Executive summary
Chapter 2: The distribution of
medical, nursing and allied health professionals across Australia
The committee considered the distribution of medical,
nursing and allied health professionals across the country. Over the last two
decades there have been efforts to quantify the adequacy of the health
workforce in Australia in order to ensure that policy is evidence-based and
accurately reflects community requirements. The task of measuring the adequacy
of the medical workforce is complex, requiring more than a national headcount.
The figures available present a picture of contrasts across
the health workforce. Although statistics show that GPs and nurses are spread
evenly across regions of differing remoteness on a per capita basis, we know
access to this workforce is inconsistent. Medical specialist numbers plummet
outside the major cities, to levels as low as one-sixth of those in the large
capitals. Accessibility, particularly in remote areas, is an issue. Health care
needs amongst populations may also vary, and the committee is aware of data
showing higher disease burdens and poorer health outcomes in regional and
remote areas for some conditions.
The committee accepts the Australian Institute of Health and
Welfare's view that the new national registration scheme is producing higher
quality data for the numbers and types of medical and health practitioners.
However the committee has heard repeatedly that there are data issues limiting
the ability to analyse the factors affecting health service delivery in rural
areas. The committee thinks that this is a key area of responsibility for the
Department of Health and Ageing's Rural and Regional Health Australia.
Recommendation 1
The committee recommends that
Rural and Regional Health Australia, as part of the Department of Health and
Ageing, prioritise the collection of robust and meaningful data on rural health
as part of the forthcoming review of rural health programs.
Recommendation 2
The committee recommends that
Rural and Regional Health Australia, as part of the Department of Health and
Ageing, review the current literature from key stakeholders and universities
and develop a strategy to address the gaps in research and knowledge affecting
rural health service delivery.
Health professionals can face both professional and personal
barriers to entering and staying in rural locations. These barriers relate to
factors including professional development, income, accommodation, and
opportunities for spouses and children. Allied health professionals face
additional challenges in delivering services to non-metropolitan populations.
This is attributable to current Medicare and other funding arrangements, social
barriers, access to appropriate, affordable and secure accommodation, and is
exacerbated by lower remuneration than doctors. More effort needs to be
expended in ensuring that appropriate policies are in place to promote the
development and retention of multidisciplinary health teams in non-metropolitan
areas.
Chapter 3: The nature of the
medical profession in rural areas
The committee explored the nature of the health workforce in
rural areas, specifically breaking down the types of medical practitioners
working in those areas. It then examined the policy proposals of some of the
specialist colleges that submitted to the inquiry.
The committee noted a growing trend towards medical
specialisms and sub-specialisms. This is having a disproportionate impact on
the supply of doctors in rural and regional areas. This is principally due to
specialisation causing a reduction in generalist training pathways which has
been cited as the area of medical practice most required in rural and regional
areas.
The committee concluded that there needs to be a significant
increase in rural generalist GPs. The committee is strongly supportive of the
efforts of various stakeholders to increase the numbers of rural generalists in
the rural medical workforce through the development of rural generalist
training pathways.
The committee is strongly supportive of the Queensland
Health initiative to develop a program based on local needs. The evidence the
committee has received has also endorsed the program as being successful in
delivering increased access to healthcare in rural areas. The committee accepts
that this program may not be suited to all areas of the country, as each
jurisdiction faces distinctive challenges in terms of its dispersal of
population and workforce arrangements. Each state and territory Government may
wish to explore different pathways to provide increased access to health care
tailored to local need.
The model adopted by the Central Australian Aboriginal Congress
displays innovation necessitated by need. The emphasis on multidisciplinary
teams allows professional development across the health specialties and appears
to be successful in combating professional isolation. The collaboration
between different education providers to provide health workers and training
opportunities has also led to a steady flow of GPs, nurses and Allied Health
Workers that appears to be sustainable, and the committee was impressed with
the systems put in place by Congress to provide a blueprint for centrally
managed healthcare in remote areas.
Recommendation 3
The committee recommends that the
Commonwealth place on the agenda of the Council of Australian Governments'
Standing Council on Health an item involving consideration of the expansion of
rural generalist programs. It further recommends that, as part of that agenda
item, the Council consider an evaluation of the Queensland Health Generalist
Program and whether it should be rolled out in other jurisdictions.
Recommendation 4
The committee recommends that the
Commonwealth government work with education providers and the medical
profession to address the issue of the inadequate supply of rural placements
for medical interns in their pre-vocational and vocational years.
