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Community Affairs References Committee
Health services and medical professionals in rural areas

HAMBLETON, Dr Steve, Federal President, Australian Medical Association

HOUGH, Mr Warwick, Senior Manager, General Practice, Legal Services and Workplace Policy Department, Australian Medical Association

RIVETT, Dr David, Chair, AMA Rural Medical Committee, Australian Medical Association

Evidence from Dr Hambleton was taken via teleconference—


CHAIR: Welcome to witnesses from the Australian Medical Association. Before we start, have you had information provided to you on parliamentary privilege and the protection of witnesses and evidence?

Dr Hambleton : Yes, I have.

Mr Hough : Yes.

Dr Rivett : Yes.

CHAIR: We have your written submission, which is submission No. 42. I invite you each to make an opening statement and then we will ask you some questions.

Dr Hambleton : I would like to thank the committee for providing the AMA with an opportunity to present further evidence to this inquiry. The AMA has a very strong interest in rural medical health and supporting initiatives that encourage doctors to practise in regional and rural areas and in ensuring that Australians living in the bush have access to high-quality medical care. We know there are no easy solutions in this area, and certainly no one size fits all. Our submission to your inquiry does, however, look at these issues strategically and broadly. It proposes a range of initiatives and solutions that would provide more incentives for doctors to consider working in rural and regional areas.

As you may be aware, the AMA releases position statements on a range of health and medical issues. These position statements are updated periodically, particularly when issues need further policy attention. In recognition of the imperative to improve rural and regional healthcare and support for health practitioners working in the bush, the AMA recently updated its position statement on regional and rural workforce initiatives 2012. This replaces the 2005 position statement. I would be happy to arrange for the updated position statement to be tabled to this committee. Quite a lot of the content is in our submission, but we can provide that to the committee.

CHAIR: That would be helpful.

Dr Hambleton : I will hand over to my colleague Dr David Rivett, who chairs the AMA Rural Medical Committee and who himself is a doctor practising in a regional area, to outline the key issues the AMA believes are crucial to the supply of health services and medical professionals in rural areas. Before I do, what I have been saying publicly and am happy to say to the committee is that I often hear governments asking, 'What's the one thing we can do to fix the problem?' In this circumstance, really there are a range of things that we need to do. That is why we tried to put all of that information in the submission to the committee to really help the deliberation. There are a whole lot of things that make a difference. If we can build all those in, we can actually make a difference.

Dr Rivett : Thank you, Steve. I reiterate our thanks to the committee for providing this opportunity to address it today. Since I graduated I have practised in Batemans Bay, on the South Coast, which I am sure you are all familiar with. The population has grown in that time from about 1,700 to 17,000 and we now have five nursing homes in town. We are not pulling in new doctors, so people at the end of their working lives, like me, are being forced to work harder and harder, which is just not tenable. This is not the situation just on the South Coast; this applies all around Australia. We have to get robust systems in place to attract more doctors to go rural. At the moment government is putting substantial funds into facilities. We are seeing good training facilities for students and better generalist training in Queensland, and that is going to spread around Australia, by the look of it. So resources are being spent.

Facilities and training are being addressed, but we are not seeing incentives to get them there. You have just been talking to somebody about general physicians, which is a really gaping hole in trying to staff regional hospitals. Our rural medical committee does not look just at the tiny hospitals the RDA represents; we are looking at regional hospitals as well. We have a spread of doctors on the committee from throughout Australia; all states are represented. Some of the big regional hospitals are having a lot of trouble getting generalist staff. General physicians in New South Wales are just about extinct—or are extinct, I think you have just been told. General surgeons are not coming through the scheme. There is more and more subspecialisation. Some of this is driven by Medicare differentials; there are higher incomes to be made in subspecialisation at times. So there are lots of factors that have to be fixed, not one or two.

