people working harder to meet the need that is unmet inrural and regional Australia. Senator NASH: How do you balance that with your earlier comment about doctors needing a lifestylewhereby they can actually enjoy the community, enjoy their job and have some sort of balance? There is thiscrazy work ethic. Then you have a per patient loading and, as you were just saying, doctors can work harder. Isthe balance just in the middle there somewhere? Dr Rivett: This covers both fields. If somebody wants to work fewer hours, they still get paid more per hourfor those hours. If they are a workaholic and they enjoy working 70 hours a week, which I used to enjoy doing butdo not any longer— Senator NASH: They will be able to be compensated for that. Dr Rivett: they will earn even more. But that should not be driving them, no. It should be work satisfaction,not monetary reward. But there needs to be some to differentiate it to the younger graduates coming though andsaying, If I go to rural Australia, even if I just do it for three, four or five years, I am going to pay off my housemortgage in that time. Hopefully, some of them will stick and stay there. Certainly, not all of them will, but ifthere is some sort of incentive to get them there to give it a go, a lot of them will put down roots. If they can gettheir family to go to school and their wife to find a job there you have got the battle won. Senator MOORE: Dr Rivett, I am sorry. The attachment has not come through. Dr Hambleton: We will undertake to get that to you. CHAIR: It is on the website. When we are producing the packs, it is often quite bulky. But we do have it. Senator MOORE: I am interested to know exactly how much money we are talking about. I read thesubmission and saw that there was a recommendation. I do apologise. I am trying to— Mr Hough: Senator, if I can— Senator MOORE: That would be useful. I am just interested in the money. COMMUNITY AFFAIRS REFERENCES COMMITTEE
  • 70. Page 66 Senate Friday, 11 May 2012 Mr Hough: The overall funding that we calculated—this was a couple of years ago—was in the order ofabout $300 or $400 million dollars per annum. Senator MOORE: Per doctor, but not— Mr Hough: Per doctor—we would settle for that! That also reflects the reality, though, that there is a disparityin terms of Medicare access for rural versus metropolitan people, who proportionality get a much better share ofMedicare funding. So in some ways it simply redresses some of that imbalance. Senator MOORE: Which is based on usage, though. Mr Hough: In terms of per capita, yes. Senator NASH: You never know this, but I am interested in what the annual expenditure is for provision oflocum where there is not a doctor. Are there any state figures or federal figures on that? Dr Rivett: The state figures would be very interesting to see because we see musical chairs getting played allaround New South Wales where a doctor will not work in his own community for the weekend but go to anothercommunity 80, 100 or 200 kilometres away and get paid a large sum by the state government to be the on-calldoctor. The whole thing has become farcical, really. He can earn more in one weekend in another town thanworking at the surgery for 50 or 60 hours. So the specialist in rural areas are doing the same thing. They are flyingto other towns to provide obstetric care or anaesthetic care over a weekend or a week for a couple of weeks whilesomebody is on leave and earning much larger sums than they can earn billing people through Medicare in theirpractice. Senator NASH: I asked the question in the context that it might be quite a significant saving. Dr Rivett: If you can encourage people to provide services locally in the long term— Senator NASH: And you do not need the locum requirement, yes. Senator MOORE: This is a proposal you have put to government a number of times. Dr Rivett: Yes. Senator MOORE: The other issue is that certainly as the AMA your focus is the doctor issue but are issueslike incentive payments the kind of thing that could flow on to other medical professions? One of the things wehave heard in our evidence is that a lot of the programs that the governments have been driving have been focusedon doctors. The issue at which this committee is looking is much wider than doctors. It is services. In terms of thatkind of work, is there any view that the kinds of things you have put out from the AMA, such as the incentivepayments, could flow on to other— Dr Rivett: When I spoke to Health Workforce Australia I supported that concept very strongly, especiallystudent training and the repayment of HECS and students going to rural areas to do physio or whatever. We needall those people in rural Australia and there are no incentives for them at all. Talking to those other groups aboutwhat incentive they have to go rural, it is virtually nil. Care is not just about doctors; it is about a whole team.They have to be a happy team and attracted to go outside the cities. Senator MOORE: Do you have nurses in your practice in Batemans Bay? Dr Rivett: Yes, we have two nurses. Senator MOORE: Do you have any difficulty in attracting nurses to your practice? Dr Rivett: Usually yes but having just advertised last week and got six applications straightaway I would haveto say no! But I have been advertising for six months now for doctors and spent about $4,000 on advertising andthe only applicants who have been interested are people from Iran, India and others outside the country. If