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Inquiry into Health services and medical professionals in rural areas

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Community Affairs References Committee Hansard

  1. 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. 2. INTERNETHansard transcripts of public hearings are made available on the internet when authorised by the committee. The internet address is: To search the parliamentary database, go to:
  3. 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. 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. 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. 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. 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. 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. 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. 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. 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. 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. 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. 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. 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. 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. 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. 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. 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. 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. 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. 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. 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