Glenn Sterle (WA, Australian Labor Party) Share this | Link to this | Hansard source

I rise to speak to the Labor amendment to the Health Insurance Amendment (Medical Specialists) Bill 2005. The Labor amendment provides an opportunity to reflect on how well Australia’s system of medical specialist accreditation ensures that Australian citizens have access to quality medical treatment and care. The fact that 90 per cent of the costs of medical services in Australia are funded from the public purse means that the senior levels of the medical profession have a collective responsibility to the Australian public with regard to the quality of medical care in this country. Australia’s system of postgraduate medical specialist training and accreditation has for decades been heralded by the medical profession as being highly successful and amongst the best in the world. It has been the repeated stance of many senior members of the medical profession that the current system of medical specialist training and accreditation should be touched only very lightly by the hand of government. Sadly, it seems to be the view of some members of the medical profession that it is the job of government merely to provide the money and to cop the blame for their mistakes.

In 1995 the Quality in Australian Health Care Study established that adverse medical events were involved in 16.6 per cent of hospital admissions at a cost to the nation of around $1 billion annually. The initial response to this study by many members of the medical profession was lukewarm at best, particularly as the findings of the study went to the very foundations of Australia’s medical specialist training and accreditation system. Since the publishing of the Quality in Australian Health Care Study report there has been the Campbelltown and Camden hospitals inquiry, the Canberra Hospital inquiry, the King Edward Memorial Hospital inquiry and the Bundaberg Hospital inquiry. All these inquiries have been initiated by governments in response to the public’s justified concern about the gross failures in the medical care provided by doctors to hospital patients.

Has anything really changed in recent times? No, not if you believe a recent Victorian university study into the rate of adverse medical events in Victorian public hospitals. That study, which looked at patient admissions to Victorian public hospitals in 2003-04, found that almost seven per cent of admissions to hospital had at least—I repeat: at least—one adverse medical event. In other words, one in 14 people who are admitted to a Victorian public hospital are injured by their medical treatment and care. The Victorian study estimated that the annual cost of adverse medical events in Victorian public hospitals was in the vicinity of $500 million. If we extrapolate this figure to Australia as a whole, the total cost to the Australian public hospital system of adverse medical events is now in the order of $2 billion annually. Where there are breakdowns in the standards of medical practice in this country, medical specialists as a group cannot avoid bearing a significant part of the blame for these breakdowns.

Over the past 10 years the Australian public has seen and experienced enough to be deeply sceptical about the degree to which some sections of the medical profession have an uncompromising commitment to high medical standards and patient safety. There are now volumes of documented evidence that medical error is far from rare. On any reasonable measure medical errors are commonplace. Because these are so commonplace, they appear to be regarded by many in the medical profession as a fact of life. This may explain the clamour of outrage we hear from the medical profession when there is any concerted effort towards greater individual accountability in respect of adverse medical events and of individual medical practitioner competency to perform particular procedures. Sadly, it seems that it is much easier to blame processes and administrative procedures than it is for the profession to audit the ongoing performance and competency of individual doctors. There appears to be a deeply rooted culture of denial that pervades some elements of the medical profession when it comes to accepting blame for medical error.

Representatives of the medical profession have often responded to independent inquiries that seek to get to the truth about medical practitioner error or negligence with fierce resistance. It appears that each time an inquiry finds evidence of a serious breakdown in medical standards, the public is told by representatives of the medical profession that the problems have long since been remedied and the inquiry is only documenting ancient history. However, year by year, new breakdowns in the quality and safety of Australia’s medical services continue to find their way to the surface.

In recent years we have seen the heroic actions of whistleblowers who have taken the lid off major incidences of gross medical incompetence and negligence that have led to major harm to patients and, unfortunately in some incidences, to the deaths of patients. Writing about a number of recent inquiries into breakdowns in hospital medical practice standards in the July 2004 edition of the Medical Journal of Australia, Thomas Faunce and Stephen Bolsin noted:

... none of the substantiated problems had been uncovered or previously resolved by extensive accreditation or national safety and quality processes; in each instance, the problems were exacerbated by a poor institutional culture of self regulation, error reporting and investigation.

They went on to comment that:

... even after substantiation of their allegations, the whistle blowers, who included staff specialists, administrators and nurses received little respect and support from their institutions and professions.

The head of the special commission of inquiry into the Campbelltown and Camden hospitals inquiry also wrote:

This inquiry to date discredits the notion that individual accountability through professional disciplining is inconsistent with the systemic improvement of clinical care and institutional administration.

It is instructive that these inquiries were not demanded by the medical profession; they were demanded by the public. Almost invariably, they were resisted by senior elements of the medical profession.

