November 1996

© Commonwealth of Australia 1996

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Participating Members





The Bill was referred to the Committee upon its introduction into the House of Representatives for report on 7 November 1996 by the Selection of Bills Committee in Report No 12 of 17 October 1996, for consideration of the following issues:

The impact of the provisions which limit benefits to services provided by medical practitioners with formal postgraduate training, and the impact of the provisions of the Bill which relate to an increase in the maximum gap between benefits and fees.

The legislation was introduced into the House of Representatives on 17 October 1996 and was passed by the House 6 November 1996.

The Committee was to report on 29 October 1996 however the Committee sought and obtained from the Senate an extension of time to report, to 21 November 1996. On 18 November 1996 the Committee sought and obtained from the Senate a further extension of time to report, to 25 November 1996. The Senate agreed on 25 November 1996 to a further extension of the reporting date to 26 November 1996.

Other developments relevant to the Bill

On 16 October 1996 the Minister for Health and Family Services, the Hon Michael Wooldridge MP ('the Minister') announced that, as part of the Government's commitment to improving health and medical services for people in country areas, new doctors would be allowed to use the provider numbers of rural GPs on a temporary basis for the purpose of providing locum relief. [1]

On 29 October 1996 the Minister announced a ten year moratorium on granting Medicare Provider numbers to newly arrived medical professionals, in a move which the Minister estimated would cut the numbers of overseas trained doctors each year from about 600 to about 100. [2]

All overseas trained doctors who have not registered to practise in a State or Territory or who commence the Australian Medical Council (AMC) assessment process by 1 January 1997 will not be eligible to receive a Medicare provider number for billing under Medicare for at least 10 years. New Zealand trained doctors and overseas students who are graduated from an Australian medical school are included in this measure. [3]

The Minister stated that he would be asking the Australian Medical Council to ensure that all applicants for the AMC exam, including those already here in Australia, will only get two further attempts or two attempts in total if they have yet to commence the exam, at a maximum of five years to complete the process, as this is in line with the opportunity given to Australian students. [4]


The Committee received 96 submissions and these are listed at Appendix 1.


The Committee considered the Bill at five private meetings; public hearings were held on 7 and 18 November 1996. Details of these meetings and the public hearings are at Appendix 2.



Medical Practitioners recognised for Medicare purposes

The purpose of these amendments is to set minimum proficiency requirements which new medical practitioners must meet before the services they provide attract Medicare benefits. [5]

A number of minor amendments have also been made to improve the administrative efficiency of the operation of the Vocational Register for general practitioners.

The date of effect is Royal Assent or 1 November 1996.

Financial impact

The financial impact of the above proposed amendments for all medical practitioners, including overseas trained doctors, will result in savings estimated at $23.6m in 1996/97; $100.12m in 1997/98; $171.4m in 1998/99 and $241.67m in 1999/2000.

Level of Medicare Benefit

These amendments introduce a number of separate changes dealing with multiple services rules, the greatest permissible gap and payments for services of unusual length or complexity. [6]

The multiple services rules allow for fees to be reduced for later services when multiple services are provided to a patient. The measures are part of a package to strengthen the incentives in Medicare benefit arrangements to promote appropriate, quality and cost effective diagnostic imaging practice. The same multiple services rules concept already applies to pathology services and its introduction for general medical services aims to ensure uniformity across all services.

The maximum gap between the Medicare Benefits Schedule fee listed for any out of hospital service and the Medicare benefit payable for that service is to increase to $50.

The ability to seek an increase in fees for services claimed to be of unusual length or complexity is to be removed.

The Date of Effect is Royal Assent or 1 November 1996 for the multiple services rules and increase in the greatest permissible gap and on proclamation (or 6 months after the date of Royal Assent) for the removal of increased benefits for services of unusual length or complexity.

Financial impact

The implementation of the proposed regulations relating to multiple services rules for diagnostic imaging services would result in Budget savings estimated at $69.7 m over the period from 1 November 1996 to 30 June 2000 ($9.7 m in 1996/97).

Development costs and on-going administrative costs are estimated by the Health Insurance Commission (HIC) at $0.8 m.

The increase in the greatest permissible gap is expected to result in savings of $8.6 m in 1996/97, $15.7 m in 1997/98, $16.5 m in 1998/99 and $17.1 m in 1999/2000.

The savings to be achieved through the removal of increased benefits for services of unusual length or complexity are expected to be $2.4 m in 1996/97, $4.4 m in 1997/98, $4.7 m in 1998/99 and $5.1 m in 1999/2000.

Temporary Resident Doctors (TRDs)

These changes require that Temporary Resident Doctors meet proficiency requirements equivalent to those for Australian trained doctors before the services they provide attract Medicare benefits. [7]

The date of effect is 1 November 1996.

Financial impact

Savings for measures in Schedules 1 and 3 together accrue from a reduction in the overall number of doctors providing services under Medicare - $23.86m in 1996/97, $100.12m in 1997/98; $171.4m in 1998/99 and $241.67m in 1999/2000.



The Committee examined the following issues:

The impact of the provisions which limit benefits to services provided by medical practitioners with formal postgraduate training; and

The impact of the provisions of the bill which relate to an increase in the maximum gap between benefits and fees.

The majority of persons providing submissions to the Committee addressed the first of the two issues. Of the 96 submissions received by the Committee, only four addressed the 'Gap' issue in any detail those of the Royal Australian College of Radiologists (RACR), the Australian and New Zealand Association of Physicians in Nuclear Medicine (ANZAPNM), the Australian Medical Association (AMA) and the Department of Health and Family Services (DHFS).


The 'Doctor Providers' Issue Benefits related to doctors with post-graduate training'

The purpose of the legislation as set out in the Department's submission is to:

The Committee appreciates that these issues have been of concern to successive Commonwealth governments for a considerable number of years, and certainly since the 1980s.

The 1988 Committee of Inquiry into Medical Education and Medical Workforce chaired by Dr Ralph Doherty identified seven main areas in which medical graduates needed to have more training before they were qualified for general practice.

In 1992 the general Practice Consultative Committee document launching the General Practice strategy said '[the] AMA, RACGP and the Government support the principle that general practitioners should complete appropriate post-graduate training as signified by the FRACGP or equivalent'.

In 1992, Ms Jenny Macklin, now Shadow Minister for Health and then Director National Health Strategy, confirmed in the National Health Strategy Paper on the Future of General Practice that '[t]here is widespread agreement on the need for vocational training to produce doctors with general practice skills' (p73).

