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COMMUNITY AFFAIRS LEGISLATION COMMITTEE
11/06/2009
Health Workforce Australia Bill 2009

CHAIR (Senator Moore) —Good morning, everyone. This committee is commencing its inquiry into the Health Workforce Australia Bill 2009. I welcome representatives from Universities Australia, Medical Deans Australia and New Zealand and the Australian Council of Pro-Vice-Chancellors and Deans of Health Sciences. Do you have any comments to make on the capacity in which you appear?

Ms Magarry —I am Acting Chief Executive Officer, Clinical Placements Advisory Group.

CHAIR —That is a very big card!

Prof. White —I am also wearing another hat and representing the Council of Deans of Nursing and Midwifery.

Prof. Hensley —The Joint Medical Program is between the University of Newcastle and the University of New England. I am also an executive member of Medical Deans Australia and New Zealand, which is the representative body of the 18 Australian medical programs and the two New Zealand medical programs.

Prof. Wronski —My substantive role is Pro-Vice-Chancellor and Executive Dean of Medicine, Health and Molecular Sciences at James Cook University.

CHAIR —Are you in Townsville, Professor?

Prof. Wronski —I am in Mission Beach at the moment. I do live in Townsville.

CHAIR —That is outrageous, Professor! I do not know that we should take your evidence on that basis. I have just been assured that you are at a conference.

Prof. Wronski —Yes.

Ms Stronach —I am also Executive Officer for the Faculty of Medicine, Health and Molecular Sciences at James Cook University.

CHAIR —Where are you?

Ms Stronach —I am in Townsville.

CHAIR —We have submissions from each of your organisations. What I suggest is that people make an opening statement and then we will go to questions. It is always difficult when we are trying to balance phone hook-ups, but I am sure you are used to it, as we all have to be. I will look to the witnesses in the room first. Has anyone prepared an opening statement?

Ms Magarry —Yes. Thank you for the opportunity for Universities Australia to make a presentation today. Before I start, I want to extend the apologies of Professor Richard Larkins, as he is unable to attend due to an unfortunate personal circumstance in Melbourne. He has asked me to make the opening statement and represent Universities Australia.

We are the peak national body representing Australian universities in the public interest. Australia’s 39 universities are the primary educators of health professionals, and approximately 120,000 health students are currently enrolled across a range of disciplines. You may be aware of the increasing numbers of health students entering the system over the next few years in medicine, nursing, midwifery, allied health and dentistry. We believe that effective clinical education placements are a vital component of the education of these students and, consequently, Universities Australia has shown a keen interest in the establishment of Health Workforce Australia and the accompanying bill.

In correspondence to the Minister for Health and Ageing in March this year, we stated that a correctly established and adequately funded agency will alleviate many of the issues and concerns currently experienced by those involved in clinical education and that the $1.6 billion proposed could substantially improve the availability and effectiveness of clinical education placements.

Our concern is that the bill does not currently provide any substantive detail on the powers and responsibilities of Health Workforce Australia, and this aspect requires greater clarification before we believe it would be able to be supported widely. We believe that a national agency must act as a facilitator to provide funding, administrative and higher end strategic planning support for universities and healthcare providers. It should not impose a new level of bureaucracy that is not responsive to local needs or to changes in curricula and practice which may erode the good relations that have built up between individual universities and healthcare providers over decades.

We believe effective representation on the governing board is vital, and we note the bill envisages a 13-member board. However, we believe it is heavily weighted towards government at the moment, in a nine to four ratio. Universities Australia does not consider that such a composition will adequately reflect the relative importance of all stakeholder groupings. We understand those groupings to be government, education providers and health providers. We note that only three board places—four if you include the chair—will be expected to accommodate education providers, and those providers are currently universities, the VET sector and private education—also private and not-for-profit healthcare providers and discipline specific groups, including registration and accreditation bodies.

I have the benefit today of having Professor Jill White with me as a member of CPAG and also the dean of the University of Sydney nursing and midwifery faculty. I believe that she would be able to provide some further information for you in relation to the practical applications, as we see them, of the bill.

Prof. White —I would like to start by thanking you for the opportunity to be here. I will not repeat any of the points that Angela has made, although I do need to say, as a member of CPAG, that I absolutely agree with them and support them. The Council of Deans of Nursing and Midwifery in Australia and New Zealand also supports the points made.

There are a couple of additional points I would like to emphasise. I think that for the Council of Deans of Nursing and Midwifery, as with CPAG, it is the lack of clarity in the bill, the lack of information and detail in the bill, that is of concern in relation to governance but also in relation to the structure and the way in which the organisation will interact with clinical placements per se. The council of deans has written extensively to the National Health Workforce Taskforce advising that we believe the brokerage model would be the only one that would be acceptable, although we are very supportive, obviously, of the extra funding. We are very supportive also of a national repository of data that was accurate and timely, and that is seen to be a very positive aspect.

An area of concern is the absence in the bill of any indication of the relationship between Health Workforce Australia and regulatory and accreditation bodies, and we would seek clarity on this matter. Clinical placements and clinical education are absolutely fundamental components of both registration and accreditation, and therefore there would be some interaction. What that will be—what the hierarchy will be and what the relationships will be—is of great import and, we believe, needs to be clarified. I am happy to leave my statement at that point, thank you.

