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

LOCKE, Ms Melissa, National President, Australian Physiotherapy Association

KRUGER, Mr Jonathon, General Manager, Advocacy and International Relations Division, Australian Physiotherapy Association

[15:48]

CHAIR: Welcome. Information on parliamentary privilege and the protection of witnesses and evidence has been provided to you. We have your submission, which we have numbered 71. I invite you to make an opening statement and then we will ask you some questions.

Ms Locke : Thank you for the opportunity to present today. It is lovely to be here in Albury. Admittedly I have done Brisbane to Canberra, Canberra to Sydney, Sydney to Albury to be here, but it is well worth it to be in a regional hub with a regional university training physiotherapists to work in rural and regional areas.

The Australian Physiotherapy Association, the APA, is the peak body representing the interests of more than 12,000 physiotherapists and their patients. APA members are registered with the Physiotherapy Board of Australia, have undertaken to meet the APA code of conduct, are expected to use the latest research in practice and often have further and/or specialist qualifications. We set a high standard for professional competence and behaviour and we advocate best practice care for clients. It is our belief that Australians should have access to quality physiotherapy when and where required, ideally close to home, to optimise their health and wellbeing. Physiotherapists are one of the largest groups of primary healthcare professionals in Australia. We have been first-contact practitioners, having direct access for over 40 years, and we believe we have a significant role to play in meeting Australia's health challenges. We are part of the interprofessional team. The skills and training of physiotherapists mean that they are able to work in a wide variety of areas, treating conditions and disabilities that are across the lifespan. Wellness is included in that. Physiotherapists also work with groups to deliver improved population health outcomes within their local areas. Physiotherapists are valuable members of multidisciplinary teams, making an important contribution to health care through health promotion, prevention and screening as well as developing triage assessment and treatment activities.

Commonly, physiotherapists are known to treat musculoskeletal conditions. That is particularly relevant in rural areas where there is a high degree of musculoskeletal injuries, or wear and tear. But physios have a well-established role in the treatment and maintenance of chronic conditions such as cardiovascular disease, chronic obstructive pulmonary disease, diabetes, osteoporosis, arthritis, obesity and hypertension. The educative focus that we adopt in areas such as chronic disease management, self-management techniques and lifestyle in physical activity counselling aligns well with the primary healthcare philosophy of consumer and community empowerment.

But unfortunately there is a dire shortage of key frontline workers in many areas. This means that a significant proportion of the Australian population is unable to access the physiotherapy services they require. Obviously, the most critical area of underservicing is in rural and remote areas of Australia where there are significantly more potentially preventable hospitalisations for chronic conditions than in the metro areas. Physiotherapists are vital for these communities individually and for the role they play as part of these interprofessional teams.

Efforts to address these shortages have been hampered by a lack of any significant government incentives to move to a rural area or to establish a rural practice. You have mentioned before, Senator Nash, that it has been a common thread throughout today's hearing. This is in stark contrast to the medical profession, as we mentioned in our submission, where successive Australian governments have invested vast resources to encourage rural medical practice.

There are also well documented barriers to rural and remote recruitment and retention in the allied health professions. Physiotherapy is no exception. I am sure that you have heard today about the lack of career path, the lack of professional and peer support including networking, isolation, the lack of access and support to attend continuing professional development activities and postgrad study, and a lack of remuneration and recognition, staff shortages and a lack of locum availability. Some of these issues are beginning to be addressed, but we believe—as we said in our submission—that more needs to be done.

We are urging the government to extend its programs to get more physios practising in rural and remote areas. You have our submission so you know that we have some recommendations. Jonathan and I are both happy to talk to you and answer any questions you have.

Senator NASH: Thank you for your submission. There is the issue around the barriers in terms of referrals being needed to physios. This comes up time and time again. One of the things that strikes me in a rural and regional town is that if you are buggered and need physio—which is a bit like me—and you have to go to a GP first before you can get to a physio, often because of the nature of the problem, you cannot actually get into a GP for weeks. Is that one of the barriers to being able to treat patients in a timely manner? What is the reason for the necessity for the referral? Historically, why have we needed that, and why can we do without it, in your opinion?

Ms Locke : In the first instance, in the private setting you can go to a physiotherapist directly off the street. It is different in a public setting where you normally go through casualty or outpatients and are referred on to the physio practice. So perhaps that is not so much the issue in terms of referral to a GP, though I acknowledge that a non-urgent appointment to see a GP in a country area can take six to eight weeks because of the shortage of GPs in those areas.

