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Standing Committee on Health
Skin cancer in Australia

BADHAM, Ms Geraldine (Geri), Policy Adviser, National Rural Health Alliance

DEWAR, Mrs Marion, National Secretary, Country Women's Association

GREGORY, Mr Gordon, Executive Director, National Rural Health Alliance

MORLING, Mr Dane, Policy Officer, National Rural Health Alliance

Committee met at 12:16

CHAIR ( Mr Irons ): I declare open this public hearing of the Standing Committee on Health. I ask a committee member to move that the media be allowed to film the proceedings today in accordance with the rules set down for committees, which include not interfering with committee proceedings and not taking footage or still images of the papers or laptop screens of members, committee staff and witnesses.

Ms HALL: I will move it.

CHAIR: Thank you. It is so ordered. I welcome representatives of the National Rural Health Alliance. Do you have any objection to being recorded by the media during your participation in this hearing?

Mr Gregory : We do not.

CHAIR: Do you have any comments to make on the capacity in which you appear?

Mrs Dewar : I am representing the National President of the Country Women's Association, who is a councillor of the National Rural Health Alliance.

CHAIR: Although the committee did not require you to give evidence under oath, I advise you that these hearings are formal proceedings of the parliament and warrant the same respect as proceedings of the respective houses. The giving a false or misleading evidence is a serious matter have may be regarded as a contempt of parliament. The evidence today will be recorded by Hansard and attracts parliamentary privilege. I invite you all to make a short opening statement to the committee.

Mr Gregory : I will, Chair, if that is all right. On behalf of the 37 national organisations in the National Rural Health Alliance, we welcome this opportunity to make our views known about the rural and remote aspects of skin cancer awareness, diagnosis and management. The alliance's purpose is to ensure that in all processes relating to policies and programs which impact on health and wellbeing, the particular circumstances and needs of rural and remote communities are not only understood but are taken account of in action that ensues.

The alliance uses the much maligned—and soon to be improved—classification system known as ASGC-RA. Its five categories are major cities, inner regional, outer regional, remote and very remote areas. More than 6.7 million people live in rural and remote Australia, including all the people who live in the many smaller places in the inner regional classification, right through outer regional and remote to those in very remote communities.

First, let us summarise some issues for cancer in general. As you well know, it is responsible for Australia's largest burden of disease. The impact of cancers is worse for older people, people of low socioeconomic status and those in rural and remote areas. Of particular importance for the alliance is the fact that the further from a major city patients with cancer live, the more likely they are to die within five years of diagnosis. The mortality rate from all cancers combined is higher for Indigenous Australians, people living in lower socioeconomic status areas and people living in remote and very remote areas. There is a complex set of relationships here and great complexity when it comes to cause and effect. Remote areas have a much higher proportion of Aboriginal and Tones Strait Islander people and of people of lower socioeconomic status. But these two factors do not explain all of the impact of remoteness on health. Remoteness is itself a risk factor, helping to determine such other factors as years of completed education and income. The five-year survival rate from all cancers combined is lowest in remote and very remote areas.

Often referred to as Australia's national cancer, skin cancer is a largely preventable disease. Australian adolescents have the highest incidence of malignant melanoma in the world. The incidence of new cases of melanoma is significantly higher in regional areas than in major cities. Because of the difficulties experienced by rural people in accessing skin cancer diagnosis, their presentations are likely to be later, especially among men. However, published data do not show the usual gradient of incidence as one moves from regional to remote areas. The published rates in remote Australia are indistinguishable from those in major cities. We suspect that this may be a statistical artefact, due to the higher proportion of Aboriginal and Torres Strait Islander people in more-remote populations, among whom the incidence of melanoma is one-quarter what it is for non-Indigenous people, and the greater likelihood of late or no diagnosis for all of those who live in more-remote areas. Certainly, the incidence is higher for country men than city men. Another issue for rural areas is that the incidence of skin cancer is increasing among people aged 65 years and over, and the ageing of the population is more marked in regional and remote areas.

