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

CAMERON, Ms Melissa, Director of Workforce Programs, Rural Health Workforce Australia

MAHON, Ms Margie, Director of Workforce Programs, Rural Health Workforce Australia

CHAIR: Welcome. I understand information on parliamentary privilege and the protection of witnesses and evidence has been provided to you. We have your submission. It is numbered 107. I would like to invite you to make an opening statement, and then we will ask you some questions.

Ms Mahon : Thank you for the opportunity to appear at today's hearing. Unfortunately, our CEO, Greg Sam, is in Adelaide at another meeting. He sends his apologies. Rural Health Workforce Australia is the national peak body for the seven rural workforce agencies that operate in each state and the Northern Territory. Our network is government funded and not-for-profit. Together with our member rural workforce agencies we work to meet community health needs by making primary health care more accessible in rural and remote areas. They are now known as RA 2 to 5. We have traditionally done this by attracting, recruiting and supporting doctors to work in these areas. This year our agencies are extending their role to recruit nurses and allied health professionals in partnership with a program funded by Health Workforce Australia.

I would like to emphasise the word 'support' because this is just not simply a numbers game. Workforce supply and workforce retention go hand in hand. They need support services such as locum relief, family networking events and access to professional development. They also need to feel valued for the outstanding job that they do. These are exactly the kinds of services provided by our agencies, who have been doing this work collectively for up to 10 years. Over time our agencies have developed extensive linkages with individuals; practices; communities; local, state and federal government; professional bodies; training providers; registration boards; and many other parties. We navigate health professionals through these different groups. We translate all this knowledge into effective advice and assistance for those at the coalface of rural health as well as policymakers. What we know and who we know also enables us to match health professionals to communities with the aim of achieving long-term relationships.

We do this by utilising a case management model that has the interests of the community and the healthcare professional at the heart of it. It is what separates us from the others in the sector. Effective case management is time consuming but rewarding and helps foster retention. For example, our agency in Western Australia has reported that 70 per cent of overseas doctors who they have supported to work under a five-year scheme have elected to remain in rural communities at the end of that scheme, at the end of their moratorium.

Having a state-wide jurisdictional focus means agencies are well-placed to work with Medicare Locals as partners in rural health. Given our existing expertise, we can actually save them a lot of duplication in relation to the rural workforce. We also understand the complexities and the technical aspects of running effective workplace programs, particularly in the rural and remote sector. There are some transition issues around Medicare Locals, which is understandable due to their relative newness. Specifically, we are hearing concerns about continuity of services and the fact that Medicare Locals have such a broad charter that their overall focus on rural and remote may be diluted. In a number of states the Medicare Locals spread from city to bush.

On the subject of RA, we support much of what has already been said about the classification scheme. Our advice is that there are better ways to link incentives for doctors or for those contemplating a move to a community. There are well-published anomalies with the classification system, particularly in the RA 2 band, which groups smaller towns with larger regional centres. We believe that in order to achieve a more effective distribution of the medical workforce, incentives should be linked to communities of need rather than relying on a geographic measure. It would also be helpful to take account of additional measures such as the social determinants of health in any future review.

In terms of distribution, the moratorium has been a great success. It has ensured that hundreds of rural communities have benefited from the skills and the commitments of overseas trained doctors. Many of these communities would be without doctors if it were not for OTDs. It is clear that overseas trained doctors will continue to be part of the solution to Australia's rural medical shortages. We believe these doctors who choose to work in Australia deserve more support, which is why we welcome the recent findings of the House of Representatives inquiry into registration processes and support for overseas doctors, the appropriately titled Lost in the labyrinth report. The focus now should be on implementing the committee's recommendations and ensuring there is a buy-in from all parties to enable a truly streamlined national system. Looking to the future workforce, we have a major focus on university students through our management of the National Rural Health Students Network. This is a unique, multidisciplinary body that represents more than 9,000 medical, nursing and allied health students, who belong to 29 university rural health clubs. These clubs promote rural health as a desirable career option, engage students in rural health experiences and nurture those with an existing interest in rural health. The NRHSN also reflects student views on issues such as interprofessional training, rural placements, scholarships and support for country students. The students are telling us, and we agree, that more needs to be done to support nursing and allied health students who are inclined towards working in rural areas.

