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Community Affairs References Committee
11/05/2012
Health services and medical professionals in rural areas

BOLITHO, Dr Leslie Edward, President-Elect, Royal Australasian College of Physicians

GREBE, Mr Sasha, Director, Professional Affairs, HR and Advocacy, Royal Australasian College of Physicians

CHAIR: Welcome. Have you been given information on parliamentary privilege and the protection of witnesses and evidence?

Mr Grebe : Yes.

CHAIR: I know it is not the first time you have appeared before a committee. Is there anything you would like to add about the capacity in which you appear today?

Dr Bolitho : I am a consultant physician in rural Victoria, so this is a passion of mine.

CHAIR: We have your submission, numbered 76. I would like to invite one or both of you to make an opening statement, and then we will ask you some questions.

Dr Bolitho : Thank you for the opportunity to contribute to this important inquiry. The Royal Australasian College of Physicians, which I am representing today, congratulates the Senate for establishing this inquiry into the factors affecting the supply of health services and medical professionals in rural areas. We also congratulate the Commonwealth for establishing Health Workforce Australia with which the college is working to develop increased understanding of the medical specialist workforce requirements in rural and remote areas and examining ways to provide extra specialist training posts.

As the committee well knows, people in rural areas have poorer health status than their counterparts in metropolitan communities and in major regional communities, with an excess of chronic disease, an increase in all-cause mortality and with reduced access to health services. The social determinants of health and wellbeing can be clearly seen in the rural setting as there is often poorer housing, limited schooling choices, limited shopping for appropriate dietary requirements and limited work opportunities. These are influential factors reflected in the consensus report published recently by the Australasian Faculty of Occupational and Environmental Medicine with the college, Realising the health benefits of work, which presents compelling international and Australasian evidence that work is generally good for health and wellbeing and that long-term work absence, work disability and unemployment generally have a negative impact on health and wellbeing.

However, particular to this inquiry, and significant in the interaction with other rural, social and economic pressures, is the limited access for rural populations to appropriate health services for their community needs, commonly described as 'the right care at the right time for the right illness in the right location by the right practitioner'. I am sure the committee is aware of the information about Australia's rural and regional health workforce which was provided for the first time in the Australian government report on the audit of the health workforce which was published in 2008. That report showed that, despite a range of Commonwealth and state government programs aimed at increasing the health workforce in rural and regional Australia, medical workforce shortages persisted, particularly in general practice and the specialty services, and that the supply and distribution of health professionals in these areas largely correspond with the distribution of state and territory funded or controlled hospitals. This is not surprising, as opportunities for a comprehensive medical practice rely on access to in-patient services, other professional colleagues and other clinical support services. As smaller regional communities often comprise small centres, with dispersed populations across large surrounding catchments, the capacity to attract and retain health professionals is compromised if there is not reasonable access to a public or private in-patient facility.

The audit also found that a higher proportion of rural medical workforce was made up of overseas trained doctors; a direct outcome of a significant Commonwealth program that requires overseas trained practitioners, both GPs and specialists, to practise in areas of workforce shortage for a period of up to 10 years prior to being eligible to practise more broadly. That program is based on the Australian Standard Geographical Classification scheme and directly correlates to the time restriction to the remoteness of the area of the workforce shortage.

Whilst my college has not directly assessed the effectiveness of these arrangements, there is evidence that their effectiveness in the provision of a specialist medical workforce for rural and regional areas is limited. The Australian Institute of Health and Welfare has shown that, in 2007, the rate of specialists in major cities was twice as high as the rate as in inner regional areas, three times the rate in outer regional areas and four times the rate in remote and very remote areas respectively. Whilst this is some time ago there is no indication of any significant change occurring. A particular investment by the Commonwealth, which has been increasingly significant in contributing to medical population in these areas, are the rural clinical schools and the university departments of rural health.

These have provided education and training opportunities in regional communities for some years and have enabled senior professionals to engage in supporting the teaching and training of local or temporary residents and trainees and is a win for both the professional community, the general community and the students who wish to study, work or live in a community in which they have grown up in.