Prof. Hensley —Thank you very much for the opportunity for Medical Deans Australia and New Zealand to comment on the bill. Medical Deans Australia and New Zealand is the peak body representing, as I mentioned, the 18 Australian medical schools and the two New Zealand medical schools.

Medical Deans has responded to the consultation process, and has appreciated the opportunity to do so, and very strongly supports the initiatives in the national health workforce agency reflected in Health Workforce Australia. We think it is going to make a great deal of difference to the delivery of clinical teaching. From a medical student point of view, the figures in the COAG document indicate that, even though medical students are less than 10 per cent of the health professionals in training in universities, they constitute almost 50 per cent of the clinical training days. The nature of the medical program is a very strong insistence on clinical training days, particularly in the last few years, in preparation for medical students to become doctors from day one. The expectation is a standard of clinical practice that is both safe and effective from the first day they become interns. So the clinical placements and clinical trainings for us are fundamental to the quality of the graduates that we and all the health professions provide. That is really the focus that we have: that quality of the student experience to enable them to be effective and safe health professionals virtually from the day of graduation.

That also introduces for us a couple of areas that we think are reflected in parts of the proposal but are some of the details, and one is this continuum of education and to ensure that the health workforce initiative does not break up the continuum of education and that it supports the structures that have supported education around the country. They are, particularly, the linkages between clinical education and clinical research. There is very important investment in the future of the quality of our health care by ensuring that there is a continuum of clinical education and that clinical education informs the quality of the health provided. We think that that is very important.

We support fully the comments by Angela and Professor White from the perspective of Universities Australia and the deans of nursing. We too have concerns about the specific requirements, and we have a particular concern that we have in Australia very successful health professional training based on partnerships, particularly regional partnerships between health services and universities, and that to have a process that consolidates and enhances those would be fine but anything that would fragment them would cause concern. For us, the proposal that the agency works through flexibility and facilitates training is extremely important.

We also echo the concerns expressed by Universities Australia that the role of the board will be fundamental in determining direction; therefore, we would advocate very strongly for health educational expertise on that board to ensure that what is a very large investment by state and Commonwealth governments translates into excellent practitioners across the health area.

I would strongly support Professor White’s comment that there has to be integration between the education and the health workforce planning and delivery and registration. Again, it is extremely important that the education is done in the context of our requirements for future health workforce. I am very happy to answer any questions. Thank you.

CHAIR —Thank you, Professor. It is difficult when there are so many professors. Professor Wronski—in, I regret to say, Mission Beach!

Prof. Wronski —Thanks again for the opportunity to provide evidence to the Senate inquiry. The Australian Council of PVCs and Deans of Health Sciences is the peak representative body for those Australian universities providing preprofessional education and training in the allied health areas. We welcome the focused new resources to support clinical education in Australia. We do note that $1 billion of that is new and $500 million or so counts resources currently applied to clinical education.

Our council has been actively engaged in these developments across registration and accreditation and the National Health Workforce Taskforce developments. Our starting point is that Australia’s health workforce training system is of exceptionally high quality. We do want to see the building and expansion of that. At the current time, we would estimate that 80 to 90 per cent of health workforce training in Australia is of very high quality.

We would want to see the development of a broader conception of, say, a teaching health system with a research orientation that would need to occur across the public, private and NGO sectors. It is important that that builds on the strengths of the current system and is expanded to include all health professions. We think this would be best achieved by the expansion of the tried concept of the rural clinical school, the university department of rural health model, as a delivery mechanism, expanded to become truly multiprofessional and multigeographic. We wish to see the continuation of the diversity of health professional education to deal with different needs of various health professions and to continue to encourage innovation.

So we see the HWA as largely facilitative, with important planning functions, and some brokerage role around the creation of new clinical placements, and some targeted areas, with possible national approaches for very small professions. Our concern with the bill currently is that it lacks clarity about which model is being pursued and at present could be interpreted to include a wide variety of methods of operation from what we would regard as a backward step to very positive. The current wording in the bill would allow the organising of clinical placements at a national level, which just will not work and will have a very adverse impact on the integrated arrangements at regional level and the relationships that make clinical education work.

In addition, we are concerned about the broad representation and that it does not reflect the make-up of the interested parties. We think that it needs much more and clearer representation from the health education and health professional sectors. Thanks very much. I am happy to take questions.

CHAIR —Ms Stronach in Townsville, are you wishing to make any comment at this stage?

Ms Stronach —I would support what Professor Wronski has said. The lack of clarity in how HWA would operate and the proposed composition of the board with not enough health education and training representation is of concern to us. There is already significant bureaucracy associated with clinical placement of students, and within the Pro-Vic-Chancellors and Deans of Health Sciences we represent 12 universities and those universities have at least three of a list of about 13 disciplines, so we have a very wide representation and a wide knowledge of the diversity involved in clinical placement. It is important that that diversity is acknowledged and recognised in any operations of HWA. Thank you.

CHAIR —Thank you.

Senator ADAMS —Thank you all very much. I am very pleased to hear that the ‘practicality’ and ‘flexibility’ words have been mentioned, because I cannot see this working. I have a nursing background and I have sat on a number of country hospital boards and the Metropolitan Health Service Board in Perth, so I do understand about governance and boards. That is really where I would like to start. Professor Wronski spoke about representation on the board. I would wonder whether this would be a mix-of-skills board. It cannot be representative because there are so many areas out there. We have such a great standard. I have had a lot to do with the rural clinical schools and that model works really well. What does concern me is that we have one member nominated by the Commonwealth and eight members each nominated by a different state or territory. Who do you see as being this person from each state or territory and at what level? Have you got any idea about that member or those members?