youcannot get people to come somewhere like Batemans Bay, what hope have the little towns west of the divide got?Things are pretty grim. Senator MOORE: Absolutely. Dr Hambleton: As we say on page 3 of our submission, it is not just about remuneration. That is important.We have to focus on that. It is the lifestyle factors, the professional isolation and the support of the spouse,whether you are a doctor or not, to make sure the other family members are looked after. It is education andeducational opportunities. It is the ability to get back to the big city every now and again. It is sufficient variationin the work you are doing to make it a nice and welcoming place to work. It is all of those non-medical and non-hospital things that make such a difference. Accommodation for locums and students can make a heck of a difference. Things like the lack of a requirementfor a doctor to buy the building and set the practice up can make a difference. A doctor thinks, It is five years inthe bush; maybe I will buy a practice and set it up. But then in five years Ill have invested all this money and Ill COMMUNITY AFFAIRS REFERENCES COMMITTEE
  • 71. Friday, 11 May 2012 Senate Page 67be stuck. So they will not go there in the first place. If the facilities are provided that can make a heck of adifference and make it less of a concern that you are going to be stuck there. If you have to own a house and ownthe practice people might not go there in the first place. Senator MOORE: What would be the alternative to buying a practice and setting it up? Dr Hambleton: There are already some areas where walk-in walk-out surgeries are available—in other words,there is a private practice section built on to perhaps a public hospital and the facilities and infrastructure arethere. It reduces the risk to the doctor. Senator MOORE: Is that a state government kind of thing if it is built on to hospital? Dr Hambleton: It can be state government or it can be local council. There are businesses that offer the samecorporate type of structure. If there are a few partners you do not have to buy into the practice to work there. Theycan make rooms available. In a solo doctor town, making that step of going there and purchasing your owninfrastructure is often a step too far. Senator MOORE: A member of parliament told me about a regional centre where their community hadpulled together to provide housing, infrastructure and all kinds of things and still could not attract a doctor. Thatwas a regional program where they said, We need a doctor in this town, and put all this stuff together and put outan advertisement for a doctor. They did not get applications either. This was two years ago. I have not followedup. It was Kay Hulls electorate. Dr Hambleton: It is terrible to hear those stories. It is not really saying, We have the solution. We willprovide the infrastructure. As we say, it is about more than that. Even worse, it is government policies from two,three or four health ministers ago when they said, Every doctor costs the Medicare system X dollars; therefore,we will not let the universities increase student intake and we will save money. That meant that, 15 or 20 yearsdown the track, here we are. CHAIR: Thanks very much. I think we have covered quite a lot in a relatively short space of time. Proceedings suspended from 17:07 to 17:19 COMMUNITY AFFAIRS REFERENCES COMMITTEE
  • 72. Page 68 Senate Friday, 11 May 2012ANDREATTA, Mr Lou, Assistant Secretary, Department of Health and AgeingBOOTH, Mr Mark, First Assistant Secretary, Department of Health and AgeingCUTTING, Mr Paul, Acting Director, Department of Health and AgeingFLANAGAN, Ms Kerry, Deputy Secretary, Department of Health and AgeingSHAKESPEARE, Ms Penny, Acting First Assistant Secretary, Department of Health and Ageing CHAIR: Welcome. I know you know information on parliamentary privilege and the protection of witnessesand evidence, but I have to check that you know. I remind witnesses that the Senate has resolved that an officer ofa department of the Commonwealth or of a state shall not be asked to give opinions on matters of policy and shallbe given reasonable opportunity to refer questions asked of the officer to superior officers or to a minister. Thisresolution prohibits only questions asking for opinions on matters of policy and does not preclude questionsasking for explanations of policies or factual questions about when and how policies were adopted. We have yoursubmission. It is No. 74. Do you wish to make an opening statement? Ms Flanagan: No, we do not wish to make an opening statement, since we have got, I think, a verycomprehensive submission from the department. CHAIR: I am going to go straight to Senator Nash, because she has to leave us. Senator NASH: Thanks. In the evidence that has been presented before us are a range of things that arecoming up under the terms of reference, but one of the things that is particularly causing some angst—and I amsure you will not be surprised about this—is the use of the ASGC-RA map to determine the arrangements when itcomes to the incentive payments for the doctors. The ABS say in their submission that it is a purely geographicmeasure of remoteness which excludes any consideration of socioeconomic status, rurality and population sizefactors. It has been put to us that those things—socioeconomic status, rurality and population size factors—are thevery things that should be taken into account when determining the provision of