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Community Affairs Legislation Committee
19/10/2011
Estimates
HEALTH AND AGEING PORTFOLIO
Aged Care Standards and Accreditation Agency Ltd

Aged Care Standards and Accreditation Agency Ltd

[19:39]

Senator FIERRAVANTI-WELLS: Mr Brandon, you probably heard that exchange with Mr Scott. Can I ask to respond from your perspective to those recommendations?

Mr Brandon : The only recommendation that we are required to do is one concerning the service charter. We have agreed to do that. We have our company annual general meeting next week, where the board will hopefully pass the annual report, and I am anticipating that we will report our performance in that annual report.

Senator FIERRAVANTI-WELLS: I have a question in relation to some of the comments that were made in the Auditor-General's report. Before I go there, could you explain to me what the basis is of your visits to aged care facilities? You heard the comments I made before. What is your rationale? I understand that you do it if there is a complaint, but—

Mr Brandon : We do three sorts of visits. The two main ones are accreditation audits, which for most homes happen triennially, and support contacts, which are now known as assessment contacts. The vast majority of homes last year received only one support contact; very few received two or more. We would do a support contact for a number of reasons. First, we may receive information from the complaints investigation people. Second, we place on a timetable for improvement the 10 percent of homes which are found to have non-compliance at a site audit, and we then follow them up. The other reason that we would do a support contract would be that during a site audit or a previous visit we had identified a system which had the potential to fail but had not failed. We would say in the report we gave them: 'We see weaknesses in your system. That doesn't mean you haven't met the standard, but we have concern about that so we will go back and look at that.'

We also identified and published our findings on what creates risk, such as a change of owner or a loss and change of key personnel. If we become aware that there has been a change in key personnel—because we know it is a risk creator which, left unmanaged, creates a lot of risks for residents—we will go back and do a visit. Above and beyond that, we have the government's program of every home receiving one unannounced visit. You may have noticed that in the Auditor-General's report he spoke favourably about our case management processes. The case management process decides which home we will go to, even within the unannounced program. Also, our knowledge of the home—its previous history; information we have from other sources—directs what we look at when we go to the home for a support contact.

Senator FIERRAVANTI-WELLS: How many assessors do you have all around Australia?

Mr Brandon : There are 396 registered assessors who are registered under the Aged Care Act and approximately 135 in our full-time employment. The balance of people, who generally work in the aged care sector in what I describe as their day jobs, we use on a casual basis.

Senator FIERRAVANTI-WELLS: What processes do you have in place to ensure consistency of approach by those assessors? Anecdotally, as I have gone around, people have said, 'I've got one assessor who comes in and makes comments about the way of doing things; somebody else comes in and gives me another view.' What is in place to ensure consistency of approach?

Mr Brandon : There are two things. When aged care managers talk to us about that, were meet with them and try to understand what they are talking about, because, given human nature, aged care workers will have slightly different approaches. The way we seek to ensure that there is an accuracy of the assessment—which is what it is really about, because very few people in fact complain about the outcome or the result; the few complaints we get tend to be about approach—is the selection process, on which the requirements under the Aged Care Act are quite rigorous. We have an eight-day training program and a two monthly update program for assessors. We have a performance management system. We have mentoring of assessors all the time. We have observers on audits. There are few other odds and sods, but that is about the gist of it. We also have international accreditation of our assessor training and management.

Senator FIERRAVANTI-WELLS: Will assessors that might go into a home have access to the reports of previous assessors who have gone in there? Is that part of that risk profile?

Mrs Crawford : They will have access to the reports that, via our case manager process, we think are going to be useful to them. We do not really want assessors going back over a 12-year history and looking at reports. We are interested in what is happening now but we do need to build on what has happened recently. So, if there has been an assessment contact because the home has areas where it has not met the accreditation standards then the assessors need to know what has been looked at before, what things have been improved, and how that home is moving. So they will have access to those sorts of reports on an as-needs basis.

Senator ADAMS: I would like to ask a question about the new agency Regional Health Australia, which has been created to provide a single entry point to information on regional health and age care programs. Where do I ask questions about that?

Ms C Smith : I believe that would have been under the rural health outcome.

Senator ADAMS: I did not ask it. I think that one went wrong.

Senator McLucas: I think you were asking questions about work force, Senator.

Senator ADAMS: I was, but age care is on page 6 of the department's report. I was wondering where I ask questions on age care or where I put my questions on notice.

Ms C Smith : I think you are referring to Regional Health Australia.

Senator ADAMS: Yes.

Ms C Smith : It has been designed to do that focus at a regional level on both health and age care programs. I believe there were people here before dinner who took questions on that.

Senator ADAMS: In that case I have only one question on program 4.3, aging information and support, early onset dementia. There was a younger onset dementia summit held at Parliament House in 2009. Since that summit, what action has the government taken to ensure that there is age-appropriate services for young people with dementia?

Mr de Burgh : Younger onset dementia affects approximately 15,000 people in Australia today. It can affect people in their forties and fifties. Programs and services funded by the Australian government around support for dementia are available to all people living with dementia, regardless of age. There are, however, a number of programs and supports which are specifically designed to incorporate the needs of people with younger onset dementia. This includes activity through the National Dementia Helpline, which provides counselling and support, behaviour management advice and training for people with dementia and their carers. There are some examples of particular activity that we fund for people with younger onset dementia. Would it be easier for me to take some of this stuff on notice?

Senator ADAMS: All right. I would appreciate that. Did the government take up a lot of the recommendations that came out of that summit? What was the outcome of the summit?

Mr de Burgh : I would have to take questions on that on notice and look at the recommendations before we can do that.

Senator ADAMS: The latest aged care approvals round closed in August. Given the recent undersubscription of places in residential places would you please advise the level of interest from service providers in applying for these providers. Has there been an undersubscription?

Ms C Smith : The invitation to apply for places was advertised on 18 June and applications closed on 2 August. Those applications are currently being assessed by the department and we would expect to be in a position to make announcements later this calendar year. Given that there is an active consideration and a process going on, we do not comment on the nature of the applications we received during that process. Those kinds of discussions, we can have after the round has been announced.

Senator ADAMS: The government recently changed the rules in relation to extra service places, making it easier for providers to apply for these places. This might cut across what you just told me. Has there been an increased level of interest in these places, with the extra service?

Ms C Smith : It is the same issue. We cannot comment in terms of the nature of the applications, but you are correct. We still have the same criteria in the act and the principles to apply but there was additional information in the guidelines that went out as part of ACAR on how we would interpret ESS applications.

Senator ADAMS: What do the extra care places consist of, or is that too long a list to let me know? I should know but I just cannot remember.

Ms C Smith : I am sure we can give you an example of the types of things that can be offered.

Ms Robertson : It is not actually extra care that is provided. Extra service is around the sort of amenity that you would have within an extra service place. It might be things like upgraded furnishings, a choice of different meals at mealtime—a menu, a glass of wine with your dinner—and things like that. It is having the ability to have a hairdresser. A lot of the facilities that I have seen personally have very high-tech theatre equipment for watching movies and things like that; really top-end screens and audio-visual equipment. That sort of thing. It is about making your life more comfortable rather than providing an extra level of care.

