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

MOURIK, Dr Pieter, Private capacity

[16:15]

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

Dr Mourik : Yes.

CHAIR: Do you have anything to say about the capacity in which you appear?

Dr Mourik : I am a local retired obstetrician and gynaecologist.

CHAIR: Thank you. We have your submission; it is No. 12. I invite you to make an opening statement, and then we will ask you some questions.

Dr Mourik : Thank you very much for inviting me. I am glad you made it yesterday. It was pretty foggy; I did not think you would have got in. I am aware I am the last speaker, so it has probably been a very tiring day for you all. I am going up to Queensland tomorrow to see my mother, so I am looking forward to the warmth.

Senator MOORE: I do not think it is much warmer up there.

Dr Mourik : Yes. I would like to concentrate on three topics, because you have my submission and that speaks for itself. I think I have been beaten to the punch here, because Greg Aplin, who is the local member, actually did this speech in parliament only on the 31st, last week. It was a private member's statement. I have a copy here. Are you aware of what he said in that?

CHAIR: No.

Dr Mourik : Good.

CHAIR: They are the other side of the house.

Dr Mourik : Okay, good. I do not understand all that.

Senator NASH: No, he is state.

CHAIR: He is state—sorry. I definitely do not know it.

Dr Mourik : There is a copy in Hansard, of course, but I will leave a copy here. What he said is what I am going to put to you. We have been working on our workforce issues and problems—which we have had like the rest of Australia—for the last umpteen years. I have been involved in more than 15 or 16 years of trying to improve the workforce here. We have had a couple of really big wins. The one I want to talk about is a project that we call the Walsh Street project. This was a design in 2007. We have the land in Walsh Street. We have an architectural design for 11 two-bedroom units and four three-bedroom units—because a lot of our doctors now are mature doctors with families and children. This was going to be a gated, secure area with gymnasium and swimming pool so that people work and live together and start networking. We had that sort of program here in the late seventies—I have been here since 1979—and eighties, and the residents used to come down and spend a year.

Then the Greater Southern Area Health Service or whatever they were called before then owned units all together, and these guys stayed a year. They all became friends, and 30 years later they are here as GPs; they have lasted that long. Then what happened is that the Greater Southern Area health authorities decided only to send the residents down for a few weeks—sometimes six and sometimes 12—and they did not even bother bringing their families. The doctors left them in Sydney and went home every weekend. So they did not really appreciate what it was like to live in the country, and we have lost that opportunity. Now these fellows are in their 50s and 60s and they are retiring, and we should learn from the past. If we have this facility, the doctors would come at their senior stage—they would range from junior residents to senior registrars—and they would have an opportunity of living here with their families, becoming friends and staying, which is how it worked in the past.

We presented this at one of our provincial fellows meetings in Hervey Bay. We paid the registration fees for six O&G registrars to come and see how nice the country specialists are. All six put their hands up and said, 'Can we apply now?' It is that important that they have good accommodation when they come to a rural area. Where it fell down was that, because it was up-market accommodation, it was about $100 more rent than Greater Southern were happy to pay and so it has not happened. I think it is a great mistake. I think they lack the vision of how important this would be for recruiting doctors in this area.

My comments then would expand to the rest of rural Australia. When doctors come to a country town, they do not want to be given a fleapit of an accommodation. In Wangaratta, they have one doctor. The gas supply blew up and he got badly burnt. He will never come back to live in a place that provides him with lousy accommodation. So I think it is money well spent. This is a project on which I can leave more information for you, but I would love to see this funded. It would not be a lot of money, because they would be paying commercial rent for the building. We even have local investors who are prepared to put the money in, but it has to be signed off as a rental agreement.

Senator MOORE: Is that with the state government?

Dr Mourik : Yes, of course.

Senator MOORE: I am just wondering. That is New South Wales, on this side of the border.

Dr Mourik : All our problems here have been due to the state governments. That is why in my submission I have said it is about time that the federal government took over health.

Senator MOORE: I love that last paragraph in your submission.

Dr Mourik : I said that at Alice Springs, and Snowdon was there. He said, 'You have to go and talk to the health ministers and get them to give up their jobs.' I think democracy is a bit more than that.