incentive payments. Can youperhaps give us a bit of background to start with on why the ASGC-RA map is being used for the incentivepayments? Ms Shakespeare: There might be a technical point that we need to clarify about the population size before weget into the reasons we have used RA. Mr Cutting: While it is true to say that the ASGC-RA does not look at population very locally, it is still basedon distances to population centres. Senator NASH: But they are two very different things, arent they? Mr Cutting: They are very different things. From that position to say that it completely ignores population isprobably— Senator NASH: I should say: ignores geography from population size. Ms Shakespeare: Previously health workforce programs were related to a system called RRMA, which wasquite out of date because it had been developed in 1994, I think, and had not been updated with more recentpopulation data. So there were issues with the use of that system which the government decided to address. It hada review in 2008, looking at new systems that could be used—other geographical systems to base workforce andGP incentive payments on. Following that process, it decided to use the RA system because it was kept up to date.It was developed by the ABS, and they update it with census data. That decision was made in 2009-10, and theworkforce programs based on RA started operation on 1 July 2010. Senator NASH: Is the department aware of the concerns in the sector about the size of populations and theability to deliver a service for towns—I am talking particularly about the inner regional areas—that is illogicaland inappropriate when it comes to the incentive payment? Put quite simply, if you take a region in New SouthWales and you look at the town of Wagga, which has 63,000 people and is a very distinct, good service-provisionarea, and a town like Gundagai, which is about 2,000 people and has not much in the main street, you will findthat if a doctor moves to either of those two places they are given exactly the same incentive payment. Is thatsomething you are aware of? Has that been raised with you? Ms Shakespeare: Yes. It has been raised over the period of time that the system has been operating, since 1July 2010, and there has been a review. The government asked the University of Adelaide— Senator NASH: What has been the response to the concern that it is illogical, because the incentive is notthere because of those two very different types of locations getting the same incentive payment to doctors? COMMUNITY AFFAIRS REFERENCES COMMITTEE
  • 73. Friday, 11 May 2012 Senate Page 69 Ms Shakespeare: There are a number of factors that doctors will take into account when deciding where topractice. Senator NASH: I did not ask you about that. I asked you what was your response when the unfairness andillogical nature of the incentive payments for doctors in those two very different types of towns was raised withyou? Ms Shakespeare: One of the responses was to commission the University of Adelaide GISCA, which is anexpert on the social application of geographic systems, to undertake a review of some of the issues that werebeing thrown up by the use of RA. That included places like Charters Towers and Cherbourg. They looked at avariety of locations that were either on the border of RA classifications or, because of their distance topopulations of particular sizes, might be surrounded by areas that were considered of greater RA classification. The government commissioned that report and that was provided in 2011. So it is not that there has not beenany response. The government needs to consider the recommendations of that report. The other thing that thegovernment needs to consider is that this system has not been in operation for very long and workforceprograms— Senator NASH: But it is not going to change. The criteria is not going to change. Ms Shakespeare: have an impact over a long period of time. If we are chopping and changing very quickly itdoes not allow you to see the impact of the programs. Senator NASH: Seriously? CHAIR: Hang on— Senator NASH: Sorry. Ms Shakespeare: As you will see at page 11 of our submission, the early data on the use of RA as a basis forhealth workforce program incentives has been quite positive. So we need to ensure that if are making— Senator NASH: Can I just clarify that you are talking about getting doctors to move to the regions. Ms Shakespeare: Yes. Senator NASH: But that is not the issue. It may well have been positive and it may well have got doctors outto the regions. The point is, where are they going to? I have to go. I am very sorry, because I would much rather say. Does the department think that there is not aproblem with the way that it is at the moment? Ms Shakespeare: No, I do not think that the department thinks that there is no problem. It is just that we needto make sure, if we are going to make changes to the geographical classification system underpinning ourprograms, that we have fully thought through what the implications of those changes are. If we change boundariesand include particular places in higher classifications does that then have a flow-on effect to more remote townsthan the ones that have been raised in the evidence today? Senator NASH: But it would seem illogical, would it not, that you are asking a doctor to move from Sydneyand the options for that doctor are Wagga Wagga, with a population of 63,000, specialist services, a hospital and aplethora of medical