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Senate Select Committee on Health
13/02/2015

DRIES, Ms Danielle, Indigenous Health Officer, Rural Health Workforce Australia/National Rural Health Students' Network

MUNDY, Mr Gregory, Chief Executive Officer, Rural Health Workforce Australia

[12:02]

CHAIR: Welcome. I put on the record congratulations on your presentation as part of the Closing the Gap gathering that we had on Wednesday morning here in parliament. You represented young Aboriginal people with great style and content. Thank you.

Ms Dries : Thank you very much.

CHAIR: Do you have an opening statement?

Mr Mundy : Our submission to the committee covered five key areas under your terms of reference (e) and (g). It is appropriate at the outset to acknowledge that on one of those some progress has been made in terms of improving the way we classify rural areas in Australia. A long-standing issue is finally moving and, teething issues aside, appears to be moving in a positive direction. It is important to acknowledge that.

I am happy to respond to questions on any of the areas we canvassed, but I would like to focus, at least initially, on the first priority area for improvement of Indigenous and rural health services, which is developing the Australian trained workforce. Our submission refers to the need for a holistic, multifaceted approach to this, and I would like to focus on the early stages of the workforce pipeline, as we refer to it, and in particular on Indigenous health professionals. It is for that reason I have invited Danielle Dries to speak to the committee about the perspective of a young Indigenous woman who is a medical student because she is in the early stages of what promises to be a strong and very worthwhile medical career. So, with the committee's indulgence, I will hand over to Danielle.

Ms Dries : I want to talk a bit about the NRHSN and also my experiences. The NRHSN has over 9,000 members at 28 rural health clubs across Australian universities, with students in medicine, nursing and allied health. We are currently in the process of developing our 2015 business plan, and our priorities for Indigenous health include improving communication and relationships with our key stakeholders. This is acknowledging that Indigenous organisations need to be consulted to ensure that everything we do is culturally appropriate. Another priority is increasing recruitment and retainment of Aboriginal and Torres Strait Islander students and health professionals. This is important, but what is crucial to this is the support of these students. We can walk into an area where we are already a minority and we experience racism and discrimination, but because there are few of us there is often an expectation for us to become role models for the next generation, and we can be involved in many extracurricular activities, such as being here today.

Support from organisations such as the Australian Indigenous Doctors' Association, Indigenous Allied Health Australia and the Congress of Aboriginal and Torres Strait Islander Nurses and Midwives are important for us to provide a culturally safe community and support for our Indigenous health students. Having Aboriginal and Torres Strait Islander students also, I believe, helps to break down the stereotypes, to understand that there is diversity among our people and that we all come from different places. Many times people ask me, 'How would you treat an Aboriginal person if they came into your clinic?' I usually respond with, 'Well, how would you treat me if I walked into your clinic? And would you treat me the same as an Aboriginal elder?' Probably not, but you are going to listen, show respect and try to understand our individual story.

This leads me to our next priority on our position paper, which emphasises the importance of the Indigenous health curriculum across all university health degrees as well as encouraging universities to run and participate in Indigenous health awareness events, such as Close the Gap. Each year our rural health clubs organise Indigenous community engagement activities. The aim of these is to inspire Aboriginal and Torres Strait Islander students to consider careers in health as well as make healthy lifestyle choices. Clubs have also run or attended Close the Gap events, and these events aim to increase an understanding and develop cultural responsiveness early in our career pathways. Our rural health club here in Canberra, the ANU Rural Medical Society, runs a Close the Gap event every single year, and last year we had over 100 students from the New South Wales, Victoria and ACT regions from different health professions.

We are hoping this year that, through the NRHSN, we can encourage more students to attend and run these events to promote Indigenous health awareness and health careers to young people in a culturally responsive way. We are also hoping this year to advocate for more allied health professionals to work in a rural and remote setting. As I said on Wednesday, I was previously a physiotherapist and changed to medicine when I found that there were limited job opportunities in remote areas. Where there is chronic disease, we need allied health, and I think it is important to have these services available in rural and remote areas.

CHAIR: Thank you very much. I have many questions that I would love to ask over a dinner. This is the wonderful thing about this job—we meet amazing people doing wonderful things and there is more that we would love to know. Hopefully we will catch up with you further along in our journey. We will now go to Senator McLucas for some questions.

Senator McLUCAS: Thank you for your evidence. Ms Dries, I totally agree that we need more of you, because you are having to do all the things you do as a student and then all of this other stuff, simply because you are a young Aboriginal leader in the community. Where are you at uni?

Ms Dries : I am at the Australian National University in Canberra, but I am currently in a third-year placement in Lismore.

Senator McLUCAS: Thank you for your evidence, and I commend the work you are doing in supporting students around the country. My university is James Cook, and RHINO is the organisation in Townsville and Cairns that does some amazing work in promoting career opportunities in health to Indigenous populations in North Queensland—and further, in fact.