Over the years I do not know how many meetings I have been to about planning for rural health, and everybody listens and takes the attitude that it is all too hard. They feel absolved from guilt by saying: 'It's too hard. Let's just sweep it under the table and admit we can't win.' I think you have got to have a damn good go at it. That has not been happening in the past. So I am very enthused that there is a Senate committee actually looking at this and hopefully going to bring forward some robust solutions. There are a lot of robust solutions, from different areas of approaching the problem, in this paper that has been presented to you by the AMA.

Currently, I am three doctors down in my practice. I am trying to go through an 'area of need' process, which I can assure you is an absolute morass of red tape. I have been told I can apply for one doctor at most. You cannot get three 'area of need' positions, even though I need three people desperately. All the doctors in my practice are over 60 and hanging on, wanting to get out and just slow down. But they feel they cannot do that, because they want to provide a community service. The younger doctors coming into town do not have real incentives to provide after-hours care. They want to have a life as well as be a GP—which is totally sensible and admirable. There have got to be core numbers to support this into the future. You cannot say, 'We're going to get a doctor to a town.' There have got to be core numbers, so that that doctor has a good lifestyle there, he has got good access to education and ongoing training and he can look after his patients but also have time to look after his family and his other interests.

The old days of dinosaurs like me trying to do everything at once and working crazy hours are long gone. If we look back to that old model and say that it is going to happen again, we are losing the plot altogether. We need a series of robust solutions to get doctors back to rural practice and enjoying it—not doctors drafted in, not IMGs drafted in because they cannot work somewhere else. We have got enough medical graduates coming through in Australia now that we can solve the problem. But it is going to mean some dollars spent by government to get people there in core numbers, so that they have a good lifestyle and provide a good service to those rural populations.

Again, the paper enunciates most of the areas that need addressing, in a very clear format. I will not go through it bit by bit now, but it is a real crisis and it is getting worse, because the people with the experience, and most of the proceduralists like me, are over 60 now. They are not going to be around for much longer. We need to get robust systems to get younger doctors into the loop now, while the older guys are still there to show them around. It has got to happen in a hurry, not in 10 years time. It will be all over then. There will be more and more people getting flown out expensively, as there are now. At Batemans Bay, we have a helicopter just about every day now, sometimes several times a day. Facilities are getting wound back. We need more robust facilities, with specialists and GPs. It is not just a GP issue. We need general specialists to bolster those big regional hospitals right throughout rural Australia. It does not matter what state you go to, we need more generalists. They need to be well paid and to have decent rosters so it is an attractive working life. Thank you.

Mr Hough : I have nothing to add.

Senator NASH: I will start off with a question I started with for the last witness. We have seen a lot of really good ideas. There are some terrific proposals. There are some incredibly intelligent people on the ground, involved in the sector, that actually have the answers to how we improve health delivery out in the bush and in the regions. Yet there is this disconnect. We have got the situation as it currently is—and, as you say, Dr Rivett, getting worse—and these fantastic ideas. Why is there such a disconnect? Why can't we get some of these ideas and proposals actually implemented? What is the block?

Dr Rivett : When we take it to the health bureaucracy, we get the 'too hard' or 'too expensive' answers all the time. Also, you have got a federal system battling with a state system, so there is buck-passing going on. Who is responsible? Is the state responsible or is the federal government responsible for solving the rural workforce crisis? They have both got different parts of the pie and they have both responsibility for different parts of the solution. Again, they can buck-pass from one bureaucracy to another. There needs to be a single body that is empowered to put solutions in place. These are multifactorial solutions that cannot just be done by the state government or the federal government alone. They need to be working in sync and they need to have a strong desire to actually solve the problem. I think that is lacking badly. The AMA has taken forward, with the RDAA, the rural rescue package for the last four or five years, without getting any traction on that. That should be a sexy package to any government. It has got a sexy title: rural rescue package. It is not madly expensive. Of the funding it does cost—we have costed it at $300 to $400 million a year—you are going to claw probably half of that back in tax receipts anyway. It has two key incentives. The first is to get people to go to more and more remote areas where there is the loading on the patients' fees they garner from Medicare and a second loading to encourage them to be on call at the hospital, whether it is in A&E, anaesthetics or obstetrics. It is a broad system. It is not just for GPs. It is for specialists outside the cities. It is for registrars training outside the cities so they get a higher level of pay. It gives a real incentive.

