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Community Affairs References Committee
23/02/2017
Future of Australia's aged-care sector workforce

BENEKE, Mrs Judith, Private capacity

FORDE, Mr Allan, CEO, Executive Committee Member and Advisor Senior Lecturer, James Cook University

[11:37]

CHAIR: I welcome our new witnesses. Do you have anything to add to the capacity in which you appear today?

Mr Forde : I am representing the Australian Society of Physician Assistants.

Mrs Beneke : I also support the Australian Society of Physician Assistants in the capacity of a physician assistant.

CHAIR: Have you been given information on parliamentary privilege and the protection of witnesses and evidence?

Mr Forde : Yes.

Mrs Beneke : Yes.

CHAIR: We have your submission. Thank you. I would like to invite you to make an opening statement. We are in your hands. Then we will ask you some questions.

Mr Forde : Thank you for the opportunity to speak to you today on behalf of the Australian Society of Physician Assistants, ASPA, the professional body representing PAs. I am an American trained PA and a medical educator, now Australian, and I came to the James Cook University College of Medicine in 2008 expressly to facilitate the creation of a PA course and introduce the prototype to the health-care system. Physician assistants are now utilised around the world and are growing in popularity. They are quintessential team players, educated specifically to augment and extend the services of doctors and physicians by practising medicine in a delegated capacity. The contemporary physician assistant profession arose from a crucial need to enhance and redistribute the medical workforce in the United States during the 1960s. The PA model has been widely adapted internationally, including in Canada, in the United Kingdom and in countries with healthcare systems bearing important similarities to Australia's. Other notable nations that now use PAs include the Netherlands, Germany and South Africa.

The PA prototype has been studied and written about since the 1990s in Australia, and links to a number of key documents were provided in our initial submission. An HWA report from 2011 entitled The potential role of physician assistants in the Australian context concluded:

The PA profession could make a significant contribution to addressing a number of key strategies of the National Health Workforce Innovation and Reform Strategic Framework for Action 2011-2015 (Framework) agreed by Ministers in August 2011.

Final evaluation results from two Australian PA trials, in South Australia and Queensland, combined with extensive research from overseas, confirm that physician assistants can and do provide quality medical care safely. However, the key question here has always been, 'Would the PA prototype fit in the Australian context?'

ASPA is confident that physician assistants can make an important contribution to the healthcare system, to include the burgeoning aged-care sector. In conjunction with supervising doctors, PAs can provide and coordinate the delivery of comprehensive medical care and help to manage the rapidly-escalating chronic conditions in our ageing population.

The University of Queensland ran a PA course that closed in 2012, following the graduation of two cohorts totalling 32 people. The majority of graduates are not employed as PAs. The College of Medicine and Dentistry at JCU currently offers the only PA course in the country. Since February 2012 the course has been fully integrated into the College of Medicine and Dentistry, with the same mission as the MBBS course to train highly-skilled clinicians—particularly for service in rural, remote, Indigenous and tropical communities.

Our students are all mature-aged allied healthcare providers who bring an abundance of professional experience from prior professions as paramedics, nurses, pharmacists, podiatrists, physiotherapists and others. A fair number of our small student cohorts and graduates live and work in regional and rural areas, and would likely stay there if employment as PAs were available.

Wherever our graduates live and work we promote an underlying philosophy of service to challenged populations. Disappointingly, PAs have not been added to the healthcare workforce in a meaningful way. Queensland Health now has a policy in place for its hospital and health networks to employ PAs, but the numbers remain very modest. The PA concept in Australia has encountered resistance from the early days of exploration to its current state. Like many others in the healthcare community, ASPA feels that there is a clear and pressing need for a change in policy and service delivery models. According to the Australian Health Care Reform Alliance, a major barrier to workforce efficiencies within our current health system is the existence of professional boundaries which are based on historical practices and professional political forces rather than clinical evidence or concern for preferences. Role demarcations restrict which activities health professionals can undertake, often preventing the provision of services from low-cost providers.