This was demonstrated in Western Australia when the state government initiated an inquiry into clinical standards and procedures at the King Edward Memorial Hospital. The King Edward Memorial Hospital inquiry found that clinical errors were very common amongst very high-risk obstetric cases. One or more clinical errors occurred in 47 per cent of cases at the hospital. More than half these errors were regarded as serious. Let us be totally clear about this: this situation occurred under the supervision of, ostensibly, Western Australia’s most skilled obstetricians.

Since that inquiry, enormous efforts have had to be made to lift the overall standard of the hospital’s clinical services to a level that can be claimed to emulate best tertiary hospital practice. The response of the medical profession to the formation of the inquiry was regrettable. Before and throughout the inquiry the medical profession, through its peak body, the AMA, did everything it could to denigrate its findings in advance of publication. The Western Australian branch of the AMA was particularly vocal on the matter. It denounced the inquiry as a farce. It is hard to believe, but on 5 October 2005 the AMA put out a press release with the title ‘King Edward inquiry a farce’ in which it complained that the inquiry was a ‘costly, time consuming and stressful episode’. The then state president of the WA branch of the AMA had this to say about the King Edward Memorial Hospital inquiry:

... adverse cases should have been sent to the WA Medical Board rather than wasting taxpayers’ money in this way.

And again, the AMA state president claimed the King Edward Memorial Hospital inquiry findings should be made:

... to a university anthropology unit because they would be outdated and totally irrelevant.

Despite the views expressed by the president of AMA WA, the King Edward Memorial Hospital inquiry report has since become a landmark document and has been used as a template for change and improvement in the quality of hospital medical practice elsewhere.

In November 2005, the Western Australian government released a report titled WA sentinel event report October 2003—June 2005. For the benefit of senators who do not know what a sentinel event is, it is a term similar in its clarity of meaning to the phrase ‘collateral damage’. The term ‘sentinel event’ covers a range of tragedies, including occurrences when a medical procedure is performed on either the wrong patient or the wrong body part, procedures where instruments are left inside patients, requiring further surgery, or medication errors resulting in patient death.

According to the report, in Western Australian hospitals in the 2004-05 financial year, there were 10 procedures performed on either the wrong patient or the wrong body part, six occurrences of instruments left inside patients that required further surgery to retrieve them and, unfortunately, two deaths from medication errors. These events were tragedies for the patients, their families and the medical staff involved.

I searched the AMA WA’s website for any comment on the sentinel event report, but I found nothing. The AMA WA put out seven media releases in November 2005, but not one of them mentioned the sentinel events report. There was a press release welcoming the appointment of a doctor to the Medical Indemnity Policy Review Panel. Another press release warned people to be careful of snakes in the hot weather. The advice warning people about the dangers of snakebites was helpful and timely; 66 people presented to Western Australian hospitals in 2004-05 to be treated for snakebite, and any effort to reduce this number is commendable. But, during that same time, 45 sentinel events were reported to the Western Australian Chief Medical Officer.

I am disappointed that there were no suggestions forthcoming from the AMA WA to reduce the number of times doctors leave surgical instruments inside their patients. As things stand today, it remains extremely difficult to obtain an independent and authoritative picture of whether the circumstances and events that led up to the inquiries into medical care standards at Campbelltown and Camden, Canberra, King Edward Memorial and Bundaberg hospitals are unique to those hospitals or represent a much broader problem in Australia’s hospital system.

Nonetheless, these inquiries have shown that the current system of specialist medical training, supervision and accreditation is, unfortunately, far from perfect. It requires urgent attention, as does the ongoing monitoring of specialist medical practice. The most serious and troubling concern is a reluctance of medical professional bodies to embrace the concept of accountability to the Australian public at its most fundamental level.

In summing up, the medical professional bodies must be willing to exercise discipline over their members, who receive considerable monetary benefits and privileges from the community by virtue of the professional recognition bestowed on them by the individual medical colleges. The Australian people deserve nothing less.

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

Judith Adams (WA, Liberal Party) Share this | Link to this | Hansard source

I rise today to speak on the Health Insurance Amendment (Medical Specialists) Bill 2005. This bill represents a minor procedural change to the Health Insurance Act 1973. The reason for this amendment lies in the current cumbersome and time-consuming process by which some medical practitioners are recognised as specialists or consultant physicians for the purposes of Medicare. It will streamline the procedures for the recognition of some medical specialists and consultant physicians so that their patients can access Medicare rebates at the specialist or consultant physician rates. With Australia experiencing shortages in the medical workforce, this amendment will ensure that specialists and consultant physicians can enter the workforce as quickly as possible without compromising safety and quality standards.

