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Community Affairs References Committee
Availability and accessibility of diagnostic imaging equipment around Australia

CONDOUS, Professor George, President, Australasian Society for Ultrasound in Medicine

EASTGATE, Mr Patrick, President, Australian Society of Medical Imaging and Radiation Therapy

MACPHERSON, Mrs Lyndal, Chief Executive Officer, Australasian Society for Ultrasound in Medicine

[11: 46]

CHAIR: Welcome. Have you all been given information on parliamentary privilege and the protection of witnesses and evidence? Yes? Excellent. We have your submissions. Thank you. I would like to ask each of your groups to make an opening statement, and then we'll ask you some questions.

Mr Eastgate : The Australian Society of Medical Imaging and Radiation Therapy is the peak national body representing medical imaging and radiation therapy professionals. On behalf of our organisation, I would like to thank you for this opportunity to appear at this hearing today.

Our submission no doubt reflects many themes similar to those that my colleagues have already presented previously and will present today. These include the tyranny of distance and the geographic implications of access to medical imaging and the inequalities and inequities that these challenges leave us with. We also reflect the impact of the cost of these services to the Commonwealth and to our patients. These challenges are not new, and I have no intention of spending my brief time telling you of these problems that my colleagues will eloquently cover today.

I would, however, like to spend my time telling you how our organisation is working to a solution that reflects our organisation's vision, empowering medical radiation practitioners for the health of all Australians. ASMIRT has committed to providing a national standard and expectation of its medical imaging professionals providing a comment or opinion on X-ray images at the point of care. We call this a preliminary image evaluation or PIE, which I'm sure you will agree is a great Australian-flavoured three-letter abbreviation!

The contemporary weight of evidence nationally and internationally unequivocally supports our role in providing this PIE and is best demonstrated by the extensive and highly successful use of radiographer commenting in the United Kingdom to alleviate and reduce costs in their very stretched national health system. Perhaps where our PIE proves its value most obviously is in the regional, rural and remote areas of our country, where the most readily available diagnostic tool we have is X-ray. Furthermore, it is in these geographical locations where it is often not possible to access radiologists—they are either sessional, part time or simply not employed in that particular facility or location. This can, and indeed does, seriously delay and compromise patient safety.

The evidence tells us that, when trained radiographers provide a preliminary image evaluation, in combination with that of the referrer, our sensitivity and specificity are similar to that of a radiologist. We are not suggesting that this PIE would replace the radiology report but rather that it would value-add to our part of the service provision on the front line. We are supported in this endeavour with our national registration standards, which clearly define this within our scope of practice. Indeed, the Medical Radiation Practice Board of Australia medical radiation science capabilities document mandates that radiographers must comment.

While we are not supported in every corner of the radiology team, we are committed to ensuring we are doing our part in improving our patients' safety when in our care. We believe we can achieve this through a robust, evidence based, auditable system that will have no cost impact on our services and patients. Thank you for your time.

CHAIR: Thank you.

Prof. Condous : Thank you for the opportunity to appear before the Senate inquiry today. The Australasian Society of Ultrasound in Medicine is the premier multidisciplinary society advancing the clinical practice of diagnostic medical ultrasound for the highest standards of patient care. The purpose of ASUM is to promote the highest possible standards for medical ultrasound practice in both Australia and New Zealand—Australasia.

Ultrasound is an essential tool in the diagnostic imaging space. While it's been considered safe when compared to other imaging tools that use radiation, it is operator dependent, requiring a great deal of training to enable safe practice in both acquisition and interpretation. Diagnostic ultrasound is one of the most rapidly expanding branches of medicine. Our membership is made up of both doctors and sonographers in all specialties, enabling us to have a broad view of the landscape and moving well beyond the traditional providers for ultrasound, which include radiologists, obstetricians, gynaecologists, vascular surgeons and cardiologists.

Our members have raised a number of concerns which we'll discuss today, the key issue being the Medicare rebate freeze and increasing gap payments for patients; poor access to diagnostic ultrasound and imaging in regional and remote areas; unskilled providers offering service in ultrasound; overall, in Australia, a sonographer shortage; lack of trainee positions for sonographers, with minimal or no funding; and minimum training and credentialing to ensure patient safety. Patient care is always at the centre and is always the key focus.