services, and Gundagai with—as I think a doctor said this morning—a Chinese restaurant, anRSL and a war memorial and not much else, and a complete under-servicing of doctors, yet the incentive paymentis exactly the same? Isnt that entirely illogical? Ms Shakespeare: I think that— Senator NASH: I will view your response on record but I have to go. CHAIR: I am very interested in it. I want to follow up several of the questions that Senator Nash asked. Ms Flanagan: One of the things we would say is that it needs to be looked at in the totality of differentincentives that are provided to try and get more doctors into rural Australia. That is the objective. I think wedocument in our submission a range of different programs that we have. This particular element is certainly onepart of that. There are programs around locums and there are both push programs and pull programs to try to getdoctors into rural areas. So I think we have to look at the totality. In fact, coming out of the budget announced on Tuesday it has beenagreed that we will look at all of our programs. The Commonwealth, from the Department of Health and Ageing,spends upwards of one billion dollars a year on workforce programs. Many of those are targeted exactly at tryingto get better distribution of the workforce across Australia. We are going to do an internal review during 2012-13to see what that looks like. COMMUNITY AFFAIRS REFERENCES COMMITTEE
  • 74. Page 70 Senate Friday, 11 May 2012 At the moment, this committee is focusing in particular on distribution issues, but there is a recent report thathas come out from Health Workforce Australia which suggests that, for example, we are going to have a shortageof nurses out to 2025. So we are taking the opportunity to have a look at our programs to see, if we need to dofurther distribution, whether we can make them more relevant to do that but also whether we have got the balanceright in trying to attract the workforce where we need it in a numbers sense as well as in a geographical sense. Senator MOORE: Has the University of Adelaide review been made public? Ms Shakespeare: Yes. Senator MOORE: Is there any ongoing working group engaged with the range of professions and consumerswho have raised this issue with us? Has there been some kind of working group developed to keep an ongoinglook at the work that is going on about this classification area? Ms Shakespeare: As far as I am aware, there is no working group, but this would be one of the issues that weconsult with stakeholders about during the review of workforce programs that the government has decided toundertake. Senator MOORE: So, between 2011 and now, there has been no particular engagement with consumergroups, universities, the AMA, physicians—all those people—around this review, but it is going to be part of thewider work that is going to start soon? Ms Flanagan: Mr Andreatta might like to say something, but—I have lost my train of thought, so he hadbetter say something! Mr Andreatta: We have had ongoing discussions with the ABS, GISCA, the RDAA and the AMA since theintroduction of the RA classification. We have kept them up to date on any new developments on the monitoringthat we have been conducting. They have provided us with locations where their members have said that therewere problems. We investigated those, and that was part of the GISCA review as well. We have regular meetingsto talk about the RA and how it is progressing. We talk to the ABS regularly about the introduction of the newversions of the data that underpins the classification. Senator MOORE: By the end of this year, we believe. Mr Andreatta: Yes. Mr Cutting is probably better placed to explain exactly how that discussion with the ABSgoes in terms of trying to improve what we have got. Mr Cutting: There have been discussions ranging back to GISCA, discussing the way they actually look at itand where the breakpoints are. While the ASGC-RA still stays fundamentally a distance classification, it ispictured that the new ASGS will be calculating this at a much smaller level—CCD, I think. Senator MOORE: But no lower than CCD? We spoke statistics speak this morning and we are right acrossit! No, we arent! CHAIR: You had him going then! Mr Andreatta: Street level, I think he said. Mr Cutting: Especially street level. We are calling them mesh blocks. I think that terminology has been lost,but you are looking at sort of 100 people in an ideal sort of central city area, but I will have to go back and take alook at that classification to pin it down. Senator MOORE: I had known that the review was public; I just wanted to get it on record, because it is notin the submission. In terms of the process, it still seems that there is great discontent, and the people who havebothered to give submissions and come to give evidence to this committee still rate it as one of the key issues interms of their discontent with how the system is operating. In fact, the AMAs evidence says it has actually takenit back to being worse than the RRMA experience. CHAIR: A number of people have said that. Senator MOORE: We remember great discussions at most estimates about RRMA classifications and wherepeople fit. The statements that people have made are that it is worse than RRMA. Just in terms of where we goforward, it is important to know that there is a disconnect between what is being portrayed as something that isworking well and what people are saying to us. There is a disconnect there, so that is important to know. Theother thing is the evidence that the incentive schemes are working. Is it based on statistics of how manypractitioners have actually moved to the areas? Is that the only outcome? Ms Shakespeare, I think you said thatthere was evidence that the incentive process was working. So is the only outcome the number of people whohave moved? COMMUNITY AFFAIRS REFERENCES COMMITTEE