If we are serious about creating a multidisciplinary workforce in the bush, a starting point must be the HECS reimbursement scheme currently offered to medical students. This should be expanded to other health professions. There also needs to be a greater emphasis on rural placement support, particularly for allied health students, who are often deterred by the costs associated with a rural placement. We also want to see more done to encourage students from a rural background to go to university to study health. As you have heard from others, the evidence shows that they are more likely to return to the country to practise. On that point, we would like to see all university medical schools achieve their 25 per cent rural intake target. Beyond that, we would like to see similar targets for nursing and allied health.

The rural career pipeline actually starts in secondary school. We are active in this space through our student network, and it is producing results. Each year, volunteers from our rural health clubs visit more than 300 country high schools throughout Australia. They provide mentoring to the high school students and encourage them to think about going to university. Programs like this and the New South Wales cadet scholarship feed into a holistic approach to the workforce pipeline. Creating more opportunities for postgraduate training in a variety of rural and regional settings is critical as it ensures a sufficient level of clinical supervision and mentoring for trainees. This is important because providing rural people with the medical care they deserve requires commitment to train medical graduates with the breadth of general skills needed for modern rural practice.

As you have heard from the AMA and the College of Physicians, priority must be given to increasing the number of GP proceduralists available to rural and remote communities. These are GPs trained and skilled to provide obstetric, anaesthetic and surgical services. This will magnify the professional value of rural general medical practice and will help reduce the need for excessive patient travel to access services.

In summing up, a career in rural health is not a life sentence; it is actually a way of life. It has to be valued. It has to be nurtured and recognised as such if we are to attract an appropriately qualified and passionate health workforce to meet the needs of rural and remote Australia. This country has made a significant investment in increasing the domestic supply of health professionals and we are about to see a large number of medical graduates come through the university pipeline. We must get the policy levers right if rural and remote is to get a return on that investment. This will require coordination of training places, prevocational programs and clinical support. Rural workforce agencies need to be factored into that planning as the guide rails for these emerging pathways.

We have brought some photos today showing health professionals. These two young people are both students. They started out life in Katherine. They had a rural high school visit and now they are both studying in Townsville. That shows that this program really does translate. Our next photo is Dr Lauren Cone, who is a recipient of the cadetship program from our New South Wales Rural Doctors Network. She is currently working in Tamworth. We talked today about overseas doctors, and this is Dr Sybille. She came to Australia from Holland. She has just finished her five-year scheme at Orbost and has elected to stay in her rural community.

Senator MOORE: Where is that?

Ms Mahon : At Orbost in Gippsland. Finally, we have here one of our University of Wollongong students. He is all dressed up at an Indigenous event, 'Clean Hands, Clean Eyes'. He has translated right through the whole rural health club experience to be now out working as a health promotion officer in remote Australia. These are some of the faces of our programs.

CHAIR: Ms Cameron, do you have anything to add?

Ms Cameron : No. We prepared this together.

CHAIR: Senator Di Natale, do you want to lead off?

Senator DI NATALE: I have a couple of things that I am just working on that I want to ask in a minute. I will defer to one of the others.

Senator MOORE: Your focus is across the whole workforce and I think the committee have been very conscious of that during our deliberations. We can become extraordinarily job decentric. It is really important that we look across the whole board. I am interested in your submission. There are a couple of things specifically for allied health, in particular the HECS program. Have you got information back from the students that this is an issue for them?

Ms Cameron : They have done a paper on that, which we could get for you.

Senator MOORE: That would be really good.

Ms Cameron : They are very active in putting forward their concerns and their information, as well as in the political area. We can get that for you.