More recently Professor John Young speaking for the Committee of Deans of Australian Medical Schools said 'Medicare numbers should only be given to those who have completed post-graduate courses'. He went on to say that 'nobody could really argue that it is appropriate for people who have only done one year's internship to go out and be GPs'. [9]

The Department's submission provides a resume of the post-graduate training issue and Vocational Registration (VR), introduced by the previous government in 1989, and notes that 'while VR dealt with the question of appropriate training it did not deal with other key structural issues facing General Practice':

A joint AMA/RACGP/Departmental strategy document issued for discussion in 1992 'became the basis for the GP strategy which has been pursued by the Government since that time' and has been 'progressively refined and complimented with other measures'. [11]

With reference to the particular issues being examined by the Committee this strategy implementation includes:

AMWAC concluded in 1996 that the GP workforce is in considerable oversupply in the capital cities and major urban areas of Australia and significant undersupply in rural and remote areas. The urban oversupply is estimated at 4400 and the rural undersupply at around 500.

The Committee noted that the success of the previous measures to restrict the growth in doctor numbers generally, and GP numbers in particular, has been limited.

Related to the Committee's consideration of the Doctor Providers issue are the underlying associated issues of the implementation of Vocational Registration, the role and recognition of post-graduate training providers and the quality of training provided. These broader issues are not addressed in detail in this report.

The majority of submissions received by the Committee were from individuals, particularly current medical students and their families, who are opposed to the proposed changes to the legislation.

The Committee identified a range of common sub-issues arising out of the restriction of provider numbers addressed in the submissions placed before it. These include:


Policy goals underpinning the Government's changes

The Government reiterated the vital importance of the changes to the Committee, supported by the following reasons:

The majority of submissions and evidence received by the Committee supported the concept of post-graduate training for general practice.

The Royal Australian College of General Practitioners (RACGP) applauded the initiatives in the Budget which aim to correct the maldistribution of GPs between rural and urban areas and to increase the availability of locums to rural General Practice, however cautioned that it would be a retrograde step if the effects of the current government initiative (restrictions on provider numbers) in fact worsened the scarcity of permanent and locum GPs in rural and remote areas. The College proposed a wider range of incentives for both rural and urban practices to encourage a more rational distribution as well as a more viable basis which must involve more than monetary incentives and be relevant to families. The RACGP indicated its willingness to be involved with government in setting up the structure of these packages. [15]

The Australian Medical Students Association (AMSA) also pointed to the positive initiatives of the Government - the John Flynn Scholarships and initiatives to increase the medical profession's reliance on Temporary Resident Doctors (TRDs) and to initiatives of its own. [16]

Access to employment of choice by current medical students, new graduates and Junior Doctors

The majority of individual submissions from current medical students and practitioners, recent graduates, parents and friends of medical professionals were critical of what was perceived as the potential immediate loss of some of the best trained young Australian professionals who would not be able to access the employment of their choice.

The RACGP in its submission supported the restriction of access to provider numbers under Medicare to those doctors who have been trained or are training for a particular medical discipline 'because it is consistent with RACGP policy and community expectations'. [17] In doing so the RACGP recognised that the initiative will 'have consequences for Australian Junior Doctors who are currently in hospital training and for overseas trained doctors wishing to immigrate to Australia and to practise medicine'. [18]

The RACGP did, however, refer to the' changing of the rules' by government and stated that it is crucial that the career options open to Junior Doctors be quickly clarified. The College noted the information provided by the Minister on such career options, however 'it is essential that much clearer information is available concerning the numbers of approved training posts and hospital positions'. [19]

AMSA claimed that the effects on public hospitals of a possible influx of 400 graduates per year to the proposed new positions of Hospital Medical Officer (HMO) or Career Medical Officer (CMO) would lead to oversupply and unemployment. The Committee explored this claim in evidence with AMSA, raising the issues of the current undersupply of doctors in hospitals, for example that there are 365 unfilled positions in New South Wales and Queensland; and the effects of bringing doctors back to reasonable working hours.

AMSA also claimed that graduating medical students are not in the same situation as other university graduates not assured of employment, in that they are required to undertake further postgraduate study.

Doctors in Training did not dispute that post-graduate training should be encouraged to ensure the highest quality care is available to the community and stated that this remains a policy of the AMA and the DIT group. DIT however if we are to consider legislation which makes post-graduate training compulsory prior to medical practice then we have an obligation to ensure this training is available to every Australian Graduate. [20]

DHFS stated that it considers that the suggestion that there should be an increase in the number of training places is an incorrect focus. Not only is there overwhelming evidence of an oversupply of general practitioners, there is equally strong evidence of a substantial undersupply of specialists. The current limit of 400 places is supported by the RACGP. [21]

AMWAC has concluded that there is a shortage of specialists in no less than 18 specialities. DHFS stated on the basis of this shortage that if it was to be proposed to increase the number of training places, the area to make such an increase would be in those areas of specialist undersupply. AMWAC is systematically undertaking analysis for each speciality and then negotiating an increase in the number of training places with the relevant college. To date AMWAC has completed this exercise in respect of four specialist colleges with the result that more than 50 additional training places have been negotiated. Negotiations with the remaining colleges are continuing. [22] Details of the training places now available are reproduced as Appendix 3 to the Committee's report.

On consideration of the evidence, the Committee concluded that, while application of the measures will have some effect on the career choices available to junior doctors and medical graduates, the choices of a career will not be cut off for others. The Committee noted that there would the prospect of additional specialist training positions as well as opportunities in rural/locum areas, salaried medical officer positions, government, the private sector and research. The evidence available to the Committee indicated there should be, in the future, sufficient such vacancies to provide opportunities to Australian medical graduates.

Effect of the changes on the maldistribution of doctors between urban and rural areas, in particular on locum arrangements and deputising services

While generally supporting the changes, the RACGP pointed out that it is aware that there may be a decreased availability of locums to rural General Practice. The RACGP regarded this consequence as serious as access to locums is 'essential for rural GPs to be able to take leave and to undertake continuing medical education'. [23]

AMSA applauded the government's initiative with projects such as the John Flynn Scholarships and the funding of rural Medical Faculties. The Association viewed the lack of locum relief, 24 hr service workers, other relief work filled by a majority of younger doctors and non VR GPs (OMPs) as factors most likely to have an effect on those areas of Medicare service provision in a fashion contrary to Government predictions. [24]

The National Association of Medical Deputising Services (NAMADS) claimed that there were possible adverse effects of the legislation, in particular 'the crucial locum and deputising sectors of general practice' and presented a package of alternative proposals for government to consider. [25] The Department's evidence to the Committee indicated that the Government would discuss these proposals with the Association.

In its Supplementary Submission DHFS provided a detailed statement pointing out that the Bill was never intended to be the Government's sole response to these (the rural mal-distribution) problems. The government has adopted a multiple strategies approach, consisting of the General Practice Rural Incentives Program and a range of other measures, including:

The Government believes that the Budget measures will improve the position for rural Australia by allowing the essential structural change to complement the extensive range of incentive programs. Despite claims to the contrary, the number of new doctors going into rural areas without undertaking further training (ie the group affected by the proposed measure) has traditionally been very low.