Anthony Moorhouse, CEO of emergency management consultants DynamiqGlobal, presents the same idea a bit more succinctly: 'Entrenched opposition from the status quo is the kryptonite of innovation.' The PA profession has the support of the Australian College of Rural and Remote Medicine—ACRRM—and of the Rural Doctors Association of Australia. In a 2011 position statement these key stakeholder organisations emphasised:

Physician Assistants, under the direction and supervision of doctors, are part of a broader range of solutions for increasing participation in health care to meet the needs of communities;

Innovation is urgently needed to manage the healthcare needs of the approaching tsunami of older Australians.

Incorporation of the PA profession absolutely has the potential to enhance quality and availability of healthcare services in the aged-care sector from general practice to hospitals and through to aged-care facilities. With their proven clinical competence and educational emphasis on primary care, PAs are well suited to help fill the gap in medical services in Australia, especially in rural and remote Indigenous communities, and in challenged urban health settings. The flexible negotiated scope of practice and collaborative relationship with the entire healthcare team make PAs ideal to serve in areas of critical need, like aged care.

Lack of access to Medicare reimbursement and provider numbers is a formidable obstacle to employment at the moment. Registration through AHPRA is not realistic for the foreseeable future; however, ASPA is aiming to gain eligibility for Medicare reimbursement by doing modelling on some of the other unregistered healthcare professions, like social workers. To move forward with this ambition, we are currently working with ACRRM to develop a sound self-registration system utilising the existing educational framework of the ACRRM fellowship program and continuing professional development database. JCU College of Medicine and Dentistry is also developing a plan for course accreditation by inviting the Australian Medical Council to chair a committee of key stakeholder organisations that would create and oversee accreditation for educational courses.

Despite the existing difficulties for PAs to practice in their full capacity, there are a handful of doctor-PA teams that have developed novel and creative business models of patient care. I would like to go back to Judy here, who is my colleague and friend and a JCU PA graduate, and let her explain and outline one of these unique schemes and how it works right here in Townsville.

Senator IAN MACDONALD: I am not terribly well informed, but is a PA not a GP and not a registered nurse? Where do you fit in? What can a doctor do that PAs cannot do? What can a nurse do that PAs cannot do? What can PAs do that doctors and nurses cannot do? What is the difference in training? I am asking just so I can get it clear in my mind before we go further.

Mr Forde : Those are very good questions. That model that is extended out internationally from the US trains people with different levels of background experience to be able to practice medicine under delegated authority from doctors. We learn a lot of the same stuff that the medical students do, and we do a lot of the same clinical training. PAs right out of school are more like interns when they first get out, but 10 years down the road they are much more like experienced registrars in their scope of practice. The beauty and flexibility of the delegated and supervisory model is that, over time, PAs can be given more and more responsibility and autonomy depending on the level of trust that they have with their supervising docs. Supervision does not necessarily mean that they have to work on site or even in the same town. That is another beauty of the model. So, for rural and remote locations, that puts somebody out where there might not be anybody—

Senator IAN MACDONALD: That sounds exciting, but what can a doctor do that a PA cannot?

Mr Forde : Doctors can delegate anything to PAs that they are properly trained to do—that is within the scope of the doctor's practice. So a GP, for instance, would not be delegating oncology duties to a PA if that is not in their scope of practice. But, other than that, in different places it is controlled in different ways.

Senator IAN MACDONALD: Why aren't PAs going on to become doctors?

Mr Forde : It is not a common thing, certainly, in our short history here. In the US, where they have been around for 50 years, only about two per cent of the 115,000 practising PAs ever go on to become doctors. Most of the people who choose this pathway are attracted to the team membership, being the second banana and being able to practice medicine and not necessary being the boss all the time. They are pretty dedicated team members, so it is a different mindset.

CHAIR: Can you prescribe and things like that?

Mr Forde : Unfortunately, without access to Medicare provider numbers, we do not have any ability, and that goes back to the AHPRA registration.

CHAIR: But can PAs in other places?

Mr Forde : Yes.

CHAIR: But not in Australia?

Mrs Beneke : Not in Australia.

Senator IAN MACDONALD: Is the pay different, generally speaking, between a GP and a PA? Is it 20 per cent higher for a GP—

Mr Forde : I am sorry. As part of this ageing, I can point out that my hearing is just terrible. Could you speak up a little?

Senator IAN MACDONALD: The acoustics here are not brilliant. I was just saying: is the pay scale for GPs 20 per cent more than PAs or what?