Ms Mahon : Our agencies are running the Rural Health Professionals Program. We know that the supports to allied health and nursing are as critical as they are. Professor Humphreys talked about what we are doing at the moment. We are undertaking a study, which is providing incentives. That might be to fly back to a capital city; it might be to do with relocation or CPD. Those are the things we are actually delivering in programs as we speak.

Ms Cameron : You touched on the need for those flexible incentives; that is what RHPP is doing. It is enabling the candidate, the nurse, the allied health professional going out to rural and remote Australia to actually select their own incentives that will enable them to go out there and stay out there. There is a package ad then they select their incentive. That is being evaluated as well.

Senator MOORE: We have had a lot of discussion across the whole committee about the current definition of rural and remote. Your submission refers to the current scheme not being truly reflective. You were here during the evidence of the previous witness when a model was put forward about looking at population and looking at all the other data about what does and does not affect people but also coming down in the end to a population based model. You are a workforce-supporting network. When you talk with the people whom you are mentoring and supporting for the process, what do they tell you are the kinds of things that determine what their choices are based on when they are making their decision whether or not to go back into the rural workforce? The ones you are meeting with are obviously choosing to be in the rural area. What kinds of things determine those choices?

Ms Cameron : We listened to the day in Canberra as well and I think they touched on many of those issues there with the RDAA.

Senator MOORE: The three doctors on the phone.

Ms Cameron : They are saying that incentives definitely do have an impact. I do not think we need to go any further and explain the differences between the big regional towns and the small communities. The smaller communities do not have the services. The doctors work extremely hard, they are on call, doing emergency, providing so much more mental health and all those sorts of services. If you are in a bigger regional city or in urban areas you have other health workers to assist you with those services. So incentives do help them to feel rewarded. But I think it comes down to the non-financial incentives. They need to feel supported, they need to feel loved, they need to know that there is a locum who can come and replace them if they want to do professional development and if they are sick. If they want to take their family away, they need to know they have access to that service.

They also need to be able to connect with other colleagues in rural and remote Australia. Through the rural workforce we have a number of weekends where we are connecting the doctors together. Their families also need to feel that they are doing the right thing and are feeling connected with other families. So we also have a bit of a focus on that. It is all those things—feeling that they are rewarded financially, yes, but being recognised and respected for what they are doing feeling connected and supported and that they have not just been put out there. The workforce agencies really try hard to do a lot of those things for them and stay connected through newsletters, conferences, professional development and locum programs, but at the end of the day there is only so much that our financial incentives and programs can do to facilitate those programs.

Senator MOORE: Have you done any work with your people in Queensland on how they feel about the model that we have heard so much about—the new GP process that the Queensland government started?

Ms Mahon : The Rural Generalist Pathway?

Senator MOORE: Yes.

Ms Mahon : Our advice is that it works in Queensland and that it is being rolled out. What we need is pathways to rural practice. If that is one of the pathways then we would welcome it. We need to look at all the pathways that are available for domestic and overseas doctors.

Senator MOORE: So it is not one size fits all again?

Ms Cameron : Absolutely. I think that is what the rural workforce agencies in each state and in the Northern Territory say. They need to have some national models but then be able to fit it to their needs within their communities. Victoria is a very different place from remote NT. There needs to be the flexibility that you have touched on previously and that we are touching on now.

Senator MOORE: Just one word—housing?

Ms Cameron : Housing is a problem in a lot of different areas for a variety of different reasons. I cannot say what the solution is, but it definitely needs to be looked at. To give you an example, we have a rural workforce agency in Tasmania—and this is the thing about having the local knowledge—and the doctor's residence on Flinders Island had been modified. A third of it was cut off to provide other accommodation for something. That was fine because the doctors there at the time were a husband and wife and their child had gone off to university. They have just left. The agency started making inquiries about new doctors and was trying to attract them to Flinders Island, but the housing was not appropriate. The doctor looking to go there has a number of kids, a family, and the housing was not what they wanted. So our agency did a lot of work with the local council there, and said: 'What can we do? We need to get this sorted out. The housing is not acceptable.' So we have that local knowledge. Housing has a big impact, and if you cannot get that right—you have people from outside the area or private recruiters trying to place someone in there—it is a big issue.