Senator ADAMS: Are those things flexible, if the resident perhaps does not drink wine, or cannot read the newspaper or cannot see the TV? Is there any flexibility with the home where they could add an extra something that pertains to that particular resident?

Ms Robertson : Certainly individuals will avail themselves of different services that are available and that would be up to an individual negotiation between the person or person's representative and the home. In that particular case somebody might have additional aromatherapy or massage or something like that.

CHAIR: That concludes our discussion on aged care. We will now go on to outcome 3. I will just let you know that we have had a discussion and we will not be able to fit in NHMRC tonight—we just cannot do it—so they will be on tomorrow morning. With the time frame this evening, we cannot fit them in. We will start with Medicare services.

Senator DI NATALE: I am particularly interested in the Chronic Disease Dental Scheme. Do you have any information to suggest how much the Chronic Disease Dental Scheme will cost the Commonwealth in 2010-11?

Mr Thomann : We have some information on the expenses accrued for the Chronic Disease Dental Scheme. I am not sure whether I have it for 2010-11. We have been accounting since its introduction, so we have some cumulative figures from its introduction. For the cumulative figure, I believe we are up to about $1.9 billion, but perhaps Ms Hancock would care to elaborate. We do not have it by financial year; we have not done that calculation.

Senator DI NATALE: You have not broken it up by financial year?

Mr Thomann : We do not have it with us. We would have to take that on notice.

Senator DI NATALE: Okay. Could you do that, please?

Mr Thomann : That is for 2010-11?

Senator DI NATALE: If you can, from the inception of the scheme—if I could have expenditure per financial year.

Mr Thomann : Sorry, Senator: we do have the figure. For 2010-11, it is $726.4 million.

Senator DI NATALE: That is to date?

Mr Thomann : That is for 2010-11. To date, in 2011-12, it is $144.8 million at 31 August 2011.

Mr Thomann : This is for the CDDS. In the financial year 2010-11 it is $726.4 million.

Senator DI NATALE: Do you have any idea how the figure for 2011-12 to date compares with the same period for 2010-11?

Mr Thomann : No, I do not have those figures here, but we could do an analysis on notice.

Senator DI NATALE: Great, thank you. I have not asked you to account for previous financial years, but I understand the expenditure has been increasing each year from the inception of the scheme.

Mr Thomann : It has—

Senator DI NATALE: What do you believe to be the chief drivers of the growth in expenditure?

Mr Thomann : Demand.

Senator DI NATALE: More people being seen? The types of services provided? Are we seeing an increase in the more expensive item numbers?

Mr Thomann : We have not done that analysis.

Ms Halton : It would just be more people accessing the program.

Senator DI NATALE: It is not a change in the profile of item numbers?

Ms Halton : We can check, but I doubt it. I think it would just be the number of people who become aware of the program and use it. If that is not correct, we will correct it on the record.

Senator DI NATALE: Good, thank you. What are the items on the schedule that cost the most in total?

CHAIR: To the government?

Mr Thomann : Do you mean as an item?

Senator DI NATALE: Yes.

Mr Thomann : It is the high restorative procedures.

Senator DI NATALE: Do you have that as a proportion of the total expenditure on the scheme? What I am asking is: what proportion of expenditure do the restorative treatments make up?

Ms Hancock : I do not have the exact figures, but it is just under 30 per cent.

Senator DI NATALE: We are talking crowns—

Ms Hancock : Crowns, bridges and implants.

Senator DI NATALE: Is there any evidence that that is changing? I suppose that gets back to my earlier question. Has that been a fairly static figure?

Ms Hancock : We would need to check.

Senator DI NATALE: Good. How many patients in total have been seen under the scheme?

Ms Hancock : To 31 August, 784,198 patients.

Senator CAROL BROWN: Do you have a breakdown of states and territories?

Ms Hancock : No with me, but we could get that.

Senator CAROL BROWN: Thank you.

Senator DI NATALE: Do you have an estimate on how many Australians in total might be eligible for treatment under the scheme?

Ms Hancock : No.

Senator DI NATALE: Are you able to get a gauge of that or is it too difficult?

Mr Bartlett : Essentially you have to meet the criteria of having a chronic disease, and really that changes day to day. We could not make an assessment of potentially eligible clients on that basis.

Senator DI NATALE: I would be surprised, though, if you did not have—

Mr Bartlett : We can tell you how many people are accessing those arrangements and for whom those GP items are being claimed at the moment. Whether or not they therefore need dental care is a different factor, so to try to break it down is very hard.

Senator DI NATALE: Okay. If the scheme were to continue unchanged—it does not sound like you have, but I will ask anyway—do you have any sense for the expenditure for this coming financial year? I suppose that depends on a comparison of where we are at the moment and the previous years. Do you have a sense of what expenditure is going to look like for this financial year? I have heard people suggest that we will hit the $1 billion mark and I wonder if you have done any modelling to suggest that that is the case.

Ms Hancock : Provision has been made in the forward estimates for expenditure up to the end of this calendar year but not beyond that.

Senator DI NATALE: So you have not done any modelling at all beyond the end of the calendar year?

Mr Thomann : No, we have not done any modelling of trends.

Senator DI NATALE: No modelling of trends at all. Is that something that the department—

Mr Thomann : Not into the future, no. But we are obviously observing a trend, a gradual increase month by month.

Senator DI NATALE: I have had some analysis presented to me that suggested that over time the cost per patient drops quite sharply, because that burden of existing disease is worked through. In other words, once we get through the initial burden of disease we might see a drop-off in the cost of the scheme. Have you got any information along those lines?

Ms Halton : No, Senator. I would be curious to see that analysis though.

Mr Bartlett : It would also seem to run counter to every other area of medical treatment—

Senator DI NATALE: No, it would not, because we are providing a public service that was not available previously. The hypothesis, I suppose, is that there is a burden of disease, we work through that burden of disease and eventually we reach an equilibrium and the costs might start to decrease.

Ms Halton : But countervailing that theory, Senator, essentially what that says is you are treating a backlog and once the backlog is cleared you will get to a natural state of demand. But the question you asked earlier, about what explains the growth—which is more people becoming aware—I think it would take quite some time, just speaking hypothetically, before all of that backlog (1) became aware and (2) presented itself. As the mathematicians would say, at infinity point it is a good theory but I suspect it would take probably more than my career and lifetime before we got there.

Senator DI NATALE: Perhaps I will forward you on the analysis—

Ms Halton : I would be very interested to see it.

Senator DI NATALE: I suggest it might a lot sooner than we think. How many dentists are currently participating in the scheme?

Ms Hancock : To date, 11,375 dental providers.

Senator DI NATALE: That is individual providers, all of whom have accessed an item number at some stage.

Ms Hancock : That is correct.

Senator DI NATALE: Is the number of dentists participating in the scheme increasing? I suppose what I am asking is: are we seeing an increase in the number of new dentists who participate in the scheme?

Ms Hancock : There has been a gradual increase since the program started.

Senator DI NATALE: So that is a linear increase. You are not seeing, as more dentists become aware of it, a sharp increase in the number of dentists who participate?

Ms Hancock : No, there has not been a sharp increase.

Senator FIERRAVANTI-WELLS: The increase is proportionate to the number of dentists?

Ms Hancock : Yes.

Senator DI NATALE: What is the process for making dentists aware of the scheme?

