DJAKIC, Dr Emil, Private capacity

Committee met at 09:00

CHAIR ( Senator Rice ): I declare open this hearing of the Senate Community Affairs References Committee's inquiry into the provision of general practitioner and related primary health services to outer metropolitan, rural and regional Australians. We acknowledge the traditional owners of the land on which we meet, the Palawa people, and pay our respects to elders past, present and emerging. These are public proceedings and a Hansard transcript is being made. The hearing's also being broadcast via the internet.

I remind all witnesses that in giving evidence to the committee they are protected by parliamentary privilege. It's unlawful for anyone to threaten or disadvantage a witness on account of evidence given to a committee, and such action may be treated by the Senate as a contempt. It is also a contempt to give false or misleading evidence to a committee. The committee prefers all evidence to be given in public, although the committee may determine or agree to a request to have evidence heard in private session. If a witness objects to answering a question, the witness should state the ground upon which the objection is taken and the committee will determine whether it will insist on an answer, having regard to the ground which is claimed. If the committee determines to insist on an answer, a witness may request that the answer be given in camera. Such a request may also be made at any other time.

The committee understands that all witnesses appearing today have been provided with information regarding parliamentary privilege and the protection of witnesses. Additional copies of this information may be obtained from the secretariat. I now welcome Dr Emil Djakic. Thank you for appearing before the committee today. Do you have anything to add to the capacity in which you appear?

Dr Djakic : I was invited as a general practitioner in my own right. I'm not representing any organisation.

CHAIR: I now invite you to make a brief opening statement if you'd like to do so, and then we will ask you some questions.

Dr Djakic : I'm a general practitioner by choice and consider the vocation to be the bedrock of patient health care. The role has been sorely undervalued by numerous administrations over time in Australia. I'm a practice principal of 26 years, one of four partners in ownership, in a 10 doctor practice in Ulverstone, a regional town in north-west Tasmania, with a satellite practice in the town of Penguin nearby. We employ 12 nurses, 10 reception staff, a practice manager and a part-time business manager. I'm a Launceston-born Tasmanian graduate, a fellow of the RACGP, an RACGP member, the current vice-chair of the RACGP national committee on funding and health system reform and an AMA member. I've also had roles in the division of general practice and was a national chair of the Australian Divisions of General Practice for four years prior to their migration to Medicare Locals. My interest here is really to listen to what questions you've got for me. I support the documentation put to you from the RACGP, particularly from their rural faculty, and have looked at their submission and clearly stand by that. I have another part of the presentation I can go through for five minutes with you if you wish, which answers the questions in your brief from my perspective, before taking questions.

With regard to the first question on the current state of outer metropolitan, rural and regional health services, regional and rural general practice in our region remains stressed. There is not a practice on the north-west coast and west coast that is not actively seeking new general practitioner workforce. There are also similar struggles in securing the nursing workforce for general practices. Practices have for several generations in our regions relied on the importation of GPs from out of area, particularly dependence on immigration from overseas. Our community has had a rapid population increase over the past 10 years. The town of Ulverston was at 11,000 people in 2014. The census data released in 2019 had it increasing to 15,000.

The complexity of care both in intervention and prevention has increased in a population in our region that is now known to be older, sicker and more disadvantaged than the average in Australia. Migration to the area of my observation over past years, particularly of what I consider to be urban refugees seeking more affordable housing, has brought a significant proportion of citizens carrying substantial burdens of chronic disease, further challenging our general practice capacity. We have a high proportion of population on a healthcare card and a socioeconomic disadvantage indicator in quintile 1 and 2 based on 2016 census data. Patients are finding access difficult and affordability of care an increasing problem.

A comment on the current government reforms and their impact on GPs, the Stronger Rural Health Strategy. As a practice principle I'm hard pressed to see any tangible progress apart from the moiety of change in the bulk-billing incentive for my Monash modified classification 3 region. Training pathway migration remains an uncertainty. There's little evidence of a commitment to actions on a 10-year plan. General practices are experiencing change, fatigue and worry about the continued rise in a regulation environment and the myriad of MBS item number changes that now represents impossible navigation for all but a few.

