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

CHAIR —Good morning, Professors. I am so sorry to keep you waiting. It was a combination of my poor chairmanship with the first witnesses and the impossibility of a telephone connection. I deeply apologise to both of you for holding you up. I know, Professor Stitz, you have been through this before. I am not sure, Professor Metz: have you been in one of these inquiries before?

Prof. Metz —Yes, about three weeks ago.

CHAIR —So you know the gig. Professors, we have your committee’s submission, thank you very much. We do not want to keep you too long because we know the value of your time, so if either or both of you would like to make an opening statement, we will then ask the senators for some questions.

Prof. Stitz —Thank you very much. You would be well aware that the committee of presidents is the unifying organisation for the 12 specialist medical colleges of Australia, and the medical colleges are primarily interested in standards of care and standards of education and training for the medical specialty vocations, including general practice. We provided a submission because we believe that this whole process has got considerable benefits, and potential problems. We welcome a national focus because we believe that may well do much to resolve some of the challenges that we have as national colleges—in fact, binational colleges—engaging with multiple jurisdictions, and the considerable variation in the jurisdictional approach to some of these issues. So to have a national process which is common across all the jurisdictions is in fact a welcome initiative. We believe also that that may have better planning with respect to clinical placements, and that in turn will benefit the public.

The focus of the bill at the moment is on preprofessional entry clinical training, and obviously as medical colleges we are mainly interested in the training of specialists, so this does not currently concern us directly, although we believe that this is a process which ultimately will do so, and of course it is important in education and training to understand that it is a continuum of training. It starts with the undergraduate degrees but then continues into postgraduate years 1 and 2 and then on into vocational training in the appropriate specialty disciplines. So obviously it is a very important concept to understand.

In our submission you will note that we proposed a number of principles. I will not go through all of these in detail, but I will make some special comments. The first is most important, and that is that any process which involves health workforce has to be predicated on safety and quality for the patients, for the people, and also the standards with which we deliver not only the care but also the education and training, so any training placements must be in the context of those standards. Training numbers are just one element and we would not like to see any denigration of those standards to expedite health workforce matters. Of course, as you well know, the national accreditation and registration process has indicated how important it is to have independent accreditation of those standards.

The universities at the moment obviously have a lot of expertise, but there is no question in the lifelong learning cycle that we need to be integrating with clinical carers as soon as possible. So these clinical placements are very important, particularly in medicine, where we will have doubled the number of medical graduates by the year 2011. The overarching principles of the Health Workforce Australia concept are good in terms of the longstanding relationships, but they must in fact understand that service provision and teaching and learning cannot be separated in the health professions. We actually learn how to be good doctors, in our case, and to develop judgement by being with patients, so it is critical in any education and learning programs that there is adequate clinical interaction with the service requirements—you cannot separate both of those—and the funding for the clinical training component must be adequate.

It is very important that we have common essential educational objectives across all our jurisdictions and all our medical courses, but we do need to allow of course for local innovation. Just a quick word about simulation: we are very supportive of simulation, and we believe that the technological support processes will continue to improve. There are technical and non-technical components for that, and obviously the non-technical components can be simulated currently to a great degree. Technical competence, however, at the moment with simulation is providing basic or early support for our training programs. Obviously, it has to be put in perspective. We would like to foster that, and do already have considerable expertise in this area.

In summary, we are concerned that some of the wording in this bill may in fact imply that the standards are going to be a function of the Health Workforce Australia concept. I will ask Professor Metz if he would like to comment on the particular parts of the bill that refer to that—namely, (3)(b), (4)(a) and (4)(b) under ‘Functions’.

Prof. Metz —Thanks, Russell. Would the committee want to take any more? Would you like me to speak now?

CHAIR —I think so, Professor Metz. If we can get all your concerns out first, that is best.

Prof. Metz —Thank you. We have obviously had a brief opportunity to see this bill. I think everyone is rushing to get these things through. I support all the points that Russell has made in terms of why we are here. It is a very soft line that I have got and I missed the names of people who are on the committee. I do not want you to repeat them all, but I am not sure if any of you or all of you were present when we made our submission on the national registration and accreditation interview about three weeks ago.

CHAIR —Most of us were, Professor.

Prof. Metz —If I could make a quick point, which is maybe a throwaway line but it is worth saying: we are not the AMA. We are not here for industrial reasons. We are here for standards and safety and quality, and that is what I am going to be emphasising. In the outline that accompanies the bill, it says words along the lines that the health workforce authority will encourage:

… best value for money for the workforce initiatives, a more rapid and substantive workforce planning and policy development environment …

We certainly welcome a more rapid and substantive workforce planning and development environment. We understand why people would wish to have best value for money. That sort of wording, though, could easily be interpreted as saying that ‘value for money’ may mean that we do not necessarily need to have the high standard, highly trained professionals doing the work that has hitherto been done. Obviously, it is not the intention of the government to throw the professional workforce out the window, but there is a potential in the wording there and there is a potential for the workforce authority to use those words to say that, ‘Well, we don’t actually necessarily need to have highly trained professionals in the workforce.’ That is the first point.