Ms Hancock : There is not a process for making dentists aware of the scheme.

Senator DI NATALE: Has the department been given any instructions in terms of the future of the scheme—what is likely to happen?

Ms Halton : The government's position on this is quite clear. It stated that its preferred position would be to close the scheme, recognising it does not have the support currently. That is its stated position and I am not aware that that position has changed.

Senator DI NATALE: So it would be safe to say that you are operating under the assumption that the scheme will close by the end of this year and the corresponding item numbers will be removed from the MBS?

Ms Halton : We understand the government's position and we also understand that the legislation is not being re-presented because of the circumstances which the government finds itself in with respect to the view of the Senate.

Senator DI NATALE: But the fact that you have done modelling only to the end of this financial year would indicate that perhaps you are working under that assumption? Would that be fair to say?

Mr Thomann : Senator, what has occurred is: because of the government policy to close the scheme, it is only possible to do a forward estimate for a certain period of time. That figure is the estimate agreed with the Department of Finance and Deregulation and the data of 31 December is simply for the purposes of producing an estimate for the budget.

Senator DI NATALE: Understood. Thank you. Given the current intention of the government to close the scheme, have dentists been notified of that fact? Is it your role to do that—to notify dentists that the scheme may be closed and that those item numbers will no longer apply?

Mr Thomann : I think it would be fair to say that the ADA and dentists are aware of the government's position.

Senator DI NATALE: But the department is not taking any action to notify dentists that the scheme may close?

Mr Thomann : No, we have not been. I think dentists are fully aware of the government's position.

Senator DI NATALE: I suppose there are dentists who would say that they were not aware of the framework for the scheme and of being caught up in a difficult process of auditing. At this stage the department has not done anything.

Mr Thomann : No.

Ms Halton : No, and I might make a particular comment about the auditing question, given that the comment has been raised. I am aware that the CEO of Medicare Australia wrote to dentists quite some time ago about the auditing obligation and the accountability obligations in relation to those items.

Senator DI NATALE: I have got a number of questions about the audits. I wonder whether they should be put to you—

Ms Halton : Not for us, no.

Senator DI NATALE: We will save those until tomorrow.

Ms Halton : Yes.

Senator FIERRAVANTI-WELLS: I was going to follow on from some of your questions, Senator. Will the Medicare dental items be repealed by regulation? Is that the intention?

Ms Hancock : The Medicare chronic disease dental scheme is set up by legislative instrument. In order to make any change to the scheme, including closing it down, a legislative instrument needs to be made and tabled in both houses of parliament.

Senator FIERRAVANTI-WELLS: Have you drafted this?

Mr Thomann : No.

Senator FIERRAVANTI-WELLS: You have not drafted it, so you have not contemplated registering it yet. Assuming 31 December, will the regulation be tabled in parliament before the scheme is closed?

Mr Thomann : Sorry?

Senator FIERRAVANTI-WELLS: Is it the intention to table the instrument in parliament before the scheme is closed.

Mr Thomann : That would be the process. The 31 December is the date for the purpose of accounting the forward estimate. On process, yes, the instrument would need to come before the House.

Ms Hancock : The scheme cannot be closed without the legislative instrument to give effect to the closure.

Senator FIERRAVANTI-WELLS: Hypothetically, if the scheme is closed on 31 December, or some other date, and the parliament disallows the regulation to repeal the item numbers next year, will patients currently eligible for the scheme be able to use the balance of their $4,250 in benefits?

Ms Halton : We are getting ahead of ourselves. The government has a stated policy but the government has indicated that until it is assured of support it is not moving. We are into a hypothetical here which we actually cannot answer.

Senator FIERRAVANTI-WELLS: What assessments have been made of the impact of the closure of the scheme?

Mr Thomann : Can you be more specific?

Senator FIERRAVANTI-WELLS: Impacts on the profession and on public dental services.

Ms Halton : The government's stated policy intention was to put money into public dental services—

Senator FIERRAVANTI-WELLS: My questioning was then going to ask whether you are aware of comments made by the New South Wales branch of the Australian Dental Association—and I am happy to provide a copy of this for the record—where Mr Fisher warned, 'Should the CDDS cease on 31 December, there will be flow-on effects for public dental services in New South Wales and increased demand for services beyond the additional funding and capacity made available under the proposed CDHP, and it will increase both the number of people on the public dental waiting lists and the length of time that they will wait for treatment.' Given such warnings, have you looked at and have you made assessments in relation to the effect of the closure of the scheme?

Ms Halton : No.

Senator FIERRAVANTI-WELLS: Clearly there will be an impact on the public dental system. Has this impact been quantified? How many more people will be on the public dental waiting lists? Have you done that sort of assessment?

Mr Thomann : No, we have not and I am not sure how we would do that. We have not done that kind of analysis.

Senator FIERRAVANTI-WELLS: In answer to a question on notice—and I do not have in front of me-I think you told me that there are about registered 1,600 dentists in the public system.

Mr Thomann : That is true.

Senator FIERRAVANTI-WELLS: Have you considered the impact, particularly in light of the fact that there is that limited number of dentists in the public system?

Mr Thomann : Dentists are only part of the equation in the public health system. There is also a sizeable proportion of dental therapists working in the public system. The public dental system has a different workforce profile to the private system.

Senator FIERRAVANTI-WELLS: Perhaps you might take on notice the profile of the public dental workforce. I think we have discussed this before and we confined our discussion to dentists in the public system rather than the dental workforce. Perhaps you could take that on notice and provide me with some statistics in relation to that. I do not have any more question of that scheme.

CHAIR: I am reminding people of time. What other questions do you have in outcome 3?

Senator FIERRAVANTI-WELLS: I have got questions in relation to women receiving ultrasounds by obstetricians and gynaecologists in their rooms.

CHAIR: Is that diagnostic imaging services, 3.3?

Mr Bartlett : It is probably more 3.1.

[20:15]

CHAIR: We will move to outcome 3.1, Medicare services.

Senator FIERRAVANTI-WELLS: What arrangements would be put in place to ensure that the public hospital system can cope with privately insured women patients abandoning specialist obstetricians? There have been reports about the government attempting to call back money from Medicare by refusing rebates of $29.95 to women who receive ultrasounds by obstetricians and gynaecologists in their rooms.

Mr Bartlett : Sorry, I am not aware of the circumstances you are describing. I have seen stuff about safety net changes in terms of obstetrics but the ultrasound changes I am—

Senator FIERRAVANTI-WELLS: There have been reports that public maternity wards have been overwhelmed since the cuts to the extended Medicare safety net for obstetricians.

Mr Bartlett : In terms of safety net changes, yes, there were changes made to cap outlays on the safety net. There have been a number of assertions made about people moving from the private to the public sector. There is very little evidence to support those assertions at this point.

Senator FIERRAVANTI-WELLS: Any issues in relation to that are wrong.

Mr Bartlett : There is very little evidence at the moment that supports an assertion that is being made by people like NASOG that there is a significant shift of patients from the private to the public sector.

Senator FIERRAVANTI-WELLS: Thank you. I have got further questions on that but I will put them on notice.

Senator DI NATALE: I have a couple of questions on arthritis injections and midwifery.

CHAIR: That is the PBS element?