On the distribution priority question: boundaries are always problematic. Perverse redefining of status leads to dramatic changes in a practice's competitive ability to attract GPs and to offer funding packages that will retain them in an area. Personally, we remain little affected by these changes at this stage, but colleagues further along the coast are now feeling better very bitter about their reallocation. We will edit this now and recognise that that has subsequently been addressed—this was a problem in Wynyard—and recognise that the new system in place, allowing for some petition from practices to address the questions and effectively plead their case in a more contextual manner, does appear to be a shift in the right direction.

GP training reforms: Tasmania has been well served by General Practice Training Tasmania. The registrar placements, however, remain severely Hobart centric, with only three out of 30 finding their way to the north-west coast in this year's allocation, and that's not an unusual challenge. Our pipeline for new GPs therefore is severely limited through the registrar program, and the distribution of general practitioners graduating into the fellowship process continues to feed the urban centres from my perspective. The migration to the college based program I'm well aware of. It's deferred again. We have anxieties due to what appears to be a fairly opaque process at the moment and uncertainty abounds. Our general practice Tasmania people who work with us in the current registrar process also experience uncertainty and fear for what will happen to what has been a very good, well-functioning education program for our registrars.

On the Medicare rebate freeze, the suspension of indexing of the Medicare rebate is a conscious fiscal policy to curb expenditure. Also I believe it was testing the sensitivity of general practice as a business and its response to a lowering of the insurance costs for primary care through Medicare. Federal health funding through Medicare continues to be misrepresented as the Medicare rebate as the fee, and even in the college deposition I detect misuse of the language, as the Medicare rebate is the fee for general practice. It continues to focus on bulk-billing as the metric that matters in general practice and GP health care for the population. Our practice, in the initial onset of the freeze, reflected very keenly on the deficit of up to $120,000 a year that was needing to be addressed. This deficit was compounded for four years and now remains as a recurrent deficit. The cessation of the freeze did not address the deficit of four years of indexation, and that goes on annually. The RACGP figure, again quoted in their submission to the committee, continually reflects that nearly $1.5 billion has been removed from the support and investment in general practice as a result of the freeze and continues to accumulate as a deficit in our industry. The utilisation of the bulk-billing incentive item number remains a challenge for practices to respond to this deficit. As such it's quite a subversive tool, impairing small businesses' ability to pass on costs to consumers relating to the cost of delivery, and that's referring to the increasing costs of running a business, delivering health services—whether that be urban or regional.

For us the Medicare safety net appears to either be a myth or be a missing in action policy. I remain aware of very few patients who have accessed it in our region. I perceive that it, perversely, is probably serving those affluent postcodes where private billing is the norm. The freeze had little impact on the billing patterns of doctors. In fact, I think in time it has probably benefited our specialist colleagues more than the general practice industry. The—

CHAIR: Dr Djakic, maybe if you finish up your sentence we can move to questions.

Dr Djakic : Yes. I'll simply summarise the impact of COVID: reduction of flow of doctors into our region; the early exit of doctors through partial retirement or retirement due to the environment; reduction in availability doctors to be on duty due to isolation protocols; the consumption of workforce with additional roles, especially immunisation; a slowing of face-to-face work rates due to PPE and protocols; increased complexity of consults due to discussions about COVID and a deficiency in our ability to have medical students teaching—whether it's because of changes in policies. General practices have been very happy to step up to all of these roles, but they have been an additional burden.

CHAIR: I'm sure we can cover the stuff that you haven't covered. If you'd like to table that statement we'd be happy to accept it as a tabled opening statement.

Dr Djakic : At the end perhaps the one which I didn't get to is that we need more investment in teaching to allow general practice and students to be together more often. Too many students are leaving our practices feeling like the job's too hard, it's too stressful, it's too busy and GPs haven't had time to do the teaching with them.

CHAIR: Expanding on that, how would you change things so as to improve that situation?

Dr Djakic : In our practice I originally calculated a very strategic model of saying, 'What money comes with teaching for a student? How does that money all get rolled up?' Then how do we put it in front of a doctor for the day to say: your billings for the session would normally be—let's take an estimate of $1,000 worth of billings. We want you to teach. We don't want double dipping to occur, so we'd like to give you the moiety. I think my initial estimate, and this is back near 10 years ago, was about $200 that was available for that particular student session. That means we should reduce your patient contact for the day in that session so that you've got time to teach. That way we enticed some of our contractor doctors to actually engage in teaching, because they saw that they could enjoy a similar outcome from a business case. That sort of model or logic doesn't seem to be propagating very well. We had to cobble together the funding that came from the PIP system, our local rural clinical school and some other money that came from the University of Tasmania Not every practice is going to take that sort of journey. I'm afraid a lot of practices have a student who is very disengaged—a lot of the time they leave general practice thinking, 'I didn't really enjoy that.'