Chapter 4: Attempts to address the
rural medical skills deficit
The committee considered attempts that have been made over
recent years to alleviate workforce pressures in rural areas. It looked at the
many factors involved in the decision to work in a rural area, and how
effective the various government and non-government measures have been in
addressing these issues.
The committee is supportive of the efforts of the
Commonwealth Government under the Rural Clinical Training and Support scheme.
However, the committee does not believe that four weeks structured rural
practice training is sufficient time to expose the student to the full gamut of
experience available in rural Australia. The committee also heard of a number
of instances where the local community had actively welcomed students and
ensured that they had a positive feeling of engagement and connectedness with
the area. The committee does not think that four weeks is long enough to
foster that level of input from the community.
Evidence received by the committee shows a large disparity
between the support provided for allied health professionals and that provided
for doctors to work in non-metropolitan areas. The committee considers that
this situation neither promotes access to quality healthcare in rural areas,
nor does it take into account the requirements of team-based patient care.
Most of the existing support mechanisms available for
medical specialists should also be available to allied health professionals and
nurses. In particular the committee strongly supports the introduction of a
HECS reimbursement scheme for nurses and allied health professionals for
reasons of equity and incentive.
Recommendation 5
The committee recommends that the
HECS Reimbursement Scheme available for doctors be extended to nurses and
allied health professionals relocating to rural and remote areas as soon as
possible.
Given the extensive range of government programs and
measures to address different aspects of rural health, it would be beneficial
if there was an office located within DoHA, similar to the Chief Nurse and
Midwife, that would provide a strong voice within government on all issues
relating to Australia's rural health workforce.
Recommendation 6
The committee recommends that the
post of Rural and Regional Allied Health Adviser be established within Rural
and Regional Health Australia to coordinate and advise on allied health service
provision in rural and regional Australia.
The committee considers the expansion of eHealth and
telemedicine to be an opportunity to supplement health care delivery across
Australia, with particular relevance to rural and remote areas. It should not
be considered as a replacement for personally delivered primary health. It has
the potential to improve training, access to specialist advice and professional
development and will be key in future health care delivery. However it will
need to be coordinated with current management systems and agencies such as
Medicare to ensure that remuneration as appropriate is delivered, and its
potential is realised.
In some cases communities lack the population and
infrastructure to support specialised practices, and the existing workforce in
non-metropolitan areas is frequently overworked. One way to try and overcome
this is by broadening the scope of skills and competencies of the existing
workforce, particularly though the nurse practitioner model. The committee
recognises that any reallocation of professional responsibilities will be
contentious, and may encounter strong opposition from some groups. However, the
committee did not receive any evidence against equipping the existing workforce
to as high a level as possible. Furthermore, it is aware of evaluations showing
that professionals and patients have been supportive of such initiatives.
The government is spending a significant amount of money to
try and ensure adequate health services in regional Australia. The evidence
provided to the committee during the course of this inquiry has highlighted
deficiencies in the development and evaluation of these programs. There is an
urgent and fundamental need to better understand what programs have been
effective and therefore where energy and resources need to be applied.
New programs should include an evaluation strategy that will
allow both assessment of the programs' impact and the creation of information
needed to compare cost effectiveness with other initiatives. The government
should be prepared to redirect funds from less cost effective programs to the
more effective ones, but at present it appears difficult to establish which
initiatives offer the best value for money for meeting the needs of regional
healthcare patients.
The committee acknowledges the excellent work of the House
of Representatives Standing Committee on Health and Ageing, in its report Lost
in the Labyrinth: Report on the inquiry into registration processes and support
for overseas trained doctors, tabled in March 2012. This committee endorses
the recommendations made as part of that inquiry. This committee draws particular
attention to the House committee chair's comments that:
it is clear that whilst [International Medical Graduates]
IMGs generally have very strong community support, they do not always receive
the same level of support from the institutions and agencies that accredit and
register them...
[There were] a significant proportion of witnesses describing
a system lacking in efficiency and accountability, and importantly, one in
which IMGs themselves often had little confidence. Many IMGs also felt that they
had been the subject of discrimination, and anti-competitive practices and that
this had in some cases adversely affected their success in registering for
medical practice in their chosen speciality.
This committee wishes to put on the record its recognition
of the work that overseas trained doctors are performing, particularly in
regional Australia.