Senator DI NATALE: Yes. I think Senator Fierravanti-Wells also had some questions on the injections, so I am not sure if I will cover those. The item numbers for joint injections and aspirations, items numbers 50124 and 50125, were removed. I am just wondering if you have any numbers in terms of people who have been affected by that decision. Do you have any sense of how many people would have been eligible for those two item numbers?

Mr Bartlett : I can give you the number of people for whom that item was being paid prior to the change; I cannot tell you how many have been affected now?

Senator DI NATALE: That would be helpful, thank you. Obviously, one of the ways for achieving the outcomes under those two item numbers would be for a patient to be issued with a prescription which would then be dispensed through the PBS. Have you got any evidence that there has been an increase in the number of prescriptions dispensed for steroid preparations through the PBS since the removal of those two item numbers?

Mr Bartlett : I have got no evidence, but that is a PBS matter so, unless I ask a specific question of pharmaceutical colleagues, I am probably not going to have that information; I have not asked that question.

Senator DI NATALE: So you would not necessarily look at the impact of a decision to remove an item number as it may relate to another area of government expenditure?

Mr Bartlett : We would look at it in a range of ways and, in terms of joint injections, one of the things that we have done is offered a range of the affected provider groups to apply and make a case for the need to provide joint injection items for specific services. The only group that has taken that up is the rheumatologists. There is an assessment of that going through at the moment. It was reviewed by MSAC in April. They have asked for some more information. The Rheumatology Association and the arthritis association have worked together to provide that information. It will be reconsidered by MSAC in November.

Senator DI NATALE: One of the other ways around it would be to have a radiologist use ultrasound or X-ray control for a joint injection, which is obviously a much more expensive item number. Do you have you any sense of whether or not there has been as increase in those item numbers since the removal—

Mr Bartlett : Not to the extent that you would expect to see if what you are describing was occurring, no.

Senator DI NATALE: So there has been no change in those item numbers that you are aware of?

Mr Bartlett : Those item numbers have changed over time, but there is certainly not the sort of spike that you would expect to see if you were seeing a change in practice of the type you are describing.

Senator FIERRAVANTI-WELLS: At Estimates on 10 February, you said your standard would be for there to be a decision within three to four months. I think it was in response to a question from Senator Boyce. You said, 'We would be aiming to go through and process it provide advice to government within three to four months.' That was back in February. What is the situation now?

Mr Bartlett : Within two months of that date, the application was provided to MSAC for assessment. MSAC went through an assessment process. It believes that it requires more information to be able to make a decision on the application that has been made. We have gone back to the two groups involved and they have put that information together, with our assistance. That will go back to MSAC in November. So it met that three- to four-month time frame.

Senator FIERRAVANTI-WELLS: I am following up on Senator Boyce's question.

Senator ADAMS: What progress has there been with the uptake of the new MBS items for videoconferencing?

Mr Bartlett : In the period between 1 July and 13 October, there have been 2,275 items claimed.

Senator ADAMS: You may need to take this on notice but what is the range of medical specialists so far involved?

Ms Shakespeare : There have been a fairly broad range of service groups provided so far. The most services have been provided through consultant physician attendances. There have also been psychiatric attendances, specialist consultations—item 104—and a smaller number of neurosurgery and obstetric attendances. I think those are the main categories.

Senator ADAMS: What are the number and proportions of patients that have been seen in each ASGC RA? Could you take that on notice perhaps?

Ms Shakespeare : I could give a breakdown by RA. It is 19 per cent of the services in RA1, inner and outer metropolitan areas; 35 per cent in RA2; and 34 per cent in RA3. So that is a total of 69 per cent in regional areas. And it is 12 per cent in RA4 and RA5, remote areas.

Senator ADAMS: What settings have the patients been in in those remote areas? Have they been at a community resource centre, at a health service—

Ms Shakespeare : Unfortunately, it is not possible for us to tell setting from the Medicare claims data.

Senator ADAMS: I was just wondering what facilities they were able to get to.

Mr Bartlett : The impression we are getting is that the overwhelming majority of these services, from the patients' perspective, are being done at GPs' rooms. Some of that will become clearer as some of the incentive payments for the practices that are delivering them are made down the track. At this stage, we do not have the data to be able to tell for sure. It is anecdotal.

Senator ADAMS: That is pretty good take-up for just those few months. It has been worth pushing for it. That is all I have on MBS.

CHAIR: We will now go on to midwifery.

Senator DI NATALE: I have a question about midwives who are eligible for Medicare. They need to display current competence for pregnancy, birth and post-birth care. The problem is that the preferred insurance product does not cover public patients and midwives have very limited access to private hospitals. So we have a situation where, of the 61 midwives with Medicare provider numbers, only two have been granted visiting access to a public hospital. How can midwives demonstrate competence and practice within the confines of their practice, given the limitations that exist so that they are eligible for a provider number?

Mr Bartlett : Senator, in terms of what you are describing, the MBS is designed for private practice. In terms of practice in public hospitals, there is clearly potential for midwives to offer private practice in public hospitals. There is the whole question of accreditation for visiting rights that is being dealt with gradually but, I would have to acknowledge, quite slowly. There is a program in place in Toowoomba that is starting to make that available to people. New South Wales is doing some work in looking at it. It is gradually being taken up as an issue that needs to be dealt with. Not surprisingly, there is a degree of concern about indemnity risk and things like that, in terms of people providing services outside their range of competence. It is going to be a fairly gradual process, as this has been.

Senator DI NATALE: What is your sense of why it has been so slow? What are the obstacles to improving the pace of change in this area, given that we have so many midwives who are eligible but are unable to do it?

CHAIR: Mr Bartlett, you cannot offer an opinion, in terms of the evidence that you been able to speak on.

Ms Halton : I was just about to make that comment.

Senator DI NATALE: I am asking for whether there are any obvious impediments to the necessary reforms.

CHAIR: We are trying to get an answer, Senator; I am just trying to phrase it in a way in which the officer can answer. I am not trying to stop you.

Senator DI NATALE: Thank you.

Mr Bartlett : The concerns that have been expressed to us are that it is like a lot of areas where you are introducing a significant change to existing practice. It takes a fair amount of time for people to develop confidence in that. They generally tend to look for existing successful models that give them that confidence. There are things happening at the moment that may well achieve that, but I think it will take time for that level of confidence to build and for the take-up to spread. That is not inconsistent with what we see with a range of new programs as they are introduced.

Senator DI NATALE: Okay. Senator Fierravanti-Wells, do you have any more questions on midwives?

Senator FIERRAVANTI-WELLS: I do.

CHAIR: Senator, I have to remind you of the time.

Senator FIERRAVANTI-WELLS: I am happy to put my questions on notice. I also have some questions on the extended Medicare safety net which I will put on notice.

CHAIR: We have concluded questions on outcome 3. I thank the officers. There will be several questions on notice. We move to outcome 2: Access to pharmaceutical services. Some questions flow over from the previous section.

Senator DI NATALE: I have some questions about the Pharmacy Guild. Clearly, there have been some issues recently around the guild's relationship with several pharmaceutical companies. In fact, a number of members of the profession have expressed their disappointment with the position adopted by the guild. It appears clear that the guild now no longer represents a significant body of pharmacists as a profession. In light of the recent issue with Blackmores and Pfizer and also in light of the fact that there have been some proposed changes to the location rules for pharmacies, I am interested in whether the department sees the guild as essentially representative of the pharmacy sector or the patient.