The Royal Australasian College of Physicians is a training college for medical specialists in adult and paediatric medicine. There are associated faculties, chapters and specialist societies. There are 13,500 physicians and currently 5,000 trainees in Australia and New Zealand. There are 67 training programs and 35 medical specialties within the college. The college is working in conjunction with the rural clinical schools to ensure that medical graduates can train not just in the communities in which the schools are established but in training pathways supported by these schools across wider and less sparsely populated catchment areas. There are early programs established, such as the Murray to Mountains Program in north-east Victoria where intern training is entirely in the rural setting. This program will be expanded in the future.

Whilst learning and working in rural communities is likely to contribute to the recruitment and retention of health professionals in these communities, this is not likely to be sufficient to develop an adequate specialised medical workforce. And by 'adequate' we mean a workforce that meets the particular health requirements of rural communities noting, as I have said earlier, the higher levels of chronic disease in these communities. The RACP recognises that education and skills mix needs to be tailored to the needs of the community, and to the aspirations of the health professionals who could be encouraged to work in these communities.

The RACP has been working with government bodies—the Commonwealth and state governments and Health Workforce Australia—to promote and develop new and integrated models of service delivery and to expand our ability to train physicians. There is increasing recognition of the need for the health system overall to have additional general physicians with expertise and diagnosis and management of patients with multiple chronic and multisystem disease.

General physicians or general medical specialists encompass the breadth of expertise to deal with undifferentiated complex presentations and coordinate and manage illnesses affecting more than one organ system. In addition, dual training providing some physicians with an additional specialty will enable a broader range of expertise to be provided with a smaller workforce to be committed to smaller populations.

RACP is working to encourage the development of a robust general physician workforce to improve services in rural and remote regions. General physicians with dual training would provide skills in the management and diagnosis of these complex conditions and enhance the scope of treatment provided regionally and would work in collaboration with the metropolitan and tertiary referral centres.

   The college urges this committee to recognise the compelling need to encourage more general physicians and dual trained physicians to live and work in rural and regional areas. Not all regional or rural hospitals will be able to have a full complement of specialist physicians. General physicians are able to cover many of these areas to provide services for the more complex patients and are able to liaise with the major centres for collaborative clinical care as required. The model of dual trained physicians has been in place in New Zealand for over a decade with that country's district health boards employing general physicians who are dual trained to provide services throughout New Zealand. This model of service delivery requires additional resources to ensure there is a structured career pathway which will attract quality trainees and enable them to be provided with skills to deal with chronic and complex patients.

The RACP is working with all governments to develop training positions for this model and acknowledges the increased capacity to train in nonmetropolitan areas as provided by the Commonwealth funded Specialist Training Program. The RACP is involved with the administration of this and applauds this initiative but encourages the provision of increased funding to allow additional training places to be established. Rural-based specialist training would encourage trainees to remain in the country. There is a need to support physician teachers, supervisors, mentors and to ensure that the trainee is nurtured and will return to the rural setting for long-term gain in the medical specialist workforce.

The college would encourage the establishment of centres of excellence in rural medical education in conjunction with the rural clinical schools to provide a continuing postgraduate training and education, particularly in the early years of graduation from medical school. We also encourage an inquiry into the early education requirements after medical school graduation. There is a significant degree of commonality across all the colleges in the first three years post-graduation. An entrance examination for advanced training could be held at the end of the first three years of training, with the award of an intermediate certificate to acknowledge the learning process, and then acceptance into advanced training for all medical colleges would ensure a highly skilled and educated workforce. The infrastructure to assist training and retention of medical specialists could include a specialist practice incentive program. This would be similar to the GP Practice Incentives Program and would ensure there is adequate funding for installation and upgrade of IT equipment, preferably connected to the NBN, to ensure adequate and timely communication with general practitioners, hospitals and ambulatory healthcare services. The ability for IT communication across various platforms is essential to provide information access between pathology services, medical imaging services and private and public hospital facilities.