CHAIR: Some people do not know that physiotherapy is what they need. They go to a GP thinking it is something a GP can fix.

Ms Locke : Exactly, and the big issue is probably those who have issues where physiotherapy is noted to treat it better and who should also perhaps be referred to a specialist. So there is a circuitous path there, as well as with imaging. At the moment patients get the same Medicare rebate for spinal and pelvic x-rays if a physiotherapist refers them as if a GP refers them. But let's say someone is playing footy on Saturday and rolls their ankle significantly. They go to the physio and the physio has a high degree of suspicion that they may have avulsed their lateral malleolus. By rights they need to go back to the GP to get that referral to get the same Medicare rebate. There is your barrier.

Senator NASH: Yes, I see what you mean.

Ms Locke : Another really good example is shoulder wear and tear, which unfortunately in the perimenopausal female is high on the list of chronic disabling conditions. It is a real issue. Physios have to do the rehab. That is the best outcome, best practice. The patient may benefit from an ultrasound guided injection to relieve some of the inflammation, but again we have to send them back to the GP to get a referral to go to the local radiographer, radiologist or ultrasonographer to do that. So they are the barriers to efficient management, especially when we have been direct contact practitioners for 40 years and we have it embedded in our undergraduate courses and in the accreditation of those courses.

Mr Kruger : It is worth pointing out this is not a competency barrier; it is a funding barrier. It is the Medicare system saying that you can refer somebody on to a specialist, but if you want Medicare to pay for it then you have to go through the GP.

Senator NASH: Why is that?

Mr Kruger : It is an interesting point, because many physios have set up their practices with a specialist. So you will have a paediatric specialist setting up with a paediatrician et cetera. Ideally you would want patients to walk into the room next door—

Senator NASH: Seamlessly.

Mr Kruger : and for the two practitioners to work together. But in fact what happens is the patient comes back six weeks later.

Ms Locke : Even in metropolitan areas I, as a paediatric specialist physio, will ring my paediatric neurologists, paediatricians and paediatric orthopaedic surgeons and say, 'This patient needs to see you; this is the best direction,' and they say, 'All right, but he needs to go back to the GP.' I then have to ring the GP. I have made the appointment with the specialist already because they know I will not send anyone who is not appropriate, and the GP then says, 'I almost sit a viva for the reason that this patient should head off to a specialist.' Or they have to go back and get a referral. That is in a metropolitan setting and it takes time. Think of that in the rural setting, and then add travel onto it.

Part of our submission was about e-health and the fact that physios cannot talk to specialists in metropolitan areas. One of the first e-health initiatives started 10 years ago by Trevor Russell at the University of Queensland and it was on monitoring flat head syndrome in babies—plagiocephaly. It was mapped on a computer and you could see someone out in a rural area. Who treats plagiocephaly or torticollis—restricted neck movement? Physios do. So to not have access to e-health consultations with specialists seems a little bizarre.

Senator McKENZIE: Just to follow on from Senator Nash, I think it is a valid point to ask what your perspective is on having to go back through the GP.

Ms Locke : I think that it is history and tradition. I think it is time to move on for health workforce issues and for the best outcome for patients.

CHAIR: Good luck.

Ms Locke : Yes. The classic example is sports physicians and when they became specialists. Sports exercise medicine physicians have been fighting to gain specialist status, and they were successful 18 months ago. That meant that a beautiful primary health model, where physios had directly referred to them and were co-located, suddenly went by the board, because suddenly they became specialists and the medical model is for a GP to refer to a medical specialist. There is something we have been doing since the inception of sports exercise medicine physicians in Australia, and we have lost it. I think that we need to be really careful. I understand there has been a concern about the potential for specialisation in medicine to limit access for patients. The APA does not see it that way in terms of physiotherapy. We have a college of physiotherapists and we have a training program, as well as an associated academic pathway. We have 150 clinical specialists. What we see is that that is the more efficient route to manage certain things. Rather than going to your general physio, you go to a neurological physio to manage best outcome for stroke management. We are doing so much in the communities, and that is part of our fighting with specialist registration as well. Having physiotherapists extend their scope or delineating their expertise for public safety and the best outcome is really vital. Jonathon, is there anything you want to add on that? I have pushed that barrow.