You guys have the levers on it. If you put in too much money and the country is flooded—heaven forbid!—then you can pull back the lever and say, 'We will make that incentive slightly less.' Or if there are not enough doctors you can push the lever forward and say, 'We need to put in more incentives there.' You are in control of it. It is not a blank spend where you are throwing money around willy-nilly. It is a package that has been well worked out by the RDAA and the AMA, but it has not garnered any traction.

Senator NASH: What has been the response? When you brought this up to bureaucracy and government, what was the response to the package?

Dr Rivett : Usually we are told it is too hard. The usual answer is, 'We are broke. We do not have any funding to do anything.'

Dr Hambleton : David has hit the nail on the head. It is the state government-federal government interface that is a huge problem. We have to look at funding in real terms. When you get the tax receipts from doctors going to the bush and have a look at the net cost it is across two portfolios. That is always very hard for government.

The other major reason that this has not happened is, just as I said in my opening address, that governments tend to say, 'Tell me the one solution that will solve the problem.' What they have used is the 10-year moratorium. What that effectively did was stop people solving the problem. For a number of years we have had an unhealthy reliance on our international colleagues to save the day. We have not put these systems in place. We have not forced governments to sit in the one room and nut it out and send up the white smoke when they have a solution. We have relied on our colleagues from overseas and put them in one of the most difficult places to work in our country. I would hate to think of myself working in some of the countries these doctors come from without appropriate support, and they are without the ability to demonstrate to Australia that they are reaching the same standards as our local doctors and they do not even have access to Medicare or public schooling. We have said that the 10-year moratorium should be scrapped because it would force us to look for the real solutions. This is the one solution that has delayed the real solutions.

Senator NASH: It is a band-aid. That is very useful. Just on the generalism issue, you talked about elevating the status of generalism. It sounds good, but how do you actually do it?

Dr Rivett : I think most colleges are now looking at this. The College of Physicians has recently announced that they are going to have a double training scheme where physicians will come through with two skills in their kitbag, which will be good for big regional hospitals and for providing an on-call roster. Also general surgery needs to be boosted. There need to be better payments for general surgeons providing on-call services in the country and also in the cities. Most of your hospitals in the city need a generalist on call who can man the emergency department and take somebody to theatre in the middle of the night. They have to be lifted in the esteem of the medical profession, so the deans have some responsibility. Medicare benefits need to be looked at to see if they are giving the right incentives. At the moment, if you are a subspecialist doing a lot of procedures you can certainly earn a higher income and your chances of being called in the middle of the night are much smaller. This needs to be wound back to some degree. There has to be a balance. I am not saying we do not need subspecialists. They are vital if we are going to give top-quality care to the Australian populace. But there needs to be a balance. The wheel seems to have turned too far.

Dr Hambleton : In relation to generalism, I think David outlined some of the issues about elevating the status. The status of someone who says, 'I am prepared to accept all comers,' is very important because that is the essence of a general practitioner. A specialist general practitioner is quite prepared to see whatever problems come across his desk, not just tailored into a specific area. That quality is—

CHAIR: I am having a little bit of trouble hearing you. Could you speak up a little bit?

Dr Hambleton : Yes, sure.

CHAIR: That is better. Thank you.

Dr Hambleton : I was just saying that the quality of an individual, be it a general physician, a general surgeon or a specialist general practitioner who has indicated they are prepared to see all patients no matter what their condition, is what we need to applaud because that is the essence of a general practitioner or a general specialist. They are prepared to see a range of conditions and not simply tie themselves to a small part of medicine. I think that it is an attitudinal change. Something the colleges have got to pick up, something the AMA has got to pick up, something the government has got to recognise in remuneration, or at least in rebates is that those who offer themselves across the board are valuable to our health system.

CHAIR: When you are talking about the training, we heard earlier from the College of Physicians that one of the states, which was not specifically named but which we worked out—New South Wales—had cancelled its general programs about 10 years ago and was—

Dr Rivett : It was general physicians which have been wound right back.