The college cautiously welcomes the introduction of Medicare locals and looks forward to the maturation process. Medical specialists work closely with primary and ambulatory care services, as well as with acute services in and outside hospitals. Medicare locals should be inclusive and embrace Medicare's specialist services to enable the active shared management and support of patients, particularly between the smaller workforces in smaller rural and regional communities.

Currently the provision of additional medical service specialists is via MSOAP, Medical Specialty Outreach Access Program, and associate programs in Indigenous health and other areas. This has enabled medical specialty services to be provided to patients in rural and remote areas. There should be an expansion of these programs, which would increase services to rural and remote patients. These services can be delivered in various ways, including fly in, fly out, fly in, stay, fly out and various driving in, drive out facilities. We would also encourage this inquiry to examine the possibility of encouraging the nation's major metropolitan and large regional hospitals to be responsible for provision of specialist services in designated rural and regional catchment regions. This could also provide a platform for coordination between Medicare locals, local hospital networks and private practitioners.

The provision of medical specialties services in rural and remote regions ensures patients receive the right care at the right time, in the right location, by the right provider. Facilitating the growth of accessible medical specialist services in small communities could lead to reduced hospital admissions, improved quality of life for patients through reduced interactions with the healthcare system and the development of system-wide savings over time. One of these savings could be the reduced cost of patient transfers and travel to metropolitan settings. We note the recent increase in budget in several states to cover the assistance required for patients travelling to access health services in the metropolitan areas.

The Commonwealth should be encouraged to examine the cost benefit of provision of services in local settings—that is, work with the states and territories to review the benefit of financially assisting patients to travel to necessary specialist services, compared with the opportunities to financially support the provision of specialist services to entire communities through expansion and redevelopment of programs such as MSOAP. In summary, the Royal Australasian College of Physicians encourages the inquiry to examine not just the factors influencing supply of health service and medical professions in rural areas but to consider innovative options to enable the health workforce to learn and work locally, to fly in or drive in and drive out and to develop dual skills to enable the necessary smaller workforces in regional hospitals to provide comprehensive specialist and multidisciplinary healthcare to smaller communities.

Senator NASH: It strikes me listening to that, which is eminently sensible—we are hearing a lot of eminently sensible views about what can address the problems for regional health delivery, yet we are hearing of long-term decline when there are such practical, good ideas. Why is there a disconnect to making them happen?

Dr Bolitho : If we look at the number of Commonwealth funded programs for general practitioners and the number of specialty programs we see there is one for specialist medical care, the STP, apart from me with locums for obstetricians. This is something which has not been integrated and Medicare locals do not mention medical specialist services of any description. There is a total disconnect and local hospital and health networks also do not mention any specialty services. Between 70 per cent and 80 per cent of medical specialists provide services in private outside the public hospital setting and 57 per cent of surgery is carried on in the private hospital setting.

Senator NASH: Is that across the board or just regional?

Dr Bolitho : It is across the board, in regional centres as well as metropolitan centres.

Senator MOORE: And the same figures for regional?

Dr Bolitho : As far as I am aware it is the same figures, so that more surgery and more services are delivered outside the public health system than in it at this stage. Certainly the metropolitan is concentrated. We have great difficulty attracting specialists to the rural setting. The MSOAP has certainly been influential in providing services to our smaller communities and we are directly involved with it. I should say that I have been involved on the MSOAP board for the last 10 years until it was recently re-formed, both for Victoria and for our local region. Looking at the services provided is essential. With the involvement of the metropolitan tertiary centres taking responsibility for doing these services, it seems logical that if you take a specialist to a region and they can see 15 or 20 patients it is far more cost-effective than having to provide assistance for 15 or 20 patients to travel to the centre.

Senator NASH: Are you suggesting a fly in, fly out model? How would it work?

Dr Bolitho : We would prefer them to be regionally based. We would certainly encourage people to live and work regionally. In our system we have six general physicians in Wangaratta. We have all undertaken to visit up to 100 kilometres from the centre at least one day a week. So we all go to regional centres and cover 100,000 patients in about a 100 kilometre radius from Wangaratta, including one of our fellows flying to Echuca every Tuesday.