This legislative amendment does not bestow specialist or consultant physician status on medical practitioners. Medical practitioners are identified as specialists or consultant physicians by medical boards when they are registered and by specialist medical colleges. Currently, a medical practitioner is recognised as a specialist for Medicare purposes via one of three pathways. The first pathway is automatic recognition. Applicants can seek automatic recognition if they are living in Australia, have a fellowship with a specialist medical college and have the relevant qualifications from a specialist medical college. Recognition is then provided by the managing director of the Health Insurance Commission, following advice from a relevant specialist medical college that the criteria have been met.

The second pathway is alternative recognition. For those Australian trained medical practitioners who are unable to meet the criteria for automatic recognition an alternative pathway is available. In the alternative pathway the minister’s delegate must refer the medical practitioner to an appropriate state or territory specialist recognition advisory board. State and territory specialist boards are administered by the Health Insurance Commission and meet every two months. The Minister for Health and Ageing appoints committee members from panels of nominees put forward by the relevant professional bodies and colleges. For those medical practitioners who are seeking recognition as consultant physicians, which are a subgroup of specialists with qualifications as physicians, rehabilitation specialists and psychiatrists, this is the only pathway for recognition.

The third pathway is for non-domiciled medical practitioners. Medical practitioners not domiciled in Australia at the time of application may seek recognition through a determination of the Minister for Health and Ageing. Applications for temporary residence were previously considered by an overseas specialist advisory committee. These committees were abolished in July 2004. The government was able to do this administratively because there was no mention of the overseas specialist advisory committees in the act. The government is abolishing the specialist recognition advisory committees for much the same reason that the overseas specialist advisory committees were abolished: these committees have become redundant. Since the committees were first established, specialist medical colleges and medical registration boards have been developed and they have implemented assessment processes which are used by the specialist recognition committees in making their determinations.

That the specialist recognition committees have relied on the assessment advice of specialist medical colleges and medical registration boards in making their decisions means that the specialist recognition committees have become a redundant administrative layer in the processing of applications. This unnecessarily extends the time between the registration of specialists and when they provide services under Medicare. According to an official at the Department of Health and Ageing, the Health Insurance Commission is reporting that since the abolition of the overseas specialist advisory committees it has been processing applications within a shorter time frame than was previously the case. Applications are now usually processed within 28 days, as opposed to the previous time frame of two to three months.

It is intended that the decision-making powers of the disbanded specialist recognition advisory committees will pass to the delegate for the Minister for Health and Ageing in the Health Insurance Commission. This will streamline the application processes for special recognition by avoiding the necessity to meet cut-off dates for applications to the specialist recognition advisory committees and then wait for up to two months for the committees to meet.

The amendments proposed in the bill include the recognition of the consultant physicians domiciled in Australia in the alternative method of recognition. Because the specialist recognition advisory committees have been the only means by which medical practitioners could be recognised as consultant physicians, disbanding these committees will remove the provision for them to become recognised. To correct this, consultant physicians will be included along with specialists in the alternative method of recognition. Transitional arrangements have been provided to ensure that specialists and consultant physicians previously recognised by the specialist recognition advisory committees will continue to be recognised under Medicare. Arrangements have also been made to allow the delegate to immediately consider existing applications with the specialist recognition advisory committees at the time of abolition.

This bill involves minor changes to existing procedures. The objective of these minor changes is to reduce the complexity and time currently involved in the recognition under Medicare of medical specialists and consultant physicians seeking to enter the Australian medical workforce. According to Dr Felicity Jefferies of the Western Australian Centre for Remote and Rural Medicine, commonly known as WACRRM, anything that streamlines the process of recognition of specialists is an excellent idea. As Director of WACRRM, Dr Jefferies has an intimate understanding of the medical needs of rural Western Australians and is at present greatly concerned about the lack of general physicians practising in rural and regional Western Australia.

According to Dr Jefferies, there is currently only one general physician practising in each of the three major population centres in rural Western Australia. There is one general physician in Albany, a city that services the specialist medical needs of towns as far afield as Katanning, Narrogin and my own hometown of Kojonup. There is one general physician in Geraldton, a city that services a huge area of the northern wheat belt in Western Australia. There is one general physician in Kalgoorlie, which is one of the most remote cities in the whole of Australia. These general physicians need support and, more importantly, they need to be able to pass on their knowledge to the next generation of country medical specialists.

General physicians are an interesting class of medical practitioner. They have undergone an enormous amount of training, including some of the hardest exams faced by any medical student. They are not surgeons and they are not specialists such as the cardiothoracic or ENT specialists that we are used to finding in our capital cities; rather, they are a highly trained general medical consulting physician with a detailed understanding and knowledge of most human symptoms, complaints, ailments and diseases. They are exactly the sort of medical practitioner that country regions need, and we are running out of them very fast.