Melanoma mortality is higher in inner regional areas than in major cities, but, as is the case for incidence, in outer regional and remote areas it is indistinguishable from major cities. We believe that these figures are moderated by the fact that some of those diagnosed with melanoma relocate to larger communities, particularly towards the end stages of the condition. Farmers have a 60 per cent higher death rate due to melanoma and other malignant skin cancers than the general population, and skin cancer deaths in farmers 65 years of age and over are more than double the rate of other Australians in that age group. Five-year survival rates for patients with melanoma appeared to be similar across remoteness categories. Again, this is likely to be moderated by the relocation of patients.

In our submission there is a specially prepared table showing the latest data for the availability of medical practitioners, primary care doctors, general practitioners, medical specialists, enrolled nurses and registered nurses by rurality. Notwithstanding their serious maldistribution between capital cities and country areas, it remains the case that nurses, doctors and allied health professionals are at the heart of primary care, including for skin cancer. GPs cannot provide cancer care alone. Nor does the solution lie in the recruitment of more specialists such as dermatologists. Much of the specialised expertise relating to skin cancer is clustered around the city centres, despite the fact that doctors are likely to see more big lesions in the country. Dermatology is one of the most poorly supported medical services in rural areas, with very few Dermatologistsresiding outside metropolitan areas.

Skin cancer awareness, early diagnosis and management should therefore be given a high priority in work to support and extend the expertise of existing health professionals in rural and remote areas. Professional development and further education on skin cancer detection should be made available to all health professionals working in those areas. Better support could be provided through more training in skin cancer for health students, continuing professional development for health professionals in rural and remote areas and enhanced access to and support for clinical decision making support tools such as teledermatology and other telehealth programs. The alliance welcomes the rural, remote and aged care focus on access to telehealth consultations with specialists through the MBS, where country patients and their local doctor, nurse or Aboriginal health workers are involved in the appointment. There is potential for further development of this approach to better target specialties such as skin cancer and to better involve the full range of local health professionals, whether it is through the MBS or in community or hospital settings.

Finding the means by which best practice in prevention, early diagnosis and ongoing management of skin cancers can be made available away from the major cities and regional cancer centres is a critical challenge for governments and health service providers. Last year's parliamentary roundtable had some good ideas on this. Patient assisted travel and accommodation schemes are important, as are outreach programs that are well integrated with local services and local clinicians. All levels of government have a role to play in promoting SunSmart messages and the development of health-promoting infrastructure such as shade trees and shaded areas for recreation. Melanoma patient support groups should be resourced and promoted.

With regard to awareness and prevention, health promotion messages need to be sustained over a long period and effectively targeted to people living in rural and remote areas. Evidence from quit smoking campaigns suggests that the messages are not being received and acted upon in rural and remote areas to the extent they are in the major cities. The same could be true for skin care messages. Prevention and early diagnosis require all sectors of the community, health professionals and other groups to be well informed. Ideally, to some extent the prevention of skin cancer and its early diagnosis should be everyone's business.

CHAIR: In your experience, what types of awareness campaigns have worked best in getting messages out to rural and remote areas?

Mr Gregory : We are very concerned that health promotion campaigns across the board are almost certainly not working as well in rural areas as in the cities. The one that we mentioned in the opening statement is smoking. As you well know, the rates of smoking are not declining in country areas as they are in the cities, despite the good work being done and the significant amount of resources being put in that direction. We see the smoking issue as being absolutely critical both because smoking itself is terrible for your health and because we think it is a case study of what might be done better in order to get health promotion messages out to rural areas and having effectiveness. In relation to skin cancer we think that whatever health messages there are and have been have not worked so well in rural areas as in the cities. As to which of them are working well, I am not sure we are equipped to say. Our concern is that whatever works well in the cities does not do so well in the bush.

Mr STEPHEN JONES: Do you know why?

Mr Gregory : We suspect it is because the nature of rural communications is different. People receive messages in a different way. We have known for a long time that, for instance, to get to country people it is good to go to country shows and to field days and to pubs and sports clubs. So some of the standard ways in which we are spending our big money on health promotion campaigns such as television ads, radio campaigns, billboards, clearly do not suit the means by which rural people tend to receive communications.

Ms HALL: There are two issues. You talk about the high incidence of smoking and in your submission you also refer to socioeconomic factors. I think that socioeconomic factors probably come into play in rural, semi-remote or remote areas, and you might like to comment on that. You talk about the different ways of disseminating the message, but maybe we need to package the message in a way that people living in those areas can identify with rather than packaging the message in the way that people in cities and in many metropolitan areas can identify. Would you like to comment on that?