CHAIR: Yes. I presume that means that to do this you need to wind that back up again.

Dr Rivett : You would do. It would have to be a substantial change because there are not a lot of general physicians left to train those coming through.

Senator NASH: Who made that decision? Who decided that that would happen?

Dr Rivett : I could not answer that. I am not aware of that information.

Dr Hambleton : So many of these decisions are made in isolation. Never before have we had an entity take a bird's eye view of the profession in a comprehensive way. Health Workforce Australia recently delivered the report Health Workforce 2025 to look at the nursing profession and the medical profession, and to look at, with some sensitivity analyses: if we do this, that and the other right through until 2025, where will we be? We all know that the major concern is the number of students coming through. The question we have to ask health ministers is: 'Is our target to be self-sufficient?' because, if it is, we are not going to get there under the current setting. How many specialists do we need in what area? That work is yet to be done. Health Workforce Australia needs to do it. The Medical Training Review Panel needs to be part of that process. A bird's eye view needs to be taken so we know how many general physicians we need and how many general surgeons we need, whereas a state may make a decision at a state level, ignorant to the impact of that on the workforce 10 or 15 years down the track.

The pipeline is a long one in medicine. It is going to take until 2015-2016 until the real crunch comes in terms of training positions for those young men and women now in our medical schools who will be in our hospitals in the next few years. We absolutely need a bird's eye view, a national view, about the pipeline from the start—at medical schools through those prevocational years, through vocational training and into where these specialists are going to work. Unless we have that, we are not going to have the ability to manage our workforce. The warning from Health Workforce 2025 is that the settings that are currently dialled up will not render us self-sufficient. We are going to be relying on our international colleagues right up until then. We simply have not got the capacity to train one more student properly under the current settings and we need to really think about that.

Senator NASH: On the generalist issue, as part of the recommendation you say:

... improve the level of remuneration for generalists to encourage generalist practice, including the removal of anomalies in the MBS that reward sub-specialisation over generalism.

What are those anomalies? Can you expand on that for us?

Dr Rivett : We can give some clear-cut examples of anomalies.

Mr Hough : Yes. I think at the end of the day there is a consensus that the MBS generally speaking rewards subspecialty, as Dr Rivett said earlier on, particularly in the procedural areas.

Senator NASH: How does it do that? What is the reward? What actually—

Mr Hough : Through higher rebates for those particular item numbers. Whereas the thinking doctors, such as the generalist physicians, generally speaking are not looked after as well. There certainly does need to be a review of those particular areas to try and restore some of the balance. So, ultimately, if you have got young graduates looking at careers in these areas they will see that if they want to go into generalism financially they will not suffer as a result compared to some of the other specialties.

Senator NASH: That is a good point.

Dr Rivett : I think Steve's point about needing national blueprints is a really big one. I think you need to work out numbers—and a demographer could easily do that—and look at the populations in the big regional cities and say, 'So this town has got 30,000,' or 100,000 people or whatever it is. 'What will we need to staff that central hospital there? How many general physicians will we need? How many emergency physicians will we need? How many anaesthetists will we need? How many obstetricians will we need?' Then you collate the national data and try and move your training targets to meet what the demographer says you are going to need in so many years time. That is fairly simple, I think, and it would set some fairly realistic targets. Sure, they are going to change. Some towns are going to go downhill if they have their water supply cut off in the Murray River basin, for example, and some towns are going to grow faster when they find a huge mother lode of coal or something. That is going to give you a baseline so you can get the colleges to work towards producing the right numbers. This is a long-term thing, but firstly you need a plan and you need to start counting some numbers as to what you are going to need, what Australia needs now and what people will need in 10 or 20 years time because there is a long flow-through, as Steve said. But without a plan, and there is no national plan at the moment, you are not going to achieve your goals. Putting a bandaid here and a bandaid there, like we have been doing since I have been involved in medical politics, is not the answer. We need a robust solution that we work towards, and it has got to be malleable and changeable so it keeps abreast of the times.