CHAIR: What do you see as the main barriers to recruiting GPs to your practice?

Dr Djakic : In regional Australia, full stop, the tide of population was moving in the wrong direction for a number of years. I'm led to believe that that might be turning around, for a range of reasons. I think our students are graduating older because most of our graduating doctors are from mature-access postgraduate programs. They're already partnered up—that is, married—frequently, but not always, with spouses in professional roles. That means we need to be working out ways of bringing them to a region; but that spouse, that family, that other existing life, is already well-established. That's a real challenge.

I don't believe it's just purely fiscal; obviously, yes, they want to see a business case for it. But there's a strong perception about regional Australia. I don't view Ulverstone as all that isolated. But we constantly hear negative thoughts about access to good quality schools, access to arts and culture and sport. Again, I'm fairly biased; I've lived in that community for that time and I live there by choice. Seeing the career path and business case for being in a regional business is worthwhile.

CHAIR: Okay, so it's much more the appeal or lack of appeal of being in regional Australia rather than, say, the workload or what the actual work is in a regional community?

Dr Djakic : Yes. I see the work as being much more rewarding work. I've had a continuous relationship with my population for 26 years. I see that as the very traditional role. I think younger cohorts are feeling a desire to be more portable with their lives—perhaps visiting an area for a shorter period of time and then moving on. I think that's to their detriment, but I can't help that.

CHAIR: Deputy Chair, would you like to continue?

Senator ASKEW: Thank you very much for making yourself available today. I know it's a busy time for you, always, but I really appreciate you taking the time to be here. I want to go back to the training aspect again and actually understand a little bit more the commitment that's provided by your clinic or surgery to supervising and co-supervising doctors during their GP specialisation. What sorts of hours are involved, how is it supported and where can you see some improvements? You've already mentioned, I notice, the need to provide more time. Is there enough time spent together? What could we do to improve that?

Dr Djakic : We teach or train at all levels, so we have students and registrars. We were participants in the previous PGPP program, the John Flynn program, which is now morphing into the next level which is intern based programs.

General practice is a complex space. It's a difficult job. The transition from hospital based work into general practice based work involves a lot of acquisition of new skills. Having a first-term trainee requires us to review all of their notes; be available for them during consults to respond to questions; sometimes to be invited in to assist with the consult or take over in a mentoring, teaching way; to actually undertake tutorial work with them, which we do, specifically, for two hours a week; and to take time out to sit in with that registrar to watch them consulting and also for them to watch us. So they get four hours of direct, hands-on, sort of 'I'm away from my desktop and able to see my own patients,' but—

Senator ASKEW: Is that four hours per week?

Dr Djakic : Yeah, but there's also the indirect work, which is us reviewing files and following up on questions that might relate to that. And that's mostly in an education role. There's also a significant risk management role there for us as a practice, because we're very much accountable for the health care of that patient as well and answerable to things that might not have gone as well as they should have.

Senator ASKEW: No, that's fair. So what time frame are they in your clinic for? Is it six months?

Dr Djakic : It's a six-month term, generally. Then they move on to what is their second-year terms and then subsequent terms as they mature through the system. Naturally enough, they also become more autonomous.

The early phase is also very impaired by their limited ability to interact in any sophisticated way with the Medicare billing system. The MBS is an entire new language for them to have to learn, and the diversity of numbers and the diversity of ways a patient can be billed on any one day is, to most of our new registrars, just a fright. They've got numbers racing around their heads till the cows come home. None of the numbers make any sense. None of them are built on any binary logic system. They're just evolved random numbers. If there's one thing that needs to be taken out and completely rewritten, it's the entire MBS schedule—in some sort of codified logic so you can understand what the number means.

Senator ASKEW: The people probably all agree with you. Can I pull you back to your comment from before, then, on not enough time being spent together? Where is that? What's lacking with that?

