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

TRIDENTE, Miss Angela, Manager, Northern Territory Health Workforce and Member Services, General Practice Network Northern Territory


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

Miss Tridente : Yes, it has.

CHAIR: I invite you to make an opening statement and then we will ask you some questions.

Miss Tridente : NT Health Workforce is the rural workforce agency for the NT. We are unique because we are the only agency that is part of a bigger network. The General Practice Network was formed in 2008 as a merged organisation of the Rural Workforce Agency, the divisions of general practice and the state based organisation. Whereas in other states their workforce agency is its own entity, we are part of a bigger group, which is quite an advantage in a small jurisdiction. I will not go into a lot of the stuff you have already heard from my colleagues in AMSANT and the department but basically, when we put in our submission, we said the key issues would be relative across a lot of the sectors and a lot of the states: housing and the isolation factors.

It was interesting to hear your comments about the comparative salaries. We also have had differing views with our services. We primarily provide services to the Aboriginal medical services, Aboriginal community-controlled groups and private practice, which now includes Darwin.

CHAIR: Private practice often gets lost in that discussion.

Miss Tridente : Yes.

CHAIR: It is really good that you will be able to talk from the private perspective as well.

Miss Tridente : We took over the Darwin services in July 2010 when they changed the refused classification. Having now had a chance to listen to some of my colleagues as well, and I do agree with everything they have said, we do work very closely with the organisations. I am a relative newcomer. I have been in the territory for about 2½ years in this role. So I am a bit new. What I have seen over the last couple of years is very much a push to work together to provide services. It just cannot work any other way up here. Jo is absolutely right: when we go to conferences or do any of those things, we share information and we share vacancies. Our aim is to get people into the territory. Whether it works under our banner or under the department or AMSANT, we are not really that worried about it.

I guess the focus for us has always been general practitioners. Our funding comes through Department of Health and Ageing as a rural workforce agency, and that has always been a GP focus. We are in fact just in the middle of signing up to a contract with Health Workforce Australia to offer positions to nursing and allied health professionals, which is great. We are really enthusiastic about that. I do not know how many other workforce agencies you have spoken to or have heard from.

Senator MOORE: Not in this inquiry. We have spoken with them, but this is the very first hearing of this inquiry.

CHAIR: Other than-

Senator MOORE: In the NT.

Miss Tridente : We have been badged in the past, I think, as recruitment agencies. So what we have been trying to do over the last five years is to really emphasise the fact that we provide a case management service, from the moment we bring in the doctor all the way through their working life. We work with them and their families. We work with the health service on an individual basis. So we are working to place the right person in the right position. We provide cultural and community orientation and clinical, obviously, and we provide site visits. We have been working on a video project to showcase people the communities that they are going to work with, so that we do not get people coming out and saying, 'This isn't what I expected.' I guess we are trying to be a little bit creative about opening people's eyes to what the communities in the Northern Territory are like before they physically land on our doorstep and have signed up and do not realise what they have signed up for.

We also do a lot of retention and support work. We provide locum services and, as Jo said, we will offer them to the department as well if they are needing locum services. We run what we call 'compass' weekends, which we run twice a year—one in Darwin and one in Alice Springs—where we bring the doctors and their families into the major centre and provide continual professional development and social networking to give them a break but also to give them a chance to talk to other people in the same boat. That is also open to the remote health doctors in the department.

We run a very strong locum service for general practitioners, and there is a huge retention issue there. I thought the title of this inquiry was interesting in terms of the supply, and I think it is just as important to emphasise the retention and support.


Miss Tridente : That sometimes gets a bit forgotten along the way. Whilst retention in remote locations here in the territory might only be two or three years, that is actually quite a strong number when you are talking about a very isolated location. We tend to pick up doctors who have very small children—usually preschool—or doctors whose children have grown and have left the house and they are looking to try something different. Like the department, we promote the type of medicine that can be practised because it is a different type of medicine that you are practising—tropical medicine. Our closest group that could do that is North Queensland. So it is very unusual medicine that you can practise in the territory. We also promote the support that they will receive.

From the perspective of an international medical graduate, we are a little bit different from the department; we have consciously chosen not to place international medical grads out in solo remote locations because of the lack of clinical supervision that is available, unless they are a fellowed IMG. Usually that is a UK trained, which is pretty much the equivalent of Australian trained. So we do have a lot of UK trained doctors—or we did—in places like Timber Creek, Lajamanu and places around Katherine. But we tend to keep them around the outer area of Darwin and Alice Springs, rather than outside.