Mr Kruger : No, but that is a model for referral to specialists. It could be that specialist physiotherapists are referring on to specialists, recognising that when you get to that level you are most likely to be able to refer on appropriately.

Ms Locke : It is done informally anyway. It is done through other professions as well. You refer to occupational therapists. You refer to podiatrists. There are also models where—

CHAIR: You can always do that.

Ms Locke : Yes, absolutely, and optometrists refer to ophthalmologists. There is already a precedent for that.

Senator MOORE: It is just the medical background.

Ms Locke : It is just the medical model. Indeed.

CHAIR: We came across it too. It is mental health as well. The mental inquiry found the same issue.

Senator NASH: In your opening statement you were running through the issues and factors limiting the supply of physios. It is a fairly extensive list, which is in your submission as well: lack of career path, isolation and lack of professional and peer support, and it goes on in the paragraph here. You indicated in your opening statement that some of that is being addressed. Could you take this on notice. Insofar as those things are being addressed, how is it being done? Which ones really are not being addressed, and what should be happening?

Ms Locke : Sure.

Senator NASH: I think that would be quite useful for us. Thank you.

Ms Locke : I think the positive—I am very much a 'glass half full' person—is the rural locum scheme. That is a good initiative. It means that people can come in to have some peer support and mentoring, and it means that they can have professional development. The flip side of it is that it is very meagre. Jonathon, what is the number of hours that are available per annum?

Mr Kruger : I am not sure, to be honest.

Ms Locke : We can find that out for you, but in the back of my mind I think it is 10,000 hours. But that is across allied health and nursing.

Mr Kruger : But I do not think we are reaching it yet. There is an issue of people being unaware of it, but for an individual physio I think it is up to two weeks.

Ms Locke : Yes, you get a maximum of two weeks locum relief.

Senator NASH: Finally, is that then—as it is with other professions—going to move to the Medicare Local to be the distributor of the locum program? We had a discussion earlier from the rural workforce people saying that obviously they had had control over it but it was now going to shift to Medicare Locals. It was quite unclear how the provision of those locums was going to work. Is that going to be the same for your sector?

Mr Kruger : I do not believe so.

Senator NASH: So this has been a rush. Extra funding came through Health Workforce Australia, did it?

Mr Kruger : At the moment a private company runs the scheme.

Ms Locke : Our understanding is that will continue from Medicare Local. They are evolving and some of them are unclear about what their scope of practice and responsibility will be.

Senator NASH: The one thing that is becoming very clear is that it is not clear.

Ms Locke : I know the dentists were saying things before about the HECS payment. Interestingly enough, a lot of physios co-habit with medical students—

Senator MOORE: They form multidisciplinary teams.

Ms Locke : Absolutely, to the nth degree.

Senator MOORE: It always has been. I do not see why it should change now.

Ms Locke : Exactly. And the number of young physiotherapists who say to me, 'This is so unjust. Here am I in the country with my partner who is getting the HECS forgiveness and I am having to pay it, and I am not even earning as much as they are.' I think that is something we really need to look at across the professions. If you want young people out there in the country then give them a reason to go out there, with their mates, with their partners. I feel passionately about that.

Senator NASH: We have definitely taken that one on board. Thank you very much.

Senator McKENZIE: I have two questions. I am always interested in this waiving of HECS as an incentive. Do you have any evidence on it being an incentive or just a nice bonus at the end of something you were going to do anyway? Secondly, on the consultations with physiotherapy as a profession around the set-up of Medicare Locals, how are you involved in the process?

Ms Locke : They are good questions, thank you. Have we got any data or have we got any serious things on HECS waiving? No.

Mr Kruger : No. We are consulting without it.

Senator McKENZIE: It seems a policy idea made up for people who are at a point in their life when they are paying off the HECS fees and all of a sudden realise that it is a lot of money coming out of their wage each week. Rather than as an 18-year-old going into a degree, it is probably not something that you quite think about.

Ms Locke : Absolutely not. I do not believe that education should be devalued. I do not believe that there should be this quick fix of getting rid of your payment. However, I do think that we have a dire workforce shortage in the rural areas so I see it as an incentive. It is not so much about why it is done. It is more the question of why it is not done for one and done for the others. There needs to be parity across health professions. I think that goes to the nub of that elitism, almost, with referral and with opportunities. We have talked about practice incentive payments. The same applies. You could argue that that dentist's chair would be filled if there was a practice incentive payment in the rural area. The same with the physio practice. The load it would take off the public sector is quite profound.