Senator MOORE: A sizeable chunk of Victoria.

Dr Bolitho : It is a sizeable chunk of northern Victoria.

Senator NASH: Is that sort of model replicated anywhere else?

Dr Bolitho : No, and I have not written it up yet—in my spare time occupation! I have been encouraged to write the model. We have had to attract three overseas trained doctors to help us with that.

Senator NASH: Even when you do get the time to write the model up, if you could would you provide it to the committee—whenever that might be? It would be very useful. You were saying in your opening remarks that the hospital should be responsible for doing that. What is the mechanism for making them do it? In a perfect world, if you were going to say to a larger hospital: 'You are responsible for providing X amount of specialists out into the rural communities,' what would be the process or the mechanism to make them actually do that? Or is it something that they cannot be made to do, that they have to be led to the trough to drink?

Dr Bolitho : The college covers both Australia and New Zealand. The process in New Zealand is a totally different one. There they are employed as dual-trained physicians and are expected to provide services in the local regional communities. It is part of their employment contract. I do not think that is in the Australian vernacular at all. I see that we have interns coming up from the Royal Melbourne, St Vincent's, the Austin, Monash and the Alfred in Victoria—from all the major centres—and they all go out to areas. They say, 'That is our catchment region.' We are saying, 'Why don't you come down and actually see the patients and see what is going on?' We have developed a very good relationship with our tertiary centres, so, as general physicians, we provide the follow up.

I was listening to the evidence from oncology services. We have rural and regional oncology service in Albury-Wodonga. We have their specialist come down one day a week to Wangaratta. We have delivery of regional treatment in Wangaratta. I supervise the oncology on day to day. These patients have multisystem disease. They do not just have cancer; they have diabetes and heart disease. That is where I come in. The oncologist tells us what they are going to have and supervises that. But as soon as they end up with pneumonia or their diabetes is out of control or their heart disease has been right, they end up being coordinated. The integration of care in the regional services or across rural and remote is a role specifically for general physicians, because we have that broad ability to integrate care.

Senator NASH: To do a whole heap of things. I think it was the previous witness who said that they would like to see a rural health plan instead of it being so ad hoc. Is there a way of having some kind of plan that sets out the requirement for the major hospitals to utilise their specialists—they would have a regional requirement around the type of model that you have in Wangaratta?

Dr Bolitho : I am not aware of one in the Department of Health in Victoria. I cannot comment on the others.

Senator NASH: I am not asking about existing, sorry. I am asking whether it would be possible to have the world look like that?

Mr Grebe : I think one of the big opportunities here is having the arrangement between the Medicare Locals and the local hospital networks. You touched before on why these things have not been addressed to date. Some of those legacy issues relate to having essentially a dual-track system. You have the Commonwealth looking after one setting and the states looking after another. For a lot of these patients, you end up having siloed care being delivered. We are talking about getting greater fluidity, where patients really do not know what they are accessing, whether it is Commonwealth or whether it is state, but they are getting is the right care that they need. The opportunity there is also is for more of those state based services to be delivered in a different setting, which could be outside of the hospital as well.

We are also looking at having those people with the right skills around multidisciplinary care and coordinated care. In particular, we are looking at the opportunity for our fellows to play a role in that, particularly for general physicians, with their broad based skills, to deal with chronic illnesses and co-morbidities. There are changing patterns of illness occurring and there is also that running up against what is often a very hospital-centric care arrangement—I think Australia has one of the highest hospitalisation rates in the OECD. We need to reduce a lot of those unnecessary and avoidable hospital admissions. There is a change that needs to occur and, potentially a framework with the health reforms to adapt to that.

Senator NASH: I was just going to ask about the New Zealand contracts that have a requirement for doctor to do regional work. Would it be possible to provide a copy of that type of contract for the committee or direct us where to go to?

Mr Grebe : They do not have states is there issue there—in terms of that dual tack.

Senator NASH: But, as far as you can—

Dr Bolitho : We could see if we could find the model.