I want to go to the question of training. Let's talk about doctors, first of all. We get people to come into our universities, and they then go into graduate training and need to be placed. That is what the PGPPP program was particularly focused on—ensuring that prevocational doctors get training opportunities in rural settings, by and large. Mr Mundy, did you have conversations with the government about why this program was cut? I think you were in the room when we spoke to Professor Campbell previously.

Mr Mundy : Yes I was. They did tell us why they had cut it, which is not really the same thing as having a conversation. But I would agree with you that—and it was one of the points we made in our submission—it takes persistence to encourage young medical students to pursue rural careers. The more exposure that people have to rural medicine the more likely they are to continue their careers. There is a lot of evidence, including a recent study published in the Medical Journal of Australia which focused on a cohort of students from James Cook University—if I recall correctly—that says that, if students are from a rural background and train in a rural setting, the statistical likelihood of them working in rural areas goes up quite a lot.

From our perspective, the continuity of that rural exposure is another variable because, if people have to go back to a city to complete part of their training, there is a risk—and some evidence that suggests that it does occur—of breaking that cycle, and you tend to lose a number of students who potentially might have become rural doctors. If you look at the data in our submission about the number of final year students who intend to pursue a career in rural medicine, it is actually quite low, and it is much lower than when they start. It is partly, we think, because people do not necessarily see a clear career path for themselves in rural medicine.

We also refer very briefly in our submission to some research—that we have commissioned from the University of Queensland—about the factors early-stage doctors and students take into account when they are making those sorts of career decisions, so that we can try and make some sense out of the correlation by saying: 'Why is that so?' It is early stages; we have only done the initial qualitative part of the research. But the thing that came through very strongly is that the thing that early medical students think about is their career. They want to know that there is something to go on to and that working in a rural area is not going to compromise their aspirations, which are newly formed. Other things are important, but the thing that comes through very strongly is being able to build a good, rewarding and successful career in medicine that will not be thwarted or compromised by working in rural areas. It should not be, because the nature of the work in rural medicine is actually challenging, rewarding, broad based and not overly specialised. It has lots of positive things about it, which I guess is why people do it. If that continuity is broken, we actually place that investment at risk.

We now have a large number of Australian medical graduates coming into the system. The figures in our submission represent a 64 per cent increase over the five- or six-year period. That is a big increase. I think as a nation we cannot afford to let those people down by thwarting their careers when they come out. We have invested a huge quantity of their money and public money getting to that point, so there is a question too about capitalising on that investment.

Senator McLUCAS: With that increased pipeline, we still do have a lumpy geographical spread.

Mr Mundy : Absolutely.

Senator McLUCAS: From the evidence we had from Professor Campbell, it would seem that the current policy settings are going to exacerbate those circumstances, if those graduating doctors are looking to country practice and saying: 'That is not a future for me.'

Mr Mundy : I do not think we can afford to be complacent. Over the 10-year period from 2002 to 2012, the proportion of patients to doctors in remote parts of Australia has actually improved, so it is not all bad news. The ratio has gone down by about 400 patients per doctor over that 10-year period, so progress has been made. But I think it is one of those things that you cannot afford to rest on your laurels and be complacent about. You have to understand what has made that success possible and what sorts of factors might place it at risk.

Senator McLUCAS: My final question goes to a piece of work that the deans of medicine are doing in tracking doctors post-graduation—it has got a name that I cannot remember. I am led to believe that that piece of work has been defunded. I will ask the department later today.

Mr Mundy : It is the Medical Schools Outcomes Database project—

Senator McLUCAS: That's the one.

Mr Mundy : and it was funded through Health Workforce Australia. The functions of Health Workforce Australia have been transferred to the Department of Health. So, they are exactly the right people to ask. I actually do not know what its future funding position is. If it was a 2014-15 program, the question is, what happens on 1 July this year? That is a question that many Commonwealth funded organisations will face at that point, including us.

Senator McLUCAS: The piece of work you referred to earlier that UQ is doing—or was it James Cook?—about tracking people would I dare say come out of that data.

Mr Mundy : Yes, it did. The James Cook cohort came out of the Medical Schools Outcomes Database project.

Senator McLUCAS: I will ask the department about that later.

Mr Mundy : And the work that we are doing is, rather, looking at the correlations, trying to make some sense of why those correlations are there, what goes on in people's heads when they are making their career decisions. And that is a work in progress.

Senator CAMERON: Thanks, Mr Mundy, for coming along. Perhaps I could just put to you some propositions that Professor Campbell asserted, and that is that we have a demographic time bomb in rural medicine in terms of the ageing of the workforce and that we have a policy crisis. Do you agree with those propositions?