Mr Forde : That is a very good question, and I might be able to let Judy, who works in general practice, tell you about that. Since there are so few PAs who are actually employed in general practice in Australia, there really has not been any baseline or framework set yet.

Senator POLLEY: How long do you train for?

Mr Forde : As I said, we are integrated into the College of Medicine and Dentistry, so many of the same people who teach in the MBBS program also teach our students. There are three PA staff members and we all teach into the MBBS course, so it is fully integrated. There are a lot of different people, especially in the clinical skills department, where we are stationed, that teach into our course and run the clinical skills for the med students. We also have visiting specialists and specialists from across the street at TTH. We do two years of academic training in a blended format, so the students are off campus getting most of that material online but they return to campus eight times during the three years for seven to 10 days at a stretch.

Senator IAN MACDONALD: Let me be more specific: the medical graduates course at JCU is six years.

Mr Forde : Correct.

Senator IAN MACDONALD: What is a graduate course in PA at JCU?

Mr Forde : Three years. So it is six semesters versus 12—so half the amount of time.

Mrs Beneke : We should remember that the candidates that are accepted into the course have previous experience in the medical field as well, as nurses, as paramedics—

CHAIR: As physiotherapists.

Mrs Beneke : That is right.

Senator IAN MACDONALD: Thank you, Chair. Sorry about that.

CHAIR: That is okay. I was going to ask similar questions. I have a couple more, but let's hear your evidence and then we will go from there.

Mrs Beneke : Thank you very much for the opportunity to address the committee and the members of the community. I am here today in support of ASPA but, more importantly, to represent the ageing population of Australia. Most of us know that the over-75 age group is showing the fastest growth and the highest demand for health care and other services. How do we improve the current system of aged care and create a multidisciplinary team environment? And how do we reduce the pressures on existing medical services? I am referring here to staffing ratios, education and training, the working environment and skills development of the workforce.

With medical models of care, it has become increasingly important to provide highly efficient and effective services. I am in a very unique role and part of an innovative model that allows a comprehensive and continuous service to our ageing population. I work as a physician assistant and extender of medical of services in collaboration with a medical practitioner. The bulk of my job is to conduct annual health assessments for the over-75 years of age population. It involves very lengthy consultations—and possibly, previously, this was not managed to its full capacity due to the lack of manpower and time. This is where my role fits in. We need time to offer a proper service.

In a busy GP practice, it is often difficult to give full attention to this very fragile and ageing group, and lot of time is needed to work through their chronic problems and health concerns. These annual health assessments include the following: chronic disease management—and this includes review, interpretation and discussion of recent results and flagging concerns with a patient and the general practitioner. We do medication reviews and we refer, as appropriate, to clinical pharmacists if polypharmacy or the risk of falls is evident. We also request further investigations, which can include imaging and appropriate pathology. In conjunction with nursing staff and administrators, we coordinate follow-ups and we rebook future appointments. This helps with compliance of reviews of chronic disease and treatment regimes. We also write referrals for ongoing specialist treatment and reviews, and we communicate with emergency department doctors in the case of acute presentations, providing information on preliminary assessment. Based on the assessment, we identify needs and connect the older people to support services—allied health, physiotherapists, occupational therapists, speech pathology, podiatry and dietitians. We also initiate aged care assessment via the My Aged Care portal on behalf of the general practitioner or the patient. We do cognitive and mental assessments, as well as falls risk assessments. We do physical examinations and identify new problems and formulate appropriate plans. We provide lifestyle advice and also advanced care planning to the aged person, and we also involve their loved ones or their carers in this.

Where can this model be applied in the future? We can contribute to multidisciplinary teams to conduct similar assessments of a resident in an aged-care facility like a nursing home or to review existing care plans on a regular basis. We can contribute to home visits. Often there is a transport or a mobility issue, and offering to conduct an assessment at home in the comfort and privacy of their own home is well accepted. We can also offer a service as community based educators in nursing homes or retirement villages. Flu vaccination clinics—they are coming up in the very near future—which have been historically done by GP and nurse teams, can be done by a physician assistant and nurse team, freeing the doctor up to attend to more urgent medical needs of other clients. We can also be used as adjuncts to geriatric units in Queensland Health or private facilities.

