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Health Workforce Australia Bill 2009

CHAIR —Welcome, Mr Sullivan and Mr Hough, from the AMA. I know you have information on parliamentary privilege and the protection of witnesses. We have your submission, thank you very much. Would either or both of you like to make some opening comments. We will then go to questions. You know that we always have questions!

Mr Sullivan —Thank you very much once again for allowing us to appear. On behalf of our new president Dr Andrew Pesce, I extend his best wishes too. In summary, the AMA welcomed the COAG announcement back in 2008 about the health workforce package. We believe it made a lot of headway towards addressing the challenges, particularly the commitment to lift funding for undergraduate clinical training.

From that perspective, we are supportive of the extra funding that the health workforce agency will bring. We welcome the fact that the funding made available through the agency will support much more undergraduate clinical training to take place in the community. This will better utilise available infrastructure and will mean that available training opportunities better reflect the reality of how healthcare services are delivered and the growing burden of complex and chronic disease.

We do, as you would expect, have a number of concerns in relation to the bill as it is currently drafted. Essentially, they come down to the fact that the bill does not clearly specify the role of the agency; it allows the Minister for Health and Ageing to establish many of their functions via regulation, the details of which we have yet to see. The bill does not give any comfort to the various health professions—as you just heard from the previous presentation—that they will have a role in the activities of the agency.

As it is currently drafted, the bill could allow the agency to interfere with the accredited undergraduate medical education courses for the use of funding conditions, the overall placement coordination et cetera. It could expand its role into the prevocation specialist education training. It could exclude the profession from input into workforce planning and reform activities. In the context of other health workforce reform measures that are presently before you in other settings, it is at least fair ground for us to have concern over the encroachment of another agency into the whole accreditation field.

We know already that Australia has a renowned system of medical education, and it is built on accreditation arrangements that are independent of government. We consider this to be the gold standard, and it means that the role of the agency should be focused on activities that boost our capacity to deliver training according to these standards, rather than lowering the benchmark, or in some way having a role in setting standards, or having a role in how those standards will be applied. We do not think that the Senate should reject the bill outright, but we do think the Senate should seriously consider amending the bill, so that it preserves Australia’s high standards of medical education and ensures an ongoing and meaningful role for the various health professions in the activities of the agency.

It is interesting to note that, in the department’s submission, it gives clear assurances that the agency will not interfere with accredited training courses, nor will it try and set standards for clinical placements, but the submission also says that postgraduate education is out of the scope of the agency. Given these assurances are not in the bill, we would humbly submit that it could fall to this committee to recommend that amendments in the bill could go to make sure that those assurances are there. Thank you.

CHAIR —Mr Hough, are you going to make any comment at this stage?

Mr Hough —No, thank you.

Senator ADAMS —Thank you both for appearing. I would like to go to the composition of the board. We have earlier had evidence from your old organisation, Catholic Health Australia. They raised the issue of the not-for-profits and for-profits, non-government agencies, and also aged care. Again, as have most witnesses before us today, they have said that they should have one of the three positions available. We have got one Commonwealth position, eight members from states and territories, which we presume will be—definitely, I would think—bureaucrats because of the funding that has gone in, an independent chair and up to three other members. So could you give us an idea on who your organisation thinks these new three members should be?

Mr Sullivan —The first principle I think you recognise—and clearly the others have as well—is that the engagement of the health professions, not only at the governance level but at the health workforce and planning processes, data collection and decision making, is essential. Like everything, when you have only got three spots up for grabs, everyone will think it is theirs. The truth of the matter, though, is that this agency has the potential to do a lot of good, and at the same time has the potential to undermine what is already good, and the undermining is particularly in the areas of standards setting, particularly in the area of how courses are conducted in local situations to adapt to local circumstances so that there is diversity, and we think that is of value.

Just quickly, the medical profession was involved in the past in an established workforce planning process called AMWAC. It was subsequently wound down. There is the Medical Training Review Panel whose future now is uncertain. We support the AMA, through its junior doctors as well as the AMA more broadly, and we have concerns there that the medical profession’s input could be at risk in the planning process. So, of the three, I think we could have a strong case that the medical profession could have one. I understand the concern around the representation of for-profit and not-for-profit and aged care—and I wish them well in pressing their case, because there is probably one to be heard—but in the context of what we are talking about, the medical profession, I would think, would need to have a place on the board. But certainly—and I am sure it is echoed by my friends behind me—we need to also have very established, collaborative working arrangements over the planning processes per se.

Senator ADAMS —It is terribly important for the success of the board that the board sets the role and direction of where the whole organisation is going, and if that is not right from the start we have got huge problems with it. So the next question I would like to ask you is that, if there is no position on the board, how would you see your input—or input from all agencies—coming forward to the board so that they can use the expertise that is out there—and there is an awful lot of it—wisely?