Senator MOORE: The AMA have been really keen on contracts with doctors.

Mr Grebe : Yes, I will probably leave that one to them. I would just point out that in New Zealand you start as a generalist and then pick up something else. That gives much greater flexibility for the allocation of resources.

Dr Bolitho : With the integration of care, we looked at the national health reforms as a marvellous opportunity to improve services. Ambulatory and primary care extend through all the medical specialty. It is where we manage the patients before they get to hospital as well as after they have been in hospital and with our appointment in-hospital—if we need tertiary services, coronary artery disease, coronary angiogram, with or without surgery, and then they come back. But the majority of our services in rural and remote regions are provided outside the hospital system, particularly in Victoria. Nobody has actually seen that from a government department point of view—that is to say that a significant amount of Commonwealth money is expended for ambulatory care by specialists and it is not recognised in any of the documents that have come out today. There needs to be a rethink so that specialist services are integrated more closely with primary care and general practitioners. Our role is ensuring that the communication is there. That is where we talk about the communication across all our regional communication, which is electronic. We have set it up with the general practitioners for the 100 kilometre radius so that all communication is electronic and the letters are integrated into the general practitioners program.

This leads me to the difficulties envisioned with the introduction of PCEHR, the personally controlled electronic health record, where the person who puts the information in is the GP. If you have somebody under an oncologist who is having their breast cancer treatment, which may require weekly or fortnightly or so visits to the specialist, none of that is going to be put in until they go back in three or six months to the general practitioner, if it is done elsewhere than in a public hospital, where the discharge summary will be incorporated. So there will be no capture until they go back to their general practitioner if we as specialists cannot put the information in or the change in medication in. So, the PCEHR is potentially going to be only as good as when they have gone back in three or six months time to their general practitioner, who then has to put in a huge amount of information.

Senator MOORE: We thought that was still under discussion.

Dr Bolitho : I would like to emphasise that it is a real concern.

Senator MOORE: The other issue is the view of the AMA and the GPs that they are the single portal for this information. From someone who is not in the medical profession one of the things that constantly comes up in these discussion is the different views of the various people in the medical profession.

Dr Bolitho : I am sure the AMA will provide you with the general practice view. I will not say any more.

Senator MOORE: On the issue about the area of acute care and ambulatory care—primary care—being dominated by GPs, and also the electronic health stuff, it is because the GPs are promoting their ownership of it. Where is the discussion between the various medical areas about it? In previous evidence it was said that specialists do a lot of the—what was the term you were referring to? It was in the areas where the GPs do own it—the discussion and the promotion of it.

Dr Bolitho : They have been bequeathed it. They do not own it. For the complex patient—

Senator MOORE: It is a matter of trying to get agreement between you guys. That would be good.

Dr Bolitho : We see complex patients. We see the diabetes, the heart disease, the heart failures, the kidney failures, the lung disease, smokers. All of those come through when the general practitioner either requires additional assistance or it is chronic and complex or it is integrated care. With our population now getting older—average lifespan for women is 87 and for men 79 to 83—no longer is 70 considered the end of the line, I am very pleased to say. We are now aiming for everybody to get to their mid-80s. So management of care is across the board and we are managing with, and deferring to, the general practitioners.

Mr Grebe : That has been the other change, too. In shifting to saying it is the Medicare Locals instead of the GP Networks is a recognition that it is a setting and who provides which care in which setting should depend on what the patient needs. So more specialist care in that primary or ambulatory setting can be delivered. A good example of that at the moment which is encouraging development was the agreement between the Commonwealth and the New South Wales State government for the clinic in Raymond Terrace which is a 50-50 joint venture and has all the GP, allied health and specialist services being provided by all levels of government in one place. So we think that is the sort of arrangement when it does not matter to the patient: they just arrive and say they need to see X and that person is there and available for them.