As you've already heard today, the Medicare rebate hasn't changed for ultrasound in over 20 years, restricting services in all specialties, which in turn affects patient management. This relates to many patients not attending appointments due to the fee or gap incurred, which is crucial to the management of their disease, often then creating a burden on Medicare to support the patient, who then subsequently needs additional care because they may present with a later or more advanced disease stage. The costs of training, employing staff and servicing of equipment continue to rise, and the expectation under current requirements demands that both doctors and sonographers continue to develop professionally, which also comes at a cost. Accreditation of both doctors and sonographers remains an issue, and there are currently extremely loose rules in the MBS allowing any specialist to perform and claim an ultrasound. This is especially so in the space of point-of-care ultrasound and in many traditionally non-ultrasound-based specialties.

This shouldn't be the case. As stated previously, ultrasound is operator dependent, and patients would therefore assume, if they get an ultrasound performed by a particular person performing a scan, that that person would indeed be qualified. This is an expectation the patients should be able to have, but unfortunately it is not always the case. This will potentially lead to many examinations, requiring an ultrasound study to be repeated and again putting the patient at risk of potential missed diagnosis or misdiagnosis, as well as adding a further burden on the Commonwealth purse. Sonographers are also currently registered for MBS claims with the Australian Sonographer Accreditation Registry, though this is one step too short with regard to patient safety and the expectation of the patient.

The issue of accreditation for doctors and sonographers is more noticeable as you move to rural and remote areas of Australia, where access is further limited, and this also affects training opportunities. Increasingly, due to the nature of learning ultrasound, GPs in the rural setting and remote areas need to have supervision and feedback, and this is often not the case.

The lack of funding has also seen a change in the number of clinical training placements that are available for sonography students. These are essential for their training, yet the investment in both private and public sectors for sonography trainees is less and less. Currently there are over 1,000 sonography trainees registered within the Australian Sonographer Accreditation Registry, with approximately 15 per cent of these trainees not able to get a clinical placement, while sonography has remained on the skills shortage list for over 10 years. Australia sets the highest standards for sonographers globally, yet we're spending money on immigration and reduced skills to fill gaps in the workplace.

These are but some of the issues that ASUM wanted to highlight to the committee today. Thank you so much.

Senator BROCKMAN: I just want to ask a framing question. Perhaps my fellow senators understand this very quickly, but—particularly for you, Mr Eastgate—could you just talk about where your organisation sits in the overall picture alongside the Diagnostic Imaging Association. Who are you representing, as distinct from them, and what's the shape of representation across diagnostic imaging?

Mr Eastgate : We're a not-for-profit organisation that purely represents the professional needs of radiographers and radiation therapists. We often meet with those other organisations—the college and ADIA—but actually stand independently of them and represent the professional values of what we're trying to achieve.

Senator BROCKMAN: So you're representing just the professionals, as opposed to ADIA, which represents a broader—

Mr Eastgate : Absolutely. We only represent those that are registered through the Medical Radiation Practice Board of Australia, so none of our members are actually medically trained. We're allied health professionals.

Senator WATT: Mr Eastgate, your submission notes that no standard approach has been developed for minimum-level provision of services, and you go on in the submission to propose one. Can you explain that proposal to us a bit further and what would be the use and benefit of it?

Mr Eastgate : What we're trying to propose goes back to what I think a lot of my colleagues have already stated today, about that equitable access, irrespective of where you are in Australia. At the moment, we see that there is almost a second-rate or second-tier form of health care the more rural and remote you go. We heard that from our colleagues, particularly from Mr Cook in the western side. We're trying to propose a model that may try and even that up a bit. We tend not to go into the higher level discussions that have been had today, partly because we have very little influence in that more than the college and the likes of ADIA. I guess we come at it from more of, for want of a bit of term, a grassroots level—what we think we can influence as an organisation that's at an allied health professional level.

Senator WATT: You've pointed out, again in your submission, that private providers are not required to provide the entire range of DI services. They determine what services they will provide, based on financial returns, in turn setting the fees based on that bottom line. What do you see as any harms that arise from that, and what policy responses could we be considering?