Prof. White —One of our concerns is that they will be nominated by health ministers and they will be workforce people from departments. That is of considerable concern.

Senator ADAMS —But are they going to be practical people?

Prof. White —Even if they were practical people, from workforce components of departments, it is still a single industry voice. It is not a voice that also brings into play the understandings that come from the disciplines and from education. That is a significant component of Universities Australia’s submission—a suggestion on how one might constitute a board differently and with a slightly larger composition, but at least with acknowledgement and representation. It must come from universities, it must come from the major disciplines—and I think, progressively, we are seeing that there are three major councils. There are the major councils of deans. They are the ones represented here today—and in the ether! But also there is, as our submission suggests, the need to understand that there is all of the private health care industry that is not necessarily going to be represented by department of health nominees from workforce. There is also no mention of the registration or accreditation bodies—and particularly the accreditation bodies, that even the communique from COAG suggests must be independent—that are still critical in terms of informing the work of Health Workforce Australia, because they are the ones who set the standards for entry to a profession and accreditation of a program. To leave them out of the mix leaves one important voice absolutely silent.

Senator ADAMS —Ms Magarry, any comment?

Ms Magarry —I would agree with what Jill has said, and say that universities are headed up by a -chancellor and president, who are responsible for a number of disciplines in their universities. We have felt that the governing board should at least have one eminent vice-chancellor on the board, and reflect the range of disciplines that will be affected by an agency seeking to broker arrangements for clinical placements.

Senator ADAMS —Professor?

CHAIR —Judith, I will just check whether Professor Wronski has a comment to make.

Senator ADAMS —Yes. I am going to go to him.

CHAIR —With that same question or your next one?

Senator ADAMS —Yes. I was going to ask the five.

Prof. Hensley —As Medical Deans Australia and New Zealand, we have indicated in our submission that we support the concern that the board should be able to contribute to the major business of HWA, which will be enhancing clinical education, preparation of a workforce—

Senator ADAMS —Surely that is its role, Professor.

Prof. Hensley —and I think the concern of the jurisdictions, given that Professor Wronski said that they are contributing $500 million to the process to have a degree of governance, is understandable, but I would hope that that can be achieved by ways other than a domination on the board. I think that is where all of us have a concern. This is a fabulous opportunity to really not only support expanding clinical education but innovation as well, and there is a lot to be done.

Senator ADAMS —And get it right.

Prof. Hensley —And to get it right for the future.

Senator ADAMS —Thank you for that. Professor Wronski?

Prof. Wronski —Boards can be very important, and this is maybe a once in a lifetime opportunity to reshape and facilitate the further development of high-quality health professional education in Australia, so the inputs at board level, we think, are very important. Size of boards has an implication too, but I think that the states possibly do not need to be represented individually, just as it would not be possible for every health profession to be represented individually. I mean, we have a dozen or so across the allied areas. But what people bring is a perspective of the world from their own profession that is very useful in understanding how to take a system forward, and so we need some balance of disciplinary dimension to the sort of decision making that HWA is going to make. When you get into the details of how professional education is carried out, it is remarkably divergent, and needs to be because the health professions do things quite differently in some areas, and it is required to be so. What is important to be established through the board process is the representation of views of the world from across the health professions, as well as from universities and from the disciplinary areas that are important in making these sorts of decisions. Also, if we are going to expand clinical placements, the great untapped areas are the private sectors and the NGO sectors, and yet they seem to have been excluded, so I think there is some rethinking to do about that.

Senator ADAMS —Yes, they will be giving evidence later today. Ms Stronach, would you like to comment?

Ms Stronach —I agree with everything that has been said so far.

Senator ADAMS —Thank you very much. We have got eight members that we have talked about for the states and territories, and then there are up to three other members. Would you consider that, because of the budget of this particular proposed board, you would need legal expertise plus financial expertise on that board? These other three members, we do not know who they are, what they are, or what role they would have to play, but would the board—

Prof. White —And possibly community representation.

Senator ADAMS —I was about to get to that, because that was my role before I entered parliament. But it is terribly important. I really wanted to tease out how you felt about that. We do not know who these people are that come from the territories or from the states, and somewhere there has to be a balance. Something I was rather shocked about was that the board has a minimum number of three meetings a year. I would think that, with the things that have to be covered by this board, once a month would be an absolute minimum requirement, because it is a huge area, and then having all these sorts of advisory committees coming in from different areas of expertise, and the staff—from the bill—will not be Commonwealth public servants. So I am wondering who the staff are and what the composition is going to be. There are just so many questions to be asked. I would like to hear from you about whether you have had the same sorts of ideas as I have, reading this.

Ms Magarry —Can I answer that one?

CHAIR —Yes, thank you.

Ms Magarry —I would make the comment that we have observed exactly the same issues in relation to the bill and what it actually states. We have raised the issue of the composition of the board and its skills, the people on it, with the department, and I note that they are coming to speak this afternoon—

Senator ADAMS —They are, later on.