The Department also outlined the arrangements approved by the Minister whereby new doctors will be allowed to practise in a rural or remote area, by issuing them with temporary provider numbers (under the approved placement arrangements on S 3GA of the Bill) on condition that they are working in appropriately supervised arrangements such as an approved rural locum service or an Aboriginal Medical Service. As these doctors will not have undertaken post-graduate training appropriate supervision arrangements are essential.

The Minister has also announced that doctors completing approved assistantships in rural hospitals will have privileged entry into the General Practice Training Program. This means that provided they can meet the minimum standards required by the RACGP they will be guaranteed a place in the College Training Program. This is seen as a significant incentive for young doctors to work in rural Australia. [27]

The Committee believes that, on balance, the Rural Incentives components of the changes will improve the prospects of doctors working in country areas either in locum services or in full time practice.

Impact of the changes on female graduates

A majority of submissions from peak bodies including AMSA, the AMA and Doctors In Training and individuals, drew attention to the adverse effects on female graduates of restrictions on provider numbers.

The Committee notes however that the Bill does not have any specific provisions within it which change the way in which women doctors in training are treated. AMWAC is reviewing the issue of increased flexibility and part-time work in relation to hospital career positions. Issues around fairness and gender equity in post-graduate training have always been of concern but are not directly related to this measure. The Minister has indicated that he will vigorously pursue these issues with the medical colleges should it be demonstrated that a problem really does exist. [28] The Committee welcomed this initiative.

DHFS addressed the implications for female doctors in its Supplementary Submission, stating that it 'does not have any evidence to suggest that women will be disadvantaged by the measure'. If it were true that women were disadvantaged by the requirement to undertake training before entering general practice then [the Department] would expect to see female non-specialists over-represented in other medical practitioners (OMPs). The figures produced by the Department indicate that there is a similar spread of females between the non-specialist categories, at about 30% in each. The Department also points out that the proportion of women entering medical schools has increased dramatically in recent years and the representation of women in the workforce is improving. For women doctors who choose not to become GPs there will be as wide a range of alternative options, as there is now.

The roles of Temporary Resident Doctors (TRDs) and/or Overseas Trained Doctors (OTDs)

As outlined in the introduction to this report the Minister has made a decision in relation to new Temporary Resident and/or Overseas Trained Doctors, which, in the Committee's view is widely supported in the submissions and evidence. The number of OTDs coming into Australia in a year is the equivalent of three medical schools' student bodies combined. To allow this situation to continue will have a deleterious effect on Australian medical graduates.

The Australian Doctors Trained Overseas Association stated that it recognised the problems associated with Medicare and the Health system, understood that the continued migration of overseas trained doctors contributes to a more complex problem and recognised the Government's need to take measures to cap the flow of overseas trained doctors into private practice. The Association generally supports the measures proposed. [29]

The Association however highlighted three issues it felt consideration could be given to:

The RACGP, in noting the distinction made by the Minister between those OTDs already in Australia and those arriving after 1 January 1997, drew attention to the need to be aware of 'exceptions', such as the recognised equivalence of the vocational training for general practice of the Royal New Zealand College of General Practitioners, which it saw as being exempt from the changes for OTDs.

The Committee has considered the submissions and evidence placed before it relating to OTDs and on balance does not intend to recommend any further amendments in this area.

Cost issues

DHFS states that an underlying premise in the changes proposed is that there is a relationship between doctor numbers and Medicare services.

In the Department's view the relationship is clear, illustrated by the growth in Medicare attendances relative to population and doctor numbers for the period 1984 - 1995 and stated that a similar relationship can be demonstrated at State and local levels. [30] The Department quoted examples of patient visits to doctors in Forbes in rural NSW, compared with Ryde in urban Sydney where the average number of visits per year are respectively four times and 7.3 times. The only factor this can be correlated to is doctor numbers. [31]

DHFS in its supplementary submission noted that various witnesses had challenged the Government's estimates of the savings likely to be achieved from the proposed Budget measure and pointed out that the estimates have been agreed by the Department of Finance and the Department.

A number of groups including, for example, the Australian Medical Association (AMA), questioned the costings prepared by DHFS and the Department of Finance.

The AMA stated that the estimated Budget savings are 'implausibly high' for the following reasons:

The AMA described this assumption as 'patently wrong' as many doctors completing their intern year would work as a junior Resident Medical Officer (RMO) for a further year upon registration and many would continue on as a senior RMO for a second year before either obtaining a training position (as a hospital registrar or GP in training), taking a general RMO position or entering private practice as an OMP. The AMA claimed the effect is to bring forward the savings by a year or two.

The implied annual benefit earnings is well above the average Medicare benefit earnings of a full-time GP within three years of registration.

The Association claimed that the estimation is based upon an assumption which holds that the only determinant of doctors' Medicare benefit incomes is the number of doctors.

DHFS described the AMA's independent costings as 'deficient in a number of areas', in that:

These effects, after being discounted, add almost $150m to the savings. [32]

The Government has used the figure of $176,000 per annum as a combined total of Medicare earnings, pharmaceutical and other flow on costs for a full time equivalent doctor, as evidence available suggest that the true figure for existing full time doctors in terms of Medicare income and other costs is well over $300,000. [33]

The Government acknowledged that not all of a new doctor's patients would be the result of supplier induced demand by that practitioner, or others. The OECD suggests that between 40% and 75% of increased demand is due to supply factors.

The calculations made by the Department also assume that each new doctor prevented from accessing Medicare would have been 0.8 of a full-time equivalent. The Department stated that 28-30 year old doctors work well in excess of an average full-time load; on average 36% higher - again reinforcing the conservative nature of the savings.

GP trainees work an average of 0.16 of a full-time equivalent outside of their training program, working predominantly in bulk-billing super-clinics. This measure will not allow this, so that trainees can concentrate on their studies. Likewise specialist trainees undertake this work at an average FTE of 0.17. Half of the savings for these effects on trainees and TRDs have been discounted, reflecting the conservative bias of the estimates.

Quality of workforce data

A number of groups and organisations raised issue concerning the quality of the workforce data used to support the changes.

The Department of Health and Family Services provided detailed statistical workforce information from 1996/97 projected through to 1999/2000 in its main submission, and, attached to its supplementary submission provided available estimates of specialist training place numbers, based on advice to date from specialist colleges. [34]

The Committee noted from the Department's main submission that the GP Training Program has a quota of 400 places, covered by specific Commonwealth Government funding and that the specialist (training) places, estimated at 800, are determined by specialist Colleges and State hospital funding.