With the change to RA3, the con was that we did not get any more money to help support them. So we had to do a little bit of rejigging about what—

CHAIR: That was nice—not!

Miss Tridente : we could offer them. In Darwin alone there are probably about 35 private practices and the Superclinic that we have in Palmerston. There is a handful in Alice Springs and a couple in Katherine. That is where the private practices come in. We try and offer all of the services that we can, but we do probably offer a little bit of a limited cash-in-hand. For a relocation grant where we might offer up to $15,000 to $20,000 to a remote relocation, we might only offer $5,000 to a Darwin based practice. Similarly with the orientation and training: where we would offer up to $5,000 to a remote doctor coming in, we would offer $3,000 to a Darwin practice. That is purely about their access: it is much easier in Darwin because as part of the service and part of being part of the General Practice Network, I can offer continuing professional development under my arm We offer over 100 events a year throughout the territory, mainly in the regional centres—Katherine, Gove, Tennant Creek et cetera, Darwin and Alice Springs. We are also investing in things like the webinar processes and we always offer a CPD attached to our weekends so we can actually have our remote doctors do some face-to-face as well. That is why we looked at Darwin and went, 'They have got a lot of access to those things.' So, we thought we would not offer as much.

The take-up has been interesting. We have done a lot of work with the superclinic, a lot of work with Danila Dilba, which is the AMS in Darwin, and some of the smaller practices. The bigger practices seem to manage themselves. They do not have a real call for locums because as they have more than one doctor; they tend to manage their own leave et cetera. We have not had a lot of intake of the locum program, but certainly some assistance around helping them recruit.

Senator MOORE: How many doctors at the superclinic?

Miss Tridente : I would not know off the top of my head.

Senator MOORE: I was thinking about where the superclinic size would compare with another clinic in Darwin.

Miss Tridente : My sense of it is that since it opened we have put in three full-time doctors and a part timer. I think what is interesting is that we are also seeing a number of private practices being opened by doctors who have worked in the territory either through an AMS or a DH supplement. We are seeing a few more practices being opened. It is not just because of the superclinic; I know there was a lot of politics around the superclinic in the NT and probably in other states as well.

Senator MOORE: It is a political issue.

Miss Tridente : That seems to have moved and not affected as many as everyone thought. A lot of the private practice clinics around that area went, 'We are going to go bust.' It does not seem to have happened.

CHAIR: Have you got some allied health professionals in there as well?

Miss Tridente : I understand they do, but I am not aware of the details of them. I can certainly find out for you.

CHAIR: If you could that would be appreciated.

Senator MOORE: When are you going to start your allied health nursing service?

Miss Tridente : We are just waiting to sign off the contract, but as part of the initial scoping we looked at vacancies across the whole of the territory. I was just talking to my program officer and she said that she has currently got 17 vacancies that cover nursing and allied health. We are also looking at the aged-care providers, again which is Darwin. The key areas where that came up when we did the scope were remote area nurses, which is obviously one of our top ones, psychologists and enrolled nurses in the aged-care area. Those will be the ones we focus on.

Senator MOORE: It is going to be a wide scope, isn't it?

Miss Tridente : There are 10. The contract outlines or the guidelines of the program outline 10 priority professions across Australia, but there is plenty of leeway for us to look at other professions.

CHAIR: Across the board they have identified the priority professions, but specific locations can then fit what they need into those priorities. Is that correct?

Miss Tridente : All the workforce agencies when we did all the scoping, we put to Health Workforce Australia what we saw as our priority areas. Form that they have developed this priority professions list, but it is not exclusive.

Senator MOORE: It is also your capacity.

Miss Tridente : Absolutely.

Senator MOORE: As a smaller area.

Miss Tridente : The thing with allied health, as you have probably already heard, is there is a lot of need for allied health, but you cannot necessarily keep a full-time person in a remote location working full time. One of the things that comes from what was the old division, General Practice Network, they run an allied health service based in Alice Springs, but an outreach service to the Barkly region. It is the same group of professionals going out to the same communities, so there is continuity but it is still a visiting service, and that is because when you looked at the numbers you needed a 0.3 physio here, and a 0.2 OT here, so that has been one of the programs that has been run under the old division banner. We will probably be looking more at placing allied health people in the regional centres, again for that reason, but for us the first focus is going to be remote area nurses because that is always where we are going to be wanting to focus, and enrolled nurses in the aged-care sector. They are our strong ones.

CHAIR: I think you were here when I think it was Dr Wright made the comment about fixing some of this issues with the Medicare Local. How do you fit into that scheme?