Senator MOORE: Is that across all the professions—nurses, physios? It is the whole bit, not just doctors?

Ms Mahon : Absolutely.

Ms Cameron : In the Rural Health Professionals Program with Health Workforce Australia, the retention supports that go out there are for housing as well, so that we can offset the rent. Broome and areas like that are very expensive for candidates. That is the level of flexibility needed in that program; it needs to be able to support housing.

Senator NASH: No. 8 of your key recommendations states:

That Universities be held accountable to their rural intake goals and should a University be consistently unable to fill this quota, the funding associated with these rural intake places be transferred to other Universities which can demonstrate their ability to recruit more students of rural origin.

What is your sense at the moment of where the quota is not being filled? Are there particular universities or particular areas where this is happening? And have you got any sense of the reasons for this?

Ms Cameron : We have done some work around the medical—so only medicals. The quota is for medical. I do have an in-confidence paper that we did at work. It is mainly around the metropolitan campuses where their targets are not being met, and that is substantial. It is down to seven per cent. As to the targets and qualifying for a rural background, you do not need to have spent your whole life there; it is a very small proportion of your childhood. But because they have linked it so closely to going back into that rural community and they have set the targets, we need to get some accountability there. It is quite a challenge; they are not doing the enrolments. There is this 99.9 per cent entry score for someone to get into medicine. There are a few different policy levers that need to be worked out to enable that target to be met. But something that we would like to see is universities being made accountable for meeting the 25 per cent target.

Senator NASH: It is a very good point. We were having a discussion earlier about the 99.9 per cent. It is more a supply and demand and prestige type figure than one about the knowledge or the ability to intake knowledge of any of these students who might have 80, 85 or 90 per cent. Do we need to look at the fact that the entrance mark is so high?

Ms Cameron : Absolutely.

Ms Mahon : And the personality type, and now the move to postgraduate medicine. There is a change afoot. Even 20 years ago, when I had colleagues at university doing particular courses, it was the same issue then. We really have to address the features and characteristics of the professions—let alone medicine, but the other professions that we need to go into rural.

Senator NASH: Do we need to have a more across-the-board look at the entrance mark—I am really just talking as I am going—and have a combination of factors for entry? Getting through your HSC and getting a reasonable mark is one thing, but, if we are talking about potentially increasing the workforce in rural Australia right across the health professions, do we need to take a whole lot more things into account in terms of application for university?

Ms Mahon : I think what we need to do is stop looking at medicine as separate. We need to look at everyone together, because the youth of today are working in multidisciplinary teams. They are the future health models. Health service delivery will change. That is the first point. Leading up to that, yes, I think we need to look back here at the policy levers that inform the new models. In remote Australia we do have to look at different models of care that are not doctor-centric. There are new models to be considered, and one of those might be back here about how we select those who go into rural practice.

Senator NASH: That multidisciplinary model is really exciting in a lot of ways. Things have happened in a certain way in the past just by the nature of how they are—you had your GP and everything sort of satellited around that—but putting in a more collaborative model seems to make sense when at the end of the day the patient is the person we are trying to provide all these services for. How is it all going to best work? How do you see that being received out in the community on the ground about the changing face of it?

Ms Cameron : Change is afoot. Even in the latest edition of Australian Rural Doctor magazine there is an article a little bit on that concept. The doctor was saying he was sent off to participate in these sorts of meetings and he was gruff and all that, but he has changed, as has his ability to manage his patients because now the nurse in his practice is doing all the diabetes education and she is doing the haemoglobin testing. Approaching that multidisciplinary teamwork together has actually been in the best interests for his patients and he is a lot less stressed. So I think it is going to take time and there are going to need to be some leaders and some people who give it a go and then talk to their colleagues and say, 'You know what? It works.' We need to have some role models out there to say it is working. But it is happening at grassroots levels and we need to encourage it a little more.