Mr Mundy : We certainly have a demographic challenge in the rural workforce, because the composition of the workforce is changing. There is a cohort of doctors who are getting closer to retirement. And the other demographic factor that is relevant is that the medical workforce across Australia, not least in rural areas, is also becoming much more evenly balanced in terms of gender. And the combination of those two factors from a workforce planning point of view is that you actually need more doctors to replace the existing ones when they retire, because the new generation of doctors is less prepared to work the excessive hours that the older generation of doctors works. From an occupational health and safety point of view that is a good thing, but it means that if one of the overworked doctors retires you might need 1.1 or 1.2 doctors to replace them. And it is a factual thing—not a judgemental one at all—that the female doctors, on career average, work a smaller number of hours, which is not a good or a bad thing; it is just a thing. But it means you would need 1.3 or 1.4 to replace one doctor who leaves.

So, although we have made progress, there is no room for complacency, because those changes that are just occurring in our society would actually increase the need for more doctors to be encouraged to work in rural areas. Is there an impending crisis? I was struck by the extent of the threat to business models in rural practice by the person who gave the previous evidence. And certainly that is a major concern. If we start losing practices for economic viability reasons, then there is a risk that much of the gains that I talked about before might be lost.

And the point that Ms Dries made in her evidence, of why she made a career change, is that in very remote parts of Australia private practice models are much less sustainable. You actually need an employer if you are going to be able to provide those services when there is not a population either sufficiently dense or sufficiently affluent to support a private practice model. And if you do not have an employer you do not have the service.

Senator CAMERON: Yes, and I should have acknowledged Ms Dries and thanked her for the effort she has put into making the submission today. Has your organisation had any discussions with the assistant health minister in relation to this demographic problem that we have identified?

Mr Mundy : We certainly have apprised her of our views on that and had them acknowledged—that yes, those changes are occurring in the workforce and that is why the work that we do at Rural Health Workforce Australia is a very important part of the solution to that problem of increasing the flow of doctors into rural and remote parts of Australia. That is our role, and that is what the Department of Health funds us to do. So, we have had that kind of conversation with the Assistant Minister for Health.

Senator CAMERON: And what is the assistant minister saying about the funding and the incentives to increase the workforce?

Mr Mundy : We have not had specific budget-type discussions, if that is what you are referring to. We do get the strong feeling that the assistant minister values the work we do, appreciates the nature of it, sees the results of it in her own electorate office and so on. So, we have had positive discussions but not specific budget-type discussions with Minister Nash.

Senator CAMERON: Everyone seems to have lovely discussions with Senator Nash, but they do not get any practical outcomes in terms of workforce planning or funding. And you are the same, aren't you? You have had no commitments on funding.

Mr Mundy : No, not to date.

Senator CAMERON: How do you then read the $500 million that has been taken out of essential services in Indigenous communities in relation to the last budget? Does that have a health impact?

Mr Mundy : As an organisation we do not have a formal position on that issue, but we would not see that as being at all helpful in terms of improving health outcomes.

Senator CAMERON: Do you agree that poverty is a major issue in Indigenous communities and does contribute to poor health outcomes?

Mr Mundy : Absolutely. Our role in trying to increase the activity of rurally based health professionals is a very important contribution to the health of those communities, but it is by no means the only one, and I think the figure quoted in early evidence today that two thirds of the explanation lies outside of that in the social determinants of health is a good way of looking at it. There is much more to improving the health of communities than what medical professionals can do and what we can do to support them. They are not entirely separate questions. But certainly things like poverty, education, good-quality housing, and ending family violence are all things that are not irrelevant at all and are in fact, to put it the other way, quite significant in creating health outcomes—in all communities, but not least in rural ones.

Senator CAMERON: What was your relationship with the federal body that was doing the workforce planning and assessments?

Mr Mundy : Health Workforce Australia? I suppose we were a consumer of their products in workforce planning and our network of state based agencies were also funded by or through Health Workforce Australia for the Rural Health Professionals Program, which was a program to increase the supply of allied health professionals and nurses in rural and remote parts of Australia. I think it was the first time there had been a program with that as a strong target focus. At this stage we anticipate that that program will continue beyond the current financial year, but we do not have any confirmation of that, and I suspect 12 May will be the time when we know for sure that that program is going to be extended. We think, and our submission says, that it has been an extremely valuable contribution to rural workforce and it should continue. As our submission says, and Ms Dries has reinforced it, with the increase in the burden of disease coming from chronic diseases, the importance of allied health inputs to people's care is getting greater, not less. Not everything is done or can be done or should be done by GPs or by hospitals. But, in hospitals and in the community, what allied health professionals can do is a very important contribution. So, that program, because it did target that area, is a valuable one and we would look forward to seeing it continued.

Senator CAMERON: So, apart from getting some nice discussions with the shadow minister, have you got a nod and a wink that the program will continue?