Senator MOORE: Dr Rivett, has it always been this bad? I am interested in the fact that for GPs, and in particular specialists, if you are living in certain parts of Australia there have never been specialist services.

Dr Rivett : Some years ago we had a lot of overseas doctors come in from South Africa and the United Kingdom with a broad range of skills and good training in those countries and they held rural Australia together for a long time, but they are not coming any longer.

Senator MOORE: That is right. And it was nothing to do with special incentive payments or anything like that.

Dr Rivett : They enjoyed rural Australia from the time they got there, but they are not there anymore so you are not going to look to them for a solution. You have got to look at the modern generation doctor and say, 'What's going to attract him to rural Australia?' You have got to have the numbers so that he can do the other things in his life that he wants to do or you are not going to win. You cannot conscript people into rural Australia and make them work there. That is not going to happen. They are not going to be happy. They are not going to look after their patients and enjoy their work.

Senator MOORE: And they will not stay.

Dr Rivett : They will not stay. As soon as their conscription period is over they will be out of there or they will avoid the conscription by working overseas. There is a big international medical market and Australian graduates are very well trained. It needs to be a robust solution and a plan has got to be part of it. As Steve said, you have got to plan what you need and tell the colleges you need so many generalists because they have got to staff base hospitals and outer urban hospitals so you have got the right on-call numbers 24 hours a day.

Senator MOORE: So where have the specialists for your regions come from in the past? For specialist treatment have people from Batemans Bay come to Canberra?

Dr Rivett : Most of the care needed comes to Canberra and if it is too complicated for Canberra it goes to Sydney—or if Canberra is full or if the highway is blocked, as it was the other day.

Senator MOORE: But in terms of someone who needs a specialist? Say they have seen you or someone else at Batemans Bay and something has been identified for specialist care. Traditionally it has always been Canberra.

Dr Rivett : Yes. We do have visiting specialists.

Senator MOORE: So they do come down, don't they?

Dr Rivett : So you do have your schemes in place to encourage them, and there are excellent schemes and they encourage more specialists to go rural, so they have been a great success.

Senator NASH: Would you mind taking it on notice and providing to the committee how those schemes work?

Dr Rivett : Certainly.

Senator NASH: Thank you.

Senator MOORE: The AMA submission naturally spends a fair bit of time on the remoteness classification issue. I am interested to see whether anyone wants to add anything to what is in your submission because it has caused a lot of discussion with witnesses and with people who have given submissions to us. So is there anything you would like to add as to this constant struggle that governments—and I say 'governments'—seem to have had going back a long time in defining remoteness and regions and all those things?

Dr Rivett : The current scheme is a nonsense. When it first came in everyone thought it was going to be an improvement on RRMA but it is actually worse than RRMA. I am a doctor who provides on-call service to the hospital on one in three days. Our hospital is run by GPs. There is no specialist help there virtually at all. I get the same government incentive to work there as somebody living in Hobart does. The way it is being done at the moment is just plainly idiotic. They will bring out lots of excuses and say, 'This parameter is different to that parameter and you've got to look at the road distances' instead of a common-sense approach.

Senator MOORE: Where is road distance from, for you? Is it Canberra or Sydney?

Dr Rivett : Most of our tertiary care comes to Canberra.

Senator MOORE: So on the scheme, is that under—

CHAIR: Would that be the measurement point?

Dr Rivett : That is the most vital measurement in their classifications now.

Senator MOORE: You are counted as coming to Canberra. You are in band 2. Where were you in RRMA?

Dr Rivett : We were RRMA 5.

Senator MOORE: So you actually had the highest rating under RRMA.

Dr Rivett : No. It goes to RRMA 7.

Senator MOORE: In terms of your allocation in RRMA, you were considered more needy under RRMA than you are under this?

Dr Rivett : These other areas did not get benefits until the new scheme came in. A lot more doctors were covered under the new scheme, including the whole of Tasmania.

