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

LENNOX, Dr Denis, Executive Director and Senior Adviser, Medical Services, Office of Rural and Remote Health, Queensland Health

Committee met at 13:52

Evidence was taken via videoconference—

CHAIR ( Senator Siewert ): I declare open this public hearing and welcome everyone who is present today. The Senate Community Affairs References Committee is inquiring into factors affecting the supply of health services and medical professionals in rural areas. Today is our sixth public hearing.

These are public hearings, although the committee may agree to a request to have evidence heard in camera at any time or may determine that certain evidence should be heard in camera. I remind witnesses that giving evidence to the committee is protected by parliamentary privilege and it is unlawful for anyone to threaten or disadvantage a witness on account of evidence given. Such action may be treated as a contempt by the Senate. It is also a contempt to give false or misleading evidence. If a witness objects to answering a question, the witness should state the ground upon which that objection is taken and the committee will determine whether we want to insist on an answer. If we do insist on an answer, the witness may request to have that answer heard in camera, and any witness may request that at any other time anyway.

I welcome Dr Denis Lennox from Queensland Health's Office of Rural and Remote Health to today's hearing, via videoconference. Doctor, I understand that information on parliamentary privilege and the protection of witnesses and evidence has been provided to you?

Dr Lennox : It has indeed, Senator, thank you.

CHAIR: We received your submission yesterday, thank you. I invite you to make an opening statement, and then we will ask you some questions.

Dr Lennox : Thank you. I thought to anticipate questions and to make my opening statement in response to proposed questions or possible questions. The first question is: what is the Queensland rural generalist transformation? It is the systematic creation of a joined-up supply line to produce a fit-for-purpose designed medical workforce for our rural and remote communities. It takes advantage of existing supply lines, so it does not reinvent what already exists. It links together the medical service needs of rural and remote residents with the aspirations of a new generation of secondary and medical students and recent medical graduates, and it attempts to embed the reform elements into the established health system in Queensland.

So the discipline of rural generalist medicine along with a number of other disciplines necessary for our medical services, we have now formally recognised as a state initiative in Queensland. We have integrated that with the reform of our industrial instruments by which we can provide appropriate value of this practice in our state industrial system. In effect, we have made the practice of rural generalist medicine equivalent in value to specialist practice and any other specialised discipline within Queensland.

We have developed a joined up, principle based pathway from secondary education at high school through medical training to postgraduate establishment in practice and registration, and then to vocational training in Australian general practice training, along with other elements that we require for the credentials in rural generalist medicine in Queensland, and that particularly relates to advanced specialised disciplines. We have eight approved advanced specialised disciplines covering areas of obstetrics, anaesthetics, emergency medicine, Indigenous health, adult internal medicine, paediatrics and mental health. These are all disciplines in which these doctors practice in rural settings that would otherwise be the prerogative of specialised practitioners in those disciplines. Then we need to progress a site by site community level reform of medical service to transition from the historical status into these new arrangements.

The final question in my presentation is: could this transformation in Queensland be replicated nationally? My response is overwhelmingly, yes, indeed it could. The need is common with variations upon the theme in each jurisdiction. The innovation we have embarked upon has been principle based; it is based upon evidence; it is based upon joining up policy and strategy, and existing operations. It is evidence based, it is systematic, it is principled and it can be extrapolated to other jurisdictions, and adjusted according to local need. Providing that happens, providing that it occurs in a principled way, I would argue very strongly that, yes, the transformation could be nationalised.

Senator MOORE: I have heard good things about this across Queensland. The regional centres are very happy with the process—between Stanthorpe, Mount Isa and Townsville, they are happy. I note that it came out of a Roma agreement—and I like the sound of having an agreement from Roma; that is a good thing. We had evidence in Albury from the RACGP and their representative said that specialist programs such as Queensland Health's could act as a deterrent in the longer term to getting people into the country. They did not expand on that. They said that they liked to go through their standard processes. Had you heard that from them before?

Dr Lennox : Yes, I had.

Senator MOORE: Can you explain what their problem is? I noted with particular glee that they were one of the original partners in setting it all up. What has happened?