The second one I want to talk about is something that I think you may know about, and that is the Border Medical Recruitment Taskforce—again, in 2007. Both of these projects were with our Dr Scott Giltrap. We have an amazingly innovative person in Scott. He was the president of NASOG, the political arm of our college, and he decided that we have a bigger problem at home. There were only three GP practices taking new patients; all the others had closed their books. So he decided he would get the businesses together and he did something quite extraordinary. He got representatives from all the hospitals together—the private Albury hospital and Wodonga Hospital. Even more amazing, he got the Albury City Council and the Wodonga council together. They even put money into this. That is the only outside funding. He got businesses in. He got Nicki Melville from the Bogong network. He got serious money. I think he raised $900,000 through businesses, local doctors and local support. There was no government funding apart from the council.

Since then, Greg Aplin has referred to 90 new doctors. Doctors come and go. It is a bit hard to tell what the actual number is, because they have come and they have not all stayed—one of them was not provided a theatre list, so he left. But the thing that attracts people is not the medicine, because that is much the same; it would be the social life. We find that the partner is more important than the doctor. So we arrange for the partner to be shown the schools, the shops, the university and the sporting facilities. We make a lot of effort with our manager of this BMRT to make them feel they are welcome. We have barbecues; we invite them to homes and have dinners. That has worked very, very well. As someone said, nothing succeeds like success. We know that it has been taken up by two other places, where they got the local businesses together, but it needs someone to lead the show—someone who has the energy that Scott Giltrap has. Yesterday's Border Mail, if you have access to it—I should have brought a copy, but you would be able to get yesterday's editorial—talks about the border medical recruitment, what they are doing and the fact that we should not lose the impetus.

The third thing I want to talk about—we are talking now about recruitment for this area, but it is transferrable to any other rural area in Australia—is that we feel that the highest chance of having doctors in the future is to work on the local students. We started fourth year at high school. We do a careers night. We then offer the smart kids that get into medicine a scholarship called the Border Medical Association Scholarship. This has been going since 1991, so we have had the runs on the board for over 20 years. In those days, it was one student, sometimes none and then maybe two. In the last few years, we have had nine to 12. This year we went down to four, but I am expecting that next year there will be a lot more because we have expanded our region.

Senator McKENZIE: How many of your scholarship recipients are from the local public high school?

Dr Mourik : I can get those details for you because they are on my database, but I do not have that with me. We cover the schools for about 100 kilometres: Wodonga High School—or secondary college, I believe it was called—Albury, Scots, Corowa and Corryong. Also, there are some amazing small schools such as Tallangatta High School and so on. So it is probably a third of them.

All the students have to do is have a local mentor. So when they come home to see mum and dad they sit in with the doctor. We prefer that they see a GP, because it is silly to start off with a plastic surgeon when they are a first-year medical student. If they want to see a delivery they call me. If they want to see an operation they come to the theatre as a first-year student. So they have a distinct advantage over the other students, who do not see clinical work until the third or fourth year. A total of 80 per cent of these students are in a rural pathway.

Someone asked how many have come back. If you consider that it takes six years minimum training, two years as a resident and then six to eight years to specialise, we have some who are just coming out now as specialists and we are desperately trying to get them back—an ENT surgeon, an anaesthetist and a general surgeon. As soon as we get them back here we have a winner, and it has not cost a lot of money. We give them $1,500 in cash to translocate to Sydney or Melbourne—one went to Perth. When they come back we might put on a dinner or barbecue for them. They have to send us an email to say where they are up to so that we know what they are doing and where they are at. When they are just about to graduate we invite them for dinner with the specialist or the GPs in that practice.

I am teaching women's health at the university, and that is one of the best initiatives the federal government has done. It really does work well, except it lacks teachers. Out of the eight O&G specialists in this town I am the only one who does teaching—and it is onerous—because they are too busy doing the work. I do not have a real job, so I can do the teaching!

