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Thursday, 26 November 2009
Page: 13189


Mr ADAMS (4:13 PM) —The Health Insurance Amendment (New Zealand Overseas Trained Doctors) Bill 2009 has been developed to find a solution to a problem that has been caused through certain health legislation and to accommodate our New Zealand friends’ rights to immigration. The purpose of the bill is to amend the Health Insurance Act 1973 to remove restrictions which apply to New Zealand permanent residents and citizens who are medical practitioners who obtained their primary medical education at an accredited medical school in Australia or New Zealand. The act specifies that the period of 10 years during which overseas trained doctors are restricted from accessing Medicare benefits must commence from the time the doctor becomes a permanent Australian resident, even if they became medical practitioners prior to gaining that residency status. The bill also introduces a time period in which medical examiners can appeal against the refusal to grant a section 19AB exemption or a decision to impose conditions in connection with an exemption which has been granted.

In the mid-1990s the view that Australia produced sufficient medical practitioners to meet the health needs of the population, which had dominated policy thinking for some years, began to be questioned as doctor shortages became increasingly obvious in rural and remote areas. Initially, because general practitioners and specialists were concentrated in major urban areas, it was considered that, rather than there being actual shortages in the medical workforce, there was a maldistribution between the bush and metropolitan areas. This thinking prompted the then government, following its election in 1996, to introduce legislation and initiatives intended to address medical workforce maldistribution.

As there is a constitutional restraint on governments which prevents them from introducing legislation to conscript the services of Australian medical practitioners to work in certain areas, doctors who obtained their primary medical qualifications overseas became the focus of government strategy. Amendments to the act were introduced which obliged those doctors to agree to practise in rural and remote areas where medical workforce shortages had been identified if they wished to access Medicare benefits for the services they provided. In addition to the restrictions on overseas trained doctors, the government of the day limited the granting of new Medicare provider numbers to people who had achieved minimum proficiency qualifications—that is, specialist medical qualifications including general practitioner qualifications.

The minimum proficiency requirements for new medical practitioners are imposed under section 19AA of the act. Under this section, medical doctors who were first recognised as medical practitioners on or after 1 November 1996 are unable to claim Medicare benefits unless they satisfy certain conditions. These are that they are recognised general practitioners, specialist or consultant physicians, or they are undertaking approved authorised placements.

Section 19AB of the act imposes restrictions on medical practitioners who did not obtain their primary medical qualifications in Australia. These medical practitioners are known as overseas trained doctors or international medical graduates. Under the 1996 legislation, permanent-resident overseas-trained doctors were not subject to restrictions if, before 1 January 1997, they were registered with an Australian medical board or eligible to have their qualifications assessed by a board. However, those who did not meet this requirement were not eligible to claim Medicare for a certain period. Those restrictions were commonly referred to as the 10-year moratorium. Temporary-resident overseas-trained doctors are subject to restrictions under section 19AB of the act for an indefinite period.

Exemptions to the requirements under section 19AB can be granted to overseas trained doctors if they agree to work in areas where medical workforce shortages have been identified. These areas are known as districts of workforce shortage—DWS. These are areas in which the community is considered to have less access to medical services than experienced by the population in general. This can be because of the remote nature of certain communities or because of the lack of services available to those communities, or a combination of the two factors.

Added to these details is the unique situation that New Zealand citizens have found themselves in as far as accessing Australian work and benefits is concerned. New Zealanders were allocated a special visa to accommodate the Australia-New Zealand relationship which was developed in 1973. That entitled the citizens the right to visit, live and work in each other’s countries. So when New Zealanders present their passports at immigration they are considered to have applied for a visa and, subject to health and character considerations, they automatically receive an Australian special category visa.

New Zealanders do not need to be granted permanent residency in Australia. They are allowed to remain and work in Australia lawfully as long as they remain New Zealand citizens. However, New Zealand citizens who arrived in Australia on or after 27 February 2001 must apply for and be granted Australian permanent residency if they wish to access certain social security payments, obtain Australian citizenship or sponsor their family members for permanent residency.

New Zealand medical students do not enjoy the status generally afforded to their fellow citizens. In fact, that applies to all New Zealand students, as I have found a number of New Zealanders living in Tasmania who have been trying to study there and have been asked to pay full fees as they are not Australian citizens. They are treated as temporary residents.

This bill is to try and rectify this. It proposes to remove New Zealand citizens and permanent residents from the category of ‘former overseas medical students’ and allow those who are here to train or retrain into this profession. However, it should be noted that the proposed changes to the legislation will not exempt New Zealanders from the requirements that apply to Australians, in that graduates of Australian medical schools will be required to gain postgraduate specialist medical qualifications or be in approved placements before they are able to access Medicare.

Hopefully this legislation will allow a few more locally trained but New Zealand born doctors to be available to practise in Australia. However, I do not believe that this alone can assist with the serious shortage of doctors and specialists in this country. I am aware that our waiting lists are not growing any shorter. In Tasmania we are faced with ongoing shortages wherever we look. Some of our few specialists have lately retired, been killed in accidents or, in a couple of cases, murdered—not for the work they did but maybe because of some of the pressures they come under.

We have to make the system work better. It is not right for people in their 70s to wait 18 months to four years to have elective surgery because insufficient operations can be carried out under Medicare because there are not the doctors or theatres to perform them. The state hospital systems are not coping with the demand. Surely it should be only a few months after diagnosis of the need for it that an operation takes place. Those in their late 60s or 70s do not have that sort of time left and cannot live a fulfilled life if they are in constant pain and anxiety from having to wait for an operation.