  • 75. Friday, 11 May 2012 Senate Page 71 Ms Shakespeare: What those numbers are based on, which is set out in our submission, are Medicare billingstatistics. So there have been increases since the package of programs started on 1 July 2010. It is very difficultfor us to isolate the impact of one particular aspect of that compared with the other programs that we have for theworkforce, but it shows that overall in the RA2 to 5 areas there has been an increase of over four per cent in full-time work equivalent GPs based on Medicare billings. That is sustained across each of the RA areas; it is not justin RA2 or 3, where there are large centres like Townsville. Senator MOORE: And small centres like Gundagai. CHAIR: Can I go back one step to the process of review for the Adelaide report. You said that thegovernment is yet to respond to it. That is what I understood you to say. Is that correct? Ms Shakespeare: There is a response. The government is considering the findings of the report. CHAIR: Yes, sorry. Is that now going to be wrapped up as part of the internal review process that you weretalking about, Ms Flanagan? Ms Flanagan: We are going to look at all aspects, including this particular program. We are also contactedvery regularly with concerns about this program. It is a relatively new program. Again, as I think Ms Shakespearesaid, when you think about a GP making a decision to move to a rural area, they do not necessarily just up sticksfrom metropolitan Sydney or wherever and decide to move. So one of the things that we are concerned to do is togive it a little more time to see whether it is actually producing the results that we expect. Early indications arethat we are seeing an overall increase in the services provided in rural Australia, but it is very early on in theprogram to really get a good understanding of whether it is going to achieve results. Senator MOORE: The distribution is fine. I have this information in front of me and it is positive, thoughthey are most positive in the RA5 area. I think the RA2 area is where we have had the most pressure. Is there anyinternal assessment of these differences? If this is rating all RA2 areas across the country, is there anything thatcan give us information about how many people have moved to Toowoomba, as opposed to how many peoplehave moved to Roma? Mr Andreatta: As part of the review we have looked at individual towns, and they are the ones that wereidentified by the Rural Doctors Association. Senator MOORE: But you only had 23 and that is a really small sample. Mr Andreatta: We looked at those. We looked at why doctors were moving and there were reasons notrelated to financial incentives. There were other reasons. Some were retiring and some were moving to othertowns because of spouse employment issues. So I guess there are a range of reasons why the distribution— Senator MOORE: So perhaps they would have moved anyway and it had nothing to do with the programs. Mr Andreatta: It could well be. Ms Flanagan: Possibly. It is really hard to tell. Mr Andreatta: We just do not know. CHAIR: The point is—I will use the examples we have been using today—Gundagai and Wagga Wagga havethe same rating of RA2, so the doctors would get paid the same. What people have been saying to us is: Whywould I go to Gundagai if I could go to Wagga, where I can go to the pictures? or whatever—all the things youwere talking about that relate to quality of life. This is not going to show up, is it? Mr Andreatta: No. CHAIR: That is the point they are making: My family is going to want to go to Wagga because there is betterschooling in Wagga and I get a better quality of life there because I get more access to services. So what processdo you have to highlight where people are going within the classification? It is the same question Senator Mooreasked; I suppose I am just reinforcing it. Ms Flanagan: You would almost need to do that by survey work, to ask why they made the decision theymade. In some of the survey work we have done—we have not specifically asked about whether someone wouldmove to Wagga or to Gundagai—a lot of the decision is based around non-financial incentives. CHAIR: Sorry to interrupt, but the point they are making is that if you gave a bit more incentive, if youfurther defined RA2, for example, or you used some other factors as well, the extra financial incentive could beenough for them to say, Okay, its worth me being here because Im getting a bit more recompense for the extrawork that I do. And it is extra work. Their argument is that it is extra work. That extra incentive then makes itworthwhile for them to move, forsaking those other benefits in another town. That is their argument. COMMUNITY AFFAIRS REFERENCES COMMITTEE