Ms Magarry —so you could ask them. In relation to the employees, my understanding is that, as this bill enables the agency to be established under the Commonwealth Corporations Act, the employees would morph across from wherever they currently are working, in say the task force, and be employed in the corporation. I would not see that it would be that big an issue, whether they are Commonwealth public servants or not. Once they are employed in a Commonwealth statutory authority, I would think they would have the same responsibilities as any of us who work in any corporation. We have raised these questions with the health department and have been told that some of these issues will get fleshed out over time.

Prof. White —I agree with what Angela is saying. I think that, in each of our professional groups, exactly the questions that you have raised have come up, and the bill does not go very far at all in answering those questions, and that is why we are here. But particularly in relation to the frequency of meetings, three times a year seems incredibly tokenistic, rather than something that drives the agenda; and I would see that it should be the board that would drive the agenda. So I agree with you.

Prof. Hensley —I would support the need to think about this and go back to the first principle of addressing the core business of Health Workforce Australia, the composition of the board and obviously the recruitment of the chief executive officer, to ensure that that core business is followed out and that whatever due processes are required from a financial area are also accepted, given who is funding the organisation. But it would be important that the core business is managed through the board and the CEO.

Professor Wronski indicated some of the programs now through the Rural Clinical Schools Program, the university departments of rural health, the practice improvement program, where there is a great deal of experience of appropriate management of Commonwealth funds and reporting against KPIs to ensure that what has been agreed to is done. I think there has been a very good track record with those initiatives and very much the management of those initiatives is with the educators, with a process of contracts and monitoring and auditing to ensure that everything is done appropriately. So I believe very strongly that there is an opportunity to make a big step in education of health professions by having a board, CEO and an approach that focuses on health professional education.

Prof. Wronski —I think we need to be a little careful. I agree that the representation of the board is not appropriate at the moment. Nonetheless, I am not keen to see the establishment of a central agency that tries to run clinical education from the national level. A board that meets all the time would be tempted to expand its role. I think what is important about the current system is its devolution, and that the methodology of the sort of rural clinical service or UDRH sort of model for delivery of this system of clinical education and its expansion is best.

Given that, it might be that a board, appropriately constituted, could meet three times a year and the managers be allowed to manage. It is not so important that the board meets a lot; it is important that it is well constituted and that we expand the distributed model of clinical education around a model like the university departments of rural health, rural clinical schools, all of whom have their own boards but they are regionally made up and take on issues of interest around the community.

Prof. White —Just for clarification, my comment really in relation to the frequency of the meeting of the board particularly related to the set-up phase—

Senator ADAMS —That is right.

Prof. White —as Health Workforce Australia is trying to determine exactly what it is that it does and how it does it. Once it makes those determinations and is in full operation, it would not need to meet as frequently. I would like to pick up the issue of the rural clinical schools, and I know that is a model that has been promoted. I would like to draw attention to the fact that at the moment that is predominantly medicine, and it is medicine that is funded, so it would require a significant expansion of that role to take in nursing, midwifery and allied health, but we would not want to see the diminution of what has been at the moment provided for medicine, which is a fantastic model and one that we would aspire to be part of.

Ms Stronach —The composition of the board will be important in ensuring that we continue to produce quality professionals. We should not get away from our focus of producing quality health professionals, and that is a partnership at the moment between the training and education institutions—be they universities, TAFE and some private providers—and also health services, which are predominantly at the moment state based. But if we are to increase clinical capacity, it needs to include the private sectors, the NGO sectors, and some of the more community based organisations perhaps, which I think are missing from here. I think it is necessary to have that broad representation and not just have government and a few other providers which are not detailed as to who they would be. Thank you.

Senator ADAMS —As far as the role of the board goes, I certainly agree with Professor White. At the start, they have to set the direction. The board will not be dealing with day-to-day issues. That is why the CEO is employed and the staff. But without direction, they have to abide by what the board directs them to do as to how everyone is going to fit into this. Do you think there will be a number of education facilities that will fall through the cracks with this? We have a huge conglomerate of organisations out there that are all involved with education, whether it be with medical education or with the allied health side of it, and, with the focus towards primary health care, this is just huge. I agree with the concept of the board but I wonder how it is going to work practically, because it is going to take a lot of time and depth to work through this process. As to flexibility, geographically I have been based in a rural area so I am fully aware of all the issues in that respect, without getting into teaching hospitals and the other areas as well. Could you comment about that?

Ms Magarry —The only comment from Universities Australia would be that we would hope that none of the clinical education facilities would fall through the cracks and that the agency should be established in order to maintain the goodwill and not break any of the current arrangements. We have always said that we think 80 per cent of the current circumstances in relation to clinical education and the training of health professionals work well. The agency should try and facilitate and broker for that extra 20 per cent, either in new growth of students required for the future or to fix some of the arrangements that may not work that well in certain jurisdictions. We would be very disappointed if the agency was established to result in further fragmentation or destructive behaviour. That is our position.

Prof. White —My concern primarily is getting it right for the major contributors to the health workforce, and I think that again they are represented by the deans of medicine, of allied health and of nursing and midwifery. We cover the major areas and, if we can look at a model that gets it right for that, we can look at the small amount that is around the fringes. One would not want anything to fall through the cracks. I think if we look at not disturbing some of the arrangements that are in place at the moment, the relationships have been built up over decades and decades, and I can assure you that we have looked with fine toothcombs at some of the arrangements that are possible. So I think that there would be a strong vested interest in all of the universities not letting clinical placements fall through the cracks.