Mr Eastgate : Probably 'harm' is not the right word to use. It's always that battle between business and doing the best by Australians. We would like to see, as we've heard already today, that individuals aren't financially encumbered with some of the costs of health care that they may require. It's about getting that equitable service to all Australians.

Senator WATT: Do you have any thoughts on how we can ensure that we achieve that?

Mr Eastgate : It's very difficult. There are some great examples of where the private sector has actually promoted the health care of rural and remote Australians, and we saw that with the advent of CT being deployed in some of the rural and remote towns within Queensland. There are benefits to that population. The question is always going to come back to the cost to the patient and whether they will go elsewhere to seek it without having a cost to them personally.

Senator WATT: You also pointed to funding and workforce shortages in public hospitals, saying that that reduced their capacity to provide DI services. Again, have you got any thoughts on public policy responses we could consider to those challenges? It might be increasing Commonwealth funding for public hospitals or it might be other things.

Mr Eastgate : It's almost the mantra of public health that we require more staff. I actually think it's not too dissimilar to the sonographers, who are still listed as a shortage—we're actually starting to see a trend the other way, where we're not seeing a shortage. That's because we're starting to see an increase of graduates coming out of the university system. For us, that argument is slowly starting to evaporate, because we are seeing that we actually have a good supply of professionals into the workforce. We're seeing that that is becoming less of an issue for our profession at this stage.

Senator WATT: So the workforce issues aren't as challenging for you for the moment?

Mr Eastgate : That's correct.

Senator WATT: But that was obviously a key theme of what you raised, Professor Condous. You've given us a bit of a rundown in terms of sonographers. Is there anything more you'd like to say about the workforce challenges and what we might do to address them?

Prof. Condous : There is no doubt that there are greater issues as you move more out of the centre hubs, the city hubs, but I think you probably need to have an overview in relation to the way in which we provide services in ultrasound generally. We've talked about this, particularly with bedside ultrasounds being available, being used, in the cities. They are generating a potential $30 fee from a Medicare rebate perspective, as a non-referred scan. I just did a bit of number crunching potentially in the world of obs and gynae. If someone is busy with 400 confinements and deliveries a year in the private sector, they see their patients at least 10 times during that period. That generates $300 over the 400 deliveries—that's an extra $120,000 a year that's completely Medicare funded by the Commonwealth. If you then multiply that by 2,500 OB-GYN specialists and 1,000 of them are doing that on a regular basis of 400 confinements, there's $120 million.

If you were to look at the way in which bedside ultrasounds are provided and potentially credential it in a way that you incentivise people to get credentialled so they can then provide a service which is Medicare rebatable, those savings could be utilised to fund sonographers to go to the country and fund additional positions in the public sector. It needs to be a global approach with strong leadership from the top down to make these changes happen.

Senator WATT: It really wouldn't matter what specialty we're talking about as getting people to go to rural and regional areas is a constant problem. Does it come down to pay levels to provide the incentives to people to work in regional areas?

Prof. Condous : Probably not.

Senator WATT: What other responses would there be available?

Prof. Condous : I think you could even start at the level of medial students, having entry level, so there's a certain percentage that come from country. I know there are systems in place now where those of Aboriginal or Torres Strait background are not necessarily preferentially given places to go into medical school but they're weighted in a way that they have a higher chance of getting in. If you did the same for those who come from rural communities, they're more likely, once they do their training in the city, to go back to give back to those communities. Most of our doctors at Nepean are home-grown now, so they tend to stay in the region, whereas when I started there 11 years ago, we had people coming centrally from the east side and north side of Sydney. They'd finish their training, leave and then go back to the city. That's, I think, a way to encourage people to go to the country. Do you want to speak to the sonographers?

Mrs Macpherson : I think for sonographers as well it's very much operator dependent to learn, and it takes a good 12 to 18 months of clinical practice for someone to be able to do an ultrasound on their own. Without that supervision or someone to watch over them while they're learning, it is something they don't have access to and the problem becomes worse. Whether there's any sort of mechanism by which we can bring people into the city or we look at funding to get supervision or the use of teleradiology and different methods—and that goes across in that point of care space as well. Whether it's for GPs or other doctors, particularly in rural and remote, we do a lot of outreach particularly up in the Northern Territory to teach midwives ultrasound. So they're doing very, very basic and they know their scope of practice, but it's actually contributing to the care of the patient and I think more of that needs to happen.