DHFS indicated further that it had commissioned the Australian Medical Workforce Advisory Committee (AMWAC) to quantify the oversupply and provided the Committee with a copy of the AMWAC report. In addition the Committee obtained further statistical information from DHFS in answer to queries from the Deputy Chair, Senator Lees. The Committee had earlier (7 November) heard evidence which cast some doubts on the validity of some of the AMWAC data and followed up these and other matters at its public hearing on 18 November with the Department. [35]

Notwithstanding the claims, the Committee noted that the estimation of training place numbers provided by the government was not rejected by any of the witnesses. Similarly it was noted that the general assumption of the government's measures, that there is an over-supply, was not challenged by nearly all of the submissions, although there are some differences of opinion about the validity of data in general.


The 'Gap' Issue

The purpose of the legislation is to reduce government outlays by adjusting the amount above the Medicare rebate (but less than the Schedule fee) that is payable by patients. [36]

Medicare rebates for out-of-hospital services are currently payable at 85% of the Schedule fee, with a maximum payment of $30.20 (indexed annually) where the Schedule fee is charged. Under the indexation arrangements the maximum patient gap increased to $30.20 on 1 November 1996. The measure will increase the maximum gap between the Schedule fee and the Medicare rebate for any out-of-hospital services to $50.00 (indexed annually). [37]

The Committee in evidence explored with the College and the Association the safety net provisions which apply and noted that the maximum additional amount any patient would pay, irrespective of the number of services they received, over a twelve month period was $270.00. [38]

The Committee also notes that the measure affects only 0.5% of Medicare services and those who are most vulnerable will be bulk-billed. The Committee is mindful also of the ethics and time-honoured practices generously followed by the vast majority of members of the medical profession whereby patients with a demonstrated incapacity to pay will invariably be bulk-billed.

In its submission the Department stated that ' a significant proportion of the items affected by this measure related to diagnostic imaging services. Services affected are mostly computerised tomography scans, nuclear medicine imaging services and to a lesser extent, certain ultrasound and angiography services.' [39]

The Department points out that budget savings were developed in cooperation with the RACR and ANZAPNM and states:

If the measure is passed this amount will be made available for use within the diagnostic imaging parts of the MBS. The precise way in which the funds will be used will be determined in consultation with the RACR and the ANZAPNM. [40]

RACR stated in its submission that since early 1996 the College of Radiology and ANZAPNM have worked in close consultation with DHFS to restructure the Diagnostic Imaging Services Table ('the Table') through a specially convened Diagnostic Imaging Task Force. [41]

The purpose in setting up the Task Force was to reduce Medicare outlays in those sections of the Table which were growing faster than the other areas of expenditure in the Medical Benefits Schedule (MBS). The restructure was also targeted to remove incentives for inappropriate itemisation and to allow description of item numbers in the MBS to reflect current practice.

The range of proposals produced by the Task Force were designed to deliver the government's required savings of $254.7 m over a four year period and restructured the Table. As part of the cooperative arrangements, the RACR and ANZAPNM are committed to an on-going monitoring role.

RACR and ANZAPNM held the belief that diagnostic imaging was to be quarantined from the effects of any other measures introduced in MBS during the period of the agreement. In a letter dated 3 October 1996 the Minister's Chief of Staff had confirmed the government's agreement to quarantine diagnostic imaging from other budget measures. [42]

One measure which was not included in the agreed package and which would have an impact on diagnostic imaging, the RACR had been assured, it would be fully compensated for. [43] This inclusion was the proposed increase in the maximum gap between Medicare rebates and MBS fees for Medicare patients for non in-patients from $30.20 to $50.00.

The College expressed reservations at the manner in which this proposal was introduced and the significant consequences for the patients of medical imaging practices. In its view the major effect of the change will fall on the Diagnostic Imaging section of the Schedule.

ANZAPNM supported the College's views pointing out in its submission that:

In answer to queries from the Chairman as to why these patients (for example the elderly or seriously ill) would not be bulk-billed the College stated:

[We] do not believe that that is necessarily the way it works outside. The bulk patients who are on benefits are all bulk-billed but different practices have different ways of practising. I guess many of them charge the schedule fee. If they charge the schedule fee the patient will still be up for the $50.00 gap. [45]

The College acknowledged that 'in an ideal world they would all be bulk-billed, but the economics of the situation are that it is the schedule fee which is the viable amountI do not think it would be viable to bulk-bill everyone in a radiology practice at the moment.' [46]

It was pointed out, however, that not everyone who utilises the facilities on a fee-for-service basis is either elderly or seriously ill. There are a lot of people who have one or two tests in three or four years. In acknowledging this the College stated:

In its Supplementary Submission, DHFS stated that there has been no breach of faith with the RACR and/or the ANZANMP. There has been some disagreement about the Department's calculations and about the patient billed component. The Government has made it clear that it will provide an amount equal to the effect of the $50.00 measure on the bulk-billed component of diagnostic imaging and that the calculations will be verified with the RACR and the ANZANMP. However it is not appropriate to compensate radiologists for increased costs borne by patients. [48]

The Committee is of the opinion that the Government has taken steps to ensure, as part of its Budget measures, that radiologists and diagnostic imagists, are not disadvantaged. The Committee noted that discussions between the government and the profession, about implementing these measures, is ongoing.



The Committee has identified a number of areas that require further clarification and ongoing monitoring to assess the impact of the changes.

In evidence to the Committee, a number of witnesses expressed concern that there may be a decrease in the availability of locums to rural, metropolitan and deputising services. The Committee believes that there needs to be a system established by the Government to monitor the effects of the legislation on availability of such services so as to ensure that there is no diminution of services to patients.

The Committee considers this is a matter for legitimate concern. Although the Department has stated that there is an excess of some 4,500 General Practitioners in Australia at the present time, the Committee notes that the National Association of Deputising Services submission referred to the difficulty in filling locum positions at present. [49] The Committee does not consider it to be in the interests of the community were the situation to be exacerbated.

The Committee received no cogent evidence as to the optimal number of medical practitioners per head of population, nor whether increasing the numbers of trained medical practitioners alone would ameliorate the shortage of locum placements. Obviously, other initiatives, beyond the scope of this Report, including perhaps collaborative night care arrangements with General Practices, in association with local public hospitals, need to be further investigated.

Graduates taking up rural placements with approved supervision will be guaranteed a place in the General Practice Training Program ('GPTP'). The Minister has referred to the time frame for this option to be available as being 'after a period of time'. [50] The principle of offering medical graduates guaranteed access to the GPTP by means of a credit for prior learning, lends itself to consideration of the possibility of an accreditation system which could be worked out on a sliding scale and available to ALL medical graduates.

