Jan McLucas (Queensland, Australian Labor Party, Shadow Minister for Aged Care, Disabilities and Carers) Share this | Hansard source

The Health Insurance Amendment (Medical Specialists) Bill 2005 implements changes to the prerequisites for the recognition of certain medical specialists and consultant physicians. The changes will remove separate processes that these medical practitioners must undertake to access Medicare. Currently, there are three ways in which medical practitioners can apply to the HIC to provide Medicare services. These processes vary depending on the circumstances. Firstly, if a medical practitioner lives in Australia, if they are a fellow or if they have a relevant qualification from a specialist medical college they are able to seek automatic recognition. This recognition occurs after the HIC receives confirmation from the medical college that these qualifications have been satisfied. Secondly, consultant physicians and other medical practitioners who do not meet these criteria must seek recognition through the specialist recognition advisory committees. These committees exist in every state and territory and meet every two months to perform this task. They are appointed by the minister. Thirdly, all other medical practitioners not domiciled in Australia must seek recognition through a ministerial determination.

The government is of the view that these committees present an obstacle to practitioner recognition because they rely on the advice of specialist medical colleges and have the effect of delaying recognition for the purpose of Medicare because the committees only meet every two months. In their place, this recognition will come from a delegate of the minister in the Health Insurance Commission. This bill tidies up an administrative process associated with the recognition of medical practitioners for the purposes of Medicare and Labor supports this. However, the bill demonstrates that the government is happy to play around the edges of our medical workforce policy but not to look at the big picture and focus on the larger and longer term issues facing the sector.

The first of these is the shortage of GPs and specialists in rural, remote and outer metropolitan areas. Australia is facing many challenges with regard to the supply of medical practitioners. The absolute number of medical practitioners or doctors is important, but their concentration, distribution and working behaviour is becoming even more important to the way we shape our medical workforce policy. Over the 30 years to 2001, the rate of growth for medical practitioners grew faster than the population. In the 1980s and 1990s this rate of growth slowed. This was largely due to the number of medical graduate places being held stable over the 1980s and 1990s relative to previous decades. It also reflected policies aimed at streaming students into specialist places rather than into general practice.

At the end of 2002, there were nearly 22,000 primary care practitioners employed in Australia, of whom 64 per cent were males and 36 per cent were females. The majority of the group, around 87 per cent, covers vocationally registered GPs who are essentially Medicare licensed GPs. A critical aspect of the changing nature of the medical workforce is the increased number of women practising general medicine and the number of hours worked by GPs, both male and female. This has resulted in a declining contribution of males to the GP workforce and an increasing contribution of women practising general medicine, while the total number of doctors in the population is beginning to decline.

An important measure of the medical workforce is FTE, full-time equivalents. Measured in FTE, there were 101 primary care practitioners per 100,000 people in Australia, based on a 45-hour standard, which is a decrease from 108 in 1997. So we have gone from 108 to 101 in quite a short period of time. While the number of women in the primary care workforce has increased, their average number of hours worked is significantly less than the total average, while men work slightly more hours than the 45-hour standard full-time week. The policy response has to be that the overall workforce level must increase if the growing trend of women in the workforce continues. The days of the single practitioner, particularly in a country town, working from 8 am till 6 pm in a surgery from Monday to Friday, 8 am till 1 pm on Saturday and on call 24/7 are over. We welcome of course the increase in the number of women doctors. I remember that, when I first went back to Cairns in 1985, finding a woman doctor was a very hard thing to do. It is much easier now and that is terrific, but the reality is that women are more family focused than the traditional male GP in a country town and therefore they see fewer patients. As a community, we should welcome that. We should be welcoming the fact that we have a GP workforce that are increasingly focused on their quality of life. This is in no way casting any aspersions on the role of women GPs—quite the contrary, women GPs are far more welcomed—but the government has a responsibility to recognise that the contribution they make in hours of operation is less than the traditional male GP in a country town of bygone years.

Another phenomenon at the heart of the medical workforce trend is the ageing of the health workforce. About 39 per cent of people employed in health were aged 45 years or over, up from 31 per cent in 1996. The proportion of workers aged 45 and over increased faster for females than for males, which reflects the fact that our nursing workforce is rapidly ageing. Parity in access and distribution of GPs is also very important, considering that about a third of all Australians live in rural and regional areas. Generally, these Australians have higher mortality rates and higher health risk levels than their counterparts in the city, due to their greater tendency to develop chronic illness and their likelihood of working in physical employment which can be hazardous—for example, mining and forestry—and not to mention that Indigenous communities are far more concentrated in rural, regional and remote areas.

In 2002, the AMA commissioned Access Economics to investigate the extent of the shortage of GPs that we will face in the future. They found that the availability of Australian trained doctors is falling well below both the demand and the requirements of the health sector, with the shortfall being partially covered by a major increase in the recruitment of overseas trained and temporary resident doctors.