  • 76. Page 72 Senate Friday, 11 May 2012 Senator MOORE: When a practitioner at Batemans Bay has been advertising for seven months for a doctorand he cannot get any response—I say he because it is all on record—one of the issues that dwells on his mind isthat any practitioner in Hobart can be advertising at the same time. There are a whole lot of reasons why you go toa different place, but he is saying that if he is in Batemans Bay he is in the same competitive model as Townsvilleand Cairns, and Hobart on the other extreme, and that makes it particularly hard to say to someone, There will besupport for you to come and move to our area. I know you have given evidence that you are aware of it and that itis a process, but it is a running issue with the areas and has been mentioned everywhere but the NorthernTerritory. They are remote and classified as RA5, and that is where you have had the biggest growth. CHAIR: We have only got a bit over 15 minutes. I have a plane to catch—I am very keen to go home. Is theprocess of your internal review going to look at this within classifications? I have not heard people say you havenot been getting doctors into the bush, but the question is where they are going within the classifications. Throughyour internal review, are you looking at a process for identifying that? I understand what you are saying that itwould presumably have to be qualitative rather than quantitative. Ms Flanagan: We have the draft terms of reference framed at the moment. This is something we can look at,but I have to say that all the evidence I have seen is that financial incentives would have to be much increased toactually tip somebody in terms of their behaviour. There are lots of other things. For example, it might be veryattractive to live in Gundagai because housing is cheaper than in Wagga—I do not know whether that is true ornot. Senator, you look sceptical. Senator MOORE: I am just thinking that there are not that many houses. Ms Flanagan: I used to drive through Gundagai quite a lot, to Batlow, in fact. Senator MOORE: Even the most concerned submissions accept that the incentive payments are but one ofthe elements that make people change their lifestyle. There are a whole lot of other things they are suggesting thatwe can do to make it more attractive to practitioners and their families to move, but because this has been themost recent change it is the area of comparison. Ms Flanagan: Certainly the review will be trying to look at the whole suite of products that we have to try toincentivise behaviour, and this will be one of them. CHAIR: The National Rural Health Alliance have given us a 20-point plan, which we will give you. It wasone that they tabled; it was not part of their original submission. It is saying exactly what you said—it has a widerscope and is not just saying we should change the classification. Not one person has said, Fixing what we see as aproblem is the answer; they are all taking an integrated approach. Senator MOORE: We have had a number of comments about the use of overseas doctors and a number ofclaims that it is short term and the end result is not going to be better medical practice in their region. There arealso some concerns about the degree of competence—people being very careful not to be in any way derogatorybut genuine concerns about the levels of skill for people who have that as their only way into the system asopposed to an option. I think that would be a fair way of putting it. There is also great concern expressed by people on the 10-year moratorium process. Can you give us someindication of when the 10-year moratorium came in, how it works and just some indication about policy in thatdirection? Ms Shakespeare: I think we might have to get back to you on when it started. Senator MOORE: It is not particularly mentioned in your submission. If you would like to send up somemore information, because it has been particularly identified by some groups as a negative. Ms Shakespeare: I think it has been going on for a while. Ms Flanagan: Yes, I think it is 1990s. Ms Shakespeare: We will take that on notice and get back to you. CHAIR: I did specifically want to go to the training aspect and Aboriginal health workers. When we were inthe NT I must say I was very pleasantly surprised with the report from Congress and the excellent work they havedone. They were very proud of the fact that they had a really good retention rate and did not have any vacanciesother than audiologists—they were a little embarrassed about not having audiologists. Senator MOORE: They were pretty embarrassed to have to even admit to us that, because they have alwaysbeen so perfect before. CHAIR: There are still ongoing health issues—no-one is pretending that it is all fixed—but one of the keythings that came up everywhere, even when we were doing the Stronger Futures inquiry it came up, was COMMUNITY AFFAIRS REFERENCES COMMITTEE
  • 77. Friday, 11 May 2012 Senate Page 73Aboriginal health workers and not getting enough people into the system, struggling to keep up with therequirement for updating their qualifications, an ageing workforce. So I am very interested in looking at how youare dealing with that. It is not the first time we have heard it, by the way. Ms Shakespeare: There is a few things to mention there. Firstly, from 1 July this year there will be a newcategory of health professional through the National Registration and Accreditation Scheme, which is theAboriginal and Torres Strait Island health practitioners. CHAIR: And this is playing into the concern. Ms Shakespeare: That, as you are probably aware, will require certificate IV, which is training provided by abody accredited by the new ATSIHP board. That, I think, has been received quite positively as it is going toprovide a career pathway