If this is a viable option, all graduates who are unable to access a training program would go onto a waiting list and be offered credit points towards the GPTP for relevant work experience. There would possibly need to be an appropriate caveat as to suitability of applicants to meet RACGP standards, such as observance of guidelines on relevant work experience in accordance with the sliding scale. While the incentives for rural placements would need to be highlighted, a sliding scale would enable all graduates to progress towards registration in the event of training places being available.

The Committee is anxious to ensure that new graduates who go to country hospitals be assured of proper supervision, and that the hospital must meet adequate training standards. To do otherwise is to provide patients with inferior treatment by untrained doctors and for there to be adverse long term consequences for medical practitioners thrust into difficult areas of practice without having been effectively supervised or trained.

Rural training incentives and schemes in some States to encourage and assist rural doctors in a variety of ways are welcome, but the Committee believes that the effectiveness of the multiple strategies approach in the Government's General Practice Rural Incentives Program, and the range of other methods identified in the Report, [51] will need to be critically evaluated as measures to improve the prospects of doctors working in country areas, either in locum services or in full time practice.

The question of the number of actual training places available, and in what specialties and in what geographical distribution, remains unconfirmed as at the time of the tabling of this Report. [52] This exacerbates the concern about what happens to training place availability when, for example, doctors who have accepted placements in country hospitals (thereby guaranteeing them entry into the GPTP) actually enter the program. Do they then take positions of new graduates who would otherwise have filled those vacancies?

The Committee considers that it would be desirable for there to be a National body responsible for supervising and setting strategies and policies for medical training at all levels in Australia, including monitoring the number of available training places, assessing barriers to entry and issues of maldistribution of medical practitioners throughout Australia; and whether there is an oversupply of medical practitioners, and if so, in what areas of practice.

A survey carried out by the Australian National University, National Centre for Epidemiology and Population Health, entitled 'The Future Role of Operation of Australian General Practice, General Practitioner Survey', conducted in August 1995, concluded that since the introduction of the Vocational Register, the number of years of hospital training of medical graduates prior to entry into general practice, currently stands at a mean average of 3.6 years. [53] Evidence before the Committee failed to establish the number of medical graduates who would wish to enter general practice before undertaking graduate training in any event.

It is therefore difficult to accept that in effect, placing a cap on availability of General Practice Provider Numbers to new graduates, materially differs from the position which has obtained since introduction of the Vocational Register by the former Government in 1992. In effect this proposal formalises the present position with respect to training time spent before entering general practice.

Given that there is universal acceptance by witnesses appearing before the Committee that undifferentiated medical graduates require post-graduate training in the public interest, and that the practical effect of the requirements for the Vocational Register imposes the need for further training, in any event; the Committee considers that concerns expressed by various witnesses will be addressed by ensuring the availability of adequate training places on a national basis, and that the other areas of concern identified herein be properly monitored on an ongoing basis.



The Committee reports to the Senate that it has considered the Health Insurance Amendment Bill (No 2) 1996 and RECOMMENDS that the Bill proceed.


Senator Sue Knowles


November 1996




The Labor Opposition dissents from the majority report on the Health Insurance Amendment Bill (No 2) 1996.

The Opposition believes that this Bill will have an unfair and retrospective effect on current medical students and interns. We are concerned that it may aggravate the shortage of doctors in rural areas and severely restrict the options of medical students and interns who are seeking to postpone their postgraduate training or undertake that training part-time.

The Opposition also does not support the increase in the maximum permissible gap for an out-of-hospital Medicare services from $30.20 to $50.

The Committee examined the issue of removing the Medicare Benefits Advisory Commission's power to award higher fees for services of unusual length or complexity. The Opposition does not support this change because patients who receive services of unusual length or complexity will face very high out-of-pocket costs.


Workforce Issues: Provider Numbers and Post Graduate Training

The Opposition understands the necessity of managing the medical workforce and in particular of managing access to Medicare to ensure the best possible value for the money for the Australian people.

The Opposition also understands the need to ensure that those practising medicine in Australia are of the highest possible standard and are appropriately trained.

In recent years it was the Labor Government which took a number of decisions aimed at limiting the number of overseas trained doctors coming to Australia and who worked with the medical profession to improve the standing of General Practice and to develop a system of postgraduate training for general practitioners.

The Opposition cannot support this legislation however because of its unfair and retrospective nature in adversely affecting the careers of medical students and interns who are already in the system.

Parents and Friends Supporting Medical Students said in its submission that:

The Opposition believes the Government should have paid greater attention to lowering medical school intakes and restricting access for overseas trained doctors rather than reducing medical students' options half way through their degrees. This is a view supported by the Australian Medical Students' Association. [55]

Though the Opposition welcomes Dr Wooldridge's belated announcement of a 10 year moratorium on overseas trained doctors, the Opposition remains concerned that this measure has not gone far enough to ensure that current Australian medical students and interns are given priority in relation to the provision of provider numbers.

The Opposition is also deeply concerned that this Bill was not introduced to the Parliament until four sitting days before its date of effect (1 November 1996). Indeed the consideration of this committee is taking place after the date of effect of the Bill. Moreover, the Government has indicated that if it is unable to secure passage of the Bill during this session of the Parliament it will take back provider numbers from doctors who receive them from January next year. The Opposition does not support this retrospectivity.

The Opposition is also concerned about the apparent contradiction in the Minister's recent statements on this Bill. He has given public assurances that no Australian graduate will miss out on a training place - though he has failed to offer a guarantee of a training place to existing students and interns. However, he has also asserted that the effect of the Bill will be to force graduates into rural training positions and rural hospitals. These statements do not appear to be consistent.

A major problem of the provision of medical services is still the maldistribution of doctors and the shortage in rural areas in both hospitals and in general practice. This legislation provides no solution to this problem.

The Opposition remain concerned that Dr Wooldridge's proposal may also have an adverse effect on the provision of medical services in rural areas and on the options available to young doctors, particularly women, who do not wish to proceed immediately after registration to full-time training.

The National Rural Health Network said in its submission that the 'the proposed restrictions on provider numbers will discourage junior doctors and medical students who are considering practicing in a rural area'. [56]

Several of the submissions and a number of the witnesses, particularly women, have expressed their concern about the practical difficulties in getting a deferred or part-time training place.

Ms Janine Manwaring, an intern at the Bairnsdale Regional Health Service Hospital, said, 'It will no longer be possible for women to combine their child-rearing responsibilities with part-time employment. The inflexibility of many training programs will mean that many women will have to make a choice between family and career. This is occurring at a time when Medical Schools have over 50% female intake.' [57]

Other submissions have expressed concern about the effect of this measure on the provision of medical services in rural areas, particularly locum services.