Mr Gregory : That is a much better summary than I gave of how health promotion in rural areas should be done. It should be done better. It should be packaged in ways that suit the culture, the environment, the infrastructure, the means of communication of people who live in quite different circumstances, yes.

In terms of your reference to socioeconomic status, can I commend to the committee a piece which was published in The Conversation, the online blog, just last week in which we, the alliance, make the case that place itself is a health risk factor. That is, it is not just the fact that in rural places there is a higher proportion of Aboriginal and Torres Strait Islander people; it is not just that in rural places there is a higher proportion of low income; it is that rural places actually help determine those things. We are making the case that socioeconomic status is critical, as we all know, in the determinants of health, but rural place itself helps to determine those social and economic variables. So I say again, I commend to you a piece in The Conversation last week on that subject.

Ms RISHWORTH: This is probably following on a little bit from your question, and thank you for the evidence you presented. In terms of one of your recommendations that the best-practice clinical guidelines for general practitioners need to take in particular some of the challenges that you have outlined about the rural and regional areas, can you give me some examples about what changes you would like to see in those guidelines, and some examples of what you think general practitioners need to be considering when they are looking at this issue?

Mr Gregory : I guess we would take a lead from the fact that rural general practice, as you well know, is quite different from city general practice. The commitment of time is different. The capacity to refer is different, and so our concern is to be sure that in the clinical guidelines that there is not just a single set of clinical guidelines for doctors who have such disparate ways of practising. In a metropolitan bulk-billing practice it is all about—how can I describe it—risk aversion and referrals rather as if there is not any doubt at all, as distinct from a rural or remote area where the general practitioner is a proceduralist who has much less capacity to immediately seek help—notwithstanding telehealth, which of course we support strongly and hope will further develop. So where clinical guidelines are concerned, it is not one size fits all, because the nature of rural practice, as you well know, is quite distinct.

Ms RISHWORTH: Does that variability exist in the best-practice guidelines at the moment, do you think, or is it not reflected enough?

Mr Gregory : Can you help on that, Geri? We suspect that it is not.

Ms Badham : I would agree with Gordon. We suspect that it is not. I felt that had come through a little bit perhaps in discussions at the roundtable last year and, when we were working on the submission, we became aware of the fact that there is possibly a need for guidelines to encompass more of what affects people in rural and remote areas with regard to all health issues. But in this case, we are working on skin cancer.

Mrs Dewar : May I look at the subject from the opposite side. Why would one waste half a day in order to get to a doctor who is not there, who is booked for three or four weeks, when one probably knows what the doctor is going to say anyway? So first one needs to get the subject to the GP, if there is a GP. Going back to the other subject, it may well be that the way to a gentleman's psyche is not only through his stomach but nagging from his wife and mother: you do need to go to the doctor sometimes, occasionally.

Ms HALL: So what is your answer? How do you solve the problem?

Mrs Dewar : Any advertisement should be geared that way. Nowadays all advertisements seem to be geared from the clever female point of view. So maybe if the clever female suggested that the male people in her life could be around for longer if they went to the doctor even occasionally.

Ms CHESTERS: I have a question on workforce and specialisation in workforce participation. The statistics on the number of dermatologists in the region are pretty scary. What are the barriers and why do you believe that to be the case? Do you have any ideas to attract dermatologists to the region? Do you know of any training places for interns who may wish to specialise in this area? Do any exist in regional hospitals or in a regional setting?

Mr Gregory : The alliance is not aware of what dermatology specialist places there might be out there; we are not that close to the matter. The general question of the availability of specialists in remote areas is something which concerns the alliance all the time. As you could well understand, the question of the access of rural people, especially in more remote areas, to more specialised services, is something which challenges us every minute of the day. However, perhaps what we have done in the opening statement and/or in our submission is to suggest that we are careless about the relative absence of supply of dermatology services. That is not the case.

What we are saying is that, in terms of the balance of things one needs to achieve, we would like the balance to be focused on those existing health professionals in the areas. But we are still vitally concerned with whatever means are possible to get a greater number of dermatologists and other medical specialists available in rural and remote areas. So we are interested in models that work, such as fly-in fly-out. We are interested in models such as hub and spoke. We have reservations about some of these. For instance, fly-in fly-out should only be undertaken in such a fashion as supports, enables and builds the capacity of the locals. We do not want a specialist flying over, doing their good work and flying back. We want them to fly into a place to work in a collegial and integrated fashion with whatever specialist or indeed nonspecialist may be already on the ground. So, yes, we spend a lot of time concerned with various approaches to how we can get more medical specialist services available.