The second point that I am concerned about, to go with that, is that if you look at the constitution of the board, there is a chair, there is a Commonwealth member, eight members—one from each state and territory—which totals now 10, and then three others. The three others may or may not be jurisdictional; I suspect that they are not jurisdictional. If we assume that they may be professionals, they would not all be doctors obviously. There may be a doctor and a nurse and a something else. This really means, to my reading of it, that the health workforce authority will have almost no professional input into its deliberations and recommendations.

You may say, ‘Well, it’s an overarching group and that doesn’t matter,’ but we looking at that do worry about it because it smacks of changes in the United Kingdom recently where they had a similar statutory authority—and I note in reading the fine print that this will be a statutory authority—called the Postgraduate Medical Education and Training Board. That is a statutory authority which means, according to the chairman, who I had breakfast with about six weeks ago, that it is not able to modify or move around any of its delegations without changes to legislation. It meant that they were really in a straitjacket in terms of what they were able to do and were not able to do, one of which was that they were not, according to their chairman, to interact with the professions. They were to make decisions independent of the professions and at the direction of the UK government. This is a second issue which worries us in terms of the connection between this authority and the professional people who it will be directing.

The third point I would like to make is that it talks about the minister making legislative instruments specifying kinds of students eligible and kinds of clinical training eligible. Again, obviously the minister does not want to make every decision, but the minister will delegate these decisions to what appears to be an authority that will make decisions about the kinds of students that will be eligible and the kinds of clinical training that will be eligible, without actually having professional people on the board.

CHAIR —Thank you, Professor. We do not want to take too much time, so I am going to ask the senators if they have a question each.

Senator CAROL BROWN —Professor Metz, on the point about the membership of the board and whether they will be experts in particular fields, what is your view on the expert committees and consultants that will also be engaged to assist Health Workforce Australia?

Prof. Metz —Reading further down, it also says that the health workforce authority will have the ability to establish subcommittees and it will determine the membership and the terms of reference of those subcommittees. Again, it may be that HWA will establish subcommittees which will have all the expertise and all the professional input that we would wish, but on the other hand it may not.

It is a real concern to us that we are going down the same path that the United Kingdom went down. The former chairman of PMETB, who has just stepped down and become chairman of the General Medical Council, is Professor Peter Rubin. His observation to me was that, under his direction as chairman of the PMETB, because they were in a straitjacket with a statutory authority and did not have professional input into their deliberations—I think they had three professional people in a board of 15, and this looks like the potential for three professional people in a board of 13—they really lost the plot in terms of the direction that they were going in in relation to how they should engage with the professions and how they should train people. His view, which is certainly held by the colleges in the United Kingdom, is that postgraduate medical training in the United Kingdom has gone backwards in the last six years, and they are only now changing the legislation this year.

Senator CAROL BROWN —I think the minister has been talking about the committees being expert committees, so it would follow that they would be professionals in whatever field the committees are being set up. Does that allay any of your concerns?

Prof. Metz —They are welcome words, but one would need to see exactly how such committees were being appointed and how they were constituted. It may allay fears. I am not a paranoid person but I am just fresh from the United Kingdom experience, which has been a disaster for them and could be repeated, depending on who chairs this committee and who constitutes the board.

Senator FURNER —I want to get an elaboration on your comment, both in your submissions orally and in writing, that HWA will lead to better planning and result in better access to appropriate care for the public. Can you expand on that comment, please.

Prof. Stitz —Maybe I should take that one. We believe that at the moment there is a considerable variation in the clinical placements and the clinical exposure that students have and that, by having better planning across the whole of the country, we will produce better quality people and that they will then go on and be better prepared for their specialty training. That is the first thing.

The second thing is that, with the increased numbers of medical students, there is considerable pressure on the clinical exposure that is going to be available to these young people. If we have national planning which looks at that, then we are better able to use all the capacity that we have.

The third thing is that in this process we need to be able to engage the human resources. It is all very well saying that we have considerable funding for this, but the reality is that you need experienced professionals to educate and train the health workforce. There needs to be considerable support and orientation towards the human resources available if we are going to maximise the training, which in turn will produce a high-quality health workforce, and that will benefit the community.

Senator FURNER —When you say it will benefit the community, will it lead to the chronic shortage we have currently?