Dr Hambleton : The AMA has a solution in its submission. It recommends that we review the divisions and it says, 'Let's make us continuous.' Then at least there would not be this gaming between RA2 and RA3, where we have got most of our problems. It has been done. It has been introduced. If not, let us have a more granular structure.

Senator MOORE: Yes. It is one of the huge issues. We have heard it in every place we have been, except the Northern Territory, which was all the top one. The other issue is the payment process. The AMA's submission recommends that we have a standard rural payment that is put on for all doctors, the rural—

Dr Rivett : Loading.

Senator MOORE: The rural loading. Have you given any thought to what level of loading that would be? It says there should be a loading.

Dr Rivett : Yes. The suggested percentage loading is in that attachment to the paper. They are only suggestions. The levers will need to be tweaked to see how successful it is. That came as an attachment to the AMA paper.

Senator MOORE: I am sorry. Sometimes the attachments do not come through.

Dr Rivett : The good thing about the loading is that it drives people to work longer hours also. It encourages them to see more patients because it is a per patient episode loading. It is not a weekly payment or an annual payment where you can see a small number of patients and still collect the same incentive. If you work harder, you will get a bigger payment. We certainly want to see people working harder to meet the need that is unmet in rural and regional Australia.

Senator NASH: How do you balance that with your earlier comment about doctors needing a lifestyle whereby they can actually enjoy the community, enjoy their job and have some sort of balance? There is this crazy work ethic. Then you have a per patient loading and, as you were just saying, doctors can work harder. Is the balance just in the middle there somewhere?

Dr Rivett : This covers both fields. If somebody wants to work fewer hours, they still get paid more per hour for those hours. If they are a workaholic and they enjoy working 70 hours a week, which I used to enjoy doing but do not any longer—

Senator NASH: They will be able to be compensated for that.

Dr Rivett : they will earn even more. But that should not be driving them, no. It should be work satisfaction, not monetary reward. But there needs to be some to differentiate it to the younger graduates coming though and saying, 'If I go to rural Australia, even if I just do it for three, four or five years, I am going to pay off my house mortgage in that time.' Hopefully, some of them will stick and stay there. Certainly, not all of them will, but if there is some sort of incentive to get them there to give it a go, a lot of them will put down roots. If they can get their family to go to school and their wife to find a job there you have got the battle won.

Senator MOORE: Dr Rivett, I am sorry. The attachment has not come through.

Dr Hambleton : We will undertake to get that to you.

CHAIR: It is on the website. When we are producing the packs, it is often quite bulky. But we do have it.

Senator MOORE: I am interested to know exactly how much money we are talking about. I read the submission and saw that there was a recommendation. I do apologise. I am trying to—

Mr Hough : Senator, if I can—

Senator MOORE: That would be useful. I am just interested in the money.

Mr Hough : The overall funding that we calculated—this was a couple of years ago—was in the order of about $300 or $400 million dollars per annum.

Senator MOORE: Per doctor, but not—

Mr Hough : Per doctor—we would settle for that! That also reflects the reality, though, that there is a disparity in terms of Medicare access for rural versus metropolitan people, who proportionality get a much better share of Medicare funding. So in some ways it simply redresses some of that imbalance.

Senator MOORE: Which is based on usage, though.

Mr Hough : In terms of per capita, yes.

Senator NASH: You never know this, but I am interested in what the annual expenditure is for provision of locum where there is not a doctor. Are there any state figures or federal figures on that?

Dr Rivett : The state figures would be very interesting to see because we see musical chairs getting played all around New South Wales where a doctor will not work in his own community for the weekend but go to another community 80, 100 or 200 kilometres away and get paid a large sum by the state government to be the on-call doctor. The whole thing has become farcical, really. He can earn more in one weekend in another town than working at the surgery for 50 or 60 hours. So the specialist in rural areas are doing the same thing. They are flying to other towns to provide obstetric care or anaesthetic care over a weekend or a week for a couple of weeks while somebody is on leave and earning much larger sums than they can earn billing people through Medicare in their practice.

Senator NASH: I asked the question in the context that it might be quite a significant saving.