Of course, the great white hope is telehealth, and we have mentioned that in here. We support telehealth very strongly. We support the MBS changes; we would like them to be more extensive, because we believe that a greater range of healthcare professionals on the ground should be able to be billing. Aboriginal health workers and nurse practitioners talking with others should be included. We are seeking further extension on that front.

Ms CHESTERS: How do you see telehealth rolling out in this space?

Mr Gregory : Teledermatology and Tele-Derm are both referred to in our submission and are success stories. They are going quite well, as we understand it. I do not want to get too specialised, but we support teledermatology and we think there is greater capacity for it to be developed and potentially extended. This of course is the $64 billion question—extending Medicare. But whichever health service professionals are on the ground should be the ones who should be able to bill MBS for the services delivered by a medical specialist off site. Because sometimes there is no doctor available. You do not want your patients to be precluded from the telehealth services of a specialist merely because there is no GP present.

Mr STEPHEN JONES: Looking at the data provided on page 7 of your written submission, which relies on the Cancer Council of Victoria's 2008 study—I think you adverted to it in your opening statement, as well—you mention the 30 per cent higher incidence of melanoma for rural men as compared to men in the city. That is something that is going to attract the eye of any policy maker. I am also interested in the fact that you said that place was the issue, not necessarily the fact that they are men. I just want to interrogate that a bit. It seems to me that the obvious thing is that they are spending more time outdoors. My kids cannot go out in the playground without a hat and sunscreen. If this was any other sort of workplace you would also be looking at this through the prism of workplace health and safety—whether there is a role for the insurer to create incentives in all of this. You would be looking at a range of different policy levers or tools. I would be interested in your comments on those aspects. Am I wrong? Is it just the fact that these guys are spending more time outdoors than their city equivalents? Are their parallel policy levers you could pull?

Mr Gregory : I am sure that you are not wrong. We were at some pains in our opening statement and in the submission to make the point that the gradient does not exist. Given the evidence you suggest, because of the occupations that are preponderant in rural and remote areas, you would expect that people would get more exposure to sun. You would therefore expect to see a gradient from major cities right through to very remote. We have gone to some trouble in the opening statement and the submission to suggest why that gradient does not exist from the middle ranks to very remote. So you have a gradient from major cities to inner regional, which shows inner regional being worse, but you do not then have a continuation of gradient into remote and very remote.

Mr STEPHEN JONES: If I was to get a study of building workers, truckies and rural man, would I see a very close correlation in the incidence of melanoma between those three groups?

Mr Gregory : We assume you would, but also the fact that the terrible data for farmers are age-related. We have spelt out the assertion that the SunSmart campaign has not had an impact on people who are currently in their 60s and over, because they started too late, maybe, or perhaps it did not suit them, or whatever. The age factor is significant, yes.

Ms HALL: I was going to ask a question very similar to Stephen's. I was wondering whether or not there has been any study undertaken that breaks up occupations and also compares it to remoteness, and whether there has been a comparison between the different regions and different occupations, which would answer the question that Stephen is asking. Has there been such a study?

Mr Gregory : There are some studies on farmers, distinguishing farmers from other occupations.

Ms HALL: But you don't have farmers in, say, inner Melbourne. I am thinking about studies of people that undertake certain occupations in a metropolitan setting and comparing them with people who undertake the same occupations in a rural setting.

Mr Gregory : I see—so taking a truck driver who lives in Melbourne compared with a truck driver who lives in Mildura or somewhere?

Ms HALL: Yes. Maybe there has been some sort of study; maybe there has not. Maybe it is something that you would be interested in looking at.

Mr Gregory : We are interested in every aspect of rural place. If such a study were to be proposed we would support it very strongly. It is a very good idea for a research study, but as far as we are aware there is no such data available.