Mr Sullivan —I will go to the first part of your commentary, which is that the bill is not very clear on the criteria on which a lot of operational matters will be progressed. I think this is why it is so difficult, even for the department—and it says this in its own submission—to give you a comprehensive analysis of the bill and its implications, because there are many questions we have around the overall influence of the agency, particularly when it says it is part of workforce redesign and reform and advice and planning and function. What does that mean? We have seen this through the whole national registration and accreditation process; that there is, whether wittingly or not, the potential for bureaucratic processes to actually interfere with established accreditation processes. So, firstly, the governance arrangements need to be based on clear direction from the legislation, which we do not believe is there. Secondly, I think the board would need to be charged to put in place a transparent planning process which is about engagement, not just collaboration in the broad or consultation at a conceptual level but, rather, the protocols of how consultation will occur with the various professions in a mutual way. I think that is important. Thirdly, the accountability of the agency along those performance indicators should be clarified in the regulations.

Senator FURNER —Notwithstanding your concerns expressed about the composition of the board—and I would be surprised if that is not the case with every submitter that appears before this inquiry—HWA will be empowered to apply and establish expert committees. I imagine people like your own organisation or previous witnesses would be in a position to be on those committees and provide more appropriate information to feed back up through the board. This is not dissimilar to what happens on many other boards. Does that alleviate your concern of not having a voice, if you were to be one of those players on the expert committees?

Mr Sullivan —Board governance obviously instigates committees for various interests that the board has, but in the first instance, the health workforce agency, it appears, will have a fundamental role in planning the workforce needs, and that in itself is a core governance activity. Certainly, it may put aspects of that to committee work, but in the instance as a function, we would have much more comfort if we were part of the formal governance arrangements, because we are talking about the workforce into the future.

We already know, through previous government decisions, that there are going to be more medical graduates by 2012 and we want to make sure that not only is there adequate training in the undergraduate space but clearly in the postgraduate, the post-medical school period, for medical education. I do not think it would suffice to simply be on an expert committee that may get heard at the governance level, depending upon the other competing interests.

Secondly, and it goes to the first question, the board is primarily populated by state governments. State governments primarily have an interest in public hospitals. We would not want to see that the public hospital interest overcomes the other genuine interests in the health system. As we said earlier, general practice, community settings, community nursing settings, the evolving way in which we are going to have to manage chronic disease and the evolving primary care rollout and reform are not found in public hospitals.

Senator FURNER —I guess it comes down to the number of people and that will be the issue here with the number of stakeholders. It is so broad and far-reaching that you cannot possibly imagine a board consisting of complete representation across the whole of industry. That is the reason why—once again, not too dissimilar to other boards—there is the establishment of committees to provide that information back to them to make sure their position is heard and dealt with.

Mr Sullivan —If we are just brainstorming it, there is no set magic number for board members. We have seen some very successful boards with greater than nine people or greater than 12. It comes down to how well they function, how well they are led and if they stick to their core business, which is a question for the committee generally.

Senator FURNER —Exactly.

Senator BOYCE —Mr Sullivan, we have had a lot of concerns across what is going to go in the regulations and that we do not have a clue how this is all going to function until we see the regulations, but I note that you say:

The Bill does not provide a clear definition of clinical training ...

Is that something that could go into regulation?

Mr Sullivan —It is clearly a hope it would be at least in regulation but one wonders whether it should not be brought into the bill more properly because it is fundamental.

Senator BOYCE —Is it a fundamental?

Mr Sullivan —It is a fundamental issue if we are talking about workforce. Warwick, you might want to say some more.

Mr Hough —What we have suggested, rather than try to define ‘clinical training’, is that there be some provision in the bill that requires Health Workforce Australia to recognise accredited clinical training—that is, accredited by the relevant accrediting body. That is the approach we suggested, because clinical training takes place in a wide variety of settings, and putting forward a definition may not pick up some of the granularity between different professions and different settings.

Senator BOYCE —We had a conversation with the Australian Medical Council before about what would happen if there were disagreement between the two bodies on what constituted accredited training. The answer is, ‘No-one knows.’ My other question—and I think you started to touch on this earlier—related to your comment in your submission:

There is now deep suspicion about the workforce agenda being pursued by the states and territories through the NHWT—

which is about to go out of existence for the HWA. Could you explain to me what you mean by that comment?

Mr Hough —To give you an example, up until 2006, as Mr Sullivan discussed, there was the Australian Medical Workforce Advisory Committee, which was involved in workforce planning and research related to the medical profession. There were similar bodies established for nursing and other professions. As a result of the Productivity Commission recommendations, that body was wound up in 2006. It had broad stakeholder representation and engagement around workforce planning activities. Those responsibilities were taken over by the National Health Workforce Taskforce. As a profession, we have not been engaged in almost any further workforce planning activities, other than some discussions around clinical placements in the last couple of months.