Dr Djakic : I was using that in the student example, particularly where every single case is an opportunity for us to discuss the education and learning points for a student in a structured way. To consult and do 15 minutes with a patient and then have to just move on to the next patient robs the student of a chance for us to do the teaching.

Senator ASKEW: There's not that reflection.

Dr Djakic : I roughly edited out about a quarter of the consults in what would have been a 15-patient session in order to allow for that to happen. That sort of funding example needs to be built on that, to show that a session where you're teaching a student should allow you to have that sort of time funded equitably, so that you finish the morning or the afternoon not disadvantaged for doing what is an incredibly important professional role and hopefully delivering the student the feeling that they actually got an educative session. We work very hard at it in our practice. Feedback coming from our rural clinical school clearly says that's not uniform. A lot of practices are in fact walking away from taking students, because life's busy and they don't fit in their business plan. That needs to be changed so that it's seen as an attractive and important role in investing in our next generation.

Senator ASKEW: You've answered some of my next question with your earlier responses, but are there any other ways that we can stem the loss of doctors in regional and rural areas? You've sort of talked about creating a better lifestyle, and that's an attraction, but what about the losses? You've already indicated that we've lost some through COVID, through early retirements, but is there—

Dr Djaki c : There's also the traditional pathway of bringing international medical graduates in. We lose a lot, quite rightly, because, when they reach their autonomy threshold and get their full licence, we see a lot of retreat back to cultural communities which they're attracted to. They're fantastic doctors, a lot of the time. We'd love to see them stay in the area, and some do and have, but we lose a fair percentage back to the larger communities in Melbourne and the bigger cities, where they culturally have a better fit. That's because of spouses and family and kids and the like. So we're trying to build our own system. Our practice, I think, is 25 percent Tasmanian graduates; the rest are immigrants from one country or another.

Senator ASKEW: That's indicated a good retention rate. So have you built a community for them? Is that what you're indicating?

Dr Djakic : We work very hard at making it a cultural site, ourselves. It's a very tight business environment. You spend a lot of time with each other. You need to make sure it's a welcoming place and a place you enjoy being at. We work very hard with that and all of our staff.

Senator ASKEW: Can you highlight any issues you've had along the way with the visa system for attracting overseas doctors?

Dr Djakic : The process is complicated. There's no doubt about that in terms of immigration. We have been fortunate in the last few years where we haven't had to utilise that pathway a lot. Our last international doctor that joined us was really a windfall—that is, the other practice in town had done all the hard work with his wife, who was the sponsored person who joined the practice. He, as a qualified doctor, was then able to get access to the system and so got a very short pathway through and chose to come to us to enjoy his working career. He's now a partner who's bought in, and basically he's one of our team.

Senator ASKEW: That's a great success story. I'm getting the look from the chair, so on that note I will hand back to the chair. Thank you very much for your evidence.

CHAIR: Senator Urquhart.

Senator URQUHART: Dr Djakic, I want to touch on a couple of things continuing on that thread around keeping people in the practise, but also I'm interested in what sort of incentives or support do you think could be offered to get GPs to come to rural and regional, and certainly to Tasmania, where we are now.

Dr Djakic : Previously a lot of the work that belonged with the divisions of general practice worked in that space. They had a lot of program funding that was on the ground aimed at welcoming new GPs, particularly the international graduates, following them and their families up and assisting them in getting established in a community and building links. It was very much focused on the social side of that, making sure they were introduced to information about schools and about how things get done in the region, leaving the professional role of the doctor work to be supported by the practice. That on-the-ground support has retreated or evaporated, and HR Plus now are involved with that at a state level. And of course in the primary health care networks that's now a completely different brief. We thought at the time local support was well appreciated. We used to run events that brought these newer doctors together occasionally so that they could share stories and so that we could get feedback from them as to what they were seeing as problems. I think there's a lot of perception that we know what the problems are, but we don't actually get time to stop as a collective and find out from them what else could we be doing that makes it easier for them. Getting people from afar to come here is a real challenge, and obviously in the last two years that's been horrendously disrupted, but that's not the fault of any administration; that's the nature of the pandemic we've been in.

Senator URQUHART: How important has telehealth been and how important is it that that continues in one way or another to support your practice and obviously the patients?