Ms Halton : You have couched that question in a context which brings a whole series of loaded meanings to it. Can I make a couple of observations. Firstly, issues in respect of the guild and the Blackmores arrangement are largely regulatory, and you would be aware that the Therapeutic Goods Administration has taken a number of actions in relation to that particular arrangement. The government has a remuneration agreement with the Pharmacy Guild, and that has been the case for as long as I have been involved in these issues. The Pharmacy Guild and, to a slightly lesser extent, the society have been the key parties with whom we have negotiated those remuneration agreements for, again, as long as I can recall. So I do not think we have a view about the representation or otherwise of patients in this respect. The reality is we have a relationship with the guild in relation to remuneration for the services that they provide in the dispensing of pharmaceuticals.

Senator DI NATALE: My questioning really relates to the exclusivity of that relationship and whether in fact the department is considering other voices within the profession and other representative groups who may actually take a different and, I would suggest, in some instances more representative view of the profession when negotiating on issues that relate to the profession.

Ms Halton : I think we need to make a distinction in terms of what matters we are discussing. The reality of professional matters in relation to the profession of pharmacy, workforce issues and a series of other things is that they are not just matters for people in the pharmaceutical benefits area of the department; they are a more wide-ranging issue. We would talk to a number of people, including academics, in respect of the practice of pharmacy as a profession, and that has always been the case. I think we need to be quite clear about which domain we are talking about here because the people we discuss these various matters with varies depending on the subject of the conversation.

Senator DI NATALE: Let us look at a specific example, the Urbis review. Given that the intent was to provide an independent review, do you think it is appropriate that the review committee directing Urbis was made up essentially of representatives from the guild and the department exclusively?

Ms Halton : It would depend on the context. The officers can talk to you about the context in which that particular review was undertaken because I think that goes to who was party to it. Ms McNeill can give you more detail on that.

Ms McNeill : The new rules you are talking about emanate from the Urbis review, which was concluded in 2010. Whilst the action of those recommendations is something we have been negotiating with the guild, the input into that broad consultation and the development of that review included a large number of stakeholders—over 16. There were representative groups such as the Consumer Health Forum, the PSA, hospital pharmacies—a wide variety of stakeholders. That review was independent and thorough and gave us a suite of recommendations. Actioning those recommendations has been the responsibility of the department, which we have done in consultation with the guild as part of the implementation of the Fifth Community Pharmacy Agreement.

Senator DI NATALE: Given those extensive consultations with stakeholders other than the guild, can you indicate whether the government's announcement on the location rules differs at all from the original proposals of the Pharmacy Guild?

Ms McNeill : The announcement on the pharmacy location rules, which came into effect yesterday, reflects the consideration and recommendations of the review. Not all recommendations are fully supported by the guild. Not all recommendations were necessarily fully supported by any particular stakeholder that was consulted. What they reflect is extensive negotiations that have gone on between the department and the guild over the previous six months to give effect to those findings, which was about maintaining community access in existing locations and making it easier for pharmacies to establish in new community pharmacy locations. One of the things the department put a lot of effort into, in the implementation and negotiation of these revised rules, was to look at the fact that it was predominantly based on the relocation of pharmacies, which means taking a licence from one pharmacy in one particular area and moving it to another area. That was the predominant way that the rules were supported. Twelve of the 14 rules relied on that. We have restructured that quite significantly to make sure that pharmacies stay in communities where they are already needed, and made it much easier and simpler to make new pharmacy applications, to try and stop that shift.

Senator DI NATALE: In terms of the location rules, which ones were not supported by the guild? How many?

Ms McNeill : I would have to take that on notice. I do not have that information with me.

Senator DI NATALE: Finally, has the department communicated, either formally or informally, with the guild about the relationship—now no longer—with Blackmores? If so, what was the nature and purpose of that communication?

Ms McNeill : I think the secretary has already answered that. That work was already done predominantly by the TGA.

Senator DI NATALE: So your department has not—

Ms Halton : The TGA is part of my department.

Senator DI NATALE: Okay, sorry. What was the nature and purpose of the communication with the guild on that matter?

Ms Halton : We will take that on notice so that I do not mislead you, but I can assure you that the matter was of some concern to us.

Senator DI NATALE: Good.

Senator FIERRAVANTI-WELLS: I have questions further to some of the questions that Senator Di Natale was asking. In relation to the change in the pharmacy location rules, what organisations were consulted on the changes to the rules after the review was conducted?

Ms Janz : As part of the review there were 17 different organisations that were consulted, including the guild and the department, of course; Medicare Australia; the Royal Australian College of General Practitioners; the Australian Medical Association; the Pharmaceutical Society of Australia; the Australian Community Pharmacy Authority, which is the authority that makes the recommendations around the location rules; the Association of Professional Engineers, Scientists and Managers Australia; the Society of Hospital Pharmacists of Australia; the Pharmacy Board of Australia; the Consumer Health Forum; and the National Rural Health Alliance. As well as that there were four independent brokers that usually act on behalf of pharmacists who apply under the rules. The Primary Health Care centre provided a submission and there was an on-line survey of 15 applicants who had applied under the location rules, to seek their views, as well.

Senator FIERRAVANTI-WELLS: Did this all take place as the single consultation or were there individual consultations?

Ms Janz : It took various forms. There were conversations and interviews, mostly, with the organisations or representatives of the organisations, and then there was the on-line survey of the 15 applicants. There were workshops held following the review, as well, which built on the findings of the review and how those might or might not be taken up.

Senator FIERRAVANTI-WELLS: Were some organisations agreeing to the changes? Did everyone agree or was there a mixed reaction?

Ms Janz : They had various views. They expressed their views around the existing rules and things that could be done to improve those. Those views were looked at to take a way forward in terms of streamlining the arrangements to make it easier, cheaper and more efficient for everyone—for applicants as well as the administration of the scheme.

Senator FIERRAVANTI-WELLS: What problems are the new location rules attempting to fix? Why did they need to be changed? Can you just give me an outline of that?

Ms Janz : Yes. The rules that came into effect yesterday were looking to address the unintended consequence of the previous rules. For example, there became a trade in approval numbers. So in order to establish a pharmacy there were many of the rules that relocated a pharmacy often from a rural or a regional location into another location. In doing so there became a trade in these pharmacy approval numbers up to about $500,000, which was then increasing the costs of establishing a pharmacy in another area. At the same time that then created a temporary or a longer term gap in services in the areas where the pharmacy approval number came from until that could be filled. So it was addressing that—

Senator FIERRAVANTI-WELLS: By another trade?

Ms Janz : Yes. Or a new pharmacy coming in to a rural area which was easier to establish. So this is really looking at a way of dealing with that and also opening up the rules. Under the old rules there were 14 rules. Two of those were for establishing new pharmacies, and under the new rules we have seven ways of establishing a new pharmacy. So what we have done is open it up to make it easier for pharmacies to be established in locations based on community need.

Senator FIERRAVANTI-WELLS: So you obviously went through a consultation process in relation to what needed to be changed in respect of the old rules, but what organisations were consulted in relation to the new rules specifically?

