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Community Affairs References Committee
Health services and medical professionals in rural areas

WAKE, Ms Patricia Morayne, Director Remote Health, Northern Territory Department of Health

WALFORD, Ms Nikla Louise, Acting Executive Director Health Services, Northern Territory Department of Health

WRIGHT, Dr Anthony Joseph (Jo), Director, Activity Based Funding, Northern Territory Department of Health


CHAIR: I have to do a bit of a different spiel for you because you are government—there are extra words we have to say. So bear with me and thank you for coming on a Friday afternoon. Please put up with this: we have had a full week on the road and we are getting a bit stir crazy, I think.

I remind witnesses that the Senate has resolved that an officer of the department of the Commonwealth law of a state shall not be asked to give opinions on matters of policy but shall be given reasonable opportunity to refer questions asked of the officer to senior officers or to a minister. This resolution prohibits any questions—we both have to bear this in mind—on matters of opinion on policy. It does not preclude questions asking for explanations of policy or factual questions around policies that have been adopted.

Dr Wright : As well is being the Director, Activity Based Funding, I appear because I have spent 21 years working as a senior doctor in remote health.

CHAIR: I would like to invite you to make an opening statement and then we will ask you some questions. I am sure you are used to the process.

Ms Walford : Yes, thank you. The Department of Health welcomes the opportunity to present a submission around factors pertaining to the supply of health services and medical professions in rural and remote areas. Like all states, the territory has special challenges in recruiting to rural and remote Australia and providing health services thereon. However, the territory health landscape is unique. As outlined in our paper, the percentage of Territorians living outside urban areas is 44 per cent, to an average two per cent of Australians overall. Approximately 23 per cent live in areas classified as very remote. Over 30 per cent of the population is Aboriginal, who mostly live in remote and very remote areas—that is, 74 per cent. Our paper reflects our learnings in this space. The focus is on a multifaceted approach: one recommendation does not need to be pursued at the expense of another. There are many issues to consider in this space, and our paper discusses appropriately upskilling through to direct financial incentives through to systems solutions from this perspective.

The Department of Health is a significant provider of health services in rural and remote areas that has long managed with recruitment and retention of workforce and maintenance of health services. We welcome Commonwealth initiatives such as the RAHC and the Rural Health Workforce agency. Accordingly, a recurring theme across the recommendations and comments in our submission is around a collaborative, joined-up approach to this issue. We look forward to further discussing this.

CHAIR: Thank you. Does anybody else want to add anything to begin with?

Dr Wright : We have a couple of broad themes. I suppose we have tried to concentrate on the things that would be of substantial interest to the Commonwealth government. Clearly there is a range of dimensions associated with workforce. There is availability, training, recruitment and retention issues. We have tried to address each of them in our discussions. Obviously the focus in the Northern Territory primary healthcare sector has been on multidisciplinary teamwork, and so the previous discussion about Aboriginal health workers is of equal importance in the community controlled sector and the NT government sector, because essentially when you step into the primary healthcare space it is a space that is shared—the patients are shared and the practitioners in many locations are shared. It is a very similar approach. The importance of the Aboriginal health worker workforce and their lack of availability currently has a major impact which should not be underestimated in any way.

Senator MOORE: Ms Wake, I thought you were going to say something earlier. Would you like to throw yourself in there now?

Ms Wake : In terms of the remote health workforce, I think Mr Mackinolty actually probably really described the issues that we particularly have around Aboriginal health workers. The NT government is no different. If we look at our own statistics, we see a 32 per cent decline in Aboriginal health worker participation in our workforce in the Northern Territory Department of Health primary healthcare centres. It has been a real concern. One of the key messages that we have certainly worked with our AMSANT partners is around wanting to take a collaborative Northern Territory-wide approach rather than it being a particular government approach or nongovernment approach. We are a small jurisdiction and it is very important for us to work together to address, particularly, that area of our workforce. The issues that Mr Mackinolty raised, like I said, are the same issues that the NT government is experiencing.

Senator MOORE: For the record, can you tell us what professional training there is in the Northern Territory for health professionals? What courses can you do in the NT in terms of medical jobs—doctors, nurses, OTs, the whole range?