Prof. Hensley —I would strongly support that comment, and also to say that—as I am sure you know from your own experience—there is a wealth of work being done on these partnerships in the metropolitan and outer metropolitan and rural areas; very strong partnerships between public health service providers, individual hospitals, community centres, divisions of general practice, GP training programs in our instance. I think what the new Health Workforce Australia has generated is a blossoming of thoughts on how to expand that, but it is very much based on regional and current partnerships, on flexibility, on making sure that there is attraction for new educators to come into the system, and that is where the funding comes in, that is where the simulated learning environments come in. I think it is a great opportunity. I would doubt if a person who genuinely wishes to participate, or an organisation, in health professional education would be left out of this process.

Senator ADAMS —The communication, of course, is going to be absolutely critical here. Professor Wronski?

Prof. Wronski —Yes, I think it is a very important point. If you look at areas that use the non-health sector for clinical training, it is a very important part of occupational therapy and speech pathology, for instance, which use the education sectors a lot and subsequently employ quite a lot of the occupational therapy and speech pathology workforce. What the regional partnerships that deliver these programs are able to do is embrace them, and so it will be important at the national level to consider the role of at least the education sector in the clinical education of a number of the allied personnel.

Senator ADAMS —Ms Stronach, can you comment?

Ms Stronach —Yes. I think that HWA is going to have to work quite hard, actually, to ensure that different arrangements do not fall through the cracks. I am just thinking of our experience in a rural and regional area where we have a lot of students placed in sole practitioner type situations in very diverse geographical areas, and even within Queensland Health a lot of those placements are based very much on one-on-one personal relationships, so there may not be much corporate knowledge at a higher regional level and, I suspect, at a state level as to what actually occurs. If you then expand that out into the private and non-health sectors I think that, if they are going to use the opportunity to expand clinical placement, a lot of work is going to have to be done in identifying a lot of those smaller, non-standard, non-large health facility type placements to ensure they do not fall through the cracks and to try and find ways of expanding those sorts of placement opportunities.

Senator ADAMS —Just on the research arm, I was wondering how you see the Australian Institute of Health and Welfare fitting into the research that is proposed.

Prof. White —Utterly critical. It is my understanding that one of the arms of this new body is in relation to innovations research and I know that our council—and, I would believe, the others—believe that it is as important an arm as the clinical funding arm. Being able to engage in research into new and innovative models of care as well as clinical education models, models that would give greater primary health care access, new maternity service models, is really important. They are all models that link into both care delivery and better educational models for clinical education, so I think that the innovations research arm is absolutely fundamental to Health Workforce Australia.

Prof. Hensley —There are two elements here. You mentioned the Australian Institute of Health and Welfare. I think one very important part here is to take the opportunity to really understand our health workforce, how they are trained and where they go. The Medical Deans Australia and New Zealand, through support from the Commonwealth, has set up the Medical Students Outcomes Database, which is a comprehensive database of all medical students entering the system, which then follows on where they go afterwards, where they have their practice. I think we do need to have more information about the effort we put into health workforce training, to find out why people go where they go and why some of them drop out of the profession, to see whether during the training program and support program we can make sure that they stay in or can come back. That is an important arm.

The other area is innovation in health professional education. I think that is where, to take Professor Wronski’s point, the consolidation about a regional base, whether it is a metropolitan or rural area—having a skill base of academics, healthcare providers, educationalists—will give you the critical mass to do the research. That is where, again, we come back to a model that facilitates a critical mass of educators, and hence educational researchers, to try new ways of providing education, to evaluate them critically and to find out whether or not they work. I think the research arm is absolutely essential, but it does need to build around academic strengths across the health spectrum.

Senator ADAMS —Professor Wronski?

Prof. Wronski —I think health systems research generally has been not as strong as it should be in Australia. In many ways, AIHW mostly plays a collections role around measuring trends, and that will continue to be very important in understanding what is happening. In addition, universities and others are engaged in research around new models and evaluation. It is not as strong as it should be in Australia. It is striking, when you are trying to find data and trying to understand trends, that there are huge gaps in understanding, for instance, what happens to health personnel who undertake a degree and then do not practise. There can be a significant proportion of people lost to the health workforce over, say, the subsequent five or six years after they graduate, and it is not always the intuitive things you think of.

Understanding how the cohorts of health professions behave, how the health professions are redefining their role as the health system changes, the behaviour of different population groups in accessing health professional education, are all going to be important in providing a relevant future workforce, as well as recruiting students from populations or subpopulations that do not normally get access to education systems in the proportions we would wish. For instance, focus on remote area populations, the rural populations in some places, Indigenous populations, some of the populations in the ex-industrial suburbs of major metropolitan cities. Understanding these trends will be really important.

Senator ADAMS —Ms Stronach?

Ms Stronach —I agree with the other speakers that the HWA research role is critical. I think the establishment of the HWA is a real opportunity to promote innovation in, for example, multidisciplinary clinical training or different models of clinical supervision. These sorts of areas will be especially important so that we can actually increase the clinical training opportunities. I think the research role for the HWA will be critical.

Senator FURNER —In respect of your introductory comments about substantive information on the powers, as with most pieces of legislation, you generally find the devil is in the detail. I can appreciate that you do not have the legislation before you now because this is a new act. I am wondering whether you would agree that that is the concern here: where you will have further explanation, particularly when it comes to the powers; where those sorts of details will be provided to you; when that is possible.

