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Community Affairs References Committee
05/06/2012
Health services and medical professionals in rural areas

WYATT, Ms Dianne, Strategic Projects Manager, Australian College of Rural and Remote Medicine

CHAIR: Welcome. I understand that information on parliamentary privilege and the protection of witnesses and evidence has been provided to you.

Ms Wyatt : Yes.

CHAIR: We have received your submission as No. 125. I invite you to make an opening statement, and then we will ask you some questions.

Ms Wyatt : Thank you for allowing us to address you this morning. I do apologise on behalf of our president, Professor Richard Murray, who could not be with us today. As you are probably all aware, ACRRM was established in 1997 by rural doctors for rural doctors. The purpose of ACRRM is to train doctors in the scope of practice which is required to provide quality, safe services to people in rural and remote communities across Australia. It is accredited by the Australian Medical Council and in fact we have three training pathways to what is called the Fellowship of the Australian College of Rural and Remote Medicine, FACRRM.

I think you are all aware that the scope of practice within rural and remote medicine is quite broad. Our doctors out there are the ones who are still providing a range of services, from office space through to delivering babies, giving the anaesthetics and providing emergency care within the hospitals. They work both within their own surgeries and within the hospitals, primary healthcare settings et cetera. They are often the medical officers for the local area. Hence our forefathers thought it was really important to ensure that our doctors were trained in the scope of practice required to service those communities. We also realised that to be a competent rural doctor you need to have a range of skills, both in primary care and in procedural medicine, and particularly around emergency medicine because often you are the only one to attend to what is happening along the way.

The three training pathways we have through the vocational preparation pathway, which is the pathway that Australian General Practice Training, through GPET, General Practice Education and Training, provide through regional training providers, RTPs, and through the Remote Vocational Training Scheme—both of which are fully supported by government for the training of doctors. Through those pathways doctors are trained towards fellowship of the Royal Australian College of General Practice or fellowship of the Australian College of Rural and Remote Medicine.

ACRRM has a third pathway that is accredited called the independent pathway. This is for more experienced doctors, as it is a recognition of prior learning pathway. Unfortunately that does not receive funding from government; the candidates need to pay for their own training through that pathway. But it does provide the opportunity for doctors who have been working, both Australian trained doctors and those trained overseas, to enter a vocational training pathway. People are amazed to learn that a high percentage of people doing the independent pathway are Australian graduates. The reason for this is often they have gone off and done other exciting and wonderful things and then reached a point when they want to come back and settle and work in rural and remote Australia. They then need to develop the competencies needed and the recognition that comes with fellowship, VR, Medicare et cetera. There is quite a group that does the independent pathway.

I noticed that earlier people mentioned the Rural Generalist Pathway in Queensland. ACRRM has worked in collaboration with Queensland Health in developing that program, and 96 per cent of those in the rural generalist program in Queensland are tracking towards FACRRM. The uniqueness of the rural generalist program is that it has a totally different approach to training. Queensland Health were having difficulty in attracting people to positions in rural and remote areas and decided a training pathway would be the way to go. The rural generalist program offers junior doctors a career path and the training pathway to go with the career pathway. Their pathways are mapped to ensure that they have the appropriate places quarantined to enable them to move through their training while at the same time providing services.

The other unique thing about the rural generalist program is the fact that it is a recognised program. Recognition is extremely important if you are going to attract people to rural areas and for their remuneration, so there is acknowledgment in Queensland of their position and they are paid accordingly. Hence it has become very popular and you cannot get in: there is a waiting list for this program. From an organisation that was having difficulty filling places, those places are now there and addressing what we all know is a major workforce shortage that is going to continue.

I am sure you have all read the Health Workforce Australia 2025 report which really shows that we have inequities in the system now and if we do not do anything about these inequities we are going to have only one in every five graduates working in rural and remote Australia. Innovative approaches to training that the rural generalist program has shown works need to be extended. The other area where they have difficulty in finding and filling positions is in specialist—other specialties other than general practice—in rural and remote Australia. There is opportunity to advance general specialist training in to rural and remote areas by using the same sorts of methods that have been trialled through the rural generalist program. That way, we will be able to train those people in situ so that right from their junior doctor years they are able to gain their training while working in the rural and remote environment. Collaborations and innovation in the way in which we train are extremely important to our investment in the future. There is an opportunity to invest in new models of training that really are locally focused in the area.