potentially for people who are Aboriginal health workers who are looking to providemore clinical services. There are programs in place, certainly, to help people with training to get to certificate IV.Health Workforce Australia has quite a significant program to up-skill Aboriginal health workers so that they canbecome qualified under the new practitioner NRAS regime. We also have the Puggy Hunter MemorialScholarship Scheme, which provides support to Aboriginal and Torres Strait Islander people who want to dotraining in any clinical field, and that would include certificate IV for Aboriginal health workers clinical training.I imagine that there would be a range of programs also running through FaHCSIA and DEWR to assist peoplewith readiness for training. So think that there is probably a lot of Commonwealth programs in place there, butthere may be a piece of work to do to get people into the training. CHAIR: That is the point. I do not doubt anything that you have just said. Given the level of concern that wasexpressed to us—and I have got to say that it has been previously—it seems to be there is something missingthere in terms of people accessing. One of the things that an older Aboriginal health worker said to me was, Imflat out in my community, I am flat out looking after my family: I actually cant get out of community to go andactually do training. The concern was who would look after the family. There were financial issues as well. Thereare whole range of reasons why people are not accessing it. What was put to us—and I do not think I amexpressing this to strongly—is that there is going to be a real problem if something is not done real soon. Senator MOORE: Yes. Ms Flanagan: Can I just mention two other things there? Within the suite of products that we have, our locumarrangements for, say, nurses who want to leave their rural community to do some extra training; we enable thatto happen. I do not know whether we have many applications from Indigenous people to do that. Again, this canbe part of the review. The second thing is that when health ministers are discussing this—the Northern Territory,WA and Queensland are talking about having a more integrated, regional Top End training workforce supportinfrastructure, which I think might go to some of the issues that you have heard about. We can get you some moreinformation on this. CHAIR: Any additional information you could provide would be appreciated. It is an area that needs someurgent attention. Each time now I seem to be going to a community where concern seems to have escalated. Senator MOORE: Over a number of inquiries. CHAIR: Yes. Did you have Medicare Locals? Senator MOORE: Yes. There have been a number of comments about Medicare Locals. Most people are atthe stage of saying: Theyre new. Well see how they settle. There have been a couple of specific issues. One isthat there is no mention of specialists in Medicare Locals and we were told that in the development and role ofMedicare Locals there was a view that specialists were not involved. Another thing was ongoing discussion aboutthe after-hours process, particularly from medical witnesses. There was concern about the control of after-hoursfunding and the role of Medicare Locals as a funds holder and body that allocates funding. That was raised. Also, from one area, the definition of after hours was raised. We were told that in this particular region afterhours was defined as between five and eight in the evening. That does not seem to me to be after hours; that is anextended service, but it certainly is not providing care in a significant region. The make-up of Medicare Locals was raised. Every professional group feels as though they should have a rolein Medicare Locals and that, if they are not in it, it is not going to be able to operate. We have had the Rangerreview suggest that it should be totally GPs because only GPs know about what happens. Everyone—allied healthand community people—has been putting forward their own view that if it is going to be truly representative ofthe community, and able to respond effectively to its needs, they have to be represented. They were the key issuesthat came up. Mr Booth: There are a few points to that. I will try to— COMMUNITY AFFAIRS REFERENCES COMMITTEE
  • 78. Page 74 Senate Friday, 11 May 2012 Senator MOORE: Mr Booth, start with this and then possibly put a little bit together on notice. That wouldbe good. Please give us some time, but because of time shortages there could be some more things you want tosend us. Mr Booth: I am happy to do that. Just briefly, then, on the make-up of Medicare Locals: Medicare Locals, asyou know, have been established to provide a population health perspective of a particular region and a particulargeographic area. The Medicare Locals have been tasked to do a number of things, one of which is to look at thehealth needs and requirements of the population within their area and, also, to look at the professional servicesthat are available. That includes general practice, allied health, community health, specialists working in thecommunity— Senator MOORE: So specialists are mentioned. Mr Booth: Absolutely, yes. Specialists are very much part of what Medicare Locals need to work with. Infact, we have been doing a lot of consultations and discussions with the Royal College of Physicians who lookafter the specialists. Senator MOORE: Perhaps there could be a little more work there, Mr Booth. Mr Booth: In terms of— Senator