The National Rural health Network pointed out that the decision will reduce the pool of locums, preventing rural doctors from getting locum relief. [58]

The Opposition is also concerned that a proposal of such far reaching consequences was not given adequate and extensive enquiry and that some key stake holders were not heard by the Committee. The Committee received 96 submissions and only five organisations, including the Department of Health and Family Services, were given an opportunity to address the public hearing.


Increase In The Maximum Permissible Gap from $30.20 to $50.00

The Opposition does not support the intention of this Bill to increase Medicare's maximum permissible gap payment from $30.20 to $50.00. This measure effectively reduces the Medicare rebate for out-of-hospital services with a value in excess of $202.

This measure represents a fundamental breach of the Coalition's election promise to "maintain Medicare in its entirety" and is a regressive measure through which the Government intends to raise $60m from a group of people whose only distinguishing characteristic is that they require high-cost medical treatment.

The Royal Australasian College of Radiologists has described the calculations of savings as 'grossly flawed' and that the non-bulk billing patient, many of whom are elderly and seriously ill, will bear the brunt of these savings. [59]

The Opposition is also concerned that the Government appears to have originally breached its commitments to the Royal Australasian College of Radiologists in relation to this measure and in trying to undo the damage caused by its mishandling of this issue may introduce undue complexity into the fee structure for the affected items.


Limitations of the Powers of the Medical Benefits Advisory Committee

The Opposition is concerned that this measure is typical of a number of the Government's arbitrary Medicare cuts.

The Government's figures indicate that this measure will save around $5 million in a full year by removing doctors' rights to claim higher benefits for services of unusual length or complexity.

The Opposition opposes this measure as being unfair and highly likely to lead to significantly higher out-of-pocket costs for patients who are unfortunate enough to require these services.



The Opposition recommend that

be opposed.


Senator Belinda Neal (ALP, New South Wales)

Senator Kay Denman (ALP, Tasmania)

Senator Sue West (ALP, New South Wales)



 The Health Insurance Amendment Bill (No. 2) 1996 seeks to require medical graduates to undertake additional post-graduate training before the services provided by them attract Medicare benefits. It seeks to achieve that aim by restricting access to Medicare provider numbers to those medical graduates in recognised formal training positions. This move has now been fully explored before the Senate Community Affairs Committee and in Estimates hearings.


The Australian Democrats' position

The Australian Democrats support the premise that medical graduates wishing to enter general practice should undertake additional training.. We accept the evidence that undergraduate medical education does not prepare graduates for unsupervised general practice (although we note that such evidence raises questions about the content and structure of undergraduate medical courses). We also note this is not a requirement exclusive to medical graduates - law graduates, for example, are required to undertake additional training before being allowed to practice as solicitors or barristers

We do not believe that access to a Medicare provider number is a 'right'. It is a privilege bestowed by the Australian taxpayers. It is a privilege which attracts a significant amount of taxpayers' funds and, as such, the taxpayers (through the government) are entitled to place conditions upon the receipt of those funds.

The Democrats also accept the benefits to the overall health system in having medical graduates fill vacant work and training places in less popular disciplines and places, rather than using their Medicare provider numbers to practice medicine as under-trained and unsupervised doctors in areas of oversupply. We also support the Government's stated desire of addressing the maldistribution of general practitioners.

Accordingly, we support the intention behind the Government's move to restrict access to Medicare provider numbers to graduates in recognised formal training positions. However, we are concerned about the impact of this proposal on medical graduates - especially over the next three years.

The Democrats have the following concerns about the Government's proposal.


1. Inadequate medical workforce data

Australia does not have accurate and comprehensive data about its medical workforce. The shortage and unreliability of the available data in this area is alarming. The absence of reliable data makes it difficult to verify the Minister's assertion that no medical graduate will miss out on a training place. It also makes it difficult to verify the claim - made by those opposed to the legislation - that 300 to 400 graduates will miss out on training places.

It should be noted that neither the Minister nor the Department have been able to precisely state the current number of training positions which are available or which are likely to be available in the future. The Department could provide accurate figures only for the RACGP Training Program: 400 places per year.

In its evidence to the Committee, the Department provided a list of the number of first year places available through the specialist medical colleges (based upon verbal advice from the colleges): 722 places in 1997. Information on the number of places available in previous years and in 1998 is not available, making it difficult to accurately determine any trends in training places or in particular specialities.

However, the Committee was also told of many training positions in 'unpopular' disciplines which are simply not being taken up. These areas include accident and emergency medicine, rehabilitation and psychiatry. Once again, inadequate data makes it difficult to ascertain the number of places which are not being taken up.

In addition, there are medical specialities which are facing shortages and which could make more training places available.

The difficulty in accurately assessing the appropriate number of future specialist training positions is compounded by the fact that the Australian Medical Workforce Advisory Council's investigation into the supply and requirements of particular specialities remains incomplete. AMWAC's work to date has covered four specialities - the orthopaedic, anaesthetic, urology and opthamology workforces - and in each of those areas AMWAC has found there will be significant shortages unless graduate output in increased.

While acceptance of AMWAC's finding by the Australian Health Ministers Advisory Council has resulted in 50 additional training places being negotiated, it remains unclear where those places will be located and how other areas of shortage will be addressed as the AMWAC review progresses.

We also note that there is dispute about the precise number of GPs currently practising in Australia and about the extent of the 'oversupply' of GPs. While the Minister and the Department continue to maintain there is an oversupply of GPs, the data upon which this assertion is based is far from convincing. For example, simple per capita calculations do not take into account the number of GPs practising part-time or the ratio of 'core' GP work to special interest work (such as sports medicine or women's health). Nor do they consider the specific or 'special' health needs of particular communities.

To overcome this problem, the Rural Doctors Association of Australia (RDAA), the Australian Medical Association (AMA) and the Royal Australian College of General Practitioners (RACGP) have proposed a mapping exercise to establish how many GPs and GP practices really exist and the hours those GPs are actually working. The Democrats share the RDAA's view that such an exercise is essential for the future planning of both the rural medical workforce and the wider GP workforce.


2. Crucial medical workforce reviews are yet to be completed

Two reviews are currently underway which should provide the Government and the Department with much firmer data and material upon which to base future medical workforce planning. These are a review of the General Practice Strategy (recently initiated by the Minister) which includes a review of the Rural Incentives Program and the AMWAC investigation into specialty areas (see above). The Democrats believe the Government should be prepared to be much more flexible in its approach to provider number restriction until the results of these reviews (and the mapping exercise proposed by the RDAA, the AMA and the RACGP) are known.