The other point I would like to make concerns overseas trained doctors. As you are aware, 40 per cent of the rural and remote workforce are overseas trained, which sets its own set of challenges. We not only have our own challenges, as highlighted by the health workforce Australia report to COAG, but also have a set of challenges around overseas trained doctors. As you know, they go into area of need and often in those areas they have limited support and limited opportunity to enter training programs and to progress through the system. This is really quite concerning to us; hence ACRRM has become quite proactive in the area of overseas trained doctors, given that they are such an important part of our current workforce and will be into the foreseeable future.

We are the only college accredited by AMC in all three pathways: PESCIs, pre-employment structured clinical interviews, for limited registration in Australia. ACRRM is accredited to conduct those in all states and territories, and we do nearly 400 a year. So we play quite an active role in looking at whether they are fit for rural and remote practice. We are also part of the area of need application within Queensland. We do have competent authority. Competent authority was not a pathway open to overseas trained doctors until ACRRM received accreditation—in general practice; that was available for hospital settings, given the complexity.

We are also accredited for assessment within the specialist pathway and we have now received funding from the Department of Health and Ageing to pilot a workplace based assessment process as an alternative to the AMC clinical exam—again, the first time in general practice it has been done. It is around the beginning of getting proper assessments in place, looking at alternative ways that we can provide the support they need to move into general registration and to specialist training. But we still have major concerns around the investment in the support of those doctors. I know from personal experience that some of them are really out there without the level of support needed. Again, there needs to be some investment into providing proper support systems and training opportunities for those doctors because they are going to be there for a very, very long time.

We also think it is important that the government responds to ensuring that the principles by which we recruit doctors into rural and remote areas, particularly overseas trained doctors, have integrity. The World Organisation of Family Doctors' rural working party did address this issue in 2002 at the Melbourne conference. Out of that came the Melbourne manifesto: a code of practice for international recruitment of health care professionals, which set the principles of integrity. That has now gone through to a code of conduct from the World Health Organisation—that we do not poach doctors from other parts of the world but instead try to develop our own workforce. You cannot stop people moving around the world but that needs to be done in a way that supports both the community to which they are coming and the doctors themselves. It should be an exchange in the skilling opportunity, not one where they are simply answering a short-term workforce issue. So there are a number of standards and I suggest you all read the Melbourne manifesto because it articulates the issue very well. I would like to concentrate with you today on training and training opportunities, on new models of training and growing the ones that we have seen to work, and that there is recognition and remuneration for working in our highest need areas.

Senator NASH: Firstly, I wish to ask about the issue of the Queensland Health Rural Generalist Pathway program that you referred to. One of the submissions, from the Royal Australian College of General Practitioners, says:

State-based medical workforce initiatives (e.g. Queensland Health Rural Generalist Program) are working as deterrents to the recruitment and retention of rural general practitioners.

That obviously seems to be a different view. Can you give us a sense of why you think they might have a different view? We will ask them, obviously.

Ms Wyatt : I do not really want to comment on another college's approach or what they have said but I can only talk about what we have seen and the fact that the rural generalist program and generalist medicine is now very much on the agenda within other states. We have a successful model now that addresses what the real workforce needs are within rural and remote communities. Hence, we would like to see that extended into general specialists within it. Those are the skills that are missing out of the area, too, so we have a challenge with that. The strength of it is that it is local training. As I said in my opening, it is about a totally different approach to workforce, wherein there is benefit to the community and the doctor providing the services out there. It is really on merit from when they are in the junior doctors stage. They are looking at career options and this becomes a very real career option for them. One of the issues we have seen is capacity, particularly with overseas trained doctors, to get their junior doctor years—that PGY1-type year.

Senator NASH: What is a PGY1?