Dr Wright : Aboriginal health worker training is available through the Batchelor Institute of Advanced Education.

Senator MOORE: And has been for 30 years?

Dr Wright : It transferred over to there in the late eighties. Prior to that it was run by the Northern Territory Department of Health, essentially on an apprenticeship type model. Many of the health workers mentioned who are reaching retirement age went through that process. The availability of other registered training organisations for health workers has come and gone, but currently I think there is only one additional to Batchelor, which I think was the one that was mentioned. Nursing is available at Charles Darwin University. It is fair to say that it is accessed by many students who arise from outside the Northern Territory as well as people from the Northern Territory. There is a pharmacy course.

Senator MOORE: You were getting people from East Timor for a while, weren't you? That is just by the by, somewhere in my brain I must have had that.

Dr Wright : There have been overseas students.

Ms Walford : Yes.

Dr Wright : There is now a medical course in the Northern Territory, which is new. They are having their second year.

Senator MOORE: Is that at Charles Darwin?

Dr Wright : It is a combination of Flinders and Charles Darwin University. They are yet to produce graduates, but that is a positive sign. In fact, a significant number of the top students to graduate from their Northern Territory certificate of education have applied for and enrolled in the new medical program, so that is a very positive development.

Senator MOORE: In 2009-2010?

Dr Wright : No, 2011 was their first year of intake.

Senator MOORE: 2011 was their inaugural year. So you have your first lot of students.

Dr Wright : Yes. There is pharmacy available through Charles Darwin University. I think that is about the extent of the various health professions.

Ms Walford : Through the Centre for Remote Health they also offer a range of postgrad opportunities for nurses and doctors pursuing interests in the rural and remote space. That goes through to master's courses as well. The Centre for Remote Health is funded from the Commonwealth, but they are linked up through CDU and Flinders as well. There is a lot of support in that Flinders/CDU partnership for growing the workforce.

Senator MOORE: So the therapy specialists and so on all have to come in from outside?

Dr Wright : Yes.

Senator MOORE: Okay. What about the use of overseas trained doctors? I say overseas trained doctors, but I mean overseas trained professionals, including the other ranges as well. What are the Northern Territory government's numbers in that area?

Dr Wright : I do not think I have them for the whole of the workforce, I am afraid, but we can supply that to you. The overall utilisation of international medical graduates is quite high. It is probably higher in the Northern Territory than in other jurisdictions. Within some hospitals it has been as high as 45 per cent. At the same time, the Northern Territory has been able to offer a supportive environment for those international medical graduates, whether they are working in the primary care space under area of need arrangements or working in the hospitals, to become fully registered locally.

CHAIR: I understand the congress's retention of international medical graduates has been quite high.

Dr Wright : Yes.

CHAIR: Does the government experience the same level of retention?

Dr Wright : It depends which sector they are in. If they are in the hospital sector there is a tendency for the churn to happen. That affects international medical graduates, though to a lesser extent than it does local graduates, who are pursuing training opportunities. But it does mean that there is a fair churn, because there are quite a few hospitals people in that situation can move to once they have had a bit of Australian experience as well. They do not necessarily go to Sydney, but they might go off to the inner west.

CHAIR: Somewhere less remote.

Dr Wright : Yes.

CHAIR: What about the primary healthcare area?

Dr Wright : I think the numbers in the primary healthcare space are so low that it is difficult to say. It only takes a couple of people to move on to change the situation quite dramatically. At times we have had in the departmental space as many as 10 or 15 per cent being international medical graduates, but typically it would be less than that in full-time employed medical staff in remote health. It is variable. When we look at the people who are doing local work, quite a large number of them are people who have been in the country, obtained their registration and then chosen to work in locum areas for a period of time. If you count people who are here as temporary locums, sometimes it might be higher than that.

Senator MOORE: What are your recruitment processes? How do you recruit?

Dr Wright : We have quite a lot of success in remote health over the last four or five years. We have dedicated resources directed towards recruiting: our Chief Rural Medical Practitioner, which was a role I filled, and a senior admin staff member, too—effectively two staff whose main job was to concentrate on recruiting appropriate medical staff—and we have included in that the ability to recruit from overseas. We advertised and visited recruitment fairs overseas. We also maintained a presence in the local medical conference circuit because it is important to be out there and actually create the idea in people's minds that they might like to visit and work here.

