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Monday, 21 May 2012
Page: 4922


Mr LAMING (Bowman) (17:19): I too commend every member of the committee that put together this important report. With my interest in this policy area, I have had a number of people around the country ask that the parliament take a more detailed look at the area of overseas trained doctors, international medical graduates, and the pathway—often complex—that they have to traverse in order to become a recognised health practitioner in Australia. The context of this discussion is the recent establishment of AHPRA. We know that they have assumed many of the roles that were traditionally performed by independent state medical boards. In the main, there has been some support for a nationally harmonised process to allow overseas applicants to go through a single national process of registration and ultimately be looked after by the same bodies that look after our domestic graduates.

This is also in the context of a much longer period during which Australia, like a number of developed economies, has been unable to provide itself with, and sufficiently train, domestic graduates to fulfil the needs of our health system. That is primarily because we have an extremely advanced health system that remains dependent on its human workforce despite the increasing use of technology in the health system. Health remains a growth area of government spending that is heavily reliant on highly trained individuals. Australia has not been able to provide for its entire population through lags in the system and also historically through the 1990s workforce modelling that incorrectly indicated that we actually did have enough health workforce being trained. In fact, many experts underestimated the number of, in particular, female graduates who would not move into full-time work. So, while the numbers may have appeared to have been satisfactory to a number of observers, in the early 2000s we were short in nursing, medicine and allied health in particular.

Australia has a long tradition of relying on overseas medical graduates coming into a universal healthcare system that is GP focused. That is why Australia's health system is so utterly dependent on IMGs, particularly in the larger and more sparsely populated states of Queensland, Western Australia and the Northern Territory, where more than half of our medical workforce comes from overseas. Setting those ethical issues aside, there has been a longstanding debate over equivalence versus competency—'equivalence' meaning 'Do you have exactly the same degree?' and 'competence' meaning 'Are you able to demonstrate a level of health or clinical performance similar to an Australian graduate?' Slowly, over time, we have been able to make important shifts towards clear equivalence. We require a demonstration of ability, which is effectively competence, but you do not have to have an identical degree to be able to be recognised in Australia. We have shifted away from demanding that overseas graduates have the Australian qualification, the speciality qualification that is identical or comparable, to a recognition that there a number of universities and certainly countries around the world that have equivalent standards and that, for those practitioners, there should be a more streamlined approach.

If there is one thing that comes out of this report for me, it is that we need to be identifying those overseas providers who can be fast-tracked into Australia because of the recognised degrees and qualifications that they hold —in particular, English speaking—and that they can be brought in with a minimum of fuss and delay. There is obviously a cohort who have potentially high levels of qualification but come from countries where the standard of those degrees is more variable. In those cases, I think it is only right and proper that we are extremely detailed in our evaluation of those qualifications and competencies. I think everyone here would agree that in no way should we shift from a belief that quality of care has to be paramount, that we cannot compromise that for any streamlining of the system.

I think it would be wrong to presume that anything that drove this particular report or any of the views of anyone who contributed to it would have supported such a proposition. But significant groups who shape the health system in this country have contributed generously with their submissions. I appreciate that, as I know that the rest of the parliament does, because it is clear that this is an immensely complex area, that there is no simple solution and that you cannot simply treat everyone in exactly the same way. When an applicant comes into the health system, up until recent years they have predominantly done so via a purely paper based application that needed to be checked in depth. It is really good to see a shift now towards a verbal examination and structured interviews, and I think what will ultimately be most effective is workplace based assessment. That has to be at the highest level. This will allow clinical fellows who are experts in their own fields, and who are performing assessments of people coming from overseas, to give fast feedback to minimise the amount of heartbreak, disappointment, time investment or financial investment that comes with not having early feedback on exactly how that person's application is going, and what their likelihood is of success.

It is also important to recognise that when people come from overseas they come, in many cases, as a family. We still have an issue where some of our highest-need areas are also our most remote. They are the areas where it is hardest to supervise an applicant, and where support for family members is most strained. So it is a real shame that we have people arriving on visas who are, in particular, providing health services to the community but cannot get health care for their own children or enrol their children in the local school. I would like to see these sorts of inequities addressed so that we can at least know that there is the social support there for people who are doing the work in the most remote parts of our country.

We have a number of times raised the anomalies between areas of need, districts of workforce shortages and the payments that are calculated through the Australian government geographic classification of remoteness. All of these, at different times, run counter to each other. In my electorate it causes enormous heartbreak in the remote islands off the coast of Queensland, where it is immensely difficult to get a doctor to practise, and where we rely on exemptions to the DWS to maintain the staffing of our medical centres.

There are inconsistencies as you move around the country, and naturally there will always be lines that have to be drawn on the map, but we are finding that these geographic zones could be better designed. There has been a long campaign run by the Rural Doctors Association of Australia to revisit this five-tier classification system that has been introduced by the current government. We think it is too coarse a classification. It may well work for other purposes, but it does not work for the decisions that practitioners make to move into remote parts of Australia. In many cases, giving someone exactly the same payment whether they are working in Central Australia or in a provincial town is quite inequitable.

It is also concerning that the additional payments that are made to people to move into really remote areas are so small; either we are going to fail to attract people in the first place or we are going to have our remote providers burning out and leaving those areas because the incentive to stay is simply not high enough for them to continue. This will continue to cause problems for remote country towns that need a continued medical service provision. If you take that doctor away the pharmacy then collapses and a range of other providers go broke, and it can rip the heart right out of a country town.

It is very important that we keep those numbers high. It is simply not sufficient to quote numbers across broad regional areas and say that there are more doctors in an inner or an outer regional area. These regions cover areas far greater than most countries on the planet. We need to be more specific, and identify towns that are in the electorates—some even belonging to members sitting here in this chamber—that can lose a doctor and have it be an absolutely harrowing situation for the social capital within that community. Retaining a doctor is everything for a number of those communities, and we need to be finding more innovative partnerships where we can partner up large practices in urban areas—and even hospitals—to provide backup to smaller towns. After all, they have the HR back end. They have the nerve centre of HR skills and administrative capacity to be hiring and finding new providers, but many country towns cannot. It is not enough just to hand them a bucket of money and say, 'Go and find yourself a doctor.' It is extremely difficult for them to do it and to keep doing it every year when they lose someone they have only just recruited.

The messages were quite simple in this report. There will not be any magic bullet, but the shift from paper based assessment to PICSE, structured interviews and work based assessment is agreed on both sides of the chamber. We need to be more imaginative in our assessment so that we can streamline and identify those who are capable and, when they are, ensure that they are identified early and allowed to work in a base hospital or a teaching hospital first so that they understand our system before they are thrown out into the remote areas.

The current moratorium has its challenges but , at this point, as long as we can properly supervise new arrivals to our medical and health system then there are elements of the moratorium that are working effectively . T o remove it would significantly compromise large areas of this country. Once again, to those who put this report together, I commend them and the contribution they have made to rural and workforce health policy.