This current general practitioner and physician assistant model allows an hour or more for consultation—and that is what I do—and then it is followed by a 15-minute consultation, together with a general practitioner, where the assessment and the plan is discussed together with the patient's input. In my experience, the patients find it a very comprehensive and thorough service and frequently do not see the need to see the doctor. We work in collaboration with our general practitioner and we work very closely with other healthcare individuals on the team, and the end result is patient satisfaction and improved medical outcomes. I find that the extra time spent with these people solidifies a trustworthy relationship between the person and the healthcare providers. Utilising this model of care enables the patient to receive a comprehensive service that they deserve where a lot of time and effort goes into their healthcare needs. The medical practitioner can conduct more complex consultations and offer training to new doctors. We increase the patient throughput and we reduce waiting times. It also reduces the burden on other healthcare individuals.

We should not lose focus, and we should remember that it will form part of a bigger picture, because one of these days we will be standing in those older people's shoes. I do have to quote Thomas Edison: 'There's a way to do it better—find it.' I think we have found a method of doing that. We just need to utilise it. Thank you.

CHAIR: Thank you.

Senator POLLEY: It is an interesting proposal. I think the obvious question is: why aren't you involved in our health system in Australia if you have had such great success in Canada and the US and other places? What is holding you back here?

Mr Forde : Largely, it has been opposition from much larger, more powerful organisations.

Senator POLLEY: Not like the AMA?

Mr Forde : Like the AMA.

Senator IAN MACDONALD: Like the doctors union?

Mr Forde : The AMA and we are opposed by most of the nursing unions.

Senator IAN MACDONALD: Now I understand.

Mr Forde : It is a fear of something new. We are also opposed by the Australian Medical Students' Association, and some of the organisations have legitimate fears. Now, the medical students are already at a fairly peak level and tripping all over one another out there, for clinical placements especially. It is the same thing with the junior doctors. So I think there is a legitimate concern when there is a new type of provider that needs the same type of clinical training. What we have tried to explain is that experienced PAs actually augment medical education and that our numbers are so small that, at the time and for the foreseeable future, we do not even show up as a blip on the radar screen. There are about 44 graduate PAs in Australia, and we have only got approximately 10 to 12 in each of our classes. Also, by being fully integrated into the med school, we have an opportunity to coordinate all of our clinical placements so we are not bumping into our own med students and the junior doctors, and, again, we are totally aware of those situations.

The nurses, understandably, have some questions and they are fearful of something new that might encroach after years and years of having to make their own headway—especially with new innovative models like the nurse practitioner. I think that nurse practitioners fear that we are redundant and that we do a lot of the same things.

Senator POLLEY: In the sector providers are telling us that they cannot afford to have full-time, 24-hour, seven-days-a-week nurses in their residential-care homes. What is the difference in the level of funding that would be required to have a practitioner assistant as opposed to a registered nurse?

Mr Forde : That is a very good question. I am not sure, since we are not fully funded anywhere. Queensland Health is the only organisation, and Queensland is the only government, to actually sanction PAs to work in public health, but even they have quite a bit of trouble figuring out how to finance PAs without that access to Medicare reimbursement. Despite the fact legislation exists for PAs to even prescribe in the Queensland health system, they cannot get the reimbursement from the PBS if they do. It is a little hogtied.

Senator POLLEY: How much lobbying have you done with the federal Minister for Health to see that change?

Mr Forde : How much volume?

Senator POLLEY: How much lobbying has your organisation done to the Commonwealth government to have that reversed, as far as access to Medicare goes?

Mrs Beneke : How much work has ASPA done so far towards lobbying for the PAs?

Mr Forde : We have put in a lot of lobbying efforts over time. My boss, the dean of the med school, has set me loose since I got here in 2008, long before we had ASPA.

Senator POLLEY: Then if you have done the lobbying, what is the sticking point? I know the big organisations are against you, but surely, from the perspective of this inquiry this is all about the sustainability and the development of a good workforce within the sector. There would be some argument for the federal Minister for Health to take your profession quite seriously, because it is going to aid and abet this sector.