Dr Djakic : Telehealth is incredibly important. It was important in that initial phase, but it was important irrelevant of COVID. I think moving to IT platforms is part of the healthcare journey. It was already happening in some ways and needs to be built on. I don't fully align with the belief that video is the way. I don't think the technology platforms and the usability are yet there. Hence, I think the data is up near 98 percent of GP based remote access has been by telephone. The patients are very accepting of it. We do see it as a deficient form of consultation though. It misses out on significant elements. It has a role, but it's not the replacement, and it should really only have a place in the setting of a continuous relationship of continuity with your GP or their practice. I applaud the federal government's efforts to ensure that that is embedded in any telehealth plan that goes forward. It only value-adds where you know the patient and you have the patient's detailed data, not just their electronic health record summary, in front of you. In 90 per cent of my telehealth consults I've been able to, happily, recognise the patient by their voice because I'm familiar with them, and hence it's just an ongoing conversation.

Senator URQUHART: In relation to allied health, obviously, your patient comes in and there are often times they'll need to be supported by allied health. How difficult is that for your patients, and for you to refer your patients to, here or from your practice in the north-west?

Dr Djakic : The allied health pathway, which is effectively for most people, is through the chronic disease management item numbers, for which the team care arrangement is a nightmare. For an item number, like item 723, for a practice like mine to still be sitting down 10 years later and reading the descriptor to try and understand how we can be compliant with it signifies that it needs to be scrapped. I can't understand how in the DVA setting we can do a very simple referral to allied health using a D904 form that simply allows that practitioner, that professional at the other end, to get on with their number of services that they're able to offer. Why then in the MBS system do we have a need to undergo a team care arrangement, a collaborative discussion with every provider on the team? We don't sit in an office and converse with these people. It needs to be simplified. I need—general practice needs—the opportunity to be able to move people to providers that are available within the community in the private setting. I don't mind the fact that MBS clearly has to have some limitations on how many services get done, but the pathway of getting there needs to be simplified.

Senator URQUHART: I guess that's only one part of the MBS process that you talked about earlier that needs to be overhauled. How does that then impact the outcomes for your patients: the lengths of time they need and how many times they are coming back to you because that's such a difficult path?

Dr Djakic : The most irritating one is a patient coming back who has done their five services with whichever provider and their provider, allied health, has said, 'You need to go back and get a repeat team care arrangement done.' The patient comes back following that instruction, but it hasn't been 12 months. They're not yet eligible again. We're spending time explaining why they're not eligible again and that they'll have to come back in January because that's when we can do it again. This whole calendarisation just trips people up and ends up wasting consult time for us.

Senator URQUHART: I presume that it doesn't help the patient either, because they're not getting that help when they need it.

Dr Djakic : No. It leads to more confusion and difficulty. We've got patients coming back to us purely to reiterate some paperwork that facilitates an ongoing relationship.

Senator PATRICK: I want to go to your story of the staff. I'm looking at the Tasmanian government's submission to this inquiry. Indeed, the committee has available to it the number of GPs in Tasmania from the National Health Workforce Dataset. I'll just read it very quickly:

Tasmania has seen some recent improvements in the number of GPs across the state.

It acknowledges that the number of doctors per 100,000 people is lower than the national average, but it says:

The 2019-20 RoGS shows Tasmania had a 10 per cent increase between 2014 and 2019; from 95.9 FTE GPs per 100 000 Tasmanians in 2014 to 105.5 in 2019.

So the data that they're presenting appears to be inconsistent—or perhaps it's not inconsistent, but you're telling a story of being busy. Would you like to comment on that? Maybe there are just too many Tasmanians! I don't know.

Dr Djakic : I haven't read the submission, and I'm not familiar with the dataset. Our experience, as lived at the moment, is that the majority of the major city to our east, which is Devonport, has closed books—that is, patients are unable to find a general practice home for themselves. That also affects Latrobe and Port Sorell. We are closed in our books to all bar the people who are from the Central Coast municipality. It's not an absolute, but we try and meet, as we can, what we see as our patch for those people who are moving into it. We also see the same happening in the Burnie setting. The patients or the consumers of the system are finding barriers to getting access because of availability.

Senator PATRICK: You're at Ulverstone, aren't you?

Dr Djakic : Yes.

Senator PATRICK: That's MM 2. Is that correct?

Dr Djakic : MM 3.

Senator PATRICK: MM 3. So you've seen numbers go from 94 in 2013 to 130. That's just talking about MM 3 across Tasmania.