Prof. Stitz —With the increased numbers, in our case, of medical graduates, there would be a great hope, of course, that we would be able to service the shortfall. As you well know, there are considerable waiting lists around the country, not only for people having operations but also for people being seen in outpatient clinics. By having better numbers of well-trained doctors, hopefully the community will be better served.

That also impacts on the regional areas, which at the moment are underserviced, and there is certainly inequity, so one would hope that this whole process of addressing the health workforce would be looking additionally at the opportunities and the capacity and the ways in which we may be able to encourage clinical placements in the regional areas. There is very good evidence now that, if you can encourage doctors to go to a regional area for their training, a considerable number of those people will in fact stay in that area for their professional life, or at least a part of it.

Senator FURNER —Thank you.

Senator BOYCE —Professor Stitz, I suspect you may be the one to answer this. Your submission notes:

The role of accrediting medical education and training must continue to be delegated to the AMC and HWA must not seek to intrude into, to fetter or to influence the AMC’s accreditation functions in any way.

What gives you concerns that they may?

Prof. Stitz —The wording of the bill certainly supports the view that Health Workforce Australia is going to be primarily concerned with education and training, and we do not have any problem with that being fostered by HWA. However, we have put a strong view in previous submissions that in relation to accreditation of standards—both of standards of care and of education and training—it is very important that those accreditation processes are independent of government and of the profession concerned so that the community can be assured that those standards are high and not influenced adversely by expeditious problems in the health workforce. What we are saying is that this whole process has to be underpinned by maintaining the high standards that we already have and we must not compromise those standards by any of these health workforce initiatives.

Prof. Metz —If I could supplement that, I absolutely agree with what Russell has said. If you ask, ‘Is there a real danger?’ the real danger, if you look at the wording currently, is that the HWA has the ability to go into the area of delivery of clinical training. As I said before, the wording suggests that it can have legislative instruments specifying the kinds of clinical training eligible. That really is getting into the area that the AMC does so very well now.

We interact a lot with professional people in Europe, North America and Asia, and they look to our current set-up with the AMC as really very good, on the basis that it is independent of the profession but it is also independent of government. The potential with the current wording of the bill is that a government agency—a statutory authority—can take this over. The warning bell rings when we see that PMETB in the United Kingdom is a statutory authority which has taken over a lot of functions from the colleges, with some terrible mistakes made that created chaos, not to exaggerate.

Senator BOYCE —Could you give us some examples of that?

Prof. Metz —For example, they took over the placement of trainees into intern positions around the United Kingdom. They did it in such a ham-fisted way that there was marching in the streets from the recently graduated doctors. They produced forms which they thought were very smart, which would give them a new way of selecting interns which would not include their professional results from their undergraduate training. It was a form which enabled them to say what they saw as their future career in medicine, with some very woolly and waffly, wordy questions. In fact, it meant that the students who were doing well in undergraduate training and got high marks were not allowed to put their marks on the application for their hospital jobs. They were not allowed to have referees from the training they had done in the hospitals or in the universities. It was a totally new, greenfields approach which was a disaster. If they bothered to ask the professional people who had previously been involved in placement of interns in the United Kingdom, they were trying to tell them that it was all wrong and would not work, but PMETB said: ‘Don’t you worry! We know better.’

Senator BOYCE —Your concern would be that that situation could develop under the current legislation that we have?

Prof. Metz —The way it is written, yes.

Senator BOYCE —I wanted to ask you to expand a little on your comments regarding ‘the ever-present tension between service provision and teaching and learning’, the need for that to be recognised and managed effectively and equitably. What concerns do you have about Health Workforce Australia not doing so?

Prof. Stitz —I will take that one. Currently, some of the jurisdictions believe that their core business is just service provision. In recent times, for example, in Queensland the department of health has accepted the concept that core business also includes education and research. There have been some major advances since that acceptance has been published. The reason for that is that you cannot train a clinician, as I said earlier, unless they are in a clinical environment; and that clinical environment has to be in a service environment. You cannot have effective training which is separated from the service requirement in terms of the clinical component of it. You can learn, obviously, theoretical knowledge from textbooks and the web and so on, and you can learn some of our competencies in the simulated environment, but the reality is that in the health professional groups you can only learn your craft by being in an environment where service is the component of it.

What happens with the pressures on public funding of health is that there is little funding available for the educational component of it and the pressure is always that we have to deliver the service and not concentrate on the education and teaching to the same extent. We believe that in this process there is a golden opportunity for us to integrate and emphasise that the two are integral to each other.

CHAIR —Thank you very much, Professors. I again apologise for the delay that you had to have before we could get you online. We have the department coming to see us later today, so we will ask them some of those questions on your behalf.

Prof. Stitz —Thank you very much.

Prof. Metz —Thank you.

[10.59 am]