Senator NASH: It is really interesting. One of the other things that you talk about is locum support as being one of the key support mechanisms. How do you see us as a nation doing the provision of locums better? Is there a way it can be improved? It is such a pressure release valve for a lot of doctors who can actually get away. How do you see the locum arrangements being provided better, and is it tough when the locums get paid more than the doctors who actually do the job?

Ms Cameron : It is very tough and it is very complex. What I can say is that our agencies have been running locum services for a number of years and get locums to go in, and the doctors are relieved that there is a subsidised service that will come into their practice. What is tough is when you have private locum companies coming in—and I do not want to exclude them from the marketplace—and there are no subsidies, so the practice has to be able to afford that. That is where the issue comes: when the practice cannot afford to get the private locum in because they are not making enough money during that period. It is not cost effective.

Ms Mahon : There is also a message out there for every health professional: go and give your country cousin a break. That is what we have been doing with one branding of our locum program. You might not want to move rural, but you can go and be a locum for someone for a week or two weeks. That is a major contribution to rural. We are happy to work with people who can do that. We need to think about budgeting and we have certainly tried to do this as an organisation. Every rural GP who may be an R A4-5 for example—and there are a thousand of them—actually gets a locum placement if they want it. We have to think quite strategically about how we do this. At the moment, we obviously meet priority. We get limited funding for a locum program. It actually needs to be broadened. We know that the non-financial incentives of locums—continuing professional development, family support and all those things that are keeping—

CHAIR: It is all those non-financial things.

Ms Mahon : That is right. So let's move away from the financial things and think about support for health professionals in rural areas.

Senator NASH: How is the initiative to give your country doctors a break going?

Ms Cameron : It is actually going very well. The government has a Rural Leap program, which is an emergency skills training program. Doctors get to do this program free but they must return 20 days of service over a two-year period doing locums in rural and remote Australia. That has been a really good lever to get people who want those extra skills—and then they go out and do locum relief. We have marketed at a number of conferences. We have been out for the last two or three years engaging with doctors to have a go at participating as a locum. We have a great national database of doctors who are willing to go out and locum. We always need to keep building on that supply. What is limiting us is the funding. Now that the funding models have changed, our nationally funded locum program has been given to Medicare Locals. So our agencies are working with state funding, of which they have a limited supply, to deliver locum services.

Ms Cameron : You can see the problem in transitioning from a seven-agency model to a model of 60-plus agencies. That is one of our concerns about the transition to Medicare Locals.

Senator NASH: You said there is some general confusion as to what their roles will be. It certainly seems at the moment that there may be some good intent in this but there is a lack of clarity about how it is all actually going to work. Is that a correct summation?

Ms Mahon : Let us start with boundaries. In some of our states RA1 and 2 are lumped together. So what is going to happen is that the focus is going to be very much about what is needed in the capital versus what is needed in a regional centre.

Senator NASH: It is really anything but local.

Ms Mahon : That is right. That is one of our concerns—transition issues around programs like the locum program. They are still getting up and running on 1 July. But what is going to happen out in the bush? People are still out there and they need a break. They do not need to wait for a transition. Their charter is quite broad; it requires them to be involved in the workforce. Workforce is a very complex technical issue. Our guys have been doing it for more than 10 years. It is naive to think you can just take on a workforce role as well as all the other roles. We would not like to lose the work we have done over all these years.

Senator NASH: Is all that corporate knowledge just going to disappear?

Ms Mahon : No, we will continue.

Senator NASH: I know you will. But if the funding mechanism actually shifts to Medicare Locals what requirement is there for Medicare Locals to continue with the types of things you have done, such as the locum program?

Ms Cameron : That is the concern. Up until recently their brief was to determine whether the locum services were required within their Medicare Locals. So it was up to them initially to determine what services were required. What concerns us is what will happen after 1 July. People are ringing us wanting locums past 1 July and we are not able to provide one. They actually have to shift their change and provide that service from 1 July. But they do not have the history.

Ms Mahon : They do not know how to run the program.

Senator NASH: That is potentially going to be a huge mess.

Ms Cameron : They have not even got all their staffing. They are still applying for CEOs and staffing within Medicare Locals.