Dr Lennox : I am not the best person to explain the problems the RACGP have with our program. Despite engagement with the college from the outset—in fact, they are a member of our reference panel which oversaw the establishment of the program—there has been continuing expressed difficulties on the part of RACGP. My personal view is that most of those are not based upon fact and many of the people who have expressed concerns about what we have done have not yet fully briefed themselves of the evidence of what we have done and the results of it in Queensland. I cannot personally see how this could create any disadvantage in the future to recruiting into rural situations. In fact, in Queensland our program has resulted in an increased number of medical graduates applying to be trained through Australian general practice training to general practice. I have a great difficulty understanding exactly what their concern is.

Senator MOORE: And they have not explained it to you through the processes? You have been going for a few years now? The document you sent us indicates it has been going for several years—there are completion rates and people are working in the regions.

Dr Lennox : Indeed. We commenced formal training in 2007 with an internship. It takes five years to progress through the pathway from internship, though the trainees are arriving in rural practice at the end of the third postgraduate year in the normal pathway and their last two years of training are actually conducted on site in a rural location. Yes, since the first group progressed through to that phase we have had a steadily increasing stream of rural generalist trainees progressing into rural practice with some fantastic results. Just recently, I was delighted to receive an email from two female rural generalist trainees—one having completed advanced skills and obstetrics and the other having completed advanced skills and anaesthetics. These presented together in the same year to commence their fourth year of training in rural generalist medicine and general practice training in Longreach, which is a significant rural centre in Queensland, as you would all know, where we have a birthing service. A couple of months ago these two young ladies sent through an email with a photo of themselves which they entitled 'Tops and bottom'—they were for the first time providing an anaesthetic and an obstetric service for a birth in Longreach. This is being replicated across the state from Thursday Island to Charleville. There was a lot of concern initially that our trainees would not go west, would not go to remote locations, and the evidence is that they are indeed.

Senator MOORE: Until you had this service, and there were the women like the ones you have described, my understanding is that a lot of the places that you have identified in your list were closing down their birthing centres. Women from Longreach would not be able to have their children in Longreach and would have to go possibly to Rockhampton or Toowoomba—is that right?

Dr Lennox : Yes, that is correct.

Senator MOORE: That urge people have to have their children where their mums and their grandmothers had them is now able to happen, partly because the program has been instituted?

Dr Lennox : We were able to rebuild our existing birthing services and we have some hope that we will be able to re-establish birthing services at locations where they have been closed down.

Senator MOORE: That is fantastic. I am thinking of a generalist GP of 20 years ago who was operating out of the Barcaldine hospital, which I know well. What is the difference between the skills level and the expectation of the community of what he did then which was birthing and anaesthetics as required, and all those things way back then, and what you are able to do now?

Dr Lennox : The expectation is very simple. This is going back in a sense with some variations on the theme to what many of us recall from the mid-20th century, when most general practitioners were involved in providing substantial advanced skills and services. For example, when I graduated in 1976 and went to practice in Bundaberg, the majority of the general practitioners in Bundaberg assisted in birthing, provided anaesthetics, performed major surgery and were substantially involved in hospital emergency services. Over the intervening period of time, general practice has gradually contracted into an office based, community based practice specialty without advanced specialised skills and an increasingly limited emergency service response. What happened was that we increasingly disadvantaged our rural communities as a consequence of that because we could not replace that pre-existing generalist capacity with specialist practitioners. Hence, the closure of birthing and other specialised services.

Senator MOORE: How much does it cost? I will not talk about the Queensland Health budget because it is too sensitive. In terms of arguing this process, as you would have to do every financial year to keep your funding, what do you argue regarding the cost-benefit of this kind of training and what is the cost of having the people doing their fellowships?

Dr Lennox : The program was commenced with a $60 million budget over a four-year period. That included the creation of an additional number of positions required to provide training for our doctors as well. That $60 million over four years is now training close to 50 additional new graduates per year. Over the five years of the training program, we have a capacity for 50 graduates in each year. Given the cost of lack of access to services in rural communities, given the cost of transporting rural residents out of their rural communities, given the cost to them personally, given the cost of their health status, given the cost to their families and their communities of them being away from those locations and given the cost of recruiting doctors internationally into our workforce which was our largest supplier previously, I believe that this will represent good value for money in terms of an appropriate supply line of doctors to supply the need. The answer to that question more definitely is that we will hopefully provide that, as we are embarking upon a very formal evaluation process with funding from Health Workforce Australia just now.