Ms Wyatt : Postgraduate year 1, their first year out. What happens is that our graduates all go out to their postgraduate years. Then we have overseas trained doctors who want to come to Australia to work in rural and remote areas. But they, through PESCIs—pre-employment structured clinical interview—are perhaps not quite up to that postgraduate year 1-type level, and a year working within the Australian healthcare system and learning how it operates et cetera would then provide them with an opportunity to move through vocational training and then general and specialist registration. What the Queensland or the rural generalist model does in fact is to quarantine their learning so that they can come in at their post-grad year. They know very well if they are wanting to move through primary health care they do a range of things—primary health care, hospital based, community based et cetera. The teaching and learning positions are quarantined to allow them to do that. Their exposure then is to the scope of practice that is required within a rural area—they can gain that. It is about the integrity of the training they are getting to what the practice is in actual fact. Part of why it works in Queensland is that people work for Queensland Health, and so there are senior medical officers and there are medical officers with private practice. They are indeed the hospital doctors and they are the general practitioners within that community, so it is actually training them for that whole scope, not for just particular office based type activities—which are quite legitimate—but also picking up those other areas.

Senator NASH: There has been a fair bit of discussion around how to raise the prestige of GPs. Prestige is probably not the right word, but I suppose the respect with which they are viewed—and maybe prestige is the right word—compared to specialists. Early on students are heading toward that specialist pathway and, in a way, we really need to have rural GPs looked at as specialists in rural general practice.

Ms Wyatt : Yes, it means you have us!

Senator NASH: How do we change the mindset or how do we make that more apparent for young people who are keen to be involved in a medical career? How do we lift that prestige level so that there is not what seems to be this hive off into specialist areas and shifting away from that rural GP specialist?

Ms Wyatt : The other thing is that we do not get the specialists out into rural areas either. Again, through the rural generalist model—which is now being taken up by other states—that is recognised, and it is recognised within their industrial awards. In fact, they do get a higher level of remuneration and they like that. They are getting recognised within Queensland Health or within the health system, and they are also getting paid for it. For another example of where this has happened—again in Queensland, though we are a national college—we do have what is called a GEM—generalist emergency medicine—a post fellowship qualification of ACRRM that is a further 18 months in emergency medicine. So they do their FACRRM and then they do 18 months in emergency medicine.

If you have a GEM then you are in fact—again it has recognition within the industrial awards—paid at the bottom level of a consultant. The top level of that is the bottom level of an actual consultant. It is an additional $130,000 per year. Again, it becomes interesting. The Royal Flying Doctor Service in Queensland—because there is competition for people to work for them—have also now recognised that within their industrial award and are also putting their doctors through that system and recognising generalist emergency medicine as a qualification. So it is about providing the training, but it is recognition and remuneration that potentially help lift that prestige of a rural general practitioner.

Senator McKENZIE: If it becomes a specialism, is there anything in medicine that will not be a generalism?

Ms Wyatt : General practice is a recognised specialty in Australia.

Senator McKENZIE: So everybody is special?

Ms Wyatt : Everyone is very special. The reality is that through the Australian Medical Council general practice is recognised as a specialty, as are all other specialties.

Senator McKENZIE: I would like your perspective on the lines of questioning we are asking everybody else. The first is the definition of what rural actually is.

Ms Wyatt : You read our definition of rural and remote, did you?

Senator McKENZIE: I read your entire submission, and I am sure everybody else did too.

Ms Wyatt : I am sure they did too. I did not want to repeat too much. Basically what we have said is that it is intersection a medical specialty within a country area. It was part of what I said in introduction.

Senator McKENZIE: Is that a widely accepted definition?

Ms Wyatt : It is a definition that we chose to put to the Australian Medical Council when we got accreditation. Considering that we are the only rural and remote college in the world, we are quoted.

Senator McKENZIE: So DoHA's definition of rural would be based on yours?

Ms Wyatt : To date, yes. I think they accept that our doctors do provide that across primary, secondary and tertiary settings within rural and remote Australia.

Senator McKENZIE: Given that Medicare Locals have now been rolled out a lot more than when your submission was probably written, could you give us an update on your perspective on how that plays out in the rural context?

Ms Wyatt : This is very much a member comment. We did consult with our members and there is still a feeling of uncertainty about Medicare Locals. In rural and remote Australia your local GP is pivotal to the whole of the healthcare system within that community. They are key people within that sector. There is certainly some feeling around that that may be challenged within those systems. I still do not think there is a clear understanding of what Medicare Locals are going to be doing and their funder-holder role is. There still seem to be some mixed concerns around that and the message is still coming from our members that this is an area of concern losing that pivotal role within the community et cetera. I think that needs to be looked at.