Dr Rivett : If you can encourage people to provide services locally in the long term—

Senator NASH: And you do not need the locum requirement, yes.

Senator MOORE: This is a proposal you have put to government a number of times.

Dr Rivett : Yes.

Senator MOORE: The other issue is that certainly as the AMA your focus is the doctor issue but are issues like incentive payments the kind of thing that could flow on to other medical professions? One of the things we have heard in our evidence is that a lot of the programs that the governments have been driving have been focused on doctors. The issue at which this committee is looking is much wider than doctors. It is services. In terms of that kind of work, is there any view that the kinds of things you have put out from the AMA, such as the incentive payments, could flow on to other—

Dr Rivett : When I spoke to Health Workforce Australia I supported that concept very strongly, especially student training and the repayment of HECS and students going to rural areas to do physio or whatever. We need all those people in rural Australia and there are no incentives for them at all. Talking to those other groups about what incentive they have to go rural, it is virtually nil. Care is not just about doctors; it is about a whole team. They have to be a happy team and attracted to go outside the cities.

Senator MOORE: Do you have nurses in your practice in Batemans Bay?

Dr Rivett : Yes, we have two nurses.

Senator MOORE: Do you have any difficulty in attracting nurses to your practice?

Dr Rivett : Usually yes but having just advertised last week and got six applications straightaway I would have to say no! But I have been advertising for six months now for doctors and spent about $4,000 on advertising and the only applicants who have been interested are people from Iran, India and others outside the country. If you cannot get people to come somewhere like Batemans Bay, what hope have the little towns west of the divide got? Things are pretty grim.

Senator MOORE: Absolutely.

Dr Hambleton : As we say on page 3 of our submission, it is not just about remuneration. That is important. We have to focus on that. It is the lifestyle factors, the professional isolation and the support of the spouse, whether you are a doctor or not, to make sure the other family members are looked after. It is education and educational opportunities. It is the ability to get back to the big city every now and again. It is sufficient variation in the work you are doing to make it a nice and welcoming place to work. It is all of those non-medical and non-hospital things that make such a difference.

Accommodation for locums and students can make a heck of a difference. Things like the lack of a requirement for a doctor to buy the building and set the practice up can make a difference. A doctor thinks, 'It is five years in the bush; maybe I will buy a practice and set it up. But then in five years I'll have invested all this money and I'll be stuck.' So they will not go there in the first place. If the facilities are provided that can make a heck of a difference and make it less of a concern that you are going to be stuck there. If you have to own a house and own the practice people might not go there in the first place.

Senator MOORE: What would be the alternative to buying a practice and setting it up?

Dr Hambleton : There are already some areas where walk-in walk-out surgeries are available—in other words, there is a private practice section built on to perhaps a public hospital and the facilities and infrastructure are there. It reduces the risk to the doctor.

Senator MOORE: Is that a state government kind of thing if it is built on to hospital?

Dr Hambleton : It can be state government or it can be local council. There are businesses that offer the same corporate type of structure. If there are a few partners you do not have to buy into the practice to work there. They can make rooms available. In a solo doctor town, making that step of going there and purchasing your own infrastructure is often a step too far.

Senator MOORE: A member of parliament told me about a regional centre where their community had pulled together to provide housing, infrastructure and all kinds of things and still could not attract a doctor. That was a regional program where they said, 'We need a doctor in this town,' and put all this stuff together and put out an advertisement for a doctor. They did not get applications either. This was two years ago. I have not followed up. It was Kay Hull's electorate.

Dr Hambleton : It is terrible to hear those stories. It is not really saying, 'We have the solution. We will provide the infrastructure.' As we say, it is about more than that. Even worse, it is government policies from two, three or four health ministers ago when they said, 'Every doctor costs the Medicare system X dollars; therefore, we will not let the universities increase student intake and we will save money.' That meant that, 15 or 20 years down the track, here we are.

CHAIR: Thanks very much. I think we have covered quite a lot in a relatively short space of time.

Proceedings suspended from 17:07 to 17:19