Senator MOORE: You would be going into a budget round? It is a four-year allocation and you started in 2007.

Dr Lennox : The allocation now occurs on an annual basis.

Senator MOORE: As much as we can say something is safe in Queensland at the moment, this one is okay. Regarding accommodation, and you mentioned this in your brief statement, all the towns that you mention would have accommodation issues—every single one. Do you actually pay for the accommodation for the people while they are training or do you give them an allowance, or what?

Dr Lennox : The training program itself does not provide for that. The key elements of this pathway is that trainees are able to progress to the completion of training in-service with Queensland Health. So as they progress through the pathway, they have an entitlement to accommodation, particularly when they are appointed in the rural locations. Their appointment as a senior medical officer provisional fellow entitles them to accommodation by the health and hospital service in which they are located.

Senator McKENZIE: Thank you for your explanation of a great program. Regarding those who want to practice in the regions with this type of qualification who are mature age, how do they access the program?

Dr Lennox : We have had a number of trainees or doctors further advanced than our first intake of trainees who have indicated interest in joining the program. In fact, there was very considerable interest from the moment that we started from more advanced doctors wanting to become involved. The pathway has three points of merit selection entry—the first from medical school into the intern year; the second in the third year into advanced skills training; and the third in the fourth year at rural placement. That is open to anyone to apply at each of those points to become involved in the program. Beyond that, it is quite possible for doctors to track independently in their own devised pathways to achieve their credentials required for practice in rural generalist medicine. They can do that directly through the College of Rural and Remote Medicine, particularly the college's independent path.

Senator McKENZIE: Could you expand on the comments you made about the state industrial changes that have been made and be more specific?

Dr Lennox : Yes. Up until 2005, Queensland recognised only those doctors with a fellowship of the College of General Practitioners for specific advancement in salary classification in the state. Every other doctor who had simply general registration status, apart from the specialists of course who had their own salary progression, were not specifically recognised.

We embarked upon a recognition of practice reform process. We borrowed a lot of the experience of the Australian Medical Council in that process but established our own mechanism to go about recognition of medical disciplines that we required for services to our communities in Queensland. Rural generalist medicine was one of those. That process was embedded into our industrial agreements in 2005 and it has been extended since then. Subsequently, disciplines in rural generalist medicine, generalist emergency medicine and others were recognised in that process.

To complement that, we reformed our salary classification system to provide an additional range of salaries equivalent to those of our specialised disciplines which could be obtained by doctors who were in the credential practice with these recognise disciplines, including rural generalist medicine. Our rural generalists are able to progress through salary ranges which are equivalent to those of specialists in certificate III or obstetrics who are practising in metropolitan or regional centres. That transformation occurred in 2005 and has been continued on and advanced in fact in subsequent industrial agreements.

Senator McKENZIE: Have other states picked up on that?

Dr Lennox : The Northern Territory has very strongly picked up on that. The Northern Territory government and Health and Human Services Department has committed itself to progress all of the elements of the rural generalist transformation that I have just described earlier, including the industrial part. They worked very closely with us. Their system is obviously quite different to ours in many respects, but we worked very closely to see that we could have a very common package of concerns and conditions available to rural generalists in Queensland and the Northern Territory for a variety of reasons: one, so that the Northern Territory can compete well in terms of the supply of rural generalists; and, two, to facilitate movement across the border for educational and service reasons between Queensland and the Northern Territory.

Senator McKENZIE: Do you have any data on where your trainees come from?

Dr Lennox : We have a limited amount. The detail of that will come out of the evaluation process that we are progressing at the moment. To a certain extent that is limited by, in the first instance, the intern selection process. We select priority 1 candidates who are Queensland graduates of Queensland medical schools in the first instance. However, we do have a number of interstate trainees who have come via scholarship schemes and a number who have joined laterally later in the course of the pathway. So we have a number of interstate medical graduates who have moved into the pathway in Queensland. We have certainly had a far greater number of expressed interest than we have had capacity to take into the program.