3. While the proposal could be a further important step in addressing the shortage of qualified doctors in rural and 'difficult to staff' salaried positions, it does not go far enough

The Department believes that salaried positions in rural and 'difficult to staff' areas will be easier to fill as a result of this measure (as untrained graduates will no longer be able to ignore or reject these positions in favour of working in cities in medical clinics and "billing Medicare in already oversupplied markets"). While there is an element of truth in this assumption, it raises questions as to why these areas and these services should have to rely upon 'untrained' doctors (most of whom are simply marking time waiting for a training place to come up) to fill their vacant positions. A better approach may be to increase the availability of formal training places in these services and areas and improve the conditions and career structures associated with these positions.

We acknowledge the initiatives currently underway through the Rural Incentives Program and we welcome the Government's decision to allocate an additional $20 million per year into rural areas and hospitals to address medical workforce issues.

We also support the Minister's announcement that doctors completing approved assistantships in rural hospitals will have privileged entry into the General Practice Training Program. However, at this early stage, it is difficult to ascertain the impact of these initiatives upon GP shortages in rural areas. It may be equally effective to ensure all RACGP trainees are required to undertake work in a rural area. The Democrats believe the Government should also explore the possibility of establishing additional GP training places in rural areas, possibly under the auspices of the recently established Australian College of Rural and Remote Medicine .

The Minister's decision to provide new doctors prepared to practice in a rural or remote area with a temporary provider number - provided they are working in appropriately supervised arrangements - is an unsatisfactory response. It clearly implies that doctor shortages are an acceptable reason for allowing an untrained doctor to practice in a rural area, while training will be required in an urban area. Again, a better solution may be to provide more rurally based training places and to take up the suggestions of the National Association of Medical Deputising Services Australia (NAMDS) to improve locum services. These suggestions include: recognising deputising practice and locum work as an Area of Medical Service Disadvantage within the RACGP Training Program and the establishment of a postgraduate diploma course in Emergency Primary Care Medicine (which can also be accredited as part of GP training).


4. The impact of the proposal on the public hospital system is unclear and it fails to resolve the current problems with the structure and career paths of hospital or resident medical officer positions

The Democrats believe problems in this area must be urgently addressed. There is clearly a problem in meeting the demand for RMOs in Australian hospitals. The Department advised the Committee that around 400 medical positions in public hospitals are currently vacant throughout Australia, confirming evidence given to the Committee that these positions are unattractive to many graduates. RMOs tend to stay only a short time in a hospital situation, with many feeling they are little more than 'hospital fodder', working long hours with often inadequate supervision or support and a lack of any defined career structure.

The restriction on access to provider numbers does nothing to improve this situation. It may, in fact, exacerbate the situation by turning hospitals into a 'dumping ground' for those graduates who are unable to get into a training position and who would previously have gone into GP practice.

However, it could be argued that it is preferable to have disgruntled graduates working in hospitals where there is at least some level of supervision than having them practising as untrained and unsupervised GPs.

AMWAC has reported that in 1994 male hospital non-specialists worked on average 56.2 hours per week and females 53.2 hours per week, while male specialists worked on average 61.8 hours per week and females 55.8 hours per week. AMWAC indicated that a reduction in hours to around 4o per week would require an increase in the workforce in the order of 15% or 1,160 persons.

Those figures suggest there is considerable room for additional specialist and non-specialist positions to be created in public hospitals - provided an attractive and appropriate career structure is in place.

The Democrats also note the pressure on graduates to 'stream' into specialities as early as possible. Those graduates who don't 'stream' early (or those who drop-out of specialist training) often find themselves with little option but to practice as GPs. A much better outcome - for both the individual doctors concerned and for the overall health system - would be to offer those doctors improved post-graduate training opportunities through the public hospital system (perhaps along the lines of the General Medicine Training Program currently being developed at Toowoomba Hospital). Such opportunities would encourage RMOs to remain working in a hospital environment. They would also provide a unique and valuable training experience while still enabling RMOs to take up specialist training at a later point in their careers.

The Democrats believe very strongly that instead of increasing the pressure of competition for training places among RMOs, the Government needs to give priority to ensuring RMOs and career medical officers in general are given strong incentives to remain working in hospitals and the public health system.

The RACGP - in a letter to all Senators - suggested that adequate work and training places are available for junior doctors, but "in disciplines and places which are unpopular. These posts are either unoccupied or filled by doctors on temporary visas doing work our own graduates will not do, as long as they have access to a provider number and can make a living practising 'triage and referral' medicine without further training in major cities". While this assertion sounds reasonable (and is supported by anecdotal material), it is - once again - difficult to verify in the absence of accurate data about the availability of work and training places. It also suggests that, unless these 'unpopular' places are made more 'popular', restricting access to provider numbers will not change the situation and these places will continue to be 'holding stations' for disgruntled graduates waiting to get into a more 'popular' course or position.

While the Democrats acknowledge the work being done by the Department in this regard, there is a considerable way to go before this problem is resolved.


5. The effect upon graduates

As previously stated, it is difficult to determine with any certainty the impact on medical graduate over the next five years. While the Minister believes there are sufficient training places for all graduates who want them, opponents of the proposal argue around 300 to 400 graduates may miss out on places. On the basis of the evidence provided to the Committee, this appears to be an exaggerated claim.

What appears more likely is that, after an initial round of take-up of training places, there will be a number of graduates who will miss out on their 'first choice' of place. Those graduates - who in the past may have opted for general practice - will now have to look at taking up training places in undersubscribed areas. Graduates who still don't have a training place after those positions are taken up will have the option of working in a hospital or some other salaried position.

The Democrats do not see anything wrong with some medical graduates having to take up 'second option' places. Many graduates from other disciplines have to opt for post graduate training or employment in areas which are not their first preference. Still other graduates are considerably less fortunate.

However, because of the gaps in the available data, the Democrats believe the Government must put a 'safety net' under its proposal for at least the next three years to ensure graduates do not miss out on either a training place or a salaried position which does not limit their future training options.

Several submissions to the Committee also referred to the adverse effects upon female graduates of this measure. The Committee received very little in the way of concrete evidence in support of these claims. However, there is evidence that female graduates are already disadvantaged by current selection practices and training requirements in both GP and specialist training. The Democrats believe this disadvantage must be addressed and we note the Minister's statements that he intends to vigorously pursue this issue with the colleges.



In light of these shortcomings with the current proposal, the Democrats make the following recommendations.

The aim of the Democrats' proposals is to establish a 'safety net' under the legislation for the first three years of its operation to ensure graduates are not disadvantaged should the Government's figures and predictions prove wrong. We believe it is fair for the cost of being wrong to be borne by the Government. On the other hand, if the Government's figures are accurate, the costs of these proposals will be minimal.. By the end of 1999, the Government should be in a position to accurately demonstrate the impact of the legislation and to make any necessary adjustments.

In the interim, these proposals should ensure no medical graduate is disadvantaged.