Senator WATT: One issue that does seem pretty important is the apparent lack of minimum standards and credentials for offering ultrasound examinations. I think you presented a position statement to the diagnostic imaging advisory committee a few months ago. Have you had a response from the department or the government to that submission?

Mrs Macpherson : No, nothing. Certainly the representatives in the room from the various colleges and associations were very supportive of it, but I've had no response from government. It comes back to patients' expectation, and it should be their expectation that the person doing the exam or interpreting the exam is actually qualified to do and that's not necessarily the case.

Senator WATT: You would have heard this morning quite a lot of discussion about the allocation of licences and quite a lot of criticism of the process, or lack of process, that exists at the moment. Have any of you got any thoughts about what we can do to improve the process surrounding the allocation of licences?

Prof. Condous : For ultrasound or for MRI?

Senator WATT: Most of the discussion has been about MRI, but I'm interested in the whole—

Mr Eastgate : With regard to MRI, from our perspective, it's well above our influence. However, we would agree that probably an objective process to those licences is appropriate.

Mrs Macpherson : For ultrasound it's almost the opposite problem: ultrasound is becoming more and more accessible and, while a lot of the comprehensive practices that are offering a good ultrasound service will buy a more expensive machine, there are certainly machines out there that you can buy online for a couple of thousand dollars. You don't need a qualification to do it, and so that's becoming a problem in itself. So tying back to credentials and making sure someone's qualified at whatever level that they're practising at needs to be brought in definitely.

Prof. Condous : One of the things that was talked about, when I was listening to this morning's submissions, was the question of whether there is data to support the use of MRI to improve outcomes, and it seemed that there was a paucity of data from some of the people who presented evidence earlier. In the ultrasound world there's definitely data to support the use of ultrasound. In 2010 we published on the use of ultrasound with women with acute gynaecology. For every 1,000 women who came through a particular service that had ultrasound available at the point of care, we reduced the admission rates from 36 per cent to seven percent, which translated to a reduction in occupied bed stays, which translated to a savings for every 1,000 women of $¼ million annually. We've done the same cost-benefit analysis for high-quality endometriosis ultrasound for women to be able to avoid two-step laparoscopies, which incur a cost to the public healthcare system. And using Medicare rebatable item numbers we modelled on, for 1,000 women, 150 having chronic pelvic pain needing potential intervention, such that for the old model, where there's no high-quality ultrasound, compared with offering high-quality ultrasound you end up saving around $300,000 annually for those 150 women. So, there's strong data that ultrasound should be the first-line imaging technique, but also actually at the back end it reduces the healthcare costs for the Commonwealth in relation to operative—

Senator WATT: What's the barrier in applying that kind of thing more broadly?

Prof. Condous : I think training opportunities, and in the context of the Macquarie unit being highly specialised, being able to disseminate that information or that type of training to other units throughout Sydney and also around Australia. So I think an issue is training people to be able to do those sorts of scans—that in itself comes at a cost.

Senator BROCKMAN: So, basically anyone can offer a point-of-care ultrasound, with no particular training, no—

Mrs Macpherson : No, the rules under Medicare at the moment state that if you're a specialist then go for it, pretty much.

Senator BROCKMAN: Any specialist? And that's happening in specialists' offices?

Mrs Macpherson : Yes.

Senator BROCKMAN: Is that bedside ultrasounds in hospital falling under the same—

Mrs Macpherson : Not probably as much. They're definitely doing it, and we're one of the providers to offer education, because that's happening anyway, so we'd prefer to make sure there's training and credentials behind it. And it's happening more broadly, I guess. Emergency medicine's very much active in ultrasound critical care. But we're seeing it then expand. It's in rheumatology, where it does actually change the management and the drug management for those patients, and that's fairly severe drugs—endocrinology, breast surgery, all of those aspects. I think ultrasound's definitely becoming more and more accessible. And in some cases they are employing a sonographer. The exam might be done by someone qualified to do the exam, but they're not necessarily the right person to interpret the exam. So there's still quite a mismatch there as well.

Senator BROCKMAN: Apart from sonographers, who are doing these exams—doctors, midwives?