Ms Janz : We needed to be careful here because we did not want to give any particular group a commercial advantage in the situation because it was around being even-handed in the way the rules were changing and not letting people know in advance what might be happening so that they could take advantage of that situation. So we were quite limited in the conversations we could have, but we did have conversations with Consumer Health Forum representatives around those issues in terms of how effective they were or whether they was going to be any gaps as a result of the changes that we were seeking to implement.

Senator FIERRAVANTI-WELLS: Only the Consumer Heath Forum?

Ms Janz : We had negotiated with the guild as well because a requirement of the fifth community pharmacy agreement under which the pharmacy location rules operate was that any changes to those would need to be negotiated with the guild, so they were included and that is why we negotiated on that basis.

Senator FIERRAVANTI-WELLS: So the guild and the Consumer Health Forum and that was it in relation to the new rules?

Ms Janz : As well as government agencies, Medicare Australia and—

Senator FIERRAVANTI-WELLS: A series of relevant government bodies. Can you tell me, with respect to rule 130, why is it necessary that there be a large supermarket within 500 metres of the proposed pharmacy? And the rule states that you need the evidence of a full-time prescribing medical practitioner and you need a stat dec or a statement from that practitioner. Can you give me the rationale behind that?

Ms Janz : One of the other reasons we were looking to simplify the rules was that there were difficulties around catchment area under the old rules. So in order to establish a pharmacy you would look at a catchment area which had a certain population. What we tried to do was simplify those arrangements whereby we reduced a subjective test to more of an objective test in order to establish that there was a community need and a sufficient community and population there to support a pharmacy.

Senator FIERRAVANTI-WELLS: If there is a supermarket there then clearly there is a need and that acted in your mind as an objective indicator of a need?

Ms Janz : Yes.

Senator FIERRAVANTI-WELLS: So what happens if the medical practice will not provide the information to the prospective person? They might just refuse to give a stat dec, for example, unless that practice has an interest in the pharmacy—

Ms McNeill : A statutory declaration is just one option available to applicants. We have other options such as going into the local councils and getting information on the services available there. You can get a practice information sheet from the doctors, their advertised opening hours, take photos of their advertised opening hours on the actual front door—

Senator FIERRAVANTI-WELLS: So there is a range of other options.

Ms Janz : There is. We are just trying to give people a variety of options to actually meet that test.

Senator FIERRAVANTI-WELLS: It also states that you need a floor plan of the supermarket demonstrating the gross leasable area and a stat dec from the manager of the supermarket confirming the gross leasable area. It is the same situation. What if the supermarket manager, for some reason or other, will not give you a stat dec? What other evidence will be considered?

Ms McNeill : It is an option for how you provide that information. There are other ways to do this. These kinds of plan are usually available from local councils when they are in with development applications et cetera, so there are a number of other ways you can provide that information. Obviously if a supermarket is being built in a shopping centre that information is also usually available from that developer as well. These are just examples of how you can provide the information. They are not necessarily absolutes on the only way to provide the information.

Senator FIERRAVANTI-WELLS: How many registered pharmacists are there in Australia and do you have information as to whether those pharmacists have equity in a pharmacy? You may want to take that on notice.

Ms McNeill : We will have to take that on notice.

Ms Halton : The answer to that will be no. Essentially, the number of registered pharmacists—people qualified to practise pharmacy—will far outweigh the number of pharmacies, for obvious reasons.

Senator FIERRAVANTI-WELLS: But they are just statistics. Can you take that on notice to see if you can provide them to me.

Ms Halton : Let me put it to you this way—

Senator FIERRAVANTI-WELLS: You cannot answer the second one but the first one you can—the number of registered pharmacists.

Ms Halton : Absolutely.

Senator FIERRAVANTI-WELLS: There were two questions. I understand it is 'no' to the second. I will put the rest of the questions, on that part, on notice.

Senator DI NATALE: I understand the rationale of using the supermarket as a proxy for demand, but clearly there will be examples—such as in growth areas—where you do want some planning. It may be an opportunity to plan for the future and there may not be a supermarket in the area but there still would be significant demand for a pharmacy. In rural and regional areas, I know myself, from living in a regional area, that would be a very difficult test to pass and yet there may be significant demand. Are there any exemptions to that particular rule, given that it is not a perfect proxy for a community demand?

Ms Janz : The rules differ. There are 11 new rules and you pick the appropriate rule for your circumstances, so you might not necessarily be using that particular rule, which is usually in an urban environment. If you were going into a rural environment there would be a different rule that would apply, which would have different criteria on it. We did some research around supermarkets of certain sizes and what sort of viability in terms of the population you would expect to draw to those. For example, a supermarket of at least 1,000 square metres would service up to 5,000 persons. A supermarket of 2½ thousand square metres would service up to 10,000 persons. That is information we obtained through the Retail Policies Futures paper and some related websites. The premise is that if a Woolies or a Coles or another supermarket was prepared to invest in the area because they would pull that kind of clientele then that was an objective proxy for population.

Senator DI NATALE: I understand that, but I suppose that assumes that Woolies and Coles have invested in every single area where they can service that population. One would imagine that there will be areas that have not been covered by a Woolies or a Coles, where that demand still exists. I suppose the question I am asking is: are there opportunities to look at other proxies given that it is not a perfect market? I do not think anyone would expect that that is the only proxy for demand.

Ms McNeill : I think, as Ms Janz has already referred to, this is only one of the rules about establishing a new pharmacy. There are other rules, and there are other rules that specifically relate to regional and rural areas.

Senator DI NATALE: I am not talking about regional and rural now I am talking specifically about urban settings. Are there other rules that could be used in an urban setting?

Ms Janz : In the Pharmacy Location Rules handbook, which is available on the website, there are one, two, three, four rules in relation to relocating existing pharmacies and seven in relation to establishing new pharmacies. You could establish a new pharmacy as long as it was 1.5 kilometres away from another pharmacy, which would generally be in an urban area. Then there would be bringing pharmacies into small shopping centres, large shopping centres, private hospitals or large medical centres, and the rules around those situations are different to the one in relation to a new pharmacy—at least 1.5 kilometres. So there are a range of rules that you could apply under to establish a new pharmacy in an urban area.

Senator DI NATALE: But, under those rules, if you are in an area that does not have a supermarket and you want to establish a new pharmacy and you think the demand is there—and there might be other measures that would support that case; other proxies—you would not be able to establish a new pharmacy?

Ms Janz : If you applied under rule 130 and you did not meet the criteria that were set in that rule, no, you would not be recommended as an approved pharmacy in that area.

Senator DI NATALE: Was consideration given to using any other proxy potentially to avoid the situation where in fact there may be demand but there does not happen to be a supermarket there?

Ms Janz : One of the issues at present with the Community Pharmacy Authority in assessing claims is that it has worked on a catchment which looks at a population base. It is about establishing a population—which was again difficult because we were using 2006 census data, which was some years old—and also about identifying the exact circumstances of a particular area. That was somewhat difficult because they were unique in different areas and there were all sorts of other factors involved. That was an expensive process where town planners and specialist consultants were involved in trying to work that out, and it was always difficult. So the feedback that we had from a lot of people was that a more objective test would be more suitable, and, from the research that was done, the supermarket test was found to be the most suitable at this point in time.