Mr Forde : There is. For example, we felt like we were making some inroads with Commonwealth government back when the Hon. Warren Snowdon was a minister. He is very pro-PA. He saw the use for PAs in the military as well as in Indigenous health, but then there was a change of government. That seems to have been the case in several different instances now.

Here in Queensland, the LNP government's Minister Springborg was the one who finally pushed policy through for PAs. Of course, now there is a new government so we are back to square one. The work towards getting the word out and moving forward has always been there, but I think a lot of variables that we have no control over have limited the access.

Again, the AMA is a very powerful organisation and it has not come around—unlike in places like the US, where the AMA started out in opposition in the sixties but by the early seventies they became the champion of the profession and set up the first registration and accreditation for teaching programs. The professional organisation in the UK is now actually part of the Royal College of Physicians and fully supported. Canada had a very similar situation, where they were fully supported and part of the department, or the organisation of family medicine doctors. We are looking for that here, but ACRRM and RDAA are fairly small compared to the Royal Australian College of General Practitioners and the Royal Australasian College of Physicians

Senator POLLEY: I have to say that until I read your submission, I was not aware of your organisation. I think that if there is only one element where you could be very useful in this aged-care sector it is in the assessment process, because that is very time-consuming at the moment and people are actually struggling to have a proper assessment. I can see that what you do in your own practice with GPs—having that time to spend on having an annual full consultation—being quite beneficial.

Mrs Beneke : It makes a big difference.

Senator POLLEY: I am looking forward to receiving some letters from you, to lobby us all to see that change.

Mr Forde : We actually got to what looked like a tipping point in 2011, after the HWA paper came out. We were considered by the Australian Health Ministers' Advisory Council, but the states were not together on the same page and they did not move forward to the ministers. They tabled it and said, 'Each state can do what they want to do'. But, of course, that cut us out of any benefits of being part of the Commonwealth health system. So we thought we might get there, but then it was back to the drawing board.

Senator IAN MACDONALD: What would be useful in this whole argument—you could put it on notice if you do not have it—is if you could tell us what the Medicare payment for a GP is and what you would propose the Medicare payment for a PA would be. That would clarify where you think you sit in the hierarchy and what you could do to help people with health needs. Do you have that figure off the top of your head or will you take that on notice?

Mr Forde : Looking at some of the other countries, in the US Medicare decided early on that they would pay nurse practitioners and PAs 85 per cent of what they would pay a doctor to do the same thing. All the commercial insurance companies pretty much followed along.

Senator IAN MACDONALD: That is interesting.

Mr Forde : Here I think there are several different possibilities, including a system that might allow a PA to bill through their supervising doctor so it would not be a separate issue but an add-on. I think cost effectiveness is the bottom line. It may not take a separate billing system for PA providers.

Senator IAN MACDONALD: Does your association have a policy on what the percentage should be?

Mr Forde : I do not think so, no.

Senator IAN MACDONALD: I think that would allay a lot of fears. Anyhow, this is really not aged care as such, but I think we are all a bit fascinated with the concept and see great benefits in having someone who is not quite a doctor but who can do a lot of things that doctors do, particularly in remote areas. I would be very interested in where you thought you fit in the pay scale, because that determines the usefulness scale. It also is an issue for the Medicare and government funding on who gets what. As you know, the budget is overstretched already. Anyhow, I would be interested to hear the association's formal policy someday.

Mr Forde : Can I come and talk to you when you are in Townsville some time?

Senator IAN MACDONALD: Okay. Where are you based?

Mr Forde : At JCU.

Senator IAN MACDONALD: Of course, you said that. Yes, please come and talk to me.

Mr Forde : That would be lovely. ASPA is a fairly small organisation at this point, with only 44 PAs out there and our students. Lack of funding is one problem. A little bit of the reason I have been at the tip of the spear is that I do work for JCU and I have been given a great ability to travel and do some of the things that ASPA as an organisation would not have been able to do. I still get that. My support—especially from the top down, from my dean, Professor Richard Murray—has been excellent. Without him, we would not exist,

Senator IAN MACDONALD: Thank you. Sorry, Senator Polley.

Senator WATT: Thank you both for coming in. Mr Forde, I do not know if you remember, but I remember having almost this exact conversation with you about seven years ago.

Mr Forde : I thought you looked familiar.

Senator WATT: I am a bit greyer!