Ms Mahon : We are happy to work with whoever. We knock on the doors of all the Medicare Locals. We are now negotiation with another layer. We are here to help and often they want that help. But it is another layer in what was a very streamlined program. So that has just happened to one program. We are not aware yet of other programs, but there must be implications more broadly.

Senator NASH: There is a real issue too about the certainty of delivery.

Ms Cameron : It is about consistency of services.

Senator NASH: Have I got it right that there will be a bucket of funding? This is just hypothetical. It might all work seamlessly and be absolutely fantastic—and let us hope it is. But if it is just a bucket of money going to Medicare Locals if they have another priority that they see as greater than the provision of locums can they just choose to do that and not provide the locum service?

Ms Cameron : That is our understanding at this stage.

Ms Mahon : We understand that they do a needs assessment. We will certainly be meeting with the new alliance next week to understand this and what advice we can provide.

Senator NASH: That is a real concern, isn't it? So with your provision of locums at the moment, over what area do you do that? Is that national?

Ms Mahon : The whole of Australia.

Ms Cameron : The whole of Australia, RA2 to 5.

Senator NASH: So what you do as one coordinated body in delivering the locums is now going to be at each individual Medicare local level to determine whether or not they are going to do it for their region?

Ms Mahon : Yes.

Senator NASH: Ouch!

Ms Cameron : We had seven deliverers, so that—

Senator MOORE: It was not one deliverer?

Ms Mahon : No, we were the national—

Ms Cameron : We were the national body, so we had each of the agencies in each state and the Northern Territory. But they looked after the whole jurisdiction, so Western Australia and the Northern Territory each looked after their own jurisdiction.

Senator NASH: And you—

Ms Cameron : We had the national pool—the national database of doctors willing to go out and be locums. They accessed that; we marketed the program.

Senator NASH: So would not somebody still have to have some sort of national database for the Medicare locals to try to tap into to try and get people to come to the regions?

Ms Cameron : That would be the most logical way. We are not sure where they are with that.

Senator NASH: And again, we are back to the uncertainty of where that is going to sit and where that data is going to reside.

Ms Cameron : Yes. We are meeting with the Medicare locals next week.

Ms Mahon : The importance of this point is that it is about the implications of decisions at the grassroots level. It is very well to construct what seems to be a good model and framework, but it is the implementation. That is where we are; we are at the coalface. That is why the implications do affect us.

Senator NASH: Would you mind just taking on notice for us that when you do get some more clarity around how it is going to work with the Medicare locals, particularly this locum issue, to provide that to the committee? Even if it is after the reporting date, I think the committee would appreciate having the information.

Ms Cameron : Sure.

Senator McKENZIE: My apologies for being late. When you mention anomalies in your submission, are you talking about structural disincentives or are you talking about the five per centers who are always going to be there?

Ms Mahon : We are talking about what is probably well-publicised now: there is fragmentation in RA2 and 3. For example, the New South Wales Rural Doctors Network submission talked about how they are actually prioritising in RA2. That is where the anomalies are sitting, in the perception of size and population.

In Professor Humphrey's presentation he very much talked about his population model. On top of his model we want to talk about need. It is about what the things are that the community needs; are they the social determinants of health? We want other things in that equation as well. His model—

Senator McKENZIE: It is a good start, but we could add other variables quite easily.

Ms Cameron : He has done a fantastic job and takes it a long way, but there are some other considerations. If we do not look at the social determinants and if we do not look at the community's needs—the cultural needs and the burden of disease in those communities—we are not going to get it right. We are still not going to attract the health needs—the doctors, the allied health and the nursing—that need to go out there and support it. And there are the new models: it might not be just plonking all these sorts of services in there, there are other models as well. But we really need to understand that broader complex scenario.

Senator McKENZIE: Recommendation 7: I am just wondering whether you are looking for 'As a bare minimum reflect the proportionality'? We have heard that a lot. Would you be happy for that to be in the compact to be a regulated thing?