MOORE: Discussion with the Royal College of Physicians. When you have a look at Hansard— CHAIR: Maybe if you have a look at Hansard and take it on notice to respond to that. Mr Booth: I was talking at their annual conference yesterday. Senator MOORE: In Brisbane, I believe. Mr Booth: In Brisbane, absolutely, and I was discussing this very issue about the role of specialists inMedicare Locals. CHAIR: Your response would be appreciated. Mr Booth: Yes. What Medicare Locals are particularly looking at is patient flow, and how we look at thebarriers between primary care and secondary care and ensure that there are pathways that link primary andsecondary care together. Specialists clearly have a key role in doing that. The make-up of Medicare Locals wasvery specifically designed that there should be skills based boards are not goods that were dominated by any onesingle profession. When Medicare Locals were established, it was indicated that they should have boards of nineor 10 people and on the boards you should have people who have a good knowledge of the local healthcommunity, you would have community representation, you should have legal, financial—the kind of skills thatyou would find on any board. Clearly there is not room for every single health profession on that board; it just isnot possible. However, the Medicare Locals do have a series of advisory boards and advisory groups underneaththem, including cross-membership of those advisory groups with local hospital networks to make sure that you doget that wider range of allied health, hospital based, all those ranges into there. That is working well. MedicareLocals have been established and are moving like that. We can give you more information on that. What is happening with after hours is that the funding for after hours is increasing and there is significantlymore money going into after hours. Historically what has happened with after hours is that some areas have beenvery well provided for and other areas have been very poorly provided for. That is because of the way theseservices have developed. Instead of doing a practice incentive payment direct to the practice, the money is goingto the Medicare Local so the Medicare Local can look across the whole of their community and the whole of thearea. If there are after hours services that are working well, they will carry on being funded, but with the increasedfunding Medicare Locals will be able to look at those areas that are not being served very well in after hours andtry and put solutions in place there. So it is about getting better after hours services across the country. Senator MOORE: The Medicare Locals are aware of the concerns. Mr Booth: Absolutely. They have put specific plans in place as to how they are going to increase after hours. Senator MOORE: And how to communicate with the people who are aggrieved by the change? Mr Booth: A lot of Medicare Locals are doing those discussions and we are doing discussions as well. That ishappening and that is going on. Another thing to mention in the after hours space is the GP after hours helplinewhich has been introduced and is now available across the whole of the country. Victoria signed up and hadpeople coming on about a week ago. Queensland has also signed up. So from anywhere in the country you cannow get to services. We normally define after hours as after six and going through the weekend. Senator MOORE: So not five to eight. Mr Booth: No. COMMUNITY AFFAIRS REFERENCES COMMITTEE
  • 79. Friday, 11 May 2012 Senate Page 75 Senator MOORE: Could you check the Hansard today of some evidence as well. The other thing that camethrough deeply from regional areas was the involvement of GPs at local hospitals and the way it has caused greatproblems and GPs are just not doing the work. The inference was that people who were there not by choice werenot picking up work in the hospitals either, so it was an ever narrowing group of people on whom local hospitalswere relying and it was creating great workload disincentives. I would think that the LANs would have a role inworking on that issue, but some of the evidence we got today really focused on that from a range of differentsubmitters. I thought that was an interesting thing. I think we are in a situation where anything else will have to beput on notice. CHAIR: There is one thing I want to raise for you to take on notice. An issue that has come up repeatedly isgeneralist specialists. It has come up everywhere and the need for this and the dual pathway that New Zealandruns. You have dual specialists? Ms Shakespeare: Under the specialist training program we are now assessing applications for the 2013intake. That is one of the priorities, the criteria for assessing applications. CHAIR: Thank you very much. I am sorry to rush you. There is only one plane to Perth a day and I want to beon it. Senator MOORE: Can I also put on record that everyone was very pleased about the Workforce Australiareview of workforce. People were speaking very positively about that, and also the report that came out recentlythat the minister released about 2025. They all felt that was a very positive process of actually doing that work. Ithink the good thing should be mentioned as well. CHAIR: And thank you for staying to six oclock on a Friday night. Thank you to Hansard, broadcasting andthe secretariat. Committee adjourned at 17:59 COMMUNITY AFFAIRS REFERENCES COMMITTEE

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