The students say that what would attract them to the country is the accommodation. It would be fantastic to have really good accommodation in a gated and secure situation with a swimming pool, gymnasium, babysitters and friends, all growing up together. The other one is more money. How many years have we been talking about rural loading? We pay the same insurance as a city obstetrician and our income is about one-third. We can cope with a half, because the cost of houses and land and other expenses is less, but not three or four times. If we said to a patient here, 'If you are a private patient I am going to charge you $4,000 as your out-of-pocket'—in Melbourne or Sydney it is $10,000 or $12,000—they would say, 'Bugger you—I'll go public.' It is the same bed in the same hospital and if there is a problem they will end up with me anyway.

We cannot attract a young person here when they have HECS, a partner, two kids and a dog. By the time they are a senior registrar or graduate as a specialist, they do not want to come here and earn one-third of the income they can earn in the city. We cannot attract them. The safety net was the greatest harm I have seen in my 33 years as a specialist here. When I said that at the NASOG conference I was not a popular fellow. It destroyed our ability to attract a young person into a practice. Those are my three points.

Senator NASH: Would you like to expand on that issue about the safety net being the greatest harm in terms of trying to attract young people?

Dr Mourik : I said this at the NASOG conference and one of the people at the college said to me, 'Tony Abbott always asks for a question. Have one ready.' So when he asked if there were any questions I said, 'Mr Abbott, thank you for opening the meeting. I represent 120 rural specialists in Australia and I am sorry to say that the safety net has been the most destructive thing I have experienced in 30 years.' I was nearly punched by the president, because they fought hammer and tongs to get the safety net and the money for the city specialists. It does not work for the country specialists.

We are disadvantaged severely by this because 80 per cent of our work in the country is public work. Who sets the public fee? Medicare does. How much was the public fee for a delivery? $450. We cannot compare that to $10,000—and they are no better than us. In fact some of the country guys I think are technically better than the city guys. You have to be better if you work in the country because you are under a microscope. You can be dodgy and get away with it in the city.

CHAIR: There isn't anywhere else to go.

Dr Mourik : Yes. People vote with their feet.

Senator NASH: They certainly do. Regarding the rural loading of Medicare items, how do you see that as working and how much would the loading be? Have you given consideration to that?

Dr Mourik : I would say 100 per cent loading, because the fees are rock-bottom. When I discussed this with Tony Abbott when he was the federal health minister I said, 'If I bulk-billed every patient and charged them Medicare I would go broke. I would not earn enough to pay my staff and my medical defence.' It is 80 per cent public and 20 per cent private, and we cannot put a loading on the private because they will just say 'Oh, it is one hospital.' There are only three private hospitals with obstetrics in the whole of country Victoria.

You have to realise that the Medicare rebates for obstetrics are the pits. Women's health is enormously underfunded. I have been involved in negotiating for item numbers for increased fees. You walk up to Canberra and the bureaucrat comes in and says, 'We have no money so anything we give you for gynaecology we will take off obstetrics.' That does not work, because some people only do gynaecology. Obstetrics used to be severely underpaid. Since the item number for a complex delivery was written it has been a lot better. Medicare loading is $26 for antenatal care. As a specialist I only do high-risk. You cannot talk to a woman in under 30 minutes when she has a high-risk obstetric problem—$26 does not pay the rent.

Senator NASH: It is a point very well made.

Senator MOORE: The point about accommodation is one we have come across everywhere. It is for the whole of the medical practice; it is not just doctors. I come from Queensland, where some of the regional country centres got rid of all their accommodation at one stage—possibly it was the 1970s. You have a clinical school here, which you described, and you have a number of students coming here from universities to do clinical placements. How is the accommodation worked out now?

Dr Mourik : They find their own accommodation. A couple of students just got digs with the midwives. Some of them share houses. If they are lucky they will get a nice young physiotherapy student to share a house with, and romance could happen!

We take fourth, fifth and sixth year students, who are between 22 and 24 years of age if they started at 18. Some of them get pushed down from Sydney. They have never been out of the CBD and they do not want to come. But once they have done a year here they love it and they sign up for the next year. We are just putting on a $300,000 extension, because it was built for 40 students and we now have 44. It is a huge success. We have students now who are determined to come back as country doctors. So it has been a really worthwhile program.