Ms Badham : I was going to make a comment that I am not aware of those sorts of studies, but in working on the submission with Gordon and looking at issues to do with a communication and education strategy, and then thinking of what could underpin it—what good quality research—the sorts of issues you mentioned could perhaps come to the surface in looking at any communication strategy. We would be looking at research and studies that might show that sort of stuff—occupations and various areas.

Mr Gregory : In response to that question, the alliance is not in a position to undertake its own primary health research, but where there is a study that has the capacity to provide insights into the differences between rural and remote and major cities we would be tumbling over ourselves to support it by whatever means we could.

Ms SUDMALIS: I think you mentioned that our adolescents have a higher than expected incidence of skin cancer. I am concerned because I would have thought that that is the generation that has had the most marketing put to them about sun-safe behaviour. They have had covers at schools and hats in their uniforms. I would have thought there would have been a decline in the incidence in that age bracket. Do you have any insights into that?

Ms Badham : Not really. But in the roundtable I think the representatives from Melanoma Patients Australia might have made the point that that group was in fact the age group that we would expect to be hearing the messages and heeding them and it was a bit of a mystery as to why they are not necessarily acting upon the messages. So it is a bit of a moot point.

Mr Gregory : There is some good news in this. Adolescents have the highest incidence rates in the world but not the highest mortality. This tells us that some of the things we are doing in managing and intervening in skin cancer are working well.

Ms SUDMALIS: It is wonderful that it is coming afterwards and that there is lower mortality. But it would be nice to know that the financial investment that has been put into prevention was actually having a pay-off, and that does not seem to be the situation.

Mr Gregory : I suspect we do not know what is happening through time with the incidence where adolescents are concerned.

Dr SOUTHCOTT: In primary care in some of the areas there are really good examples of where specialists are very involved in the primary care workforce. A lot of skin cancer and melanoma work is dealt with by the primary care workforce, specifically by GPs. Do you have any good examples of where that is working? What is your sense of how the network works between the primary care workforce, GPs, and the specialist referral?

Mr Gregory : The bottom line for our submission, as you can tell, is that the best and the most frequent good work in early intervening, in spotting skin lesions and so on, is done by the primary care workforce by the GP, the nurse, the podiatrist, the social worker—whoever is seeing a patient. That is really what we are saying. We are saying: by all means let us work on medical specialty and getting it as available as possible in rural areas and by all means let us work through clinical guidelines for GPs; but let us actually extend it so that it becomes a formally respected and accepted function for anybody to do that. Let us use the case of a social worker. A social worker might see something on your hand or your neck. We are saying that that should be respected and valued as an important part of what can be done. We are not saying that it is all going to be done by that means but that it is a mixture of the medical specialist and the GP doing their specific skin inspection.

We are painting it a little bit in the same way as the mental health sector, which is saying that everybody has the capacity to care about the mental health of people with whom they are mixing. We are trying to add a bit more of that into skin cancer care. So, if you are at the beach and see a friend or relative with something on the back of their hands or knees which is changing its shape or colour, do something about it. Does that make sense?

Dr SOUTHCOTT: Yes. Do you have any evidence on the difference in incidence between coastal Australia and inland Australia? I know you have looked at inner regional and outer regional remote, but I understand there is some evidence on a different incidence between coastal Australia and inland Australia.

Mr Gregory : We would be interested in that, but I think we must have missed it. We will take that on notice and follow it up, because that is certainly something of interest to us.

Ms RISHWORTH: I have a follow-up question about that. It is in one of your recommendations: professional development and further education of all health professionals. Do you have any good models for how that can be delivered? Traditionally professional development has been done through peak doctor organisations and peak nurse organisations. It does not really train a multidisciplinary workforce in a rural area which might be working together. Do you have any models that could deliver a similar message to all health workers—obviously recognising that their level of expertise is different, but with the same goal in mind?

Mr Gregory : There is one good model with which we are very familiar—that is, the Rural Health Continuing Education Stream 2, which is a small grants based program to provide CPD for people who are already working in more remote areas. It is very competitive, and the sorts of applications that tend to get up are those where you have a multiskilled, multiprofessional workforce. For example, in the Riverland or elsewhere you might have a couple of midwives, a couple of GPs, a podiatrist and a diabetes nurse educator who want to do some CPD together. The Rural Health Continuing Education Stream 2, which we manage for the Commonwealth government, has provided some very successful programs to enable this sort of thing. As you well know, CPD in more remote areas is a big issue. It is one of the reasons that people like doctors, nurses and specialists will not go there. They suspect, or they know, that CPD is not readily available. We think this is a real niche which could be built up.