Rural and regional Australia cannot generally support highly trained and specialised surgeons, as small populations generally mean practices such as these are not profitable. However, the practice of a general physician who can advise patients on a wide variety of medical problems can be supported in regional areas. Any change in legislation, whether technical in nature or not, any removal of barriers to entry and any scheme that facilitates more doctors and general physicians moving into rural and remote Australia is a positive step.

The Rural Doctors Association of Australia, RDAA, has supported calls for better measures to encourage specialist physicians to practise in rural Australia, adding that there is a desperate need for all types of medical specialists in the bush. The Internal Medicine Society of Australia and New Zealand and the Royal Australasian College of Physicians launched a position statement in September last year which recommended that Australia’s governments implement various strategies to attract general physicians to rural and remote areas, including improved financial arrangements, better access to training and continuing professional development.

I cannot overstate just how important that is. Continuing professional development is absolutely essential for people who go to work in rural and remote areas, and they must have improved conditions of work. Dr Sue Page, President of the Rural Doctors Association of Australia, said:

Medical specialists, including general physicians, are a critical part of the multi-disciplinary rural healthcare team ... But as with the rural GP procedural workforce, many rural specialists are now nearing retirement, with few younger specialists moving to rural areas to replace them.

Coming from rural Western Australia and having been very involved with health and health service provision over a number of years, I cannot overstate how strongly people out in rural areas feel about being unable to access medical specialist services. Another thing I feel very strongly about is that, if the specialists cannot move to the rural areas, at least we should have a better system throughout Australia for the Patient Assisted Travel Scheme. Every state in Australia is having problems with this scheme. I think we have to do something about rural people being second-class citizens in not being able to access specialist medical services, and I intend to move in that direction when I can. Dr Page went on to say:

Urgent recruitment and retention strategies are required to reverse this trend, before specialists become all but extinct in the bush and rural patients are subjected to the very serious consequences of this decline. In its recent submission to the Productivity Commission’s Health Workforce Study, RDAA’s Rural Specialists Group highlighted key actions for increasing the number of specialists in rural Australia, including:

• improving rosters and locum arrangements, so that rural specialists are not required to be on-call for after-hours duties more than 1 in 4 days and can take much-needed recreation or education leave. In cases where a 1 in 4 roster is impossible to achieve, doctors must be supported by triage back-up, special locum relief and additional recreation leave;
• increasing the infrastructure available to support specialists in rural areas, including information and communication technology, medical infrastructure, and additional healthcare and administrative staffing support;
• strengthening connections between regional specialists, metropolitan hospitals and metropolitan specialists. Rural specialists rely on these connections for clinical CPD, ready access for second opinions on clinical cases, access for the referral of patients requiring higher level services, and an avenue for locum support;
• encouraging and supporting the specialist colleges to provide enhanced rural training; and
• resolving rural specialist dissatisfaction with inadequate payments and unresolved financial anomalies between metropolitan and rural practice. For example, recent Medicare changes that allow obstetricians in private practice to charge a significant ‘booking-in fee’ do not benefit their rural colleagues who practise overwhelmingly in the public sector. Additionally, there is currently very poor remuneration available for rural doctors (whether GPs, GP proceduralists or specialists) who make a significant commitment to provide after-hours care in the bush, and a rural after-hours loading should be provided in this regard.

Importantly, the more complex caseload undertaken by all rural doctors—GPs, GP proceduralists and rural specialists (including non-procedural specialists)—must be recognised through higher remuneration structures such as rural complexity loadings. The increased complexity of rural patients’ healthcare needs, coupled with less access to additional medical support locally, often means longer consultations for rural doctors and hence reduced incomes compared with their metropolitan colleagues.

Our governments must work together urgently with the medical profession and its colleges to widen measures to support general physicians and other medical specialists currently working in the bush, and to entice more of these specialists to the bush, before there are no specialists left in rural Australia at all.

I would like to continue with some of the National Rural Health Alliance policy statements. For seven years, I was a member of the National Rural Health Alliance representing the Australian Healthcare Association. I have followed and worked very closely with the National Rural Health Alliance. This general statement really fits in with this bill:

The Alliance ... has a particular interest in:

the enhanced infrastructure, and broader system, for placement and postgraduate training of the extra medical and nursing students;

increased rural exposure in the training of medical specialists;

the references to special incentives for the training of dentists (the Alliance wants to see the Commonwealth involved in this as well as the States);

the promise of “better consultation” between the States and Commonwealth on health-related university places;

a single national registration scheme for health professionals …

I must say, having been involved with nursing and also at the moment working for Navy nurses on this issue, for the Defence Force this is one of the most difficult things as far as registration goes for nurses. Each state has its own registration scheme. As you can imagine, when Defence people are so mobile and shifted at short notice, this is causing huge problems for them. The statement continues:

a single national registration scheme for—

all—

health professionals and the fact that “other professional groups (including Aboriginal Health Workers) may be added over time”;

a single national accreditation scheme for health education and training;

a national process for the assessment of overseas-trained doctors …

Once again, this is very difficult with each state doing their own assessment through their medical boards. The statement continues:

the Commonwealth’s intention to provide rural medicine with formal recognition under Medicare as a generalist discipline; and, most importantly,

the initiatives relating directly to improving the health and wellbeing of Indigenous people, such as governments’ “long-term, generational commitment” to overcome Indigenous disadvantage, the commitment to closing the health, education and learning gaps between Indigenous and non-Indigenous children, and further measures to address alcohol and substance misuse, including through additional resources for treatment and rehabilitation services in regional and remote areas.

Having been involved in the petrol-sniffing inquiry with the Senate Community Affairs References Committee, I cannot stress enough just how important it is to have rehabilitation services in regional and remote areas—they are very important services. Once again, we need a very different sort of specialist to be able to handle and cope with these areas.

In conclusion, I commend this bill to the Senate. It is very important that the legislation is put into practice as soon as possible so that specialists are not waiting for two to three months before being recognised to practise. We cannot afford this time.

Ian Macdonald (Queensland, Liberal Party) Share this | Link to this | Hansard source

It is indeed a pleasure and an honour to follow a speaker like Senator Judith Adams. I am always very proud of the people in this parliament, mainly from this side, regrettably—regrettably in that there are not more—who have a real interest in and understanding of these issues. As Senator Adams indicated, she has practised as a nurse and worked in the health area in many other ways over a long period. The parliament and the people of Australia are all the better for the input that people like Senator Adams bring to debates such as this. Whenever I am uncertain about things in country areas, I refer to Senator Adams to get the real story. I have a general understanding of the situation and some of the needs which exist in country Australia, but it is always useful to refer to people, and to Senator Adams in particular, to get technical and accurate input to debates on issues.

As well as Senator Adams, on this side of the parliament we are very fortunate to have the input of Senator Eggleston, a very well-regarded medical practitioner from Port Hedland in his former days before he came to the Senate; Dr Mal Washer, a doctor from Western Australia; and Senator Patterson, who was a health professional. I have named only a few; there may well be others. It is certainly good to see parliamentarians with those sorts of skills and expertise coming into this chamber and lending the parliament and through the parliament the people of Australia their expertise on these issues.

With Australia experiencing the sorts of shortages we have in the medical workforce, it is important that the administrative processes are made more efficient and timely to ensure that appropriately qualified specialist and consultant physicians enter the workforce as quickly as possible. The purpose of the Health Insurance Amendment (Medical Specialists) Bill 2005 is to reduce unnecessary red tape for medical practitioners seeking to provide those specialist and consultant physician services under Medicare. It is proposed to do this by disbanding the state or territory specialist recognition advisory committees and allowing medical practitioners to make direct application to the minister or his delegate for approval for Medicare purposes. Under the new processes, registered medical practitioners will apply in writing directly to the minister through his delegate in the Health Insurance Commission for recognition as specialists or consultant physicians for the purposes of the act.

I recently attended an AMA gathering in Parliament House, and I was told that the specialist colleges had increased by 40.6 per cent training places in the colleges. But, whilst the training colleges for specialists are increasing their activities, all of the states are, regrettably, cutting training positions. There is no point in the colleges training specialists if the specialist positions in the hospitals are no longer there. It is with great sadness that I report that in my own state this situation is enormously difficult and underresourced by the state government.

I do not want to sound like a bad loser, but, regrettably, the people of Queensland have returned the Beattie government—a government which has done more to destroy the health system in Queensland than any in history. During the recent election campaign, I found some old posters that we were using at the election three years ago. We were able to use them again this year. The posters said: ‘Don’t reward Labor, with the mess they’ve made of the Townsville Hospital. Fix the Townsville Hospital now.’ They were posters we used three years ago. Unfortunately, the people of Queensland did not take the message then. We used them again this year and, regrettably, for any number of reasons—I guess it is because the people of Queensland did not have a great deal of confidence in the coalition leadership this time around—the administration that for eight years has just about destroyed the public health system in Queensland has been returned to government. It is particularly galling to me that Mr Beattie, in the pre-election advertising, would smile nicely at people and say: ‘Yes, it is a problem. I promise to fix it.’ The people of Queensland have been gullible in yet again falling for Mr Beattie’s promises.

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

Did the voters get it wrong?