Dr Bolitho : Multidisciplinary team care is a specialty of general physicians as well so that we integrate the care. Our problem on the ambulatory care side of it is that we cannot access the allied health requirements without sending the patient back to the general practitioner with a recommendation that they need to see a physio, a podiatrist, an ophthalmologist or a psychologist. We have to send them back. The rehabilitation specialists are particularly keen to try and broker that they can access it. But it is across the board in the rural setting. It seems ironic that we can see a patient and recommend that they go to cardiac rehabilitation after they have had their myocardial infarct, but we have got to send them back to the GP to access and do the paperwork. The communication is there. The letter goes back to the general practitioner. As a specialist I do not own a patient; I look after them with you and the general practitioner.

Mr Grebe : But a lot of these additional steps are fine when you are talking about going one suburb to another in a metro setting. If you happen to move around long distances. Again, just listening to the previous presentation, some recent papers have been published in the Internal Medicine Journal of the college about the treatment rates for female cancer patients in rural areas—the impost of that trip and then putting their family first in getting the follow-up care. So in a lot of these situations people are diagnosed with the problem. It is the management of the illness. You touched before about the broken leg versus a chronic illness. We are very much geared up for those procedural, episodic treatments and yet the shifting pattern of care now is towards chronic illness, which is management and ongoing care.

Senator NASH: For life.

Mr Grebe : That is exactly right.

Dr Bolitho : The other patients particularly affected are people like dialysis patients. If we can look after the dialysis for them in the regional setting. We now have one and a new nephrologist for the whole region based in Albury-Wodonga so that we provide services in the smaller centres for these people so they are closer to home. Three times a week they have got to come in. It is really a huge impost and the services required—

Mr Grebe : How far is Wangaratta from Albury?

Dr Bolitho : An hour's travel is the easiest way to say it. We are gradually attracting services to come down to Wangaratta and see the patients there.

Mr Grebe : Our working principles in developing a dual training pathway is that we want to look at increasing the number of patients who can be dealt with in the local setting, whilst recognising that there are going to be, as others have said, occasions where people are going to have to go to a tertiary setting. But how many more could we do locally and how many more treatments could be provided? That is where we believe, in particular, that general physicians with their broad array of skills—so they can, based on the scope of practice through their training—look at all of the specialty areas. We have 30-odd. Dr Bolitho is able to look at most conditions that are presented in that setting. So you get the additional benefit of having that sort of specialist—again, recognising that you are not going to have one of everybody at every hospital.

If you are not going to do that, the other issue is: how are those specialists, even those with dual training, allocated? What is the pattern of distribution? One of the things we are looking at is trying to get an alignment in those additional areas of specialty to cover the chronic illnesses. What the college has put forward in its current proposal is that if you took, say, Dubbo, Orange and Bathurst, and we had dual trained physicians with a specialty in the relevant areas, how many more patients could be dealt with in that area without them needing to travel elsewhere?

The other beauty of that model—and it is picked up in a few of the submissions—is that what we are talking about here is creating an environment where those specialists want to stay in that setting as well. So it is not just about recruiting them; it is about getting them to stay. If they can see a rewarding career, then it becomes more attractive. Of course we are interested in ensuring that the training experience they have is positive, but if they can see a future where they will be able to network with their peers and be supported professionally in their development without always having to go off for CPD—you know, that ongoing vocational training—then it starts to become a more attractive and more sustainable workforce model without relying on top-ups, incentives and all those sorts of arrangements.

Senator NASH: What is that proposal?

Mr Grebe : It is a discussion paper that we have out at the moment. We are working with Health Workforce Australia and a number of state governments on trying to get to a model that has a dual trained general physician in this additional area in that hospital and then a dual trained physician with a complementary additional specialty to treat more patients with chronic illness in the other local area.

Senator NASH: Could you provide a copy of that to the committee? That would be really useful.

Mr Grebe : Absolutely.

Senator MOORE: Dubbo-Orange is a pretty dynamic health area, isn't it?

Mr Grebe : Yes, and there is a good general practice network there as well.

Senator MOORE: Yes, and they are very proactive.