Dr Djakic : Yes.

Senator PATRICK: I'm just trying to get your perspective on it. I never trust government statistics. I'm sure they're accurate, but they don't necessarily tell the proper story.

Dr Djakic : The population data for a town that I've flagged—and obviously that's now five years out of date because we haven't got the current census stuff yet—shows a substantial population shift and growth, which needs to be tracked or paralleled by that doctor rise so that we have got more doctors in our patch in my time. I can see that happening, but we're faced with more population, an increasingly complex journey and how much contact we have to have with patients.

Senator PATRICK: So it might be that there are too many Tasmanians.

Dr Djakic : Too many sick Tasmanians!

Senator PATRICK: This is my final question. One of the contrasts I see as a South Australian senator is when looking at Kimba. That's a five- to six-hour drive to a major metropolitan area. We've only got one, which is Adelaide. Coober Pedy is nine to 10 hours. Yet the distances in Tasmania are relatively small. It looks to me like yours is within a couple of hours of either Launceston or Hobart. That indicates to me that distance is perhaps only a small part of the problem. I just wonder if you can comment on that. One might have thought that distance was a big factor.

Dr Djakic : You're talking about remoteness?

Senator PATRICK: Yes, remoteness.

Dr Djakic : I did a year working in Derby in the Kimberley, so I got a fair idea about what real remoteness and time was. Tasmanians have a very challenging mindset around disadvantage and distance. I will agree with that. Setting off for an eight-hour drive from one town in Queensland to the next—it's a very different environment. Travelling from the City of Devonport to Ulverstone is effectively a 15-minute drive. That's not a huge impost as far as we can see. So it is a challenging mindset in Tasmania, that, as a population, we—that's 'we' because I'm one of them, but I grew up with a very different idea—feel very parochial about how we view the boundaries of our limitations.

Senator PATRICK: In terms of attracting doctors, it is difficult to attract a doctor to an area that is very remote. Yet it doesn't seem, on the face of it, that remoteness is a big issue here.

Dr Djakic : I would agree. My bias is very strong, but the north-west coast is well served by resources and by schools. It has access to three excellent airports within a two-hour drive. Those things are not huge barriers compared to and contrasting with other areas in Australia, which are clearly faced with that remoteness and distance problem.

Senator PATRICK: I might explore that with other witnesses. Thank you.

Senator POLLEY: Thank you very much for your contribution today, Dr Djakic; it has been very helpful. I want to go to the change in necessity for GPs. In the north of the state there a lot of GPs who only work four days a week. They strongly believe they need to look after their own mental health. One of the burdens I've picked up in the meetings I've had with GPs is that there is a greater emphasis now on patients who come in not only with chronic illnesses but with mental health issues. Would that be a fair summation of what's happening?

Dr Djakic : Mental health is a huge part of my day and every general practitioner's day. I would venture that 40 per cent of my patient cohort on any one day either has active mental health issues that we're managing or has issues of mental health that remain undisclosed or influence their day, whether it be anxiety or depression. The workforce's choice to change the way they choose to work is a generational thing that we've clearly observed. I sit here as a very young baby boomer from 1964. Cultures have changed. Our registrars now view the normal working week as a four-day week under their contract; that's a really interesting shift. But we are also losing workforce capacity because both males and females are choosing to work in part-time capacities. The feminisation of the workforce was blamed for this a bit, but we need to be honest; it's happening with all genders. We are no longer seeing people doing the eight-to-six, 5½-days-a-week of practising. I think that's a good thing, in that the intensity of that work was not good for the health of GPs in the long term in an ever-increasing complex medical system. But it has huge implications for workforce capacities—the RACGP submission has clearly pointed at that—and how we then meet the patients' need in creating available doctors on the ground.

Senator POLLEY: There's been an issue around attracting doctors into regional areas for decades. The evidence from my contact in the north of the state is that consumers believe there aren't enough GPs and too many general practice books are closed. It is frustrating. Why aren't we training more doctors?