Ian Macdonald (Queensland, Liberal Party) Share this | Link to this | Hansard source

He promised to fix the problems three years ago and nothing happened. In fact, they got worse—Senator McLucas will be well aware of that. The problems in North Queensland that she and I are intimately aware of have got worse in the three years since Mr Beattie promised he would fix them. Again this year Mr Beattie has smiled at everyone and said: ‘Yes, dear. Isn’t this a terrible problem? I will fix it.’ But what has he been doing for eight years? Accordingly, I have no confidence in the proposition that the health problems we have in Queensland will be fixed so long as Mr Beattie and his cronies are there. More bureaucrats will be put into it and more advertising will be done. Mr Beattie has been running huge full-page advertisements for the last six months. I suspect they will stop now, the election being over. These advertisements were paid for by the taxpayers. Instead of putting the money into medical services, where it should have been put, it was put into advertising. We have had all the promises. We have had the nice pictures. We have had the announcements. But mark my words: in three years time things will not have improved. You only have to talk to anyone in the health areas to know this.

I have been approached by any number of nurses who say to me: ‘Because of the Commonwealth government we have been able to get places in universities, but we cannot get training places in Queensland hospitals.’ The training places are essential for those nurses to complete their work. I have doctors coming to me who are also grateful to the federal government for providing all these additional university places for would-be medical practitioners. But, once they finish, they have nowhere to go for their training in the Queensland hospitals. The Queensland hospitals, according to the AMA, and the hospitals in all other states, are cutting those training positions. That is of great concern to me.

The federal government has, over the 10 years that it has been in power, made a significant difference to medical services in country Australia. It has done this in so many ways that time today does not permit me to go through them all. I just want to mention one aspect of where the federal government has improved considerably the prospect of better medical treatment in country areas of Australia, and that is the introduction of a medical school at James Cook University, in Townsville, the city where I have my base. The James Cook University medical school is a real success story. I certainly give credit to Professor Bob Porter AC, who was the planning dean. When he first joined JCU in 1997 he was responsible for getting Australian Medical Council accreditation for the MBBS—that is, the Bachelor of Medicine Bachelor of Surgery. He originally came from Monash University, where he was the leading light in the development of the university’s medical school. Professor Ian Wronski, who is the executive dean of the Faculty of Medicine, Health and Molecular Science at JCU, also deserves significant credit for the great successes the James Cook University medical school has achieved.

The first-year numbers this year of Commonwealth funded places at JCU’s medical school were 83, which is a creditable contribution. Last year, in December, I was privileged to attend the graduation of some 58 students from the first MBBS program at James Cook University. I am delighted to hear that 64 per cent of graduates indicated that they were going to work in rural areas of Australia. That is absolutely fantastic, and it will certainly arrest the drain over recent years resulting in a paucity of medical practitioners in country Australia and certainly in country Queensland.

Fifty-six per cent of the graduates said they would remain in North Queensland, which means they will stay in Townsville, Cairns and Mackay. Even so, it shows the wisdom of the Howard government’s approach to problems in the bush. It is a long-term solution, but the long-term solution had to be undertaken. The thought was—and it is justified by the statistics—that there is a greater likelihood of country young people who enter medical schools in a non-capital-city university staying out of the capital cities. In the past, too many country kids would go to a capital city university to do their medical course and would get involved with a partner from that area, resulting in their staying in the capital cities. Very few of them went back out to the country.

This initiative of getting medical schools into regional areas—Townsville is just one of them but it is the one I am most familiar with—is already paying dividends. It means that the citizens of country Australia—which is where I live, in a country town in North Queensland—will have better prospects of getting a doctor in the years ahead. So congratulations to James Cook University medical school and all credit to Dr Wooldridge, who initiated this program, and the health ministers of the coalition government over the last 10 years.

This program has been very significant in getting a better deal for country people but, whilst the Commonwealth government continues to look after country people and to help the medical profession, regrettably all of the state governments—and my state of Queensland in particular—seem to be working against country people. I again mention the cut in the training positions. I urge the Queensland government to do something about that. There have been comments about the Commonwealth taking over the hospital and health systems in the state. It is an appealing thought, because the states have made such a botch of health, but the set-up—the infrastructure and the way it works—makes it impossible for the Commonwealth to take that over in the foreseeable future. One would hope that the states would learn from the disasters that have occurred.

I do feel sorry for those Queenslanders who, over many years, have approached me and my colleagues in tears about their health problems, which in many cases have been terminal and could not be treated because they could not get into the state hospital system. Whilst the leadership of the coalition might not have been what Queenslanders wanted, certainly the state coalition has an excellent policy that, if you cannot get into a public hospital and you have a life-threatening disease, the government will pay for you to go to a private hospital. I would hope that the new Queensland government will take that up. I think that is a vain hope, because the Queensland government has shown no interest over the last eight years in addressing the disaster that has overtaken public health in Queensland.