Miss Tridente : We are a very key part of it actually, because the Medicare Local's focus has obviously been on the divisions transitioning into Medicare Locals, and that is who we are. What happened in the territory is that the Department of Health, AMSANT and GPNNT went into a collaborative partnership and this submission was put into the creation of a new organisation, which would be the NT Medicare Local, but that it would be a partnership based approach. That submission was approved and we will formally transition into the Medicare Local on 1 July this year.

For me, from a workforce agency perspective, that is certainly going to help us build the whole multidisciplinary approach. I have had a dream to recruit to a team rather than just to a profession. It will also open the door for a lot more information and data sharing. Whilst we have tried, I think you still get those pockets of people who want to keep information to themselves and not necessarily be open about sharing. I see it as a really good move from the workforce agency's perspective because we are very small as an agency as well as a jurisdiction. When I compare our figures, we recruited 24 doctors into the AMSs in comparison to 16 the year before. It is such a fluctuating number, comparing us to the workforce agency in Victoria, who might have recruited 150. If you are comparing apples with apples, we are fighting above our weight because we are providing the services, but we are placing a lot stronger emphasis on the retention and support.

People appreciate that one point of contact. Some of the questions that you were asking the department around where they recruit and making that comparison, they are absolutely right. We have worked with them on national conferences—I think it is called the General Practice Continuing Education Conference. They hold them in Sydney and Melbourne every year. We have shared booths there. Prior to that, we would take vacancies from the remote health department with us if we went to overseas conferences. We were promoting remote health in the territory, and whether it is us, an AMS or a remote health centre from the department, we are not really that worried, we just want to bring people in to the territory. But we also see a lot of our locums come through those national programs.

We also do rural high school visits, so we are still trying to develop the workforce. Again, we try and do something a little bit different. We bring in university students from all the health professions to the territory, take them out for a week in Central Australia and a week in the Top End—two different groups—to visit the high schools. So whilst we are encouraging the high school students to get into the health professions, we are actually finding that the students that are going out on these trips are wanting to come back and work here. That has been a handy side bit for us that is working really well. I think we as a Territory—and I keep getting this sort of feedback from other states when I meet with other agencies—we come up with really different and unusual things and we can squeeze a dollar pretty much down to the moment because we have to—we have got a very different environment up here.

Before I came to work here I had never been to the territory. I worked in South Australia when I saw remote, Coober Pedy, Ceduna, out that way. Then I worked in North Queensland and I went to Thursday Island, and then I came here. I went to Kintore, which is 600 kilometres out of Alice Springs. It is a small community and just totally different, so you really have to adjust your thinking. The question of retention was one I was asked by our clinical adviser. Dr Thurley has been here for 22 years in Alice Springs—he was a UK doctor originally—and he asked, 'What is your idea of retention?' Of course I had worked for government so it is usually for life, and he said, 'Well, two years is good here.'

But we have opened up something around service recognition last year. We looked at recognising our GPs across the territory and we found a lot of doctors who had been here over 10, 15 or 25 years, again predominantly in the regional centres though they shift around. We are certainly seeing that when our doctors do come out of the remote areas, many of them are still interested in working in the territory. So whether they go to another location a little bit closer to Darwin or Alice, or whether they come into the city areas, we are not necessarily losing them out of the territory. But the turnover is quite significant, as you can imagine. When you do the numbers, it looks low. It looks like about a two or three per cent turnover, but if that were the case we would not be working as hard as we are. They say the territory is transient and I am learning that. In my own unit I think I have filled more jobs in the last 2½ years than I did in my previous management role in 10 years.

CHAIR: Do you facilitate people moving between centres as well?

Miss Tridente : Yes, we do. We keep an eye on contracts and so usually around the three- to six-month mark when their contract is coming up we will contact the doctor to see how they are doing to make sure they are still happy. What I would like to do a little more of is helping them negotiate their contracts because that is always a bit of an issue, but at the moment I do not have that capacity. That is sometimes where they falter, where they are not really negotiating the best deal for themselves with the employer. We will talk them through that and if they are interested in moving somewhere else, we will talk to them about what else is on offer. We have lost a couple interstate, purely because they have decided they have done enough up here. For example, one of our doctors has recently moved to Kununurra in WA.

CHAIR: That has got to be a good thing—

Miss Tridente : It is a good thing for WA.

CHAIR: speaking from a purely Western Australian perspective.