Senator McKENZIE: Do you know whether the people who come into your program are from rural areas?

Dr Lennox : Yes, a significant proportion are from rural locations. That relates very closely to the joined up supply line that I discussed earlier. We have a program which deliberately targets rural based secondary school students to interest them in health careers—not just in medicine but in other disciplines as well. That has been operating over quite a number of years now, so we have a good track record of the number of rural secondary school students who have now tracked into health careers, and a significant number of those in fact are now moving into rural generalist medicine.

We have been working very closely with the medical schools, particularly James Cook University, the University of Queensland Rural Clinical School, and through Griffith and Bond medical schools to ensure that we provide maximum opportunities for medical students with a rural background to stream into the pathway. In fact, rural heritage is one of the selection criteria for entry into the pathway. However, we do not disadvantage those who do not have a rural background but have fallen in love with the idea of becoming a rural doctor. In the merit selection process we also recognise what they have done to prepare themselves for rural practice through the medical school years.

Some have done exemplary things to make sure that they are ready to move in their postgraduate career into rural practice.

Senator McKENZIE: Does Queensland have a compulsory requirement in your undergraduate program for a rural round, for want of a better word?

Dr Lennox : Do we have a scholarship scheme?

Senator McKENZIE: No, a requirement for rural placement—or is it optional?

Dr Lennox : I think the majority of medical schools are optional, but the James Cook University program provides a very strong rural and remote emphasis for all of their students. They also have a very strong capacity to provide rural and remote placements for their students. The University of Queensland's Rural Clinical School likewise is providing very strong emphasis and opportunity for students to have rural placement. Bond University has and we work very closely with Griffith Medical School—it did not have a rural stream initially—to ensure that they do have a rural stream and provide opportunity for rural placement. That is progressing very well.

Senator McKENZIE: Thank you.

CHAIR: I want to pick up on one of your answers. You said you had a high proportion of people from a rural heritage—

Dr Lennox : Rural heritage, yes.

CHAIR: In terms of the number of people that have successfully then gone through the program, is there any difference between those with a rural background and those that come in from a city background?

Dr Lennox : I do not think we have had enough experience to document that. However, as this very formal evaluation process is implemented, we hope that we will establish a longitudinal study which will provide us very valuable information in the future about the sources of our trainees and answer the question that you have asked.

CHAIR: In that study—and I am sorry if I missed this—are you also looking at some of these social achievements in terms of the Longreach example earlier? Are you also talking to communities about how their level of support has gone up and how their access to health services has improved? Are there those sorts of measures involved as well?

Dr Lennox : Yes, indeed, and I am quite sure that we will probably build upon the initial round of evaluation as directed by that evaluation itself to get more rich and deeper answers to some of these questions. We are very keen to know the value to the community, particularly to rural communities but then to the whole state, of this program. We are hoping to get increasingly reliable information to be able to respond to questions such as you have asked.

CHAIR: Thank you. You may not be able to answer this one. I am from Western Australia and while we are also a big state Queensland has a much more regional focus and has big regional centres. In WA we have Perth, a couple of towns in the south-west, and few in the north. Do you think that the model you are using, which seems to be very successful, is translatable to a such as Western Australia where we do not have such big regional towns and we are highly urbanised?

Dr Lennox : Yes, I do. One of the important learnings that we have had from our experience to date is the engagement of specialist colleges with us in the program. I cannot tell you that I know precisely all of the reasons for this, but I believe that the recognition of rural generalist medicine has assisted enormously. The systematic engagement and consultation with specialist colleagues has been important, particularly the establishment of consultative committees led by senior specialist colleagues in the state to oversee our advanced skills training areas. We have now achieved a surprising level of support, training support particularly, from the specialised colleges for our trainees, such that for example even rich opportunities are available in metropolitan Brisbane for advanced skills training of our trainees.

We are not needing that. We actually have more than adequate capacity of advanced skills training in most of our regional and outer metropolitan hospitals at the moment. But, given that experience—and we have achieved this with the Northern Territory, which is in a similar situation, of course, to Western Australia in having Darwin and Alice Springs, basically—the engagement of senior specialist colleagues is a really important element. I think we have demonstrated in Queensland that it can be done, and that gives me hope that you should be able to establish a very effective program in Western Australia and the Northern Territory.