Dr Bolitho : It is similar in the Hume region. If we could coordinate Shepparton, Albury-Wodonga and Wangaratta, we would cover nearly half a million patients. But we do not have the services of a Geelong or anything like that available regionally. We have got the cancer centre and radiotherapy up there, and the new building is going ahead for the new oncology centre at Albury. But the other services are certainly still very rudimentary.

The other thing with the integration of care is the upskilling of nursing and allied health staff in the region. So it is not just a matter of bringing the doctors in; we need the skilled staff to support us, to improve hospital care and to ensure that we have models of care that are sustainable across the whole hospital base and also out in the community.

Mr Grebe : That is a benefit also to the GP. A great study has recently come out from an endocrinologist operating out of Toowoomba Hospital. The evaluation was that the local GPs gained significantly from having that specialist come into their general practice to treat those patients. Putting aside all the obvious patient benefits, the GPs gained an insight into the treatment and there was better continuity of care. Rather than being seen as an impost on them, it was actually seen as a benefit.

Senator NASH: It is really interesting. If you are a GP in the city, you send your patient to a specialist and you do not have that connectivity. But to actually have them come in—

Mr Grebe : Yes. A lot of the submissions picked up that one of the retention issues is access to specialist services for GPs.

Senator NASH: Yes, very much so. I think you expressed cautious support for Medicare Locals. It seems that that is a bit across the board. It is a blank piece of paper at the moment: if it goes the way of the good, it is going to be fantastic; if it goes the way of the bad, it is going to be a nightmare. Underneath that, in your submission you talked about the reintroduction of general physicians. That implies that they were there but now they have gone. Could you elaborate on that for us?

Mr Grebe : If you look back historically at the number of those places that may have been available, some states, as supposed to others, took the view that more specialty areas were the way to go—and you see that term 'the subspecialisation'—and that general physicians were less required. I think it would be fair to say that there has been a bit of a turnaround and a bit of a shift in thinking in recent times and it is recognised that, unfortunately for a lot of area health services, there are not the generalists there anymore to get the trainees. We have significant interest from trainees in doing general medicine now, so they are in a way driving the changes as well. There has been a shift back.

Dr Bolitho : Our most populated state managed to remove all general medical training units from their public hospitals just prior to the Olympics, a few years ago. I will not tell you which state. They totally deconstructed them and said they were no longer required and they only needed subspecialists, subologists.

Senator NASH: What was the rationale behind that? Particularly for a regional area, you may have a doctor, one specialist, with a patient where (a) the GP does not have a clue or (b) there is a multilayered presentation of different things. What they are saying is that the GP has to pick what the problem is before they send the patient off to the specialist. Is that correct?

Mr Grebe : That is right.

Senator NASH: And if you have more than one, you go to four or five, buddy.

Dr Bolitho : We have some wonderful letters from people who go to metropolitan centres and see five, six or seven specialists. They come back and we then have to untangle it all and reassemble them because they do not understand what organ is not talking to the other. They ask, 'How does that happen?' Whereas we say, 'You're a person. Let's get you improved.'

Senator NASH: That is very interesting.

Mr Grebe : You might also look at some of the state budgets, as Dr Bolitho touched on in his opening statement, around the significant blowouts in recent allocations for patient transfers. Some of those states might now be relooking at some of their decisions in light of the doubling of those budgets.

Dr Bolitho : Emergency transfer is particularly expensive; it is a minimum of $6,000 per transfer. If we need to send somebody acutely off to a tertiary centre it is a very expensive business. The ambulance service has learnt to create everybody into category 1, so they then charge the hospital system. With or without a medical requirement for it, there is an additional hidden cost in there.

Senator NASH: Would you please take on notice for us where to go to source some information on the removal of those generalist positions out of the equation for that state?

Mr Grebe : We will do some analysis for you and come back to you on that.

Senator NASH: Thank you very much. That would be great.

CHAIR: We have given you some homework. If we could have that back within two weeks, that would be fantastic.

Senator NASH: Obviously, if any of that is detailed you may need a little bit longer.

Mr Grebe : We expect to be able to comply with that.

CHAIR: That would be fantastic. We look forward to seeing your discussion paper. That will be really handy. Thank you for your time.