Mr Forde : I am a lot greyer!

Senator WATT: I am sorry to hear that you are still fighting the same battles. Although I think when we spoke about it in a previous life it was about the role that PAs can play in the health system generally rather than just about aged care. I am interested in hearing a little bit more about what you think specifically PAs can offer in the provision of aged care in rural and regional settings. That is obviously the main reason we are having a hearing in Townsville—to explore the particular needs of regional communities and what options there might be. Would either of you like to elaborate a little more on that?

Mr Forde : I think there are a number of different avenues that PAs could travel down. Something like what Judy does now at rural general practices would certainly be very helpful. Also, home health visits, working at small nursing homes, taking some of the same coverage and call that the doctors are now strapped with. Three of our graduates from class 1 were all paramedics with a combined total time of experience of 78 years or something like that. They recently wrote a paper that was accepted by the Australasian college of paramedicine, in a nutshell, pitching the idea of the paramedic PA practitioner, particularly focused on rural and remote areas.

If you think about this, here in Queensland in a lot of those rural and remote areas the paramedics are not all that busy. It is 'hurry up and wait for something disastrous to happen' a lot of the time. They have free time. They also have what could be converted into a rolling general practice clinic or public health van. Some of those remote communities in those areas that are now serviced only by fly-in fly-out could be serviced by PA paramedics as well as emergency services. They could spend some of that time they are not working in emergency medicine inside the small hospitals.

In fact, we have actually trialled that model a little bit with one of the three students down in Cherbourg, at the small Queensland Health facility. When he was actually working still as a paramedic and was a PA student at the hospital, he did a little bit in between. We are very flexible. We are open to anything that would help reduce the burden of care. Our focus right now is to educate PAs to be flexible. So it is a general medical model. Much like, if you will, a stem cell, they are able to continue to grow into what is needed and where it is needed. Significant numbers of our graduates and current students live in very rural communities and would very much like to stay there. We have one in Goondiwindi. We have some in Roma and Oakey.

In fact, one of the other PAs that managed to get a job in general practice is in Oakey in Toowoomba, and she was hired by Dr John Hall, who is a pretty influential rural doctor. He is the current vice president of RDAA. He has been the president of the Rural Doctors Association of Queensland. I had a feeling that these two would hit it off, and Monique was a Queensland Ambulance Service paramedic. We do progressive clinical placements as part of the training. The first-year students do one week, 40 hours, more or less just to get out there and try out their newfound skills of taking a history, physical examination and case presentation. The second year they do 160 hours, a month's worth, to try to continue on and take those skills and be able to use some of the medical information that they are getting through the didactic part of the course. They are starting to synthesise that and starting to learn how to assess, deliver and actually start to make plans. The third year is all clinical placement—1,600 hours. They do 10 weeks of general practice, 10 weeks of emergency medicine, 10 weeks of in-patient service and then a smattering of aged care, pediatrics, and O and G, and five weeks for an elective.

I thought that this woman Monique might have a good relationship with John Hall and certainly she did. She wound up spending all of that time with him in Oakey. He has a general practice clinic. He has another clinic in Toowoomba. Until recently he was the SMO of Queensland Health's Oakey Hospital. Every day Monique would show up at the hospital first thing in the morning—in fact, working with a med student from Griffith who was there for a year-long rotation. They would go in at about 6 o'clock. They would do the rounds. They would have everything ready when John showed up at about 8. They would go back. He would take all the information they had gathered, take what he needed, sign everything off. And they were out of there by 9 or 9.30, whereas if John had had to do that by himself he would have been there all that time and then had to go in and see 30 or 40 patients at his clinic. Then Monique would go to the clinic with him, along with this med student, and they would work alongside him all day. They managed to develop a plan, somewhat like what Judy is doing now. John hired her out of school: the first PA actually working full-time in a general practice setting.

We are eager to study that a bit and then publish the results of how that is working, and hopefully get that out. I know John has testified before Senate committees before, too, in Canberra. It is just another example. In answer to your question, we are pretty flexible. Right now we are looking at a number of different models to be able to fit into rural and remote Indigenous settings. We are also very keen to try to upskill Aboriginal health workers and have actively talked to QAIHC and some of the other Indigenous organisations about trying to get behind moving their Aboriginal health workers our way, to come through the course.