Mrs Macpherson : Orthopods are certainly starting to do a lot more in the ultrasound space, and gastroenterologists. Everyone's kind of dabbling in it a little bit but not necessarily with the skill set to do it. There are midwives doing it—across the board, not just in rural and remote, but certainly in metro areas as well, but typically that's under the supervision of an obstetrician who's training them to do so. Or we offer some training, where we've worked with some of our outreach, just to make sure it's being done safely.

Senator BROCKMAN: I just want to talk about the technology itself, having had three children relatively recently—well, my wife had three children! The quality has increased even just over the last five years; it's quite extraordinary how much the quality has increased. Is that curve continuing from the industry's point of view? Is the quality just continuing to improve?

Mrs Macpherson : It does seem to, and not just the quality. Within ultrasound, I think it's probably the most rapidly changing technology there is, because they keep reinventing the wheel. So, we're not just using ultrasound and doing it from an imaging point of view; we're now using techniques that allow us to measure elastography—to help us work out whether something's a benign or a malignant breast cancer or looking at the stiffness of liver to see what the stage of cirrhosis is. So, it's constantly reinventing to sort of take it that next step. And ultrasound really is quite a cost-effective way of looking at those diagnostic areas as well.

Prof. Condous : The other area where it's changing is that also the devices are becoming more portable. So, wind forward 20 years, and in the same way that they used to have a stethoscope, all medical students will carry a handheld ultrasound device, from day one.

Senator BROCKMAN: I guess one of the challenges from a regulatory point of view, then, is that we have these techniques with new uses, like MRI, ultrasound, getting much better quality. How are we going to—and I mean this in a systemic sense—determine what the best technique is: whether we use an ultrasound for this particular medical condition, whether we use an MRI, whether we use a CT? Where is that information being compiled? Where should it be compiled? How are we actually learning to improve the health system?

Prof. Condous : In the world of endometriosis there's strong data to say that transvaginal ultrasound scan—

Senator BROCKMAN: So, it's going to be a case-by-case, specialty-by-specialty—

Prof. Condous : But there have been meta analyses where they've compared ultrasound to the use of MRI, and the performances are very similar. Ultrasound's a dynamic evaluation, whereas MRI tends to be static. You can get more information from that dynamic evaluation, where you can move ovaries against the uterus to assess to see whether tissue planes have been interrupted or destroyed. And there's a big cost. Obviously MRI's more expensive, potentially, for the user and from a public purse perspective. Philosophically, it's a difficult one to answer. Personally I think that if you encourage the providers who were involved with ultrasound or MRI to be rewarded in a way that's based on outcomes rather than actually providing the diagnostic service—so therefore in a sense you try to—

Senator BROCKMAN: That's in an ideal world. I'm just wondering how we get there.

Prof. Condous : Then I think that would be a better way to potentially then—objectively someone could say yes, you should have an MRI. It's almost as though you need someone, a separate umpire. I know people don't want another layer, but perhaps that umpire who had experience across the board in a particular disease process could come in and say that based on the data, based upon meta-analyses, based upon the Cochrane review, this is the imaging technique that you could provide. I think the system in Australia is too complex to try to tackle that, because there are so many people who are involved with the costs of that service, so it would be difficult to make it happen. But in an ideal world I think that would be the best way to do it. And then it doesn't matter whether I provide ultrasound or someone provides an MRI; the patient with their breast disease gets the MRI for staging, because that's the most appropriate thing. The man with his prostate cancer gets the multifaceted MRI intervention rather than the ultrasound followed by the transrectal ultrasound followed by the CT scan followed by the PET scan followed by the MRI. So, I think that would be a way to deal with it. To implement that—that's beyond my scope.

Mrs Macpherson : But the Choosing Wisely program that's out there at the moment is certainly a good start. The college mentioned it earlier today, and a few are subscribing to it as well. It helps at least start to channel some of that and somewhere to go to actually get some form of advice. But it probably needs that little bit more input from a broader group so that it covers all the areas that are using imaging.