Dr Djakic : I held an optimistic view about eight or nine years ago, with the increasing numbers of medical school graduates coming through the system—it was a substantial change. But the number of those undergraduates who intend to follow a general practice pathway has reduced close to a depressing 15 per cent. We need 50 per cent of them to be considering that pathway. Somewhere there, we have to fundamentally influence our new graduates of our own universities to see that general practice is an attractive and professionally rewarding pathway, and one that absolutely delivers for Australia—that is, it's the pearl in our healthcare system. But we're moving away from it, and our graduates are moving and focusing on other specialities as their pathways hand over fist. And that really needs to be redressed. I would have thought that by now I'd be seeing a number of Australian graduates approaching our practices in the regions, particularly in a region which isn't overly remote or unattractive, as far as I can see, but we're just not seeing it.

Senator POLLEY: Are we actually training enough doctors at the University of Tasmania? The medical field has told me over a long period that if you train your own, you're more likely to keep them. It is difficult to attract GPs or even a specialist out of major cities like Sydney and Melbourne because, frankly, they can make more money. What do we need to do to ensure that a GP becomes a go-to career in health? Quite frankly, you're the front line keeping people out of hospitals. You're the front line keeping people out of mental health clinics. How can we really incentivise this? This is an ongoing problem over decades. What's the solution?

Dr Djakic : I celebrate the Rural Clinical School in Burnie as a place we've worked closely with over its entire duration, and I see that program has having embedded students in regional towns and cities to at least expose them to a community and a lifestyle. What we need to do is ensure that those student cohorts get enough time and exposure to functional general practice and have a positive educative experience that they walk away from thinking, 'Actually, general practice doesn't look so bad.' Sadly, as I've said earlier, that's not happening in a lot of general practices, and I think that's because they're time poor, they're very fiscally stressed, and the student is seen as an add-on challenge to their day rather than an important part of the healthcare system and an investment in general practice.

Senator POLLEY: Is the rural health strategy actually working now?

Dr Djakic : The visibility of the rural health strategy in my practice appears to be quite absent. We don't feel like we're in a strategy. Our practice doesn't feel like we're signed up to any journey that's actually leading us towards a solution for this recurrent problem of workforce shortage and lack of attraction and retention that has been failing our population due to a lack of access to competent, well-trained general practitioners.

Senator WHISH-WILSON: I know we get a lot of anecdotal evidence about attracting and retaining GPs to different parts of the state. Are you aware of any metrics at all around retention, whether it's international placements for students or locums?

Dr Djakic : I haven't got a metric that I can put my hand on and say that's what's happening in our space. Anecdotal evidence is about watching the doctors in the area who come and then leave, and they're overrepresented in terms of the international graduates. I think most of our registrars who come view the rural-term allocation or the opportunity in our region as a short-term penance, although at the moment the ones that have come here have some direct connection to our local region. Refreshingly, we are seeing more local names of people who have moved through the system and who are choosing to at least train in and experience our region.

Senator WHISH-WILSON: I was just wondering. I know a couple of GPs on the west and north-west coasts who chose to be there because they're trail runners or rock climbers, or there's a lifestyle that attracts them to that area. But they're telling me that no amount of money would make a difference really with attracting and even filling some of the vacancies in the spots, because it's more a lifestyle issue; it's more where you want to live rather than how much money you're going to earn in an area. Would you agree with that?

D r Djakic : I don't believe that it's just fiscal. To retain someone in a region, they have to feel like they want to belong in a region. I moved to Ulverstone as a trainee for six months, then went away for three or four years doing things and then went back there because I'd had a positive experience. I enjoyed the community and it looked like the pathway that I could enjoy professionally that was going to fulfil me.

CHAIR: Senator Hughes, you have a quick question?

Senator HUGHES: This obviously isn't our first hearing on this topic. We've heard from a number of GPs who have come in and talked about the burdens of training graduates and issues around their business model having to be altered. I'm just looking for some clarification. If GPs in rural and regional areas took on the training of GP graduates or soon-to-be graduates in a way that encouraged them to stay, that encouraged them to move to the region, and they invested time and effort in demonstrating to them the benefits of staying in that area, wouldn't that in turn increase the number of GPs in the area? Going forward, that would reduce the burden of training because there'd be more GPs in the area to share it. If you go to any job—I'm from Moree originally where we used to have to train header drivers and people to pick cotton and those sorts of things—everyone has to invest in training future staff. The more of them that you train, who stay where you are, the lower that training burden becomes. Yet we consistently hear from GPs: 'The burden is too high. We don't have time to do it properly. It doesn't fit our business model.' Really, in effect, shouldn't the business models be reviewed? If GPs actually look at themselves and go: 'Hey, if we invest in the next generation, we might not have this massive burden on ourselves, because we've encouraged people to stay.' It just seems self-defeating at the moment.