Ms RISHWORTH: Who helps those teams apply? You said it is very competitive. Do they need assistance with that application?

Mr Gregory : They do not get it. They write their own. The Department of Health has set guidelines and application forms, and they have to do their own.

Ms RISHWORTH: Are you aware of any professional organisation—say, the AMA—helping these rural teams to put in these applications or advertising these opportunities?

Mr Gregory : The National Rural Health Alliance helps them, but no-one else, as far as I am aware.

Ms HENDERSON: I wan to return to the issue of rural and regional Australia and the problems for people seeing a doctor and the services that are being delivered, particularly with respect to some of the public health messages that are evidently not being received. Do you have any recommendations as to how this issue can be combatted? I know you have addressed some of the general areas. In your view, what would you like to see change so that we can start to make a real dent in this problem?

Mr Gregory : The National Rural Health Alliance has had a working relationship with Roy Morgan Research. The reason they came to us is that we have a mutual interest in understanding how messages are delivered, received, accepted and acted on differently in rural areas. Obviously, you know more about Roy Morgan than I do. They have information, great details, about what people read, what they listen to, what they watch on television, how they get their messages, what times of day they do things. The alliance would love to do a piece of work using the data available from Roy Morgan, which is detailed evidence about how people get and use messages. The message we are interested in is health promotion and good health. Rather than trying to sell a product, we are interested in what it is that can sell self-care and health literacy to rural and remote people. As far as we are aware, there is no extant evidence or work on this. We would love to be involved in that.

Ms HALL: I would like to follow up on the questions about the availability of dermatology and the fly-in fly-out services. Would the majority of dermatology services in rural and remote areas be the fly-in fly-out type?

Mr Gregory : As we say in our submission, there are very few located in rural and remote areas. This means, I guess, that most services are provided when people get on their bikes and go down to a regional centre or a major city to see them.

Ms HALL: Linking into that, do you think a way to counter the lack of dermatologists would be to provide more postgraduate GP training so that more GPs would have a mini specialty in that area? What steps would need to be taken for that to occur?

Mr Gregory : Well, the short answer is yes, but I will say that we are concerned that so much gets loaded into the duty statement of a rural GP. Because the rural GP is the go-to person in a rural area, everything gets loaded on to them, and that is a problem in terms of their time and their burnout. So, in terms of the postgraduate training, we were alarmed; we are not expert in the alliance on what our medical curriculum should look like, but we were certainly surprised to find out that in at least one place the amount of dermatological training that a medical student gets was—was it two days, or was it two hours?

Ms Badham : I think two hours.

Mr Gregory : Yes—half a day. And we found that alarming—without being experts in medical education.

Ms HALL: The other issue I wanted to pick up on was the one that you mentioned about the lack of shade in rural and remote areas. Given that you can only apply it to public places, would you have a recommendation for the committee about providing shade and linking that into the planning process in those areas?

Mr Gregory : Absolutely. We think that the built environment has the capacity to deliver health-promoting places for recreation or for walking or for whatever. We are not naive; we are not suggesting that every rural local authority should be building you-beaut cycle paths with trees over the top. But it is a role for a local authority that should—and I am sure it is already recognised—be understood as being something that local authorities can do to help with health promotion and safe infrastructure whenever possible.

Ms HALL: Can you identify some priorities for research in this area, from your perspective?

Mr Gregory : The most important thing for us is the belief that health promotion in this case, as in others, is not working well in rural and remote areas. And we would like to know why, so that we can then start advocating for health promotion systems that do work well for country people.

Mr WYATT: I want to come to what you see as the identifiable gaps. I have read your paper, but in terms of screening and early detection, diagnosis, treatment and care: if you take that in conjunction with the Cancer survival and prevalence in Australia: period estimates for 1982 to 2010, the references in terms of melanoma of the skin—C43—and the other publication—Cancer in Australia: an overview 2012, about differences across population groups, where are the significant gaps that we need to turn some urgent attention to? I look at the rates that apply to Aboriginal communities, but I suspect that those rates would be very similar for lower socioeconomic groups, on a comparative basis, given the knowledge of what a cancer is and the types of cancers given. There are a range of them. And then, who do you access for treatment? I say this in the context that some remote communities across the top end of Australia have only a community health nurse; they do not have a doctor. I am interested in training for professions other than GPs. The other point I make is the number of 457 visa doctors who are now practising in rural and remote regions. It seems to me, reading these pages, that we have a tapestry of gaps in a number of areas in that whole process of screening, early detection, diagnosis, treatment and care.