Senator NASH: This is an interesting issue. It has been raised with us that the mandatory requirement for medical students to do a placement in rural and regional areas is okay but it should not get in the way of a regional student whose intent is definitely to go back to the regions. So we are in a bit of a quandary with this one. Are you saying that if the mandatory requirement had not been there we would not have students now intending to go to the bush?

Dr Mourik : We have opened up their eyes that there is good medicine practised outside the CBD. I was on council when we battled. There were two country people and 21 city people, so on anything that came to a vote, we lost. We went in tooth and nail to make it compulsory for every registrar ITP trainee in RANZCOG to do a year in the country. They watered it down to six months. It is so rigid that, if they have only done five months of their rural training, they do not get their fellowship until they go and do another month. I started the practice in Wodonga in 1979. One of the two current specialists was our first registrar in 2000 and he is now the senior specialist in Wodonga. The other registrar came back after three more years. So half of the four doctors there were registrars. That is proof that, if we get them for a year, they love it.

Senator MOORE: The evidence we had first up this morning was from a group of professors, mainly from Charles Sturt University. That point about the regional placement and how it operated, and also the 25 per cent expectation of schools, was one of the key issues. Would you mind having a look to see if you have any comments on that evidence? Given that you have a clinical school here, I think it would be very useful to see what they said. I think a counterbalance to the argument on that would be useful.

Dr Mourik : I will do that.

Senator MOORE: Does Albury Wodonga do other clinical schools apart from the one on women's health?

Dr Mourik : There are some ructions that La Trobe wants to do a medical school. But I will ask them who is going to do the teaching—because it is not going to be this little duck!

Senator MOORE: They would be wanting placement. We have not got the people who can do the teaching.

Dr Mourik : We lack the teachers, and there is no incentive for teachers. I do it out of passion. I am spending two, three or four hours a day face-to-face with students. And for one memorable month every year I do fourth years at eight o'clock in the morning, fifth years at four o'clock in the afternoon and sixth years at six o'clock at night—and it is awful!

Senator MOORE: Apart from the memorable time for yourself, that means all the students require accommodation in Albury at the one time.

Dr Mourik : Yes. We have this wonderful woman, Nanette Sweeney, who is the mother to all these students. She finds accommodation and helps them with it. There seems to be no problem getting rental accommodation. But, with Walsh Street, these are doctors who have graduated and are coming back as resident registrars.

Senator MOORE: In Queensland, parents of med students are coming to me saying that, when their kids have to go out on these country placements, it is an enormous expense to them because they have to pay all the extra process, and also the kids are paying money for it as well. And there is also HECS. So this is just one more obstacle to young people completing their training.

Dr Mourik : I have been involved with this rural workforce shortage since Professor Alastair MacLennan predicted in the Australian Medical Journal in 1993 that there would be a shortage of obstetricians in the country. I had a face-to face-meeting with Bronwyn Pike in June 2003 to tell her that we have a desperate shortage in Victoria. But nothing effective has been done. We are just talking; we are not doing.

Senator NASH: You are obviously doing an extraordinary job of teaching, but it is difficult. We want to identify the students who want to end up practising out in the bush and give them pathways to do it. In a perfect world, what do we put in place to make it easier and more attractive for people to teach these regional students we want to come back to the regions?

Dr Mourik : I am sorry to sound mercenary, but the answer is money.

Senator NASH: That is not mercenary; we just need to know.

Dr Mourik : If they have to give up an afternoon of consulting they need to be recompensed for that.

Senator McKENZIE: This has been a very informative session. Is the model you have been speaking about today population dependent? Albury-Wodonga as a joint city is now considered one of the top 20 cities in our nation, so we are not talking about a small rural centre. Where would this sort of model work? Is it only suitable for the Bendigos of the world, or can it also happen in towns like Wangaratta and Benalla?