Ms Magarry —We do have a copy of the bill and have observed the second reading.

CHAIR —I think, Ms Magarry, Senator Furner means the regulations.

Ms Magarry —Oh, the regulations.

Senator FURNER —Sorry, the regulations.

Ms Magarry —We do not have the regulations. So, yes, of course we would agree with you. If there is further detail in the regulations, then obviously we will know more.

Senator FURNER —I take on board the comments by Professor Wronski that 80 to 90 per cent of training in the medical profession is at a high quality. I would concur with that. I am just wondering where your concerns are coming from with the possible changes in curricula.

Prof. White —They come in a number of forms: firstly, the variety of roles that might be taken by Health Workforce Australia in engaging with the clinical areas in the universities in determining clinical placements—how hands-on, how hands-off. I think all of us have been to more National Health Workforce Taskforce meetings around the country on possible models than we would care to remember. At those, there are always a whole array of models put out, right from the idea that every clinical placement would be organised from a computer system in Canberra through to a completely hands-off suggestion.

Not knowing where on that spectrum this is likely to fall is of concern, but probably more particularly the movement between funding and accreditation and standards development would cause the greatest concern; hence the need for an understanding of the relationships, whether they are superordinate or not in terms of accreditation and registration.

I give you an example: if Health Workforce Australia is funding a certain number of positions, presumably they will want to strike a number of hours of clinical training per discipline per award. That in itself creates no issue if there is discussion with the particular accrediting body as to what that needs to be and it is a professional decision in relation to appropriate standards and quality. If there were some movement towards a minimum and some pressure to only fund a very minimum number of clinical experiences, we would be very concerned; so the concern is on a number of levels.

Senator FURNER —I guess that comes back to your next concern about the governance and who is represented upon the board.

Prof. White —Absolutely.

Senator FURNER —I have been on boards myself and I do understand that the composition of a board, committee or organisation needs to be reasonable. You cannot have everyone on the board or organisation, otherwise it becomes unwieldy. What would be your view of the size or the composition of that board, if you had an ideal world to have true representation on it?

Ms Magarry —Universities Australia would be pleased to provide a nomination for the chair of the board—an eminent ex-vice-chancellor for example—and then we would be happy with the composition adequately reflecting the disciplines and, obviously, the government. That is as far as we have gone at the moment. You probably have another view.

Prof. White —I would not necessarily like to come up with a figure. I completely understand the desires for the states and territories to be adequately represented in that they carry the burden of needing workforce on the ground and they are contributing a significant amount of money, but it would be absolutely inappropriate for there not to be representation from medicine, from nursing and midwifery, one from allied health, and I think there does need to be a representation from accreditation in some form. I do not think that that necessarily would need to be at individual disciplinary levels because all of us conform to the desires of the World Federation for Medical Education in relation to composition and issues that relate to accreditation.

Senator FURNER —You suggested at least one vice-chancellor on the board should be appointed. How would you see that practically? How would that be arranged amongst the universities?

Prof. White —Universities Australia has that role at the moment.

Senator FURNER —So that has been achieved. There is no politics involved in how that selection is achieved?

Ms Magarry —No. Universities Australia work on any boards. There is always an agreement amongst our members.

Prof. White —Vice-chancellors, obviously, can always have a disagreement, but they would make a decision. There are a number of eminent vice-chancellors due for retirement this year who are available to take up the position of the chair, should you wish it.

Prof. Wronski —I agree with the thrust of that. With boards larger than 14 or 15 or so, there is a trade-off, as you know, between tightly knit boards and decision-making and broadly representative boards. I think that HWA would be at great risk of making a situation worse if it did not have representation from at least three of the sectors. Medicine, nursing and midwifery and allied health at least, I would think, would bring an understanding of how the systems operate nationally. Without that, I think the HWA board would struggle to get across the issues. That poses some risk for it. All of us, by the sound of it, want this to work. If HWA, particularly in its early stages, falls over because it has representations from, say, the way medicine or nursing do clinical placement allocation but does not cover areas like pharmacy, speech pathology or one of the other areas, it will result in arm-wrestles and difficulty. In some ways, a political opportunity could be lost to do something terrific.

The board being able to function with the sort of knowledge that is required, that the professions and the education establishments bring to the table, is critical. I can understand the states wanting to be represented individually, and this is a child of AHMAC in a sense, so that is not surprising. Nonetheless, I think there is a trade-off here. If the board is going to be only 13 or 14, then I cannot see a system whereby the states are all represented. If we are going to go for a more representative structure and then deal with the difficulties of having a larger board, that may be the case. But the price of not having adequate on-the-ground knowledge of how clinical placements work across the health professions is too great a price to pay.

Senator FURNER —The proposed act provides for the establishment of committees. No doubt that would provide greater representation and expansion of knowledge to be transmitted back to the board for particular issues, whether it be training, accreditation and so on for the matters that have been raised here today. Would that be acceptable?

Prof. White —Committees are an absolutely necessary part of doing the business, but they are not a substitute for having the appropriate voices at the key table. I would not see them as a substitute; I would see them as an important adjunct to the work of the board. But it is fundamental that medicine, nursing and midwifery, and allied health are represented at that board level; and the vice-chancellors, I would believe, as well.