One of the most successful things we have managed to do is to encourage people to do short-term placements—what we refer to as a 'try before you buy' arrangement—so that they become familiar with the idea of potentially working in a remote location and can then skill up as required for the areas that they feel they need to be comfortable with. We have also gone into arrangements with a division of general practice and a practice in various locations to try to provide regular visiting staff so that there is a transition between a locum and a visiting staff from another location. We have had the same doctor come up three or four years in a row, perhaps once or twice a year, but rather than for the typical two weeks at a time we get them up for four weeks at a time and they establish a much better rapport with and understanding of the community. That has been a successful strategy in providing some continuity.

But we have had to adjust our models of care to recognise that locums and temporary staff are a necessary part of the landscape. We have come up with a range of employment options whereby some staff who are remote from the community provide what we call 'program support' to that community. The same person is on the phone to the staff; they get to know the patients, providing support for their day-to-day business—this is not the emergency care work we are talking about; it is the review of the diabetic patient's medication and a review of the pathology results for people who are on blood pressure tablets and things like that, adjusting their medication dose, recommending a review schedule, recommending changes and implementing changes in their medication dose, and writing referrals.

The program support role is one we have invented to try to bridge the gap between a situation where you have a resident GP and then suddenly no-one, versus locum GPs and someone who actually knows the community, knows the systems and policies and can provide continuity. We have had some people doing programs supporting the same community for five or six years in a row. They visit the community once a year so they get to know the staff and the people. That has been a measure that we have been able to bring to improve the quality and capability of the primary healthcare services to provide a capable service. That is one example of how we have had to adapt. Some of those people have come having done program support for a while. They have come and done resident work in our community. So we take opportunities in our service delivery model to do recruitment where we can.

Senator MOORE: One of the things that we were told in previous evidence was that there was more flexibility in packages able to be offered in Aboriginal medical services than there is in the government services, so that in attracting and retaining people, they are able to offer a better all-round package, if not in total dollars at least in other things, but often in total dollars as well. If you look at the evidence from Congress the other day, they said they could compare in their coverage area their ability to attract and retain staff directly with that available with the government. One of the things they put that down to was their environment and their salary. Is that a fair comment?


Senator MOORE: Is that a limitation in the state government arrangements? They refer to whatever the enterprise agreement is—so doctors could do better, nurses could do better, other people could do better doing the same work but in a different field. Is that a direct comparison?

Ms Walford : We in the government sector are subject to a range of arrangements that the NGO sector is not—they can work up a package that we are not able to do. In that space we look at parity across different states rather than a competitive nature around that, and you seek to recruit for a range of reasons, like the work that you would like to do. That is one of the messages that we put through. One of the advantages of a department structure is that you have access to larger support networks and partnerships and frameworks. So it possibly, as referred to before, might attract different types of people. There is a range of practitioners that move in and out of that space but there are also practitioners who are attracted to the different sector and environments, depending on what they are looking to experience and to give.

Senator MOORE: Does your government rate have parity with other government rates across the country?

Dr Wright : The rate for the medical officers agreement for rural medical practitioners is quite generous. I do not believe that it has been matched by the community controlled sector. It is one of the complaints that has been levelled at the department—that it has not been able to be matched. I do not know the evidence that they are presenting.

CHAIR: Part of it is that all their positions are filled and they have had high retention rates. I think that was some of their evidence.

Dr Wright : There have been difficulties filling particular positions in Central Australia, especially. Congress, as was alluded to in the previous presentation, is a bit of an iconic destination. So, like the Royal Flying Doctor Service, those two locations are less affected by recruitment issues for medical staff than other areas. So there are some long-term difficult-to-fill places in Central Australia, which are unfilled to this day and which have not been influenced by either the community controlled or the government changes to their recruitment policies. I would be careful about interpreting evidence that is limited rather than overall.

Senator MOORE: It is not an interpretation; it was straight evidence that was given to the committee. I draw your attention to the evidence from Congress the other day, specifically on wage rates. I am happy to check out the veracity of it, but it certainly was not an interpretation.