Senator DI NATALE: I appreciate that. It appears that it is a better way of assessing demand; my question really is: it may not be perfect, and I expect it will not be, but is any consideration given to a situation where a supermarket does not exist but perhaps it would still be a suitable candidate for a pharmacy, and would other proxies be considered?

Ms Halton : I think the thing to remember is that in all of these things the minister retains a discretion. So if at the end of the day there is some anomaly here—if there are some circumstances, which from time to time is the case—the minister can exercise their discretion.

Ms Janz : Yes.

CHAIR: Senator Brown, are you going to put one on notice?

Senator CAROL BROWN: Yes. I asked earlier about the take-up rate on the nicotine replacement therapies on the PBS. Given the time, I will be happy if you can just provide me with some information on that on notice.

Ms McNeill : Certainly we can do that for you, Senator.

Senator FIERRAVANTI-WELLS: We went through the process at the last estimates in relation to the PBS deferrals that were announced in February. We know that there are going to be deferrals into the future. In a press statement on 30 September, Minister Roxon mentioned:

The Government, industry and consumer groups agreed to work together to discuss ways to manage deferrals into the future.

Do you have a copy of that, Ms McNeill?

Ms McNeill : Yes, Senator.

Senator FIERRAVANTI-WELLS: Could you explain to me why medicines that have been evaluated as cost-effective and efficacious by the PBAC need to be deferred into the future?

Mr Learmonth : I think we covered this fairly extensively in the previous hearing. It is a matter for government to consider each and every listing in light of fiscal circumstances at the time and in light of the priorities both within and beyond the health portfolio and to make decisions accordingly about medicines that were to be listed.

Senator FIERRAVANTI-WELLS: Regarding the comment by the minister about managing deferrals into the future, what does that actually mean? Are we going to see a new deferral process announced?

Mr Learmonth : As part of the commitment that the minister and the Prime Minister announced on 30 September, medicines and price increases that were deferred in February were listed. In addition to that, there was a commitment from the three stakeholder groups—the Consumers Health Forum, the Generic Medicines Industry Association and Medicines Australia—to work with the government to look at a range of ways that go to sustainability of the PBS. Part of that was about looking at ways to manage deferrals in the future. It remains the prerogative of any government to choose where it spends its money. The government, as part of that commitment, has agreed not to defer medicines costing less than $10 million in each year over the next 12-month period while we work through things with stakeholders. In addition, those stakeholders will work with us in a couple of processes—one over the short and medium term about what might be possible to do to improve sustainability and a longer-term process starting from next year which will go to what some longer term ways might be to improve sustainability following the expiration of the memorandum of understanding with Medicines Australia. These are all matters for discussion with those groups.

Senator FIERRAVANTI-WELLS: Will any of those new listings be contingent upon offsets within the health portfolio? Managing deferrals is quite a wide ambit. Are there things like being contingent on offsets within the health portfolio or other things like therapeutic groups? Everything is on the table?

Mr Learmonth : It is an open question to be discussed with stakeholders.

Senator FIERRAVANTI-WELLS: The statement also referred to further savings in 2012-13. What additional savings will be required from the PBS?

Mr Learmonth : The commitment refers to a couple of processes. As I said, one is a short-term one, which we will try and conclude by the end of this year. It goes to discussions with those groups about the kinds of things that could be pursued in that time frame to improve sustainability. What they might be remains to be seen.

Senator FIERRAVANTI-WELLS: Are you contemplating any legislative amendments in relation to price disclosure?

Ms Halton : Not at this time.

Senator FIERRAVANTI-WELLS: I note from some reports that former PBAC head, Professor Sansom, is undertaking a process in relation to pradaxa. What is this process? Is this another committee? Mr Learmonth, can you explain the rationale behind this, please?

Mr Learmonth : Certainly. The management of our coagulant therapies is a very complex space. In looking at Pradaxa, the PBAC made a number of observations. It observed that Pradaxa, or dabigatran, gets its advantage over the existing therapy, which is warfarin, where warfarin is used suboptimally. It noted that there were other ways to improve the use of warfarin, including through such things as education campaigns, which were much less costly and could achieve the same health outcome, and it raised questions about the extent to which the results of the clinical trial might be reflected in the Australian population.

Broadly, this is a complex space involving how patients comply with existing therapies, how prescribers use and manage those existing therapies and what alternative ways there are to generate the health outcome that government is looking for, which might involve different levels of expenditure, and there are certainly different models around the world of how that is done. So it is quite a complex space with some complex interactions and some alternatives. Those go to things that are usually beyond the normal remit of the PBAC. Professor Samson will be drawing together all of those elements in a report to government and he will be doing that in consultation with the company, consumers, clinicians and a range of people to try to draw those strands together and provide some comprehensive advice to government.

Senator FIERRAVANTI-WELLS: Do we know how long Professor Samson's process will take? I assume that at the end of that process there will be some consideration given to potential listing of Pradaxa. Is that what is envisaged?

Mr Learmonth : There will be a report that goes to government that will enable the government to make a decision.

Senator FIERRAVANTI-WELLS: I will put the rest of my questions on the PBS on notice.

CHAIR: Thank you very much to the officers on outcome 2.

Proceedings suspended from 21:01 to 21:14

CHAIR: We will now go into health workforce. Thank you so much to the person who provided every FOI request in the last 10 years. That is great. We are going into health workforce and Senator McKenzie is going to start.

Senator McKENZIE: Thank you. I will get right into regional workforce shortages. In a media release dated 5 September 2011, Minister Roxon announced Labor was delivering record numbers of doctors and nurses to regional Australia, according to new Medicare data released that day. We have rung media contacts and the minister's office on the release. The Parliamentary Library has also looked into this. Despite all this, the supporting data for the media release has never actually been located. The statistics at the bottom of the release cannot be found, and their source, to the best of our knowledge, has not been verified. Anecdotal evidence is that the workforce shortage is critical. What is the source data for the media release dated 5 September which claimed that Labor was delivering record numbers of doctors and nurses to regional Australia?

Ms Halton : If people are going to comment on something then we are going to have to see it.

Senator McKENZIE: I have the media release link. I do not have a copy of the actual release here. I am happy to table the release or, on notice, the release plus the questions, which go to the source data. We have done our best to track it down, and we would really appreciate finding out where that came from. Obviously it then does become publicly available, and if it is not publicly available we would like to know why it has been so hard to track down. Thank you.

My second question goes to geriatricians.

Ms Halton : You will have to practice that one!

Senator McKENZIE: I know! I am new to the committee, as you all know. I will get better at this. Given Australia's ageing population, what is the government's strategy for attracting and training more geriatricians to meet future demands?

Ms Jolly : I can talk in broad terms about our specialist training programs. They are available to all specialties and specialties in areas of priority. We have the specialist training program where we encourage specialists to do rotations in a range of locations. We also have other, possibly more direct programs in aged care, but I would have to take that on notice to give you some more detail about those. In the broad we have a particular focus on specialist training which we deliver.

Senator McKENZIE: Thank you. Can the department provide information on the number of geriatricians there were practising in Australia yearly from 2007 to 2010?

Ms Jolly : I could take that on notice. We would have to check the AIHW data source as to how it is defined. If that data is available we are happy to provide it.