I will very briefly mention the need for increased technology in the provision of medical services. I was at Palm Island recently, and a new system was demonstrated to me. It could be technically explained, but I will not even attempt to do that. I will explain it in the way it appeared to me. Palm Island is a remote place. It is not all that far from Townsville but it is across the sea and it is difficult to get to. The medical people there do a fabulous job in difficult circumstances. They are working on a system whereby the local practitioner can, by means of television and telecasting, get the advice of specialists in Townsville to deal with problems that arise unexpectedly.

There has been something like this in place for some time in western Queensland, but I am told that this is a more interactive approach. A GP in a remote area who is faced with a life-threatening situation can look at the television screen and get advice from a specialist and even some help from the specialist to show how it is done. I know the Commonwealth government has been very much involved in the provision of these improved technological aids to allow the expansion of good medical treatment right throughout Australia.

I conclude my remarks by commending this bill to the parliament. The bill represents a minor procedural change, but the objective of the change is to reduce the current complexity in recognising medical specialists and consultant physicians under the Medicare system. It is anticipated that this amendment will significantly reduce the time taken between receipt of an application from a medical practitioner and the recognition. That will help the health system improve. It is an initiative which deserves commendation, and I commend the bill to the Senate.

Santo Santoro (Queensland, Liberal Party, Minister for Ageing) Share this | Link to this | Hansard source

I thank all contributors to this debate: Senators McLucas, Sterle, Ian Macdonald and Adams. I express appreciation for the constructive and cordial way in which this debate has taken place. I could be tempted to follow on from the contribution by Senator Ian Macdonald in relation to Queensland matters with great ease, but I suspect that I would be taking a point of order on relevance from Senator McLucas and perhaps you, Madam Acting Deputy President Troeth—maybe question time would be a more appropriate time—so I shall sum up. I will make some general statements in relation to the Health Insurance Amendment (Medical Specialists) Bill 2005 and then address some of the specific contributions made by senators opposite, particularly those by Senator McLucas, who is representing the shadow minister in this place.

The proposed amendment will reduce unnecessary red tape for medical practitioners seeking recognition as specialists and consultant physicians under the act in order to provide services which attract Medicare benefits at the appropriate rate to their patients. Currently, the administrative process for recognising medical practitioners can involve unnecessary duplication and lengthy periods. This has been the source of regular complaints from medical practitioners, specialists, medical colleges, employers and recruitment agencies. Applications for specialty recognition by certain medical practitioners must be referred to state or territory specialist recognition advisory committees, known as SRACs. All applications seeking recognition as consultant physicians must also be referred to an SRAC.

Referrals to SRACs may have been effective in the past by providing a structure for the assessment of specialists who are not eligible for automatic recognition. However, since these committees were established, specialist medical colleges and medical registration boards have developed and implemented assessment processes which are now used by the SRACs in making their determinations. Because SRACs rely on the assessment advice of specialist medical colleges and medical registration boards in making their decisions, the committees now add a redundant administrative layer for processing applications. This unnecessarily extends the period of time between the registration of specialists and when they can provide services which attract Medicare rebates.

The amendment will disband the SRACs in order to streamline the recognition process. Applicants will apply to the Minister for Health and Ageing’s delegate in Medicare Australia for recognition as a specialist or consultant physician. Transitional arrangements have been provided to ensure the continued recognition of specialists and consultant physicians previously recognised by SRACs. Provision has also been made for the delegate to immediately consider applications that are with SRACs at the time they are disbanded.

This bill represents a minor procedural change. The objective of the change is to reduce the complexity currently involved in the recognition of medical specialists and consultant physicians under the Medicare system. It is anticipated that the amendment will significantly reduce the time between the receipt of an application from a medical practitioner and the granting of recognition for the purpose of Medicare. The legislative amendment does not bestow specialist or consultant physician status on medical practitioners. Medical practitioners are identified as specialists or consultant physicians by medical boards when they are registered on the advice of specialist medical colleges.

With Australia experiencing shortages in the medical workforce, the streamlined administrative process will mean that the specialists and consultant physicians enter the workforce as quickly as possible. I note that all of the speakers generally expressed support for the legislative amendments that we are making, and I thank them for that indication of support.

Senator McLucas in her substantial contribution made mention of several aspects of the medical system, including her contention that there is a lack of formal planning by the Australian government. She made comments in relation to her belief that the government fails to show leadership on quality and safety, especially with regard to the accreditation of GPs. She also made some comments in relation to overreliance on overseas trained doctors. I will briefly make some comments about those three contributions.