Prof. Hensley —I had assumed that the committee structure would be under the executive arm of the HWA, not necessarily under the board arm. It would depend upon how that was set up. Go back to the first principle of saying, ‘This is a wonderful opportunity to make a substantial contribution and difference to health professional training,’ and have the board that represents those best interests, and cover accountability and other matters in a way that is efficient but does not overload the board. That would be the argument we would make.

Senator BOYCE —Professor Hensley, I wanted to ask you about the comment in your submission regarding the need to spell out what professional entry level education should be and the fact that there seems to be a use of professional and preprofessional without perhaps sufficient definition.

Prof. Hensley —Some of that has been clarified in the notes from the minister. I think the understanding that we all now have is that the support will be provided for clinical training related to approved university and TAFE courses for health professional education, and I think the words ‘preprofessional’ and ‘professional’ have been interchanged. There is with all the professions, as you know, a series of prevocational and vocational training extending after graduation.

Senator BOYCE —Do we have sufficient definition of the words now?

Prof. Hensley —I should check with Angela as well. I think that has been clarified in the notes to the minister but I think it is very important that we define the clinical training as related to approved and accredited health professional programs based at universities and TAFE.

Senator BOYCE —I think all the submitters currently present have noted the relationships that have been built up over some considerable time between educators and the clinical training placements that they have. Someone has described them, I think, as ‘hard won’. What is so special about these relationships that might be threatened by an overweening bureaucracy?

Ms Magarry —I think it is best for Professor White to answer it from more of a practical perspective because she has dealt with the coordination of clinical placements in the past. So I will defer to Professor White.

Senator BOYCE —I am happy to hear from anyone.

Prof. White —Clinical placement has been the rate-limiting step in the number of students that universities can take into nursing programs for some time now, and I know the government is only too well aware of that. It is the reason that we say we cannot take all of the places that have been made available. We have tried as hard as we possibly can to winnow out, where we can, appropriate, reasonable quality placements.

Senator BOYCE —You are talking in relation to nursing at the moment.

Prof. White —I will confine my conversation to nursing and midwifery, if I may. Finding those placements has been a problem that has faced all of the universities, so the universities have collaborated with each other and have collaborated, in turn, with the area health services. If I could give you an example, from Newcastle north in New South Wales, all of the universities, the area health service and some of the private providers have worked together very closely to try and align their practice needs, align their clinical calendars, so that they could absolutely maximise the number of students going through the maximum number of placements that were possibly available within that geographic area. That took a very long time to establish and it is a model that many of the other areas are emulating at the moment.

To have a system go in and then dismantle it would seem counterproductive really, so where there are already fairly strong geographically based models that are working, I think it is really important to keep those where possible, to look within those for best practice and then to emulate those further. I do not think it is being precious to say, ‘I’m this university and I’ve got my picket fence up around this area health service and no-one can come in.’ It is not that at all. That would be a strong misreading of the situation. This has been universities collaborating with each other and, in turn, collaborating with both public and private sector area health facilities.

Senator BOYCE —Professor Hensley?

Prof. Hensley —Yes. With medicine in particular, the final two years of every medicine program in the country is spent off campus at a clinical placement, so these are full-time placements. That requires development in terms of recruitment of clinician teachers, recruitment of their training, and review of curriculum quite often. The Australian Medical Council accredits each of our programs. Within that accreditation we can make sure the students leave with the same skills and knowledge, but the achievement of the curriculum may be different if we do it around the New England area, where we operate, compared to central Newcastle in terms of the availability of teachers.

There is a big investment in IT and there is an investment in academic development, but what we would like to see at outer metropolitan facilities—rural, regional and remote—are academics going there to live and stay and work. That development is a major community investment, and the relationship is with that university or provider.

Senator BOYCE —Why couldn’t Health Workforce Australia do it?

Prof. Hensley —I think they can facilitate it in the form of funding and some brokerage, but I do not think they have the expertise or the on-the-ground experience and skills to build those relationships. I think they can facilitate them with new providers, such as the private sector and the community sector, and I think they can facilitate that, as with the model of the UDRH and rural clinical school, but I do not think that will achieve the same degree of quality of education and safety, security and flexibility for the students. There is a lot of flexibility entered into on compassionate grounds, where students cannot travel.

There is a very complex operational mode to ensure that students get an excellent clinical training but do so under circumstances that are long lasting and are investments. I think that there would be enormous disruption to break that completely. Health Workforce Australia needs to focus on areas of new placements and innovations, and I think Professor White has mentioned the need for all of us to look critically at curriculum so that we can have similarity in curriculum to minimise an institution having students from three or four places, all having different curriculum. I think that has been achieved quite well with many of the centres, where they have three or four universities participating.

There is a very strong health professional education base for Australia that provides us with great health professionals, and the requirement is for it to be enhanced and facilitated. I do not think it would fare well if it were turned upside down and became a central funded process.

Senator BOYCE —Professor Wronski?

Prof. Wronski —It is regional communities of interest that really drive successful clinical placement programs and it is based on trust and relationships. We have had some experience of this in North Queensland, where we have needed to create health workforce capacity up here. We have needed to expand into new townships and communities. That has meant that communities have had to invest as well, to try to create facilities. With that goes a whole lot of trust in relation to quid pro quo. They have an interest in trying to target health professionals for the future, so many townships encourage rotations. There are quite often outstanding clinical placement opportunities in small townships because of the diversity of clinical material and so there are a whole lot of networks and trust relationships across these communities of interest that are critical.