The Access Economics report found that there is a declining participation rate by GPs, that female GPs and younger GPs are only prepared to commit to a working life of well under the 50 to 60 hours per week traditionally worked by GPs, that Australian medical schools are not graduating enough doctors to fill all of the available training places and that there are not enough training places to meet demand. The availability of training places is increasingly becoming an issue, as there has been a slight increase in the number of undergraduate places in very recent years.

The Access Economics report also found that the GP workforce shortage is greatly exacerbated by the restriction on the number of training places to some 450 per year. In 2001, Access Economics estimated that the overall shortfall of GPs—both Australian trained and overseas trained doctors—was between 1,200 and 2,000 full-time equivalent GPs. The rural shortage is estimated at approximately 700 full-time equivalent GPs and the urban shortage at around 500.

As a result of the government’s negligence we have seen these trends emerging, and the government has failed to act. Unfortunately, this problem required a response many years ago, and failure to keep track of the changing nature of the medical workforce has seen policy turn to overseas trained doctors for a quick fix. Overseas trained doctors have an important role to play in our medical workforce; there is no doubt about that. However, even the AMA has acknowledged that we cannot rely on an overseas supply and that an investment in the local workforce is required to meet current and future challenges.

Why is this the case? It is the case because not only is our medical workforce ageing but the medical workforces of other countries, which are facing their own demographic challenges, are ageing as well. Surely we have a responsibility to train Australian doctors—not just for Australians but to export to those countries that require medical assistance in times of need and emergency. As a developed nation, surely we have a responsibility to be a net exporter of doctors, not an importer as we are now.

Another key issue which requires timely government attention is the regulation of specialists by the colleges, and in particular their ability to restrict the supply and distribution of specialists. In an environment where the rights of all other workers are being attacked, it strikes me that the Howard government—and in particular the health minister, previously known for his hard stance on workplace relations—sees no need to reform the way in which the colleges control the supply and distribution of specialists. While the government does all it can to stop legitimate unions from representing their members on basic issues of pay and entitlements, the colleges continue to dominate the health workforce debate.

The Productivity Commission’s current work on the medical workforce will hopefully lift the lid on longstanding regulatory and structural elements of the medical workforce. This is not just because we are facing a medical workforce shortage but because, like other sectors of the economy, we should be applying ongoing reforms to improve productivity to enhance our overall economic performance.

While demarcations which existed in traditionally union dominated sectors of the economy have been gradually reformed and modernised, unfortunately this has not happened in health. In addressing the issue of demarcation and regulation, there is little doubt, given the submissions received by the commission, that issues related to role and task substitution will be on the Productivity Commission’s agenda for comment. Given the advances made in medical technology, it would not seem surprising that other types of health workers are very capably performing tasks which were seen solely as being in the general practitioners’ ambit in the last decade.

We should be examining ways in which other highly qualified healthcare workers can remove the burden on GPs so they can focus on providing the advice patients seek. For example, in Canada the medical association has lobbied for task substitution, in the past, as a means of transferring process orientated aspects of examinations to other healthcare professionals within a group or team structure. Rather than seeking to mark a line in the sand, the Canadian Medical Association has sought to use this reform as a means of better positioning GPs to focus on the value-add aspect of the consultation. The move to employ nurses in general practice has gone some way to increasing the use of health professionals other than GPs in processes that happen in a GP’s surgery but which do not necessarily have to be undertaken by that highly trained individual, the GP.

Another area of the medical workforce in which this government has failed to show leadership is in the area of managing quality and safety—Senator Sterle spoke very strongly about this issue this morning—and, in particular, the very fragmented approach to the accreditation of medical professionals. The Productivity Commission, in its health workforce report, has highlighted this as a key area warranting further attention. As an example, it uses the accreditation of nurses and the sorts of problems which can arise as a result. Nursing registration processes vary from state to state. Some run single registers while others run multiple branch registers which register a specialisation in nursing. When moving across jurisdictions, nurses have to prove that their existing qualification is the equivalent of that in the state or territory they are moving to. This situation discourages mobility, despite the high demand for nurses across Australia. As the Productivity Commission highlights, uniform accreditation will not just address mobility issues but may also improve quality and remove problems which lead to adverse issues.

Labor will support this bill but in doing so we move the second reading amendment which has been circulated. I move the following amendment:

At the end of the motion, add:

        “but the Senate condemns the Government for:

             (a)    failing to address the medical workforce shortage affecting our rural, remote and outer metropolitan areas;

             (b)    failing to invest in the future of the medical workforce and its over reliance on importing skilled medical practitioners;

             (c)    failing to show leadership in the area of the uniform standards for medical professionals; and

             (d)    failing to address the impact that regulation of medical professionals by the colleges has on supply and distribution of specialists”.

Australia is facing a health workforce crisis, especially in regional, rural and remote Australia, in some specialties and, as I know only too well, in aged care. I urge the government to do more to curtail our reliance on overseas trained doctors. As valuable as they are, our reliance on them raises serious questions about Australia’s commitment to education and training of the medical profession.