Miss Tridente : We put them in touch with our colleagues in Rural Health West so that they could support them in that move. If they are not happy or they think they are in a place that is not for them—we have very little of that and that is where our first-up support really makes the difference—we will talk to them about moving on and going somewhere else. They know us and that is a big plus. They are usually dealing with one person at a time and, even with the staff turnover, we always introduce the new people as soon as we can. They know they can ring us and say, 'This is happening,' or, 'I'm thinking of this, what can you do to help us out?' I think that is a plus for all the workforce agencies—that we have that case management approach from A to Z and it is the same person. It is like any service, I suppose. If you know someone who knows you, they are the ones you are going to want to talk to.

CHAIR: When you are moving into allied health and nursing, will you do the same thing?

Miss Tridente : Absolutely.

CHAIR: When nurses are thinking of moving or when their contracts come up, you do the same thing?

Miss Tridente : Yes.

CHAIR: That is a pretty significant step up in your workload, isn't it?

Miss Tridente : Yes, it is. At the moment I have only one program officer and as we work through to see what that workload is going to be for her over the next 18 months, which is the term of the contract we have been offered, then we will be looking to see whether or not I need to bring in someone else to provide that support. I am still looking at how the funding contracts are written, but I am also hoping to open the door a little more for the support mechanisms. There is specific support funding available for whoever we recruit under this program, but I want to open some of our other programs which are purely for GPs but may go wider. We do that anyway in CPD. We do offer things that are specifically for nurses, but the allied health is a really difficult one because of the range of professions. Trying to pick out something that is specific for one allied health stream or profession, rather than trying to be a bit more open, has been from a continual professional development position a little bit difficult.

CHAIR: One thing this committee constantly hears about is short-term contracts. I heard 18 months and I thought, 'Here we go again.' What is the reason for the 18 months? Is it because it is new and they want to trial it?

Miss Tridente : I could not say for sure, but I would think that would be one of the reasons. Because I worked for two health departments in other states and I had relationships with the rural workforce agencies, I was interested to see that this workforce agency does not get any funding directly from the Department of Health for this part of the GPNNT network and I have looked at how we might do that. I have had to spend a fair bit of time rebuilding our agency because of the merger and, as you can imagine, people left. There was a lot of loss of intellectual property and things like that. I am now at the point where I am talking to the department about 'maybe we can do a little bit more for you on a cost-recovery basis', which means I would not be as dependent on one stream of funding. But in the interim, we are certainly trying to work with them as much as we can, just to make sure that we are not stepping on each other's toes—as Jo said, not poaching. That is the thing about the territory. It would be ludicrous for us to be trying to recruit from Darwin to remote locations, because we would just be taking doctors out of one difficult area and putting them into another. That is a little bit easier for the bigger states to do.

For an example, we got some funding late last year, just $20,000 from Rural Health Workforce Australia for a Go Rural project. The whole program was to get doctors and medical students from capital cities to undertake rural practice. Both us and Tasmania said, 'There is no way we are going to recruit from Hobart and Darwin.' We were not going to do an event in Darwin and try to get people to move, so we ran a competition instead for med students and doctors to come up from a capital city and to spend three or four days with a doctor in the territory. We filmed their experience to show how they would work in those locations and what the social side was like. We turned that into a DVD. We will be able to use that pretty much for the next year or so. Rather than having a one-off event, and certainly not Darwin based, we are actually poaching from the other capital cities instead. Again, we have to be a little bit clever about the way we do these things, simply because we do not want to poach within and we do not want to poach from each other.

CHAIR: Are there any more questions? Have we missed anything?

Miss Tridente : I just wanted to say that the strengths that we always like to promote are the things I have said to you about working with individuals, about doing the full case management service and not just the recruitment side. Word of mouth is really important in the territory. That is what we have seen when we have evaluated our recruitment campaigns. We are actually getting just as many people through our doctors talking to other doctors, whether it is interstate or overseas. We push really heavily on that, so particularly whenever our UK doctors go home for a visit we give them information and say, 'Look, tell your mates.'

CHAIR: Take good pictures.

Miss Tridente : Yes. 'Tell your friends to get in touch with us.' All the RWAs are very longitudinal—we have the long-term view. We are looking for long-term placement as much as possible within our jurisdictions and we have history. We have put a lot of effort into making sure that we can see what the trends are and where we should be refocusing and what is happening with our workforce. I am hoping to do that in a broader role. As I said, retention and support are just as important as the supply end. That is about it, really.

Senator MOORE: Thank you. That is fantastic.

Miss Tridente : Thank you very much.

CHAIR: It was really, really useful. Thank you.

Committee adjourned at 16 : 32