There is another dimension to this. If you look at a whole range of different health professions, the network relationships within, say, speech pathology or occupational therapy or physiotherapy or pharmacy are very important in identifying new opportunities and smoothing out the rough bits that happen much more frequently than we care to think about.

How would Health Workforce Australia, which operated at the national level, work on those—I do not know what the percentage is—say five or 10 per cent of occasions on a Sunday night where a student rings up sick or the supervisor of a facility with a small number of people in a rural town gets sick and is unable to take people? Someone takes the phone call and spends several hours fixing it up. Across Australia every Sunday night there are these events.

Senator BOYCE —Particularly after a big weekend!

—I cannot see how a national system is going to cope with that. In addition, if you look at national IT systems, there has been something made of the Canadian experiments coming out of British Columbia. I guess there was lots of optimism initially as the IT systems expanded, but one by one in the last few months we have seen professions pull out. In large and complicated provinces like Ontario, the reports back are that even at the state or the province level, they have been unable to allocate adequately clinical placements across different parts of the state. They tried to do it across professions, but the point made to me by a recent visitor, who is looking after that in Ontario, was that they could not even get the nursing schools to agree on how to do it. So even at the province level in Canada, they were unable to do it in complicated situations. Central allocation could well work at a regional level, and you could then uplift data to gather information at the national level, but actually running that allocation in a country as large as Australia, with as much diversity as Australia, is just never going to work.

Senator BOYCE —Thank you, Professor Wronski.

Prof. White —Senator Boyce, if I may add to that, I think within nursing and midwifery we have some doubt about whether the quantum of this job, if it were to be considered centrally, has fully been understood. If I could just give an example: in my last job, which was at a larger nursing school than my current one, we had over 5,000 individual placements every year. That is just one nursing program. When you multiply that out across the country and then across the disciplines, it is mind-bogglingly large when you consider that every one of those requires the individual student understanding, and the placement that they are going to understanding, who is supposed to turn up, when they are supposed to turn up, and what they are supposed to do, let alone when a ward closes because there has been an infection in the ward or some catastrophe, or when the students have some problem. It is the depth of that really one-to-one knowledge that makes it function.

Senator BOYCE —Minister Roxon, in her second reading speech, said:

For the first time, there will be one single body responsible for the delivery, funding, planning and oversight of all clinical training in this country.

Could I ask for reactions, if that is how Health Workforce Australia pans out?

Prof. White —I think it is a fantastic ideal, and I think that we can go a very long way to meeting what Minister Roxon wants to accomplish. If it is done at a high-level planning and deeply-engaged way, with all of the sectors that are important, and if it particularly is focusing on the planning aspects, and if it focuses also on the means by which it gathers—

Senator BOYCE —Delivery.

Prof. White —accurate data, I think it is not impossible. But it would only work if it takes notice of the sorts of relationships that we have been speaking about this morning.

Senator BOYCE —And includes delivery of all clinical training?

Prof. White —No. It depends how one looks at the word ‘delivery’.

Senator BOYCE —Indeed.

Prof. White —If ‘delivery’ were to suggest, as we have spoken about this morning, that there is a centralised computer in Canberra that looks at individual placements, it is going to be a total catastrophe. But if ‘delivery’ suggests that there is a known process by which this will happen, and that process is elaborated, then delivery is possible.

Prof. Hensley —I would support Professor White. I think it is a fantastic opportunity. I would support the minister’s comments very strongly. The Commonwealth is responsible for the delivery of general practice care in the country, but they do not organise individual patient appointments; there is a decentralised structure. I think the delivery can work through Health Workforce Australia under a model where there is maintenance of regional partnerships and encouragement of partnerships. I think the words can be achieved, but the micromanagement of those placements, we believe, would threaten the current successful—

Senator BOYCE —Thank you. Could I just ask our two witnesses on the phone if they have comments.

Prof. Wronski —Yes. We support the development of HWA. I guess part of this discussion is trying to understand the detail behind the words. There are many partners in this. The Commonwealth role in this around delivery would be to deliver a devolved system that expands on the success of the current system and adds a great deal more capacity. In that sense, the Commonwealth delivering this is a positive step forward. The detail of what that means I guess will be important, but my assumption is that the Commonwealth would not, or should not, consider getting involved in the details of a centralised computer allocation system, where decisions are made at the national level—and there is no historical experience from overseas about where that would work. To the contrary. Nonetheless, the Commonwealth has a very important role in delivery, around making sure that clinical placements are delivered through a comprehensive, distributed model of clinical education that expands on something like a multidisciplinary, rural clinical school.

Senator BOYCE —Thank you.

Ms Stronach —I agree that the establishment of the HWA is a wonderful opportunity to get consistency in funding and also, hopefully, expanding clinical placement opportunities. The caution would be that, as all the participants have alluded to, clinical placement is incredibly diverse. There is a huge amount of work involved in it. There are a huge number of students and a huge number of clinical placement events that take place. It would be tempting, I think, for an organisation that had national responsibility to try and look for efficiencies and impose efficient models that might work in some of the larger disciplines, but would be catastrophic to smaller disciplines and smaller geographical areas. So, yes, it is waiting to see what the detail is of how the work of HWA will be organised. Thank you.

Senator BOYCE —Thank you.

CHAIR —Thank you very much. I would like to thank all the witnesses. I appreciate your time and your ongoing efforts in this area.

 [10.33 am]