Senator McKENZIE: Thank you. Would the department provide those figures for the years 2007, 2008, 2009 and 2010 as a percentage or ratio of geriatricians to Australians aged 65 years and older?

Ms Jolly : Certainly.

Senator McKENZIE: Thank you.

Senator ADAMS: What programs are available to increase the number of procedural medical skills in rural and remote areas? What evidence is available about the reduction in availability of GP proceduralists to rural people? This is also for maternity services, anaesthetics and minor surgery. The last question on this particular piece is: what is the distribution of general physicians outside major cities?

Ms Jolly : For the percentage of general physicians outside the major cities I will just have to check my reference book. In the meantime I will ask Mr Andreatta to talk about the GP procedural training program, which will answer the first part of your question.

Mr Andreatta : We have a GP procedural training support program that the department funds. It was part of the maternity services review findings that a program of this nature should be implemented. It was announced in the 2009-10 budget. The initiative targets existing GPs in rural and remote areas—in areas RA2 to RA5. It aims to improve access to maternity services for women living in rural areas by supporting GPs to obtain the procedural skills necessary for obstetrics and anaesthesia. The objective of the program is to provide funding of $40,000 to a total of 142 GPs to enable them to obtain either an advanced diploma of the RANZCOG program or a statement of satisfactory completion of advanced rural skills training in anaesthesia.

In terms of the take up of the program, for the obstetrics component we received 41 applications for the 2010 round, of which 37 met the eligibility criteria, and 26 places were awarded in 2011. For 2012, 25 places are to be awarded and 44 applications have been received. In 2013 we are looking at having 35 places available. For the anaesthetics component, for the 2010 round, we received a total of 85 applications. We awarded 16 places for 2011, and 15 places will be awarded in 2012 and in 2013.

Senator ADAMS: It is very good to hear that people do want to come out and live in rural areas again. I have a question on training places for medical specialists. Can you answer that for me?

Ms Jolly : Yes.

Senator ADAMS: In the 2010-11 budget, funding was announced to increase the number of training places for medical specialist from 360 to 900 by 2014. What progress has been made towards reaching this goal and what proportion of these training places are outside the major cities?

Ms Jolly : That is the specialist training program and it has been highly successful. This year we have 518 places in the system, which is ahead of the target we have set for this year, and the numbers will continue to grow next year as well. At least 50 per cent of those places are in rural locations.

Senator ADAMS: What progress has been made in establishing the new dental internship year outlined in the 2011-12 budget and what has been spent so far on that project?

Ms Jolly : There has been quite a lot of discussion around the guideline development of that program. There has not actually been any funding spent as yet. We have had discussions with states and territories and with the peak professional groups to ensure that the guidelines are going to deliver on the program. So we should be seeing in the next couple of months some requests for tender around the evaluation methodology for the program which will run alongside it. Then we will have requests for tenders for the actual places early in the new year. That will therefore be in place for the first placements in the following year.

Senator ADAMS: What has the cost been to date? Do you have any idea what part of the budget you have spent?

Ms Jolly : At this stage we have not spent any of the budget. We have been in the process of guideline development.

Senator ADAMS: And there is no expenditure associated with that part of the department's—

Ms Jolly : There has been, I guess, a consultation at this stage. We have not gone out for the development of guidelines. We have been doing that in consultation with the profession and with states and territories.

Senator ADAMS: I am very aware of Health Workforce Australia being here. I am trying to work out what I have to ask them and what I have to ask you, so bear with me a little bit. If I am going wrong, please tell me.

In an endeavour to address shortages of health professionals in rural and remote areas a number of programs have been implemented to encourage medical students and young doctors to take up rural practice. These include scholarships and HECS reimbursement in return for practicing in rural and remote areas. To improve the health of people in rural areas, these doctors need the support of multi-professional teams. Given that there are currently a greater number of nursing and allied health students than ever before, what strategies is the department using to encourage these health professionals to take up rural practice?

Ms Jolly : You mentioned our rural undergraduate training programs in that opening remark. Those are our rural clinical schools that have been incredibly successful—25 per cent of medical students undertake a year in rural practice. We also have a program around the university departments of rural health, which is the allied health component of our rural undergraduate training investment. We also have a program that offers dental training in rural locations. So we do have a complementary program around allied and dental professions to encourage training in rural locations similar to what we have for medicine.

Senator ADAMS: Have you evaluated just how many of these health professionals are taking up practice in rural areas since they have had that exposure to working there earlier on?

Ms Jolly : We have certainly evaluated people's experience with the program and their intention, but because of the long lead time between training and completion of training we do not have data which would give you a direct link between student intentions and results. So we have good intentions data on those sorts of programs and we have a student outcome database in medicine, which will give us some of that information in the future.

Once the AHPRA database is up and running it will also be able to give us better information about where allied health practitioners are practicing and it will give some of that workforce data. But at the moment we do not have a direct correlation other than that people are very positive about the program and indicate that it is making a difference as to whether they wish to practice in rural Australia.

Senator ADAMS: Under the so-called scaling system, incentives are available to GPs to encourage them to move from major cities to rural areas or to move from rural to remote areas. How many doctors have moved as a result of these incentives, and how much of the budget has been spent on this incentive program?

Mr Andreatta : Are you referring to the rural relocation incentive grant?

Senator ADAMS: That is correct.

Mr Andreatta : That is part of the general practice rural incentive program—one of two incentive parts of that program. There is a relocation and a retention component. We are 12 months into the relocation program. Our target for the year just gone was for 70 doctors to take up the relocation grant. We had 87 applications in that year but only 39 were assessed as eligible. The main reason we found was that the providers were not as aware of the program as much as we thought they would be, and some of the criteria was probably unclear to them in that, when they put their applications in, they did not meet a number of the main criteria. In that respect we are looking to increase the awareness of that program through our workforce agencies.

Senator ADAMS: Were the 39 or whatever it was that were eligible from the city or from regional areas?

Mr Andreatta : I do not have that data with me but they are certainly from less remote or less rural areas, so they have to move from a lesser RA classification.

Senator ADAMS: Could you take that on notice?

Mr Andreatta : I need to warn you that that data may not be able to be released, given the small numbers, and privacy might come into that issue.

Ms Jolly : We will certainly have a look at whether we can give you a trend as to where to and where from in terms of RA—

Senator ADAMS: That is fine but I do not need to know specifically. I just want to make sure that the program is working and they are not just shifting from one town to the next town.

Mr Andreatta : The data I do have is where they relocated to but not from. I can give you the distribution by RA of where those doctors actually—

Senator ADAMS: Yes, that is what I am after—just so long as I can see that it is actually working and it is not going from one place to the other, that they are actually getting an incentive to do it.

Senator FIERRAVANTI-WELLS: In terms of the Australian Health Practitioner Regulation Agency and the National Registration and Accreditation Scheme—I know that is the agency, but have the issues of registration been bedded down? We had a lot of problems at the beginning—

Ms Halton : In fact, they have just done a very, very large exercise with nurses and it has gone—I do not want to jinx it by saying 'seamlessly' but we have been watching this like an absolute hawk and it has gone very, very well.

Senator FIERRAVANTI-WELLS: I would like to ask a couple of questions about workforce planning and training of Health Workforce Australia.