Can I digress for a minute because you have just made me remember something else. It is around policy and the development of policy more generally. In the UK they have what is called rural proofing. This was developed by the UK Institute for Rural Health, which is based in Wales. Now in the UK all policy and programs need to be referred through to rural proofing. What was happening is that there were unforeseen consequences of some policies and it had a marked negative effect on rural and remote communities. We are still to see whether Medicare Locals perhaps should have gone through a rural proofing exercise.

Senator McKENZIE: That was my second question, about the level of consultation around that policy. I will put that on notice. Finally, you were talking about successful models in reference to your training, and I am interested in how you measured and evaluated that success in terms of your workplace based assessment.

Ms Wyatt : That is for overseas trained doctors on limited registration. Workplace based assessment is an alternative to the AMC clinical exam.

Senator McKENZIE: I just want to know how you evaluate it. You made a comment earlier in your opening remarks about how successful it was and I am interested in how we measure success.

Ms Wyatt : We are just in actual fact starting our program, but we are anticipating the same sort of level of success as they have had in the four pilots within the hospital system. I think that there is an anticipation that the actual model will improve their capacity to get general registration. I will just explain why.

A lot of them have not had support, as I said. They are out there and they are then trying to get through an AMC clinical exam. AMC is recognised, and hence ACRRM was invited to apply. The Department of Health and Ageing have funded us to run this model because there is a clear understanding that they are having difficulty getting through that AMC clinical exam and they are having difficulty in getting through vocational training. Hence we have the independent pathway. I am not digressing; I am getting there!

Senator McKENZIE: I am just conscious that there are other people with questions.

Ms Wyatt : The model that we are now piloting links ACRRM as the summative assessors on behalf of AMC with regional training providers or training providers locally. They are providing support through the process. They do what is called a mini-CX and that is an observation. They observe them with patients and measure their varying activities in that consultation. From that they then develop a learning plan for them. So they have a medical educator working with them instead of them being out there and trying to do it by themselves. That medical educator will go through, observe their practice et cetera and set learning objectives. They also do case based discussions with them, so it is the very first time that we have had a model that is actually built on a supportive system. That is how we know that they are starting to progress, and where you have had it in—

Senator McKENZIE: Sorry, just your evaluation mechanism will be—

Ms Wyatt : It is still a pilot. We have not evaluated it, but it will be evaluated.

Senator MOORE: My knowledge of the way it works in Queensland is that it is really looking at recently trained doctors. So these are people who are at the beginning of their careers—

Ms Wyatt : Yes, right from students.

Senator MOORE: Straight from students, so that it is actually focusing on new young doctors who are encouraged to work in this field. It is also linked to working in the health system, so it is not so much for your general practitioner who is working as a sole general practitioner, or a number of general practitioners operating in Goondiwindi, for instance. It is people working within the Queensland health system at the hospital.

Ms Wyatt : There are other models across the other states. In actual fact, in Goondiwindi or wherever they are providing much broader levels of services to the community; their qualification is indeed a fellowship in general practice. As I said, 96 per cent of them are tracking towards a fellowship with our college. That will be their end point: a FACRRM.

Senator MOORE: A fellowship.

Ms Wyatt : Yes, which gives them specialist registration and the discipline of general practice.

Senator MOORE: So they can practise anywhere with that fellowship?

Ms Wyatt : Yes, but they have procedural and emergency skills. That is the difference.

Senator MOORE: The specialist procedural skills.

Ms Wyatt : It is the skills that they get out of the training that enable them to work across the health environments within communities, because in rural practice you do not sit in an office. In rural practice you work in the hospital, you work in the primary healthcare centre, you work in your general practice or you work in providing the emergency after-hours care et cetera. So it is a scope of practice that is required by rural communities.

Senator MOORE: Good. Also, can we get some figures from you about how many people are doing the IP? These are people who are already working out there and who are upgrading? I would like to get some figures on just how many people are doing that. That would be good.

Ms Wyatt : Can I take that on notice? I do not have that right in my head.

Senator MOORE: I would hope so!

Ms Wyatt : We would like to give it to you for both Australian and overseas trained doctors, because it really is a pathway.

Senator MOORE: That would be really good.

Ms Wyatt : The issue with independent pathway, of course, is that it is self-funded.

Senator MOORE: That is right. Can you tell us all that and, also on notice, how much it costs?