Dr Wright : Sorry, I apologise for that.

CHAIR: I would like to pick up on what you just said about these positions that are unfilled. Are they with the community controlled sector or with government, or are they across both?

Dr Wright : Both. We have had some positions which almost fill themselves and we have others which are almost impossible to fill, where we have had a churn of temporary staff going through, or no-one at all, for prolonged periods of time and having to cover them with telephone and visiting services.

CHAIR: I can go back to the evidence that I wrote down because I took lots of notes from Congress. One of those relates back to the wage rates partly but they were also talking about the holistic approach, the team approach, that they are doing.

Senator MOORE: It was something to do with the iconic nature of the employment, as well. There were two particular points made by the previous witness that looked at health workers. I would like to have some follow-up on that. I would like to get some information generally from the department about what is happening with the Year of the Health Worker. What investment has gone into it? What are the goals of it? It seems to be a direct decision from the territory government to promote that. I had not heard of that until we came here, so that would be useful. The second is the issue raised about housing. I am sure that is something that you have heard before. I am interested in the background of that policy. Can you give us any information? What is the position of housing, which is an ongoing issue in my state for all people in remote areas—all professions? What is the position on housing for people in the medical field in the Northern Territory, by program?

Ms Wake : The remote area housing is provided on the basis of you not being a local recruit. It is not based on whether you are a professional, a doctor, a nurse, et cetera. It is actually this: are you a local recruit? If you are a local recruit, you are not entitled to housing. If you are not a local recruit, you are entitled to housing. So that creates an inequity because you find that a lot of the health workers and administrative staff are actually local recruits. Your nurses, doctors and other types of professions are generally not local recruits. So it certainly sets that up. The NT government is aware of the issues related to that. As I currently understand it, there is some work through the Department of Local Government and Housing to look at what are the incentives for people in remote areas who are local to come to work. There is some current work being done through that organisation, looking at a project where housing is incorporated as part of the incentive for employment, because we know from the evidence that has been provided to us in the past that having money is not always the incentive for someone to be employed in a remote community. My understanding of the project is that it is only at its very beginning—it is still in its very formative stages. The only reason I am aware of it is because we consistently raise this issue about the fact that our health workers in remote communities, as Mr Mackinolty said, are often living in very overcrowded conditions. They have to actually come to work to have a shower, and often they have to come to work to even have a sleep, in some places. It is a significant issue. We have taken that up locally with the NT government, and it is actually on their agenda as far as I am aware.

Senator MOORE: Even for the other workers, is there always available housing?

Ms Wake : No, there is not.

Senator MOORE: I knew that would be the answer, but I wanted to get it on the record.

Ms Wake : There is absolutely not. The issues of infrastructure are one of the biggest barriers in terms of the effective recruitment and retention in remote areas. It has a flow-on effect. It means we put other models of service into place—like a fly-in fly-out model. In terms of some of the anecdotal evidence that I see in my role, the fly-in fly-out model is not the most effective model. A lot of the work we do in remote areas is based on establishing good relationships. The fly-in fly-out model does affect the establishment of good strong relationships in some places.

CHAIR: I would like to go back to the issues we were talking about in Alice Springs. We were also talking to Mr Mackinolty about the fly-in fly-out, and the feedback was that some of the health outcomes are not being as effective—for locums, for example, and fly in, fly out health workers. I realise that is different. Are your district medical officers always fly in, fly out?

Ms Wake : There is actually a combination. We have resident GPs in some places, especially the larger places like Maningrida, Wadeye and Borroloola, and also one at Groote Eylandt. This smaller places are reliant on the district medical officers who provide a visiting service, and it is a regular visiting service. Again, in terms of maintaining relationships et cetera, it will be the same DMO. They will actually go out to that community over a period of time and will be involved in the follow-up and the ongoing program work et cetera.

CHAIR: While you are thinking, is there a size of community that get fly-in, fly-out before you base someone there permanently, or is it that they are also a function of whether infrastructure is available?

Ms Wake : It is actually infrastructure and funding.

CHAIR: Funding in that it is cheaper to fly somebody in and out?