Ms Cameron : Absolutely.

Ms Mahon : Yes, given the importance of rural origin to rural practice.

Senator McKENZIE: Excellent. I have travelled around regional Victoria, and I am thinking particularly of Mansfield—this small regional hospital—where they have had a really good story about attracting doctors and it is because they get to do a lot of different things within the context of their hospital. It is just the positive opportunities that are out there, I guess, for a general practitioner in the types of things they get to do throughout their training et cetera. Do we see that? Are we promoting that?

Ms Cameron : We are definitely not promoting it enough. Late last year the government gave us some money to run a national rural marketing campaign.

Senator McKENZIE: How much money?

Ms Cameron : Two-hundred and fifty-five thousand dollars to run a six-month national campaign targeted at doctors, to get doctors to consider going rural. We called it 'Go rural'. We developed a targeted campaign. We ran it for five months. Each of our seven agencies got $20,000 to deliver one to two events. It has been a phenomenal success.

Senator McKENZIE: How were you evaluating that success—show-ups, changes of mind?

Ms Cameron : We ran 13 events. Just under 500 people attended these events. There were a variety of events. We have had 8,500 hits on our Go Rural website. We have had 200 registrations on the website as well from people who want further information on going rural. The events were broad based, from targeting undergraduate students to targeting PGY students—the early career doctors. That was the biggest area of success, because the agencies say these are the people who are getting lost. They are doing internships in hospitals, they are getting targeted by the specialists to become specialists and they are staying urban.

We have managed to engage with them, talk with them about rural health. They see the great stuff that is happening out there. We have done skill workshops. We did a weekend event down in Warrnambool, along the Great Ocean Road. That event was fantastic because it targeted partners as well. So the doctors brought along their partners and there were events along the way for the partners to be engaged in and to help them understand what it is like to live in rural Victoria.

Senator McKENZIE: But I cannot imagine we are having difficulty attracting doctors to Torquay or Anglesea.

Ms Cameron : This is Colac, Dunkeld and Warrnambool.

Senator McKENZIE: I will just make another comment on geography's impact on people's decision to go rural. Dunkeld is a great example. Mount Arapiles has rockclimbing. There are chemists where you cannot attract chemists in agricultural science, simply because they rock-climb. You would find the same thing with surfing, I think.

Ms Cameron : So I think the take-home message is we have a brand. We need to get it out there because, as the other speakers have said, we need to raise the profile. We have the goods. We can raise the profile. We can target the early career doctors. We can engage with them, talk to them and get them on the right rural pathways. It is just about having the financial supports.

Senator McKENZIE: I want to ask about HECS reimbursement. I have heard this a lot about a lot of different areas. No-one can give me evidence that it actually works. Do you have evidence?

Ms Mahon : We have a paper from the National Rural Health Students Network which we will provide to the committee.

Senator McKENZIE: Excellent—thank you.

CHAIR: This is the confidential one that you were talking about?

Ms Mahon : No, this is another one. This is the priorities paper. It is not about the work but why it is needed.

Senator McKENZIE: But in terms of an incentive that changes behaviour and choices?

Ms Mahon : We will take that on notice and give you some information.

CHAIR: Senator Di Natale, have you now constructed your question?

Senator DI NATALE: Yes, I have. I tracked down the thing I was looking for. There was an audit office assessment done a few years ago that spoke about the lack of coordination and so on in this area. I have never been entirely clear about the role of Rural Health Workforce Australia. I know that at one level it is very service oriented, and I have to say that quite a few years ago I was a beneficiary of the services provided. There are obviously recruitment services and you provide direct support to doctors, but there is also a policy and program role. Is that fair to say?

Ms Cameron : Yes. Rural Health Workforce Australia is the peak body. We have rural workforce agencies in each state and the Northern Territory. They deliver the services, so they do the recruitment, retention, support and case management of doctors and now nursing and allied health professionals. We in Rural Health Workforce Australia are funded through the federal government and we contract the agencies to deliver the services. We also have policy research capabilities and communication and marketing roles. We run the student network from within Rural Health Workforce Australia.