Ms Wyatt : Yes.

Senator MOORE: That would be great.

Ms Wyatt : Can somebody give me the list?

Senator MOORE: Yes, we will send it to you in writing. The other thing is—I think I know the answer—that someone can be a Fellow in the rural and regional system, one of your fellows, and also be a Fellow with a general practice as well? That is where you have all the letters running after the name.

Ms Wyatt : Yes. You can track to both. Within the regional training provider within the General Practice Education and Training system, GPET, a large number are tracking towards both. And a lot of our own fellows have both.

CHAIR: Senator Di Natale, do you have some questions?

Senator DI NATALE: I think Senator McKenzie stole my thunder. I was interested in how the workplace based assessments were going, but I think I have got an answer to that, and I think most of the other stuff has been covered. So nothing specific, thank you.

Senator MOORE: I have one technical question. In terms of having the doctors in the regions who can be the mentors and the focus points, can we get something from you, on notice perhaps, about how many you have, what kind of training they have to have and whether you need to have more of those? I would think, using a place like Gundy again, which is a good, established place, you probably have it, but if you have somewhere—

Ms Wyatt : I am from Horsham, so I am a country girl.

Senator MOORE: The whole process seems to operate on having those little networks. It would be really good if we could get some information from you.

Ms Wyatt : Absolutely. You have raised a point that I missed—that is, we do need to invest more in developing the infrastructure for teaching out there, really developing the mentoring and the supervision type levels. We would like to be providing a higher level of mentoring and supervision, particularly mentoring for overseas trained doctors, but, again, we have not got funding to do that. You do need to. Infrastructure for training in rural is essential.

CHAIR: Senator Nash, I understand you have one more question.

Senator NASH: Thanks, Chair, I do. You raised the issue of the area of need and said that overseas trained doctors who fill an area of need position must be given additional support, and that makes sense. How are we actually addressing the support that needs to be given to the Australian doctors who are moving out to these remote locations? While they might not be overseas trained, there is obviously a requirement for them also to have support. So what support is actually in place for those doctors now moving out to the more remote areas that do need those support services?

Ms Wyatt : Again, it depends where they are within their career. Certainly, if they are training they do have medical educators that are actually appointed and they have supervisors within the practice. In fact, under the GPET system, the General Practice Education and Training, through Australian General Practice, they have to be in an accredited practice. Part of that is direct supervision. That is back to your point about ensuring that there is enough infrastructure and that there are enough people trained to be able to fulfil those roles and that they are given the support to do those roles.

Senator NASH: I am also looking at the next step, the hypothetical of a doctor having gone through that whole process and then moving to a new region to practise where there may not be many doctors. There are still some of these single doctor practices around. From the position of your organisation, what is there for those doctors?

Ms Wyatt : Again, if you are talking about once they have fellowship et cetera then we do provide a lot of support systems through the college. We have got what is called RRMEO—Rural and Remote Medical Education Online—which is an online learning platform so that they are able to do a lot of their continuing professional development et cetera online. We also use the live classroom right through from our students—because we do administer John Flynn and the bonded program on behalf of DoHA—to their registrar years. So we have had to be quite innovative in the way in which we support our doctors. We also have a number of programs—one of them is called dermatology online—where we have a dermatologist based in Brisbane and he provides the backup support system to our fellows. They have several ways of doing it. You can get a digital camera, turn it on, send images down to Jim and Jim will send you back what is going on there. But he also posts cases. They have a chat group and they all argue about what it is, and Jim drops in another little thing and off they go again. Then they store the cases so that they have access.

In mental health, we were the only college to be accredited for level II training online, in an interactive classroom. So again it is about using innovation, using IT and engaging them in college activities and developing courses that are specific to rural areas. We have developed one called REST, which is rural emergency skills training. It looks at skilling up doctors. We have another one called obstetrics for the non-obstetrician. If they have an emergency on the road, they have to deliver a baby, so they need to be able to do those sorts of things. So it is about looking at innovative ways of continuously educating and engaging our members out there to ensure they have the right support and they have somebody on the other end of the phone.

Senator NASH: Exactly.

CHAIR: Thank you. You have some homework. We will send you the questions. They were largely about data, if I recall correctly, but we will make sure we send you those questions. Thank you for your submission and thank you for your time here today.