Dr Djakic : A lot of the registrars who come to us, and I've been involved with probably 25, 30 registrars over the time now—

Senator HUGHES: We've got 35 starting today, haven't we?

Dr Djakic : In the kick off. We would look at at least half of those and say: 'Gee, I wish that person would stay here.' We go out of our way to make sure they have a positive experience in their education, which is the primary goal, but also that they are enjoying the community in order to see that this could be a viable option. But they finish their term and move on to their next training practice or on their own planned journey. We can only be as open and honest as we are.

Sadly, some of that decision-making gets picked off by some fiscal decisions the registrars make as to where is going to be in their best interest, and rightly so, I can say. If you're a young adult setting out in life and facing the prospect of securing housing and whatnot, you're perhaps going to think fiscally.

We try and offer a practice which is more about the holistic, professional experience, enjoying your working life, enjoying the teaching life, enjoying being in that community. We're not the highest payer to subsequent contractors, but we also don't work in a purely hamster-type, bulk-billing clinic model which means 'pedal faster'. We actually want to be there for a sustainable reason.

S enator HUGHES: A lot of rural GPs don't bulk-bill anyway.

Dr Djakic : Well, a lot of them are forced not to.

Senator HUGHES: From a fiscal perspective, a GP could come into a clinic and charge what they want to. That happened in Moree, I can tell you. When they talked about a $7 GP co-payment, we all laughed hilariously because we had a minimum one of $45.

It just seems self-defeating. The experience that we've heard from trainee doctors is not one of great pastoral care, not one of attention being given. I feel that rather than this being a government issue and looking for some sort of government solution maybe it's actually the GPs and the students who need to come together on how they can make this work better. Because if GPs aren't giving pastoral care and trainees aren't getting the greatest experience, we're not going to see them really start—

Dr Djakic : I'm quite a fan of responsibility, and I've spoken to that in the student environment—that you need to be given the tools and the time to be able to ensure you focus and give them the positive experience, and that should flow through to registrars and subsequent people—

Senator HUGHES: Yes, but government can't convince a GP to be a kind and sharing teacher.

CHAIR: Thanks, Senator Hughes. We'd better finish up because we are running late. So thank you very much, Dr Djakic, for your evidence today. I'm not sure whether you took any—

Senator O'NEILL: Senator Rice, could I ask a question?

CHAIR: Sorry, Senator O'Neill. Yes. You wanted to put a question on notice, didn't you?

Senator O'NEILL: If I could, thanks.

CHAIR: Yes. Go for it.

Senator O'NEILL: Thank you to the witness for your evidence. First of all, could you confirm that you agree with the election statement by the RACGP and make sure that we understand any particular Tasmanian issues. Secondly, I think you just [inaudible] Senator Hughes, her version of, 'I don't hold a hose.' The reality, I think, of your evidence today was of four years of greed by the federal government, who are trying to seek a fourth term on the basis of being [inaudible] fiscally literate and economically responsible—

CHAIR: Thanks—

Senator O'NEILL: but have essentially destroyed your business model as GPs. And that's right across the country. I would ask you to further expand on your statement that there is a $120,000 gap in the productivity and capacity of your businesses, as GPs, that the government has failed to identify and build up. The other thing is: if we've got smart people [inaudible] can pretty well figure out that a business model that's not going to work is not going to work for them, no matter how much they might want to stay in a community. So I invite you to respond to that.

CHAIR: Thanks, Senator O'Neill. Dr Djakic, are you happy to take that on notice?

Dr Djakic : I can support the RACGP's election statement and can support our president Karen Price's position at the moment in advocating for GPs to take responsibility for their billing journey, which means talking about choices around how you bill and not being locked into just talking about bulk-billing.

CHAIR: If you could you take the rest on notice—in particular, how you deal with that $120,000 deficit—that would be really appreciated. We're going to be reporting to the Senate by 30 March, so could you get any response to that question on notice to us by 17 February. In your busy life, would that be possible?

Dr Djakic : Yes.

CHAIR: Fantastic! Thank you very much.
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