Recommendation
7
This committee endorses the House
of Representatives Standing Committee on Health and Ageing's report Lost in
the Labyrinth: Report on the inquiry into registration processes and support
for overseas trained doctors and recommends that the Commonwealth
Government accept and implement the recommendations contained therein.
Chapter 5: Australian Standard
Geographical Classification for Remoteness Areas
The Department of Health and Ageing provides incentive
payments to doctors based on the geographic area they work in. The greater the
relative remoteness of that area, the greater incentive payment they will
receive. The committee considered how incentive payments are determined and
paid to doctors working outside metropolitan areas. The current scheme (which
is presently under revision) is known as the ASGC-RA.
There will never be a perfect model that does not result in
some anomalies as a result of the methodology used. However, evidence provided
to the committee during its inquiry did not support the use of the ASGC-RA
scheme in its current form as the sole determinant of classifying areas for
workforce incentive purposes. Even the evidence in general support of the
scheme was heavily conditional on it being augmented with further datasets to
provide a more accurate representation of workforce conditions across the
country. The committee was impressed with the comprehensive nature of the model
developed by Professor Humphreys and his colleagues, and the merging of
geographical, population and professional and non-professional indicators
certainly seems to provide a more accurate picture of the rural workforce.
The committee is supportive of the methodology and data
utilised by Professor Humphreys and his colleagues and would like to see this
incorporated into a new scheme.
Recommendation 8
The committee recommends that the
classification systems currently used for workforce incentives purposes be
replaced with a scheme that takes account of regularly updated geographical,
population, workforce, professional and social data to classify areas where
recruitment and retention incentives are required.
Recommendation 9
The committee recommends that the
revised workforce incentive scheme include a comprehensive, public evaluation
process.
Chapter 6: The role of universities
and medical schools
The committee considered the role of the universities and
medical schools in providing educational pathways for the rural health
workforce. It discussed the current issues facing the sector and some possible
remedies.
The number of medical students in Australia has risen
significantly in recent years with domestic student numbers at Australian
universities rising to 12 946 in 2010 from 8768 in 2006. It is not possible to
say how many students will go on to become doctors in rural areas. However there
has been a gradual increase in the number of rural clinical schools across the
country and the majority of these are in receipt of government funding through
the 'Rural Clinical School' (RCS) program. There is also a scheme, under the Rural
Undergraduate Support and Coordination Program, that specifies a target of 25
per cent of Commonwealth Supported medical students who must be from a rural
background.
Evidence suggests that while the rural intake target should
be met and enforced, it is only one element of a complex problem, and by itself
holds no promise of an increase in the rate of graduates practicing in rural
areas. However the committee heard evidence that suggests that regional
universities are more likely to meet the target and consequently provide more
graduates that will practise in rural areas. The committee supports meaningful
sanctions for those institutions that do not meet the current target, and
although it understands that this is now a mandatory target with funding
conditions attached, it would like those sanctions to be in the public arena,
and would also like evidence of those sanctions being applied where
appropriate. The committee also considers that the definition of a rural
student for the purposes of a quota needs to be reviewed.
Recommendation 10
The committee recommends the
publication of those cases where universities do not meet the target of 25 per
cent of medical students from a rural background, and subsequent publication of
information about the sanctions that are applied in those cases.
Recommendation 11
The committee recommends that the
commonwealth government explore options to provide incentives to encourage
medical students to study at regional universities offering an undergraduate
medical course.
Recommendation 12
The committee recommends that the
definition of a rural student for the purposes of a quota be reviewed, and that
the review should consider strengthening the definition to only include
students who have spent four out of six years at secondary school in a rural
area; four out of the last six years with their home address in a rural area;
or city students showing 'ruralmindedness', defined as an orientation to work
in rural and regional areas, and demonstrated by a willingness to be bonded.
The committee was impressed by the success of James Cook
University and the model proposed by Charles Sturt University for a new rural
medical school. The provision of a full scale medical school based in regional
Australia would have a significant impact on the numbers of doctors, nurses,
allied health and other essential health professionals that would come from
rural areas and would therefore be likely to remain in those areas after they
complete their training. However the committee is also mindful that the current
pressing issue is not the student numbers but the capacity in the system to
adequately train those students all the way along a pathway from student to
health professional who will work in rural areas.