Senator DI NATALE: I suppose this is a question of policy and program advice. One of the things that keeps coming up, and Senator McKenzie touched on it previously, is the question of evidence. I think it has been a recurrent theme. We have heard that there have not really been appropriate evaluations done of any of the incentive programs. They are often done in retrospect. Someone—it might have even been the previous speaker—talked about the fact that consultants were often recruited as an afterthought, rather than baseline evaluations being built in from the very start of these programs. I am still not clear as to whose role that is.

Ms Mahon : We agree with you. We actually have to educate our funders about the importance of evaluation from the start of a program. We have had success. I have been in my position 2½ years, and in this next round of funding, for 2012-13, we are actually being funded—very small dollars but we are going to be funded—for some evaluation. So the department has put on the record that they will evaluate and review their programs. But we certainly agree with you. It has not historically been seen as a priority. It must be a priority for the return on the investment by government. You will see Rural Health Workforce Australia become much stronger in this space. At the moment, we are going to look at a national minimum data set, because we need that baseline data. You will see a change of thought, but we certainly collectively need to educate funders about the investment. You will see it in America. I have been involved in farm safety programs historically. Every program over there was evaluated to death almost—bad use of terms!—

CHAIR: Overevaluated.

Ms Mahon : whereas we here in Australia probably have a tag of a bit of underevaluation.

Senator DI NATALE: That is right. Many of the recommendations seem to make sense intuitively around moving some of the restrictions that you have identified, some of the red tape, if you like, particularly some of those earlier ones around the intention payments; but there is a bigger question about how effective this is. It is a big spend, and we very rarely have the baseline data upon which to make assessments as to whether these things are actually effective in the first place and whether they are an effective use of dollars. I am still not clear as to whose role that is. What you are saying to me is that perhaps what needs to happen more is that, with some of the incentive payments, there has to be a commitment from government to ensure that evaluation is factored in as a significant component of wherever we are spending this money, particularly around things like incentive payments. Is that a fair summary?

Ms Cameron : Absolutely. To me, it is the person or the organisation running the program that should be instrumental in designing and doing the evaluation. It needs to be transparent but, as Margie said, the government need to recognise that that is a priority. It is critical that they fund the programs appropriately to do this evaluation. Evaluations are not cheap, but delivering programs that are not evaluated is even more expensive.

Senator DI NATALE: Sure. I managed to benefit from some of this many, many years ago and I am not sure that it actually made a difference to my decision; it was in essence a nice additional payment. I just wonder how many times we are paying practitioners to do something that they were going to do anyway and whether there might not be a better spend of money somewhere else in the system.

Ms Mahon : Yes. We agree with you.

Ms Cameron : Absolutely.

Senator DI NATALE: The other thing, just quickly, is the question of quotas for universities for students who have a rural background. My understanding is that most universities have quotas, and the problem is not actually defining the quota; it is meeting it.

Ms Cameron : Yes—so actually attracting the students from a rural background who are interested in undertaking that course?

Senator DI NATALE: That is right. For example, we have been told that a number of the larger universities—let us talk about medicine specifically in this case—have quotas which they are simply not meeting; they are unable to attract the students. I think one of your recommendations was around defining an appropriate quota. I would have thought the issue is: how do we actually get more students from a rural background interested?

Ms Cameron : We are doing some of that grassroots stuff with our rural high-school visits, but it comes back to—I think it was—Senator McKenzie, who brought up that we need to look at the scores and what it takes to get into medicine, what it is made up of; is it interviews? Students in the bush might say, 'I can't get that 99.9,' immediately, and think, 'It's pie in the sky; I'm not even going to try to achieve it. I will change my ideals in life and do something else.' We need to clearly get those messages out and we really need to engage with the universities to think about what it is that makes good health professionals.

Senator DI NATALE: That is good. I will wind up there, in the interests of time.

CHAIR: Do you mind a few extra questions on notice? Senator McKenzie will write them down to make them clear. Thank you for your time and for your submission.