In response to Senator McLucas’s suggestion that there is a lack of formal planning by the Australian government: she would obviously be aware that, since 2000, there has been an increase in the number of medical schools. In fact, we now have 15 medical schools. The number of medical graduates will increase from 1,500 in 2003 to approximately 3,400 in 2015. As part of the 2006-07 budget, 400 medical school places were announced and, following the COAG meeting, another 205 places were announced. I will come back to that and outline in a little bit more detail the increase in the number of medical school places.

Senator McLucas also suggested that the government failed to show leadership on quality and safety, especially with regard to the accreditation of GPs. The recent COAG announcement included new processes for the accreditation and registration of medical professionals, and my advice is that those announcements were very well supported by all governments, including state governments, represented at the COAG meeting. That is something that can be recognised in this place as a step forward.

I am sure that Senator McLucas would acknowledge that the government takes its quality and compliance responsibilities for aged care very seriously, as demonstrated by measures that I have previously announced for which we are currently drafting legislation and which we have funded to the extent of approximately $110 million. We take our responsibilities seriously. I always say that there is always more that one could do, but that statement is made within the context of the very heavy competition for government funds.

In relation to a point that I think was made by Senator Sterle on the reliance on overseas trained doctors, honourable senators would appreciate that it can take up to 11 years before a student can become fully qualified to practise. Given that that is the case, we also need measures to boost doctor numbers in the short term. I am sure that all senators would welcome the range of measures which the Howard government has put in place in order to address the short-term situation.

The government has started addressing that short-term situation by increasing the number of appropriately qualified overseas trained doctors practising in Australia, through international recruitment strategies. It has reduced red tape in the approval processes and also changed some of the immigration arrangements. I think all senators would welcome into the medical system in our country the arrival of overseas trained doctors who are able to assist in taking care of the health of Australians.

We have had unfortunate cases, such as that of Dr Patel, but we will not dwell on that situation at this point in time. I, like Senator Ian Macdonald, have been visited by a number of overseas trained doctors since the Dr Patel situation came into public focus, stressing that they regard it as an honour and a privilege to be in Australia and to work with their Australian colleagues. They believe, I believe and the government believes that they make a very valuable contribution to the health and welfare of Australians.

In addition to that, the government is supporting more than 1,600 general practices to employ practice nurses and is allowing all GPs to claim Medicare items for certain services undertaken by practice nurses. Again, feedback I have received, particularly in my local area of North Brisbane—I live in the North Brisbane area and have come into contact with GPs, including with my own GP—is that this is a very welcome move. I think that can be put on the record with some justification and pride.

The government is also assisting by making funding available for 280 short-term placements each year for junior doctors to work under supervision in general practices in outer metropolitan and rural and regional areas. When the government made the decision, it again demonstrated its commitment to Australians who live outside the major cities, including and in particular the major capital cities. I am a proud member of a government that does not forget that Australia does not stop at the boundaries of our major cities, including our capital cities. I am sure all senators in this place believe that the food baskets and the great economic, cultural and social hinterlands that rural and regional Australia represent need and deserve attention such as that shown by the Howard government in its emphasis on improving medical services within regional and rural Australia. Increased support has also been provided for rural general practitioners who provide procedural services such as obstetrics and minor operations.

Only a few months ago I visited several centres in western Queensland, and it was very clear to me that some of the measures I have just mentioned in this summing-up speech were appreciated. They were commented upon certainly to me, and to some of my other senatorial colleagues, including Senators Ian Macdonald, Mason and Brandis, who accompanied me on that trip. The measures were appreciated, and vocally so, by many of the people we met.

I would like to conclude by again bringing to the attention of senators that, at its 14 July 2006 meeting, COAG announced its support for the key directions of the Productivity Commission report Australia’s health workforce. COAG agreed to a range of health workforce reforms to address key issues raised in the report. I will not go through all the components of that agreement, because to outline that would go beyond the scope of the bill we are considering here today. But I think it is important to again acknowledge in this place that the Australian government’s contribution to the package of reforms is $300 million, and it includes funding for 605 new medical places, with 220 going to Victoria, 150 to Queensland, 110 to New South Wales, 60 each to Western Australia and South Australia, and five to Tasmania. As an aside, a commitment was also made at that COAG meeting for 1,000 new nursing places.

I listened very carefully to the contributions to the debate, particularly those of opposition senators. I think it is fair that they do raise issues of concern to them in terms of what they perceive to be deficiencies within Australia’s medical system. But I also think it is important to acknowledge that the Howard government does provide as much as it can to the improvement of health services right across Australia and, through this bill, is eliminating what is now considered to be unnecessary red tape which has hitherto hindered the efficient processing of matters related to the registration of doctors. I commend this amendment bill to the Senate.

Question negatived.

Original question agreed to.

Bill read a second time.