The committee received evidence about affirmative action
programs being administered by Queensland Health, James Cook University and
Queensland University, which the committee strongly support. The introduction
of options for underprivileged young people to enter a career in health and the
provision of appropriate support throughout their training is highly
commendable. The committee urges other regional and rural institutions and
appropriate education providers to examine ways that can increase the
opportunities of young people in the health field, with the added benefit of increasing
the likelihood of retaining a health workforce if they are sourced locally.
Effective translation of medical students into rural and
regional practice requires appropriate support at all stages in the training
and placement process. There do not appear to be adequate systems that will
support the internships, rotations, or mentoring of the expanding number of
medical students. The situation will need to be improved in regional areas if
the current drive to expand the number of students is going to translate into
actual health professionals working on the ground.
The committee is looking forward to the department's
forthcoming review of rural health and would like to see a full exploration of
ways in which blockages in the system such as the shortage of rural clinical
placements can be addressed.
Recommendation 13
The committee recommends that the
Commonwealth, state and territory governments review their incentives for rural
GPs with the aim of ensuring that rural GPs who provide training to pre-vocational
and vocational students are not financially disadvantaged.
Recommendation 14
The committee recommends the
Commonwealth government consider the establishment of a sub-program within the
National Rural Locum Program that would provide support for rural GPs to employ
locums specifically to enable the GP to deliver training to pre-vocational and
vocational medical students in rural areas.
The committee considered the accommodation issues associated
with placement programs, rotations and training. It acknowledges that a
placement program can only work effectively if students have somewhere to live
while undertaking it. The committee notes that existing programs and
stakeholders are seeking to address this issue. It is imperative that adequate
policies and programs are established to manage the increasing demand.
The specific issue of housing for Aboriginal Health Workers
needs to be addressed. The committee is aware of the difficulties this causes
in Aboriginal communities, both for staff working in remote communities and for
attracting staff to those communities. The committee urges the Commonwealth
government and the state and territory governments to work together to address
this need.
Recommendation
15
The committee recommends that a
coordinated accommodation strategy for be developed for rural health workers,
including Aboriginal Health Workers, in the government's forthcoming review of
rural health programs.
Chapter 7: Medicare Locals
The committee examined evidence about the transition to
Medicare Locals. Like the majority of submitters to this inquiry, the
committee is of the view that the newness of the Medicare Local program makes
it impossible to adequately assess its effectiveness at this time.
To be successful the program will require careful and
intensive management to ensure that all the key stakeholders are adequately
considered and consulted. Greater effort needs to be expended to ensure that
the necessary information is available for interested stakeholders. However the
committee shares the cautious optimism of the potential for Medicare Locals to
fill the gaps between local hospital networks, and GP community care provision.
In the committee's view the needs assessment element of the
Medicare Local program is the singularly most important aspect of their work as
it will provide the strategic overview that has been missing to date. The
timely dissemination of the results of the needs assessments can ensure the
constructive input of many of the key stakeholders. The uncertainty over the
provision of after-hours service provision is an area that requires evidence
based decision making as quickly as possible to dispel the fear and anxiety
that has been expressed over the status of existing services. In the medium to
long term the regular dissemination of the monitoring and evaluation of the
programs nationwide will also ensure that best practice is shared and
replicated across the country.
Recommendation 16
The committee recommends that
Medicare Locals Needs Assessment Reports are made public and a process of
engagement and consultation is undertaken.
Recommendation 17
The committee recommends that
where existing after hours services are operating effectively there should be
no disruption to their administration or funding.
A range of evidence was put before the committee identifying
potential gaps or overlaps between current policies and programs. These can
include a mismatch that sometimes occurs between Commonwealth and state or
territory health policy and resourcing. The committee is of the view that this
particular barrier should be addressed at a national level rather than locally.
The Needs Assessment Reports prepared by Medicare Locals will be a valuable
resource from which to identify potential inter-jurisdictional issues.
Recommendation
18
The committee recommends that the
Department of Health and Ageing prepare a brief for COAG's Standing Council on
Health on existing or emerging gaps affecting the delivery of health services
to rural and remote communities caused by mis-alignment between Commonwealth
and state policy, including options for measures to remediate such gaps. The
brief is to be based on engagement with relevant stakeholders, including state
and territory governments, Medicare Locals, representatives of peak bodies such
as RDAA, SARRAH and NRHA at both national and state level, and to be provided
on at least a bi-annual basis.
Navigation: Previous Page | Contents | Next Page