Mr Eastgate : And I think we're also seeing that technology will change those standards. As technology's improved we've actually seen a reduction in radiation dose to our patients. A good example would be if someone came in with a queried pulmonary embolism, and the gold standard is a CTPA. Certain cases require us to reduce the dose, so we send them off to a nuclear medicine scan, which is called a VQ scan. We're now seeing that CT doses have actually dropped below what that gold standard was, so now we're seeing that there's actually a referral back into CTs to undertake that diagnosis, because the dose is actually lower than what we historically have used.

CHAIR: We had that in Perth as well—that CT has so much improved now that people are going back to re-look at it. But it seems to me from the evidence we got in Perth and that was reinforced here that it depends on whether you've got the latest technology, who's delivering the service and what skills they have. It makes choosing wisely even more difficult, because you can't just say: 'This is the gold standard. You should be doing this.' It depends on whether the person has the latest CT machine and is trained properly to use it—all those sorts of things. How does Joe or Josephine Public know whether they're getting the service that is the best targeted service to them, given all those variables?

Mr Eastgate : They probably don't, in essence, but I think what we try to do as clinicians is to create pathways that we know do the absolute best for them with the facilities that we have. If someone walks in in Western Queensland with a queried pulmonary embolus, they may not actually have any diagnostic tools that are going to assist in that diagnosis, so it'll come back to the clinician. On the other hand, if we have nuclear medicine and CT available in the big centres, we know that they're going to be the high-end and high-spec equipment, where we can make that decision. I guess that comes down to the challenge of health care: what do we do with that patient? Do we move them, or do we try to treat them as they are based on the clinical diagnosis?

CHAIR: The difficulty laid on top of this is that the current licensing system and the current rebate system—it's not just the licensing system but also the rebate system—are perverting people's choices as well. So it seems to me that, at the moment, you're not playing on a level playing field when you're trying to assess what particular technique is the best technique. Would that be an accurate assessment of where we are at the moment?

Mrs Macpherson : I would think so, yes.

Prof. Condous : The other great unknown is the impact of social media on people's ability to decide what is best.

CHAIR: Oh, God!

Mrs Macpherson : Dr Google!

Prof. Condous : You could argue that, in this world of commercialisation of the way we provide medical services, the person who has the greatest ability to drive traffic through Google AdWords is more likely to get someone to come to have a CT-guided biopsy, as opposed to potentially having an MRI-guided biopsy.

CHAIR: Rather than asking their clinician?

Senator BROCKMAN: I must say that, when you were speaking earlier, something came into my head: when am I going to see an ultrasound for sale on a shopping channel for home use?

Prof. Condous : Well, you can go to some parts of the States and get your baby scanned whilst you're shopping for clothes, and there is a place in Perth that does it as well, called Early View. You can go and get your baby scanned between cappuccinos.

CHAIR: Let's move on, because there are all sorts of images that I'm thinking of at the moment! I want to go to you, Mr Eastgate, because in your submission you made the comment about the old machines. I have a bit of a thing about these old machines and the poor old rural and regional areas copping it. You make a pretty strong comment about the rural and regional areas ending up with the older technology. The way I interpret what you've said, whether this is implied or not, is that it's not just that they're ageing in place; some of the rural and regional areas are actually having this older equipment foisted on them. Is that a correct interpretation of what you were saying?

Mr Eastgate : Yes and no. I think it's more a case of capital sensitivity; I think Mr Cook spoke about it this morning. We often see that it's in the biggest centres that that capital sensitivity turns over quite readily, but we don't see that turnover happen in the regional, rural and remote areas as much. Mr Robertson spoke this morning about how a scanner was moved from Caloundra to Gympie, which has had a positive impact on the service that's provided at Gympie. The reality is that, if Gympie had gone to an open tender, they would probably have got a far more technologically advanced CT scanner. But that's not to say that it hasn't improved the outcomes for the patients in Gympie. At some point, there will be a cost to the healthcare system from having to replace that CT scanner.

CHAIR: So it is still resulting in rural and regional people having access to lower quality services because they have older equipment?

Mr Eastgate : Absolutely.

CHAIR: One of the points that were made to us in Perth—I'm just running the argument, before I get lots of phone calls saying, 'You're picking on rural and regional people'—is that, particularly in a state like Western Australia, it's unrealistic to expect to have some of this really expensive equipment anywhere but in the capital. Queensland is different, because Queensland's much more regionalised than WA, for example. South Australia would have similar issues to Western Australia, with the large bulk of the population being on the coast. How do you deal with those situations?