CHAIR: I am particularly thinking also of the residential facilities where they have a great deal of trouble getting a GP to come in and then when they do there is limited time. I have heard, on many occasions, people complaining that they cannot get access to a GP in residential care. Would your model be applicable to residential care, to get some better support into residential facilities?

Mrs Beneke : Definitely. Because we are trained so closely to the medical model, a physician assistant can, basically, run the nursing home and do all the assessments that need to be done. The beauty about the role is that the doctor or the supervising doctor does not need to be on-site. If they are in close connection via phone or skype that is allowed as well. I can absolutely see where we can be utilised in nursing homes. You do not have to have the doctor there. He is at another location doing urgent stuff already, and the physician assistant can complete assessments on this side, order investigations, renew any scripts if scripts are needed and do referrals as well.

CHAIR: Thank you. This committee has heard a lot of things over the years about nurse practitioners and the opposition to nurse practitioners. It seems like this is a very similar situation.

Mr Forde : From my experience, going on 10 years now, the nurse practitioners I talk to on the ground are not necessarily personally opposed to us. They also know about models from the US where nurse practitioners and PAs work together in team environments—

CHAIR: Sorry, I was coming from the direction that we have heard that nurse practitioners have been opposed by others in the medical profession—

Mr Forde : Exactly.

CHAIR: and it seemed to me this was a similar situation. Is it?

Mr Forde : I think that some of the reason they are fearful of us is that they worked very hard and it took them 11 or 12 years to get access to Medicare and PBS. As you know, it took an act of parliament to get it for them rather than going to the usual avenue of MSAC. But at this point what we are heading for is to try to have a collegial and collaborative relationship with NPs.

On campus, we actually teach into the nurse practitioner program, helping to teach them clinical skills. I have had a very long lunch with the CEO of the College of Nurse Practitioners and, again, I think, on the ground, individual nurse practitioners, especially if they are aware of PAs or if they have worked with one, are much less likely to be in opposition. It is more the larger organisations. Probably, here, the largest opposition in Queensland is the Queensland Nurses Union. We are not sure why they are so fearful of us since we do not really practice nursing, and we are not going to take their jobs away. But they are a powerful force, and we are very tiny and not so powerful. It has been an issue trying to convince them that we are not a threat.

CHAIR: Thank you.

Senator IAN MACDONALD: On the scale of pay and usefulness—skill—you would go from a registered nurse to a nurse practitioner to a PA to a GP to a specialist. Is that right?

Mr Forde : One of the differences right now is that most of the nurse practitioners—I do not think this is the way they had originally planned it—wind up going back to the speciality area that they came from. Whereas the PA students, regardless of their background—for instance, Judy and I were both nurses in a different era, but I never went back to nursing and I certainly did not go back the to emergency department for a long period of time. I think right now the way we are training PAs in Australia it is very much a general medical model so that they can be used in a primary care setting and then where they are needed, but nurse practitioners right now tend to go back to where they came from and do a lot of their training in their specialty areas.

Senator IAN MACDONALD: Over the years, I have been to a lot of country hospitals where there is not a resident doctor, and what used to be called the matron actually did the work that you are telling me a physician's assistant does. She really did everything the doctor did except sign the forms and get the pay. It is an interesting concept and it could be hugely useful. I am not sure about the cities, but I come from Ayr and have a bit to do with the homes down there, and the doctors visit them, but they really have not got time and they do it only because it is their duty. I can see a real role for nurse practitioners, with the support of a doctor. It is an interesting concept. That is really all I had. It is more of comment than a question.

Mr Forde : It is not only the time that we would be able to afford doctors to see patients; it is also time that they can spend then doing teaching, which is part of the problem with the overloaded medical students and interns right now—doctors are so pressed for time to be able to do quality teaching. It is another area where PAs and nurse practitioners can take some of the load off doctors by seeing more of the routine cases or having whole populations, like Judy does, removed from their plate so that they have more time to do things like teach medical students.

CHAIR: Thank you very much for appearing today. It is very much appreciated.

Mr Forde : Thank you for having us.

Mrs Beneke : Thanks for your time.

Proceedings suspended from 12:22 to 13:17