Mr Mundy : We have not had any definitive discussions about the budget to this point.

Senator CAMERON: I am just wondering what you have discussed, then. But thank you very much.

CHAIR: Perhaps I can just go to a last question. There is of course much more we would like to discuss. And if there is more material after you leave today that you would like to present to us, feel free to do that. We will be continuing our inquiry throughout the course of this first half of the year, and we may well see you again. Could I go to recommendation 6 with regard to the recommendations that arose from the last parliament, the Lost in the labyrinth report. I had the privilege of being a part of that committee at that time, and there was amazing evidence given from right across the country about these critical issues of staffing in rural contexts, and also about the experiment in overseas doctors, the impediments that were placed in front of them being able to access and support their communities, and the varied success and failure of that program. In the context of that and the recommendations that arose out of it, given what we have described about where we are today, could you make some policy connections between those two for us and articulate any big ice bergs on the horizon?

Mr Mundy : It is right to raise it, because we have talked about the Australian-based workforce pipeline, but the fact of the matter is that rural Australia in particular would not have medical services but for overseas-trained doctors providing that service. The average across Australia is that about 42 per cent of doctors in rural areas come from overseas, and in some states it is well over 50 per cent. So it is a very important current part of our workforce. It is a complex business; the legislation is complex and the rules are complex. One of the things that our state-based agencies assist doctors with is navigation through that system. It is overly complex. There are multiple decision points that are not coordinated between the various players in the system, and while progress has been made on some of the recommendations of the Lost in the labyrinth report, I think most of the work is still in front of us.

CHAIR: Is it fair to say that the policy response that led to the whole overseas trained doctor program, which has become so instrumental in health provision in the bush, actually reflects a failure prior to that of an adequate training of the workforce, and that the current policy settings of the government would actually re-create a similar policy crisis if they are enacted? So, if we fail to replace the PGPPP, for example, or if we fail to get the placement and training in order, then we will create a context where there simply will not be the provision of health care in the bush, especially in light of Professor Campbell's comments today about the sustainability of GP practices in the bush?

Mr Mundy : I think one of the things that pushed Australia in the direction of overseas recruitment was the Commonwealth's lack of power to indulge in what they call 'civil conscription'—sending people to country areas—unlike states who can send teachers, for example, wherever they can get away with it. The Commonwealth lacks that power, so I think that historically that was one of the factors that pushed us in that direction. There has been a policy response in terms of increasing the number and size of rural schools of health sciences and medicine, which I think is an important contribution to fixing that problem, so we have made some forward progress. If we were, for example, to have a collapse in business models for rural general practice, such as the previous witness described, that would potentially risk setting us backwards quite considerably, because in order for the new graduates in medicine to have careers they have to have people who have practices that they can join or, if we are talking about salaried health professionals, they have to have employers who will employ them. So the viability of the businesses that provide health care in Australia and rural Australia—because they are private business—is a very important part of the picture. The public sector—which is the hospitals and, in some states community health facilities, and the Aboriginal health services that are publicly funded, are an important part of the equation, but the core of service provision is actually private sector. They are private practices, and they have to be viable businesses if those services are to be provided. One of the services that our state-based agencies often provide is business support to those practices, but advice on how to do your accounting is not going to help if the numbers are not going in the right direction. We do have a private enterprise model of primary medical care in Australia, and it has to be to work on a business basis, because that is its premise.

CHAIR: If we lose GPs from the bush, we are in very big trouble as a country, aren't we?

Mr Mundy : Yes, indeed.

CHAIR: And we look like we are on precipice of that.

Mr Mundy : There certainly are risk factors and risk signals out there that no-one should ignore.

CHAIR: I am going to give the last word, if I can, to Ms Dries. You are a young woman with a passion for your community. I just want to give you the opportunity to make a significant recommendation that you think will change the future, based on your lived experience so far and your hopes for the future in terms of the Aboriginal and Torres Strait Islander people. What is the most significant thing that you would like to see us recommend?

Ms Dries : That is a big question.

CHAIR: I will write some more afterwards to you, but I will put you on the spot for an answer today as well!

Ms Dries : That's fine. Again, I would definitely like to see that there are more of us. With more of us, there is more support and there is a sharing of the commitments and the responsibility. It creates a more culturally safe environment for everyone because, when you go into a university setting, you do challenge the thoughts of other people around you, and that is the future I am hoping we get to. With the recruitment of more students, and the shared responsibility, that is where I hope we are headed.

CHAIR: I noted your comment about an Indigenous health curriculum. I promise you that this afternoon I will ask a question of the Department of Health about the current status of Indigenous health training across the tertiary sector and what the programs going forward might look like with regard to that. Thanks again. Congratulations on your journey so far, and good luck with being such a champion.