Ms Wake : The funding in terms of how we actually maintain a GP in a particular community—for example, Wadeye is a large community and to have a GP actually in place at Wadeye is an effective way of utilising that resource.

Dr Wright : There are 76 health centres in remote locations in the Northern Territory. In general there would be no GPs based in communities with fewer than about 700 people, but there are a couple of communities that are adjacent to each other that are sufficient in number to allow it—a GP might be based in a community of 200 or 300 but with a catchment area of about 700 or 800 and they visit a couple. They are the sorts of numbers and we certainly do not have access to enough GPs to base them in every one of our remote communities.

Senator MOORE: Because of the time, it would probably be easier to put some questions on notice but I couldn't not ask about the radiography breast screening program for Senator Judith Adams, who has a particular interest in this. When we had hearings once before, the breast screening process was actually not operating effectively because there were no available radiographers. At that time, we discussed it with the government—they were very open about it, they were seeking more radiographers. What is the position with radiographers at the moment and how effectively is the breast screen program operating outside Darwin?

Ms Walford : We have the Well Women's Screening Program—it is in our community health space within health services—and we do have our complement of radiographers. That is made up through a combination of different recruitment methodologies. We have the main service in Darwin, but it visits regularly in Alice Springs, Tennant, Gove and Katherine. That is all scheduled a year out and all the communities are notified around that so those clients are met through that process. That is a Well Women's Screening Program, so that means that in the normal cycle a woman in the qualifying age would go and receive that. If a woman presents through a GP service and there is some concern, obviously their pathway is straight through to the hospital services. So, there are two different streams: the regular service is a Well Women's Screening service. That is just your regular follow-up. We also have pathways for remote communities where there are negotiations with the communities and the women might come into groups into Darwin or Alice Springs.

Senator MOORE: At government expense?

Ms Walford : Through the PATS. Quite often it is coordinated when they are attending for other reasons. The connection depends on what the issue is. They will not fly in for the regular screening, but if they were coming in for something else at the hospital then the opportunity would be taken to bring them in and have the screen at the same time.

Ms Wake : In terms of groups of women coming in, we actually do provide transport to get them in, particularly if we have a large group. Sometimes that is actually funded by the NTG through our normal remote health business. Other times we have actually received direct funding from the Department of Health and Ageing to facilitate that.

Senator MOORE: We will put questions on notice about dialysis and all that stuff.

Dr Wright : One of the points that we make is that the support that has been received for recruitment and training of new staff has been largely coming from two areas. We have had the rural workforce agency that has provided support for locums, medical officers, and for the recruitment of long-term community based GPs, although ostensibly, that is mainly in the nongovernment sector. They have also provided assistance with recruitment for community based GPs employed by the department, so that has been one area of support. The Remote Area Health Corps has provided support for the locums but not for long-term recruitment. They have been able to provide support for nursing, allied health and medical staff. They provide a valuable service both in credentialing and providing orientation and transport for people but it does not comprehensively cover the whole area of the workforce required in the rural and remote locations. So there is an opportunity with the move to Medicare Locals to rationalise and come up with a more comprehensive solution to recruitment and retention support.

CHAIR: Which is more holistic and deals across the board.

Dr Wright : Yes, and covers the issue of short-term relief, orientation-type visits as well as long-term placements for permanent employment.

Ms Wake : Just to add to that, it is important that it is not really put into an NGO and a government split. We are a small jurisdiction. You mentioned congress before and one of the things we have to be very careful about is that we are not robbing from each other to provide that service—not trying to poach each other's resources. One of the really important messages for us is that we see it as being very important that we take a collaborative role with AMSANT to address the NT-wide workforce issues.

Dr Wright : I underline the point that for the last four years, when we have been attending these recruitment exercises, we have been doing it with the workforce agency, with the community-controlled sector and with the department sector, and where people actually end up. I would like to emphasise that a number of the people who have ended up in the community-controlled sector have been recruited by us and sent to them. It is not that we have been arguing; we have been trying to work together on this. We have to pick up the pieces when there are gaps in the system and it suits us when there is full employment, no matter where it is.

CHAIR: Thank you very much. I think we have already given you some homework—yes, we have—and I suspect there will be more questions on notice. It makes people read the Hansard.