The Lyons electorate is a very country electorate that covers a wide-ranging area of Tasmania, and the problems seem even more obvious there. Many people who are on waiting lists even have to move away from their friends and relatives to get services to help them while they are waiting. When you have led a very active life, it is quite soul destroying to suddenly have your independence taken away from you. Private health insurance is not the answer, because, even if some of the older people can afford it, there are still huge gap fees which throw many of them back onto the public waiting lists because they simply cannot afford the ancillary costs.

Doctors are still leaving the state in droves or retiring because of the lack of attraction of being in the country areas. Tasmania as a whole is seen as regional and is not attractive to young doctors, who do not want to be bothered with the paperwork of a small practice and would prefer to work as a specialist from a set of professional rooms set up to look after the needs and the administration of a busy city practice that would allow reasonable hours of work and extremely good pay. Some young doctors spend some time in Tasmania as locums, around the coast, which I suppose is a good thing to do if you can get into it.

I think the profession needs to take some responsibility for the present model, which is now failing. Asking young doctors to work in broken-down cottages in country towns, without proper disability access, is unreasonable. A better concept would be to have all the health professionals working out of a regional centre accessible to all patients and where the practice can reach the high standards required by government without putting too much of a financial burden on one doctor. This would allow us to look at regional health and see which areas are falling behind and which have good health standards so that governments can put extra resources into regions that are showing poor health outcomes.

There is an article in the Launceston Examiner today which describes GPs wanting subsidised rent and cars if they are to practise in Launceston. Local government is not in the business of providing properties at reduced rental, even if they had any that were suitable, which they do not. In an attempt to attract more doctors some councils in my electorate have bought houses and cars for corporate medical companies that recruit doctors. The state government is reported to have been offering ‘European cars, overseas travel, mobile phones and entertainment credit cards as incentives’ to keep doctors and specialists in Tasmania. On top of that, they get their private patient fees. I am not sure where this will all lead. Simply, if we cannot afford doctors, other medical providers such as nurse practitioners and alternative medicine practitioners will be called upon to fill some of the gaps starting to emerge. Maybe we should look at the preventative healthcare angle more seriously and stop the need for a lot of people to take up elective procedures by keeping them healthier for longer. Of course that will not stop the accidents or the chronic ailments, but if we are able to live a more healthy lifestyle certainly it would help stop the desperate need for doctors being required to prop us all up as much as they do at present.

I am moving away from the bill a little, Madam Deputy Speaker. I must put in a plug for the those who know and understand the principles behind ‘be well’—a means of dealing with a recently diagnosed ailment, people to whom you can turn so that you can turn your life around and just ‘be well’. At the moment, you come out of a doctor’s appointment with a handful of pills but no instructions or understanding of what your body is doing and why you need all the things you have been prescribed nor any real direction on how you can improve your health, other than some vague suggestions about losing weight, giving up smoking or drinking or exercising more. Then you go to the supermarket and look at food labels which bear no relationship to what the doctor has told you. There is a need for major reform in labelling laws in Australia.

We need proper, long-term health assessments for individuals, which might be available under benefits. We do not even have medical check-ups for our electorate staff these days as we used to. This means that, if someone has a chronic condition, they cannot be assisted in the workplace, which often means time off without any means of helping that person to become healthier. Governments and large corporations, and even small ones, can do more here for their employees and save themselves money. This idea needs more research and for some models to be developed. We are also helping our New Zealand friends become a further part of our system in that, under this bill, they can train here now under Australian guidelines and receive payment. I believe that we have to have a complete look at health as it is delivered in Australia today and I believe that our minister, Minister Roxon, who is in the chamber, has started that process. But we have to deal with the relationship between doctors and governments, because I do not believe that is working very well.

In conclusion, restrictions on provider numbers for overseas trained medical practitioners were introduced in 1996 in an attempt to address doctor shortages, which at first it was thought were confined to rural and remote areas. The restrictions were criticised for a number of reasons, and there continues to be some argument that they have not achieved their objectives. However, given the significant number of overseas trained medical practitioners currently working in rural and remote areas, the claim that the restrictions have had no discernible impact on the medical workforce in the bush is less than convincing.

There are strategies in place to improve the number of Australian trained doctors, which it is hoped will further improve the rural medical workforce. These are long-term solutions to medical workforce shortages. However, there can be no guarantee that Australian trained doctors will opt to practise in areas of workforce shortages. It is likely, therefore, that provider number restrictions on overseas trained doctors will remain in place for some time. Given that this is the case, the decision to reconsider aspects of the restrictions that have been described as particularly onerous and incongruous appears to be a justifiable one. Indeed, it appears particularly unfair that some practitioners have been subject to restrictions for a period of more than 10 years, when it was not the intention of the original legislation for this to occur. Similarly, it appears contradictory to the special relationship afforded New Zealanders in Australia that those who choose to study medicine in Australian medical schools should be disadvantaged upon graduation. The legislation intends to remedy these anomalies.

The other proposed changes in this bill will set a time limit on the period in which medical practitioners can seek review of exemption decisions under section 19AB. Setting such a limit also appears sensible and is more likely to ensure that the circumstances under which a review process is conducted reflect the circumstances which prompted the original decision.

In effect, changes to the act for New Zealand citizens and permanent residents will not have a major negative impact on the number of doctors who are required to complete a 10-year period of service in rural and remote areas and areas of workforce shortage. There may be more impact on doctors’ numbers from the second change proposed in this bill, although it is not clear how many practitioners have been subject to an extended moratorium. However, in keeping with the original intent of the provider number legislation and from the perspective of fairness to doctors who have already made a notable contribution to health in rural and remote areas, it appears justifiable that any effects of the proposed changes should be absorbed. Finally, the third change in the legislation is likely to have a positive effect for administrative review processes that may be as beneficial to those seeking a review of decisions as to those undertaking those reviews. I certainly commend this bill to the House.

Debate interrupted.