Dr Gregory : I am sure you are right. We may have someone who, by definition, has a more isolated lifestyle—they work alone, they are working on a property on a motorbike or a horse or whatever—or someone whose history and culture and ethics tend to see them not thinking about their own health as an early priority in their thought process. This, again, surely goes to the issue that Marion raised. How do we get rural men—and I do not just mean farmers; I mean people who work for the local shire and people who are truck drivers and whoever else—to be more aware of the possibility that they should actually get a thorough skin check?

We have gone for the approach which I have already described—that is, that GPs should be better supported, that other health professionals should be better supported and encouraged and trained to do what they can, and that the general community—the family and friends—should be involved as well. Maybe I can respond to your assertion that it is like a tapestry by saying we have got a sort of a tapestry of a response which does not rely only on the specialist medical person but it relies on the whole community to do their thing.

Mr WYATT: The other element to that, then, is what are the levels of systemic support that are missing for the work that you do in rural, regional and remote areas? I say that in the context of the MSOAP program, where they fly specialists in on a rostered basis. Your diagnosis occurs, say, early in the month, but your rostered specialist does not come until the end of the third week. So you have this intervening period of some early treatment but not a detailed diagnosis, particularly if there is no telehealth system in place.

Mr Gregory : I had a response and it has gone. No, I have lost my train of thought.

Mr WYATT: That is not a problem. It is fundamentally a systemic factor that we are going to have to look at as a committee in all of this. Based on your submission, based on the answers you have given, there seems to be some disconnect in the way that we provide a better and more consistent service to rural and remotes.

Mrs Dewar : Talking about workplaces and shires, you know the workplace checks you can ring up and someone will come and test everybody in your workplace for blood pressure, diabetes or the five-minute check of everything, you could do that for workplaces in rural and you could do it in rural/remote in the places you are mentioning before: agricultural shows, field days, sporting finals et cetera.

Ms CHESTERS: That is not a bad idea.

CHAIR: Have you got the resources to do that?

Mrs Dewar : Exactly.

Ms CHESTERS: This follows on from where we were. I have recently had groups of ex-servicemen coming to see me. There is a higher rate of skin cancer and melanoma through their group. They came to see me about fundraising to get transport to the hospital and could we help with that. What struck me was how they were educating themselves through the RSL and the face-to-face education model. That appeared to be working for the challenge of how you engage older men around skin cancer and melanoma. Do you have any other examples around that face-to-face model? We have talked about field days. Is that more of a space where we need to go to get rural men and women engaged? Is it bringing it back to community groups, organisations, workplaces to deliver this education?

Mr Gregory : We were talking on the way up here in the car about a program called Pit Stop, which is pretty old now. It has been around for at least a decade. It is successful in terms of encouraging or enabling rural men to get a full check by comparing their body to a motor car. So what we are talking about here in skin cancer is checking the duco. What your reference to the RSL and face-to-face suggests is that when you have got a particular target group who are severely affected, like farmers, the jurisdictional farm associations—the New South Wales Farmers Association and the equivalent in all states and the National Farmers Federation—should surely have a role. To some extent they do, but I know that most of the state farmers associations regard themselves as being too busy to do much in the health and education areas. But I would have thought that that should be a higher priority for them than it currently is. Similarly, for other professional groups—truck drivers, I am not sure who looks after the shire workers. So that notion of getting the professional bodies, like in your case the returned servicemen through the RSL or whatever, to actually do their work. That is surely a case study in the sort of community development approach to this which we are commending in the submission.

CHAIR: That concludes the hearing. I would like to thank you for coming along today and presenting your evidence and also for your submission. If you have been asked to provide additional information or if you have any further questions, could you forward that to the secretariat by 8 April. If we have any further questions we will write to you. If you think of anything else that you may feel we need to be aware of, please make that submission to us today.

Resolved that these proceedings be published.

Committee adjourned at 13:05