Senator MOORE: And the rebuilding of the community.

Ms Locke : And the rebuilding of the community, having young people there and staying.

Senator McKENZIE: Netball teams up and going every Saturday because of the rehab.

Ms Locke : Absolutely, because whether you like it or not though, physios have a culture of movement. That move will stay well. In the main, physios are fairly go-getting people in the community. They want to be part of the touch footy team; they want to be out there doing salsa dancing or whatever. They are on MasterChef, for goodness sake—we have two of them.

Mr Kruger : In relation to your first question, we have surveyed our student members and our rural members about this and that comes back quite strongly from them. Obviously, it depends on the question that you ask. If your question is: do you think that this would be an incentive? It is really easy for me to say, 'Yes, I think that would be great.' But when push comes to shove and I need to move from Fitzroy to Fitzroy Crossing or the Pilbara, that is a different decision. You are right about the stage in your career at which you make that choice. I do not think we are in favour of what you described as bonding somebody prior to the start of their career—when an 18-year-old makes that decision—because when you get to the end of your student time there is a whole range of factors you need to consider. But if you have graduated and there is an opportunity to go and work for a period of time, at that point you are able to make that choice—and I think this would be an incentive.

Senator McKENZIE: And the Medicare Locals decision?

Mr Kruger : We are part of the National Primary Health Care Partnership, which has members from most of the primary healthcare professional groups, including AGPN, OT Australia, the allied health professions et cetera. Over the last two or three years we have been heavily involved in discussions at that level with AGPN, and different models have come about. At a local level this is something we are really grasping with. As I am sure you have been told, the governance structures for Medicare Locals are multiple and varied. So we are getting a sense of whether, at any given place, this is something in which the APA could be involved as an organisational member or whether our local physios should be a member. It is really difficult for us to find out that information, so it has been difficult for us to advise and support our members who wanted to become involved.

Ms Locke : We have certainly been supporting members who want to be involved and we have been working extensively to try to get physiotherapists some governance training. The bottom line is that having some governance experience is one of the prerequisites to be on a Medicare Local—and that is not within allied health study. So we have been working with the AGPN to look at having some funding release so our members who are keen can get a certificate IV in governance training or something that will bolster their application to be on those Medicare Locals.

Mr Kruger : Certainly that is a barrier when you look at the amount of support GPs have had over the last 10 years in terms of getting up to speed with the divisional structure. And more recently the Consumers Health Forum got some funding from the government to essentially do exactly the same thing so consumers would be able to participate. So the doctors and the consumers have been looked after, but all the other health professionals fall into a bit of a heap in the middle. We see that as a gap.

Senator McKENZIE: There is no longer any funding for local lead clinician groups under the budget. That is where many allied health providers felt they would have a role to play—as a lead clinician locally. So now that we have that relationship between Medicare Locals and local hospital networks, where the allied professionals felt that they would perhaps be the glue, we are going to be needing allied health on Medicare Locals.

Senator MOORE: I want to put a question on notice in terms of the link between regional schools where physiotherapy is offered and whether there is any data on where your graduates go. James Cook, La Trobe and other places have a rural focus. You said in your submission that when you train locally you are more likely to stay. I would like some data on that.

Ms Locke : We can get that for you. Certainly one of the models that has been going for a little while is the rural paediatric placement from Shepparton. It has been incredibly successful in training people and giving them a career pathway and allowing them to stay—whether it is in community health, child health or in a hospital setting. That has been going for a few years with good success—and we will get those numbers to you. I would just add that the big issue there is clinical placements. When you have a clinical placement in a rural area you have a better experience as a student—as was said before by the dental cohort. The APA has been pivotal in working on this. On the eastern seaboard all the universities are aligning their clinical placements so that there is not an influx. That model has been a great success. So you do not have five universities wanting placements at one time and none at another. We are hoping we can help the heads of schools and work in partnership to have that happen in the central and western time zones.

Senator MOORE: Certainly out of the Medicare Local in Townsville they are operating rehab services for the whole of the cape and the northern area.

Ms Locke : Yes.

Senator MOORE: So I would imagine they would be dealing with your people a lot. If you are doing rehab, you are doing physiotherapy.

Ms Locke : Yes, indeed.

CHAIR: Thank you very much. We have finished just on time. We gave you some homework, didn't we?

Ms Locke : You did. Thanks for the opportunity.

CHAIR: Thank you.