Dr Mourik : It can happen in the smallest one-doctor town. In fact, it was written up in an article in the rural doctors magazineRural Pulse. An overseas doctor goes to a little country town. He put up a scholarship where he pays an inducement to a person who gets into medicine. That person is just graduating and coming back to join him in the practice. It will work in any town. I had one of my registrars from King Edward when I was the senior registrar in 1978. One of my juniors is now the vice-president of the RANZCOG. She said: 'It's all right to promote Albury-Wodonga; anybody could do that. I bet you couldn't promote Kalgoorlie.' I said, 'Oh yes I could!' Three quarters of the wealth of Western Australia comes out of Kalgoorlie. I would make an appointment to see the manager of the mine and ask for 0.0001 per cent of their profits as a contribution to a recruitment program. He would cream it. There is a lot of money there. I have done four locums there. The standard of their medical facilities is dreadful and you can go a few days without meeting an Australian trained doctor. This country should be training doctors and sending them overseas, not bringing overseas doctors into Australia because we have shortages.

Senator McKENZIE: And the ethics of that. I have one other question. In terms of intellectual rigour and capacity, is 99.9 the entry score for doctors?

Dr Mourik : No. I do not think you have to be that smart to be a doctor, but you do have to work hard. We know that rural students who go to rural secondary schools do not have the same teaching as the private schools in the city. So there must a loading for rural students. In my submission, as you saw, to get a rural doctor we start off by saying: 'If you grew up in the country, the loading is 30 per cent; if you have 10 years in the country, it is 45 per cent; if you come back as a medical student; it is 50 per cent; if you come back as a registrar, it is 60 per cent; and if you marry a local partner, it goes up to 75 to 80 per cent. If you have all of the above, tick.'

CHAIR: I think we should be recommending a marriage bureau or something.

Senator McKENZIE: I struggle with the current debate!

Dr Mourik : You should get a spotter's fee!

Senator McKENZIE: Noted!

CHAIR: I was going to ask this question of the colleges, but we kept running out of time. You may or may not be able to answer it. How many of the medical schools now interview the students as part of their entry requirements?

Dr Mourik : I think nearly all of them do. I know there were only a few, including Newcastle and Monash, when it started, but now I think it is a lot of them. I do not know much about this; I am a mere clinician. But the students say that the interview process preferentially selects females—because of a lot of the touchy feely stuff they talk about. I think most medical schools now have this to try and pick whether they have a vocation in medicine. I do not know how they do that. But I do not think you want the 99.99 intellect. I think you want someone who shows perseverance.

CHAIR: I thought it had become standard but, from a couple of the comments people have made, it does not sound like it has.

Senator McKENZIE: I think you get to the interview but there is a bar.

CHAIR: Yes. There is the bar and then you get an interview to see if you get over the next one.

Dr Mourik : I would never have got in.

CHAIR: Why is that?

Senator McKENZIE: He was begging you to ask that question!

Dr Mourik : I do not think I would get a TER score of 99. I just worked very hard.

CHAIR: I went to university before they did the interview process. Two of my very close friends were just below the cut-off. In WA—I come from WA—you could do the same course in science as a first year medical student. If you got enough marks, in the second year you could get in. These two just missed out, but they were so suited to being great doctors. Quite a few of my friends were doing medicine. Some of the students that I socialised with have subsequently have turned out to be not the best doctors,

Dr Mourik : It is so subjective.

CHAIR: If we had had an interview process then, I think it probably would have equalised them a bit more.

Dr Mourik : For your interest, I will leave you copies of this Walsh Street project, which will clarify it. I will also leave you a copy of Greg Aplin's speech, which I have just printed off from the Hansard. Basically, you have everything else.

CHAIR: Thank you.

Senator MOORE: What is the cost of the Walsh Street project?

Dr Mourik : It was near $3 million, but because of the delays it has gone up to $4 million. And if we built it now it would probably be $5 million. Since 2007, building costs would have gone up 30 to 40 per cent. It was just lack of vision from Greater Southern. We now have investors who are willing to invest in that, especially now that the stock market is so poor. You would have guaranteed rental if they were guaranteed by the Greater Southern, which they were not. They would not sign off. It all fell flat. We now have Albury-Wodonga Health, which after 15 years is battling to get a combined administration—I cannot believe we have one. We should be approaching them now to say, 'If you sign off on this, we'll put the buildings up.'

Senator MOORE: That is very impressive.

CHAIR: Dr Mourik, thank you very much.

Committee adjourned at 16 : 45