1. The Government should postpone the start-up date of the legislation until 1 November 1997.

Given the widespread concern about these proposals, it would be preferable for the Government to defer the start-up date to enable further discussions to take place with those most affected by these changes, to commence negotiations with the States on their role in medical training opportunities, to gain a clearer picture of the numbers of training places and hospital positions, and to ensure the measures suggested below are initiated.


2. The Government should set up a 'safety net' for medical graduates for the first three years of the operation of the legislation. This 'safety net' should consist of:-

(i) the establishment of a Medical Training Review Panel to oversee the take-up of training places

(ii) an agreement to make available up to 200 additional training places per year for those graduates who are unable to find places


3. A sunset clause should be inserted into the legislation causing it to cease to operate on 31 December 2001 unless its operation is formally extended by the parliament. The Minister should also be required by the legislation to report to the parliament by 30 June 1999 on the impact of the provider number restriction, the take-up of the additional training places and the current state of post-graduate medical training.

This gives the parliament two opportunities to evaluate the impact of the legislation - in June 1999 and at the end of 2001.


4. Additional requirements should be placed on RACGP trainees.

All 500 RACGP trainees should be required to undertake a period of at least 6 months' work in a rural or remote area (either in a hospital or a GP practice) and a subsequent mandatory period in a `difficult to staff' area (such as drug and alcohol rehabilitation services, community health centres, locum services and Aboriginal medical services).


5. The time in which GP training can be completed should be extended from 4 years to 6 years and provision should be made for more part-time training opportunities in GP and specialist training.

The Democrats believe this is a necessary step in achieving approved access to GP training for women.


6. As AMWAC's investigation into the speciality areas proceeds, the Government should make available at least another 100 specialist training positions in areas of specialist shortages. At least 30 per cent of these positions should be available part-time.

The Democrats understand the difficulties in negotiating funded specialist training positions with the States and the specialist colleges, but believe the Commonwealth must show leadership in this critical area. In order to ensure additional training opportunities are made available, it may be necessary for the Commonwealth to enter into negotiations with the States and to explore specialist training options beyond the control of the colleges. In any event, the Democrats believe additional specialist training positions can - and should - be made available over the next three years as AMWAC works its way through the various specialities.

The Minister should also undertake to begin further discussions with the specialist colleges on opening up the specialist selection and training processes, with a view to developing a package of reforms in surgical and specialist training by 1 January 1998.


7. Additional requirements should be placed on medical undergraduates

The Minister should undertake to discuss with the Deans of Australia's medical schools a requirement for the undergraduate curriculum to include a placement of 4 weeks a year in a rural area.


8. The Minister should undertake to develop in conjunction with the States by 1 January 1998 a package of reforms for RMO and other salaried medical positions.

These reforms should include: agreed national standards on expected hours of work and spread of shifts; improved access to post-graduate training; and a clearly defined hospital career structure (with facilitated access into specialist training).


9. The Commonwealth should establish a medical 'Training Pathways' program.

The program should include: the establishment of an independent central body to whom complaints about training positions can be directed and which can advise the Minister on GP and specialist training issues; and the setting up of post-graduate diplomas for medical graduates in specific areas such as Emergency Primary Care Medicine (as suggested by NAMDS), drug and alcohol treatment and rehabilitation, and environmental medicine. Completion of these diplomas should go towards accreditation as part of GP training.

The Democrats suggest the Medical Training Review Panel (see Recommendation 1 above) could form the basis of the Training Pathways program. For example, it would be possible to add to the Panel and extend its functions to include a complaints and advisory role.


Senator Meg Lees
Deputy Chair
(AD, South Australia)



[1] Ministerial Press Release MW 81/96.

[2] Hon M Wooldridge, MP, Minister for Health and Family Services, Press Conference 1545 (Media Monitors) 29 October 1996.

[3] Hon M Wooldridge MP, Minister for Health and Family Services, Second Reading Speech, House of Representatives Hansard 4 November 1996.

[4] ibid.

[5] Explanatory Memorandum p.1.

[6] Explanatory Memorandum p.1.

[7] Explanatory Memorandum p.2.

[8] Submission No. 89 p.1.

[9] Supplementary Submission No. 89 p.1.

[10] Submission No. 89 p.2.

[11] ibid.

[12] Hon M Wooldridge, MP, Minister for Health and Family Services, Press Conference 1545 (Media Monitors) 29 October 1996 p.19.

[13] Submission No. 89 pp.2-3.

[14] House of Representatives Second Reading Speech.

[15] Submission No. 66 pp.5-6.

[16] Submission No. 6 p.5.

[17] Submission No. 66 p.2.

[18] Ibid.

[19] Submission No. 66 p.4.

[20] Submission No. 90 p.1.

[21] Supplementary Submission No. 89 p.5.

[22] ibid.

[23] Submission No. 66 p.5.

[24] Submission No. 6 p.1.

[25] Submission No. 21 pp.9-12 and Appendix 3.

[26] DHFS Supplementary Submission No. 89 pp.5-6.

[27] DHFS Supplementary Submission No. 89 p.6.

[28] DHFS Supplementary Submission No. 89 p.9.

[29] Submission No. 94 p.1.

[30] Submission No. 89 p.3.

[31] ibid.

[32] DHFS Supplementary Submission No. 89 p.8.

[33] DHFS Supplementary Submission No. 89 p.8.

[34] See DHFS Supplementary Submission and Appendix 3.

[35] Submission No.44 p.5 and Transcript of Evidence, 18 November 1996

[36] Submission No.89 Part B p.1.

[37] Explanatory Memorandum, p.1.

[38] Transcript of Evidence p.43.

[39] Submission No. 89 Part B p.2.

[40] Submission No. 89 Part B p.2

[41] Submission No. 29 p.1.

[42] Submission No. 29 Appendix B

[43] Submission No. 29 p.1.

[44] Submission No. 43 p.4.

[45] Transcript of Evidence p.45.

[46] ibid.

[47] ibid.

[48] DHFS Supplementary Submission No. 89 p.9.

[49] Submission No. 21 p.4 and pp.6-7.

[50] House of Representatives Hansard 15 October 1996 p.5252.

[51] See pp.9-10 above & DHFS Supplementary Submission No. 89 pp.5-6.

[52] See Appendix 3.

[53] See Senate Hansard 5 November 1996, p.4939 (Document tabled by Senator Alan Eggleston).

[54] Parents and Friends Supporting Medical Students, submission 68, p. 2.

[55] Australian Medical Students' Association, submission 6, p. 7.

[56] The National Rural Health Network, submission 72, p. 1.

[57] Ms Janine Manwaring, submission 31, p. 1.

[58] The National Rural Health Network, submission 72, p. 1.

[59] The Royal Australasian College of Radiologists, submission 29, p. 2.