CHAIR: I have one last question. How many Aboriginal and Torres Strait Islander participants do you have?

Dr Lennox : I cannot tell you the exact number but I can tell you that the applicant who had the highest point score on merit selection for entry into the pathway in 2011 was an Indigenous student through James Cook University from the Kalkadoon people at Mount Isa. I cannot tell you the total number that are tracking through, but there is a good number.

The other really encouraging thing is the number of rural generalist trainees who are seeking advanced skills training in Indigenous health. This provides us with an opportunity to have a specialised workforce of practitioners with specialised skills in Indigenous health moving into those communities and addressing the health status of those communities in a way that we have not been able to in the past.

CHAIR: I presume that will be picked up in your evaluation process?

Dr Lennox : It certainly will.

CHAIR: Thank you.

Senator MOORE: Can I ask you a question on that, Doctor? I saw that one of the places mentioned was Cherbourg. Where does the doctor practise out of Cherbourg?

Dr Lennox : The appointee or the trainee is appointed to the hospital in Cherbourg.

Senator MOORE: The small health centre hospital there in the centre?

Dr Lennox : It is a small hospital, yes, but their practice—

Senator MOORE: Even with a hospital that size?

Dr Lennox : That is true, but their practice is a substantial primary care practice, which is part of the definition of rural generalist medicine—primary care in a hospital setting—although it is likely that they may move also into a community setting in association with the Aboriginal medical service in Cherbourg in future. That is a possibility—

Senator MOORE: And then to Kingaroy if needed?

Dr Lennox : with a secondary practice in Cherbourg Hospital itself.

Senator MOORE: Thank you.

Senator McKENZIE: Doctor, I was wondering if you could give us your opinion on the ATAR as a method of selection for the undergraduate programs.

Dr Lennox : The ATAR—sorry, Senator?

Senator McKENZIE: What is it called in Queensland?

CHAIR: I think that is now the national term for your higher school certificate mark or whatever, for all of us old-fashioned people!

Senator McKENZIE: No, it is the number—99.8 or whatever it is.

Dr Lennox : That is not an area of my strong expertise. What I can share with greater authority is the selection of secondary school students with a rural background through a program like our Health Careers in the Bush, for example, giving them affirmative action or assistance to enter into vocational training or enter into basic training in health disciplines including medicine, and then, through programs like those of James Cook University—and I think the University of Queensland now are establishing a very strong affirmative action program as well—assisting those students who have not had the best opportunity academically in secondary school or, for that matter, even in primary school to be able to bridge those gaps and move very well into tertiary education and vocational training in medicine. From what I can see, the evidence is very strong that they are very worthwhile programs. I have no doubt that we will see in the end strong evidence coming out of that evaluation that students or trainees with a rural heritage, including an Indigenous heritage, who have tracked through this program will provide exemplary service in the long haul in rural practice in future.

Senator McKENZIE: The assessment that is done on site in the last two years of the program—how is that done within the program? Is it done on site on a competency basis, or is there some other way that you do that?

Dr Lennox : The rural generalist pathway streams all of its trainees into the national branch of general practice called Australian general practice training. The trainees can choose the training requirements of either the College of Rural and Remote Medicine or the College of General Practitioners, which is standard for Australian general practice training. The assessment processes which are conducted in those latter years of the training are those prescribed by the respective colleges for completion of fellowship in each. I think at the moment 96 per cent of our trainees are tracking to fellowship of the College of Rural and Remote Medicine and 40 per cent are tracking to fellowship of the College of General Practitioners. Obviously a number are tracking to an endpoint in both fellowships.

The other alternative pathway which is very important for us is the distance education version of Australian general practice training called the remote vocational training scheme. That is the mechanism by which we have quite a number of our trainees in remote locations without supervision on site nevertheless tracking well to completion of their qualifications.

The assessment process is the assessment of the College of Rural and Remote Medicine and/or the College of General Practitioners.

CHAIR: Thank you very much for your time and particularly for giving your evidence over videoconference. It takes a little bit more confidence in the system when we are using videoconferencing, but it has worked really well. Thank you very much.

Dr Lennox : Thank you very much for the privilege. I much appreciate it.