Mr Eastgate : It is very difficult, and I think you're right: Queensland very much uses a hub-and-spoke model, whereas in Western Australia the hub is probably Perth, and everywhere else is the spoke. So it is a challenge, and I understand where they're coming from. I'm not sure that I have all the answers to tell you how to solve that problem, but it certainly is a problem. The regional, rural and remote areas don't have the same specs as what we expect in the big cities. But I think there is something driving part of that. When you look at the hub-and-spoke model, the more the acuity of the condition the more likely you are to be funnelled back to one of the big centres. That's where they need the high-acuity equipment to make an accurate diagnosis for treatment. Whereas, out in the regional, rural and remote areas, it may be that it's more preliminary to assess where they're at and what they need to do with the patient: do they need to move them on or can they stay there and treat them? It's about getting the balance.

CHAIR: This question is for both groups. We already know that rural and regional people overall are getting worse health outcomes on a lot of fronts—for example, in cancer, but also other areas. If we don't put in place some sort of process to address this issue, given the importance that imaging is going to play in our health outcomes, how do we intervene now to ensure that the health disparity isn't increased as our technology improves and we get better imaging, with the greater role it plays in health outcomes?

Mr Eastgate : I go back to what Senator Watt discussed before about how we promote our professionals to go further afield than the big cities. Locally, the Allied Health Professions' Office of Queensland has developed a career pathway where young radiographers can go to rural and remote sites and, during a two-year phase, can be upskilled into ultrasound training and will then get better remuneration for their skill set. There are some pathways already that are useful in looking at whether we can move those professionals to those areas to provide better health care. But there is a cost to the government in providing that pathway in the public system.

Prof. Condous : This is one of the things we'll be doing next year. We've received $100,000 from The Country Women's Association of New South Wales. We'll be going out to rural New South Wales and beyond to run outreach clinics over a weekend, for example. We will advertise to the GPs in the lead-up to that and then people from all around those areas will be able to come to the set-up clinics and, if we need to operate on anybody, we'll refer them to the Nepean Hospital for a service that's Medicare funded. From that perspective, to incentivise people to go there is potentially a way forward, to look for doctors who are keen to do so—if there were a funding model available through the NHMRC, for example, that we could apply to and put together a model of care and, in doing so, have money. It's quite expensive to take ultrasound equipment and a team of stenographers.

CHAIR: That's where I was going. What I'm taking from this is that we're rapidly updating our technology. It's increasing. All that you suggest is good, but how do we deal with it if the technology in the bush isn't equivalent to what's in the city?

Mrs Macpherson : From an ultrasound perspective, I don't necessarily think that the equipment is that far behind. Certainly, there's a cascade approach. We see that in metro as it's cascaded from a radiology department to the emergency department. That's happening everywhere. Ultrasound is a bit more cost-effective. Certainly my regional trips have shown that the equipment has not been bad, but sometimes the rooms will sit empty because there's no-one to run them. Perhaps there needs to be some sort of funding for these students, particularly local students who are trying to get clinical placements. There's just not anyone taking them on. Perhaps there could be funding for them to have clinical placements in rural and remote areas where they would get the supervision and the funding to support that. Certainly, at the moment, even through the immigration process, they're not meeting the standards for Australia. MIRT do the tendering at the moment and manage a lot of that. We're often seeing stenographers from the US or from the UK not meeting our standards. They'll get a limited clinical practising licence and it might be limited to just obs and gyny; they can't do the full gamut that you would need in rural and remote areas. We need to invest in our own local group to make it sustainable down the track.

Mr Eastgate : We would agree with that. From a radiographic point of view, we heard this morning about how most of Queensland sites within Queensland Health are actually CR. At a global level, that's very impressive. While it doesn't meet the same technological advances we've seen in the big centres, it still produces high-quality digital X-rays that we can transport afield if we're required to. It's not as far back as we think it is, and not what we see in other countries around the world either.

CHAIR: Thank you. We've run out of questions. Thank you very much for your time today. It's very much appreciated.

Proceedings suspended from 12:25 to 13:3 5