Senator BOYCE —I can see from behind you that the Nursing Federation shares this view, from the head-nodding going on, Mr Hough.

Mr Sullivan —We are always at one on these matters.

Mr Hough —From that perspective, NHWT is a creature of the jurisdictions. Whatever it is doing is a mystery to us at the moment, and obviously it is very much driven by—we think, anyway—the jurisdictions’ agenda, which is primarily linked to public hospitals and their role as employers in those public hospitals.

Senator ADAMS —The bill says it is required to establish HWA by July 2009 and to ensure it is operational within the time frames agreed and the COAG national partnership agreement. They are also going to commence management of the undergraduate clinical training from January 2010, which is seven months away. Can you comment on that?

Mr Hough —As we understand it presently, the National Health Workforce Taskforce is carrying on the work that will ultimately become the function of Health Workforce Australia. What level of engagement they are having with stakeholders around clinical placements, funding and so on is still unclear, and what resources they have to do that is not clear either. From our perspective, it is a very ambitious time frame for the bill to establish the authority and then allow it to get on with its work. Our preferred approach, given that current arrangements are working relatively well, is that in the interim we get the bill right and make sure it has the right operational basis to move forward. Whatever means there are in the meantime to get the extra funding into clinical training, the government ought to examine that. Certainly we need to get the bill right, given the importance of the issue.

Senator ADAMS —Do you have a research arm associated with your organisation?

Mr Sullivan —Yes, we have research.

Senator ADAMS —This body, of course, is going to have a research component to it. How do you see how that will fit in with the Australian Institute of Health and Welfare and the other research sectors throughout the profession? Most of our organisations do have research to a point. A lot of the data that is available to them from the national point of view is very old, not up to date. Could you just make some comments about how you see the research side of this can work.

Mr Hough —The relationship is unclear at the moment, but the AIHW, which does collect much of the data, whilst it has its limitations, is regarded as doing a much better job over time. But what relationship it has is unclear. We think the HWA should work with and support bodies such as the AIHW to improve their data collection, which is very important for making sure we have reliable future workforce planning.

Mr Sullivan —The last point is important. As we mentioned, when there were earlier processes where the medical profession was involved in workforce planning directly, there was a degree of confidence in what was coming out of those considerations. You would expect that. Here we will have a situation where, firstly, if you are not directly involved in the governance and planning of the research and therefore in the implications it brings, that in itself will not help with the application of what the findings are.

Secondly, the frustration many people have at the moment is the supply question. How do you actually define the number of bodies on the ground that are needed in particular areas, particular craft groups or whatever? The concern we would have is that other agendas, which sometimes are being driven by more short-term needs of a workforce nature, can prevail and become the orthodox view, when all that is needed is a more considered strategy so that a better balance of the workforce can be achieved. That sounds like rhetoric. It is not meant to be. It is simply saying that it is another reason why there needs to be a very direct engagement, at least of the major professions, in the governance level as well as the planning level of the processes.

Senator ADAMS —Thanks.

CHAIR —Mr Sullivan, Mr Hough, can you put on record the consultation that you have been involved with in this process?

Mr Hough —We have certainly been invited to provide a submission, which we have done.


Mr Hough —And we have also welcomed the opportunity to appear before the commission today.

CHAIR —My understanding is that the department will tell us the consultative processes that have taken place over the last few months, and you have added to your submission some papers that you have submitted to letters that were sent out through other parts of the consultative process. Exactly, from your perspective, how has the consultation worked?

Mr Hough —To clarify, firstly, the material that we have attached relates to consultations undertaken by the National Health Workforce Taskforce.

CHAIR —Yes, which was the precursor of this one, is my understanding.

Mr Hough —Precursor of this body. They have released two discussion papers around clinical training. One was to do with governance, and the other one was to do with data collection. The consultation process has involved an invite for submissions and attendance at one forum—

CHAIR —One forum.

Mr Hough —in relation to those. There were forums organised, obviously, in different capital cities. Essentially, we were given an opportunity to provide a submission and a face-to-face opportunity to participate in a forum around that. Given the important nature of the questions in those discussion papers, had NHWT been much more rigorously involving the professions in a governance level, and in terms of forming expert committees to look at some of these issues, that could have been a much more robust process.

CHAIR —To the two letters that you have attached, did you get responses?

Mr Hough —I understand that there has been a paper released in response to the discussion paper on data collection around clinical training. As yet, I am not aware of any response from the NHWT in relation to the governance arrangements for clinical training.

CHAIR —Thank you very much.

Mr Sullivan —Thank you.

CHAIR —The committee is going to adjourn now for a few minutes.

Proceedings suspended from 1.10 pm to 1.17 pm