Ross Hart (Bass, Australian Labor Party) Share this | Hansard source

Mr Deputy Speaker, I rise to speak on the bill before the House, the Health Insurance Amendment (National Rural Health Commissioner) Bill 2017, which amends the Health Insurance Act 1973 to establish a national rural health commissioner. The role of the commissioner will be to provide advice to the minister on the role of the rural generalist and to develop a national rural generalist pathway. I acknowledge that attracting and retaining health professionals in the regional and remote areas of Australia is a key factor in improving health outcomes and access to health services in rural communities.

I spend a lot of time in the more regional and rural areas of my electorate of Bass and, unfortunately, these areas experience many of the same health issues that impact regional Australia generally. Australians living in rural and remote areas have much poorer health outcomes than those living in our major cities. According to the Australian Institute of Health and Welfare, Australians in remote areas experience mortality rates that are 1.4 times higher, and suicide rates that are double those experienced by Australians living in major cities. Chronic disease is much more prevalent in rural and regional areas, with rates of asthma, diabetes, cardiovascular disease, cancer and mental health problems all higher than in urban areas. The social determinants of health emphasise that this disadvantage, in all of its forms, flows through to health outcomes. Rural Australians have a higher incidence of risk factors including smoking, being overweight, physical inactivity, alcohol consumption and high blood pressure, compared to their city-dwelling counterparts. Lower levels of health literacy and, often, living in relative social isolation also contribute to the problem. In light of this, it is of particular concern to me that the numbers of health professionals in rural areas, particularly in specialised sectors, are much lower than in metropolitan areas. Indeed, the association between the poorer health status of people in rural areas and the lack of access to health services has been broadly acknowledged in the research. Clearly, there is a need for greater access to health services in regional Australia. There is also much to be done by way of investment in preventative health, as well as in management of chronic conditions after they have been diagnosed. There is also much research to suggest that by combating disadvantage, through education programs and increasing educational attainment across communities, you achieve significant reductions in chronic disease.

The introduction of a specialised rural generalist pathway is a step towards addressing the lack of access to training for doctors in regional communities. This is why, during the last election campaign, Labor announced that we would establish a health reform commission tasked with the challenge of dealing with rural and regional health workforce matters. Labor will not be opposing this legislation. However, whilst we welcome the development of a rural generalist pathway, it remains unclear if the commissioner will have much more of a role than that. In particular, it is a concern that under this legislation the office of the commissioner will cease to exist on 1 July 2020. To this end, Labor will be moving amendments in the Senate which we believe will make for better legislation and which we ask the government to support. These amendments will be aimed at improving the proposed legislation by broadening the scope of the commissioner's role, by reviewing rather than ceasing the commissioner's role on 1 July 2020, and by establishing an unpaid advisory board to support the commissioner. Without these amendments, this is something of a missed opportunity to create a commissioner with real political support and clout who would put rural and remote health on the agenda—that is, on a permanent basis.

The coalition has a rather poor record on rural and remote health. If this government wants to make a genuine difference to the health and wellbeing of rural Australians, in particular of those living in Tasmania, one suggestion I might make is to make a long-term funding commitment to organisations like Rural Alive and Well Tasmania. Rural Alive and Well, or RAW, is a not-for-profit organisation that provides outreach support, information and strategies to rural Tasmanians, with a focus on mental health issues and suicide prevention. I was fortunate to attend the inaugural event held by the Parliamentary Friends of Suicide Prevention, organised by my colleagues the members for Berowra and Eden-Monaro. That event was addressed by an international expert in suicide prevention, David Covington. It was interesting to note that, of the risk factors identified for premature death, a lifetime history of cigarette smoking was identified as risk factor No. 2, with social isolation ranking above that. I spoke in my first speech about the disadvantage within my electorate, and I spoke of the dangers of social isolation and all of the associated health issues that have been identified as flowing from that social isolation. Organisations like RAW are essential to ensuring the ongoing health of our regional communities; particularly in Tasmania, which has the second-highest rate of suicide nationally.

In 2016 RAW worked alongside some 20 regional communities enlisting stronger community participation in local suicide prevention and wellbeing initiatives. This included direct contact with over 2,000 individuals, as well as working with over 250 families across my state. However, RAW will be forced to cut its life-saving outreach services if it fails to secure further government funding. If the government are as committed to the improvement of the health and wellbeing of regional Australians as they claim to be then I would urge them to commit sufficient funding to Rural Alive and Well, and other organisations working in this space nationally, in addition to the steps they now propose under this initiative, to ensure that our rural communities have ongoing access to both the mental and physical health services they need.

We should also not forget that one of the first health cuts made by the coalition was to abolish Health Workforce Australia. HWA was established by Labor in 2009. The premise was a simple one: if Australia was to have the best—and most efficient—health care then health workforce planning needed a coordinated, long-term approach. The abolition of HWA was a particular blow to the regional, rural and remote health workforce because that is where the largest imbalances existed. As will be outlined later in this speech, this is an issue that has dogged government for some years.

I know from my experience as a member of the governing council of Tasmanian health organisation North that regional health organisations, even in a large regional city like Launceston in northern Tasmania, can struggle to provide for renewal of their health workforce. This extends not just to staff within our public health but also to general practice. I know that North experienced difficulties in recruiting and retaining staff—from specialised surgical staff, medical staff, nursing staff and allied health staff right down to the range of support staff necessary to ensure the efficient and effective running of a complex 24-hour, seven day a week operation.

At the other end of the scale, I am aware of the pressures facing general practice in recruiting general practitioners to a regional city. Many GPs complained that they were working long hours and were unable to provide for the succession of their practices as there were no general practitioners willing to work within the city or on its outskirts. These difficulties have been recognised in studies undertaken over many years. The critical nature of medical workforce shortages in rural areas has been identified in reports over the last 30 years.

It was thought at one stage that the medical workforce was in adequate supply; the lack of supply of medical practitioners in rural and remote areas was attributed to maldistribution of the medical workforce. There have been successive attempts to address this issue with a combination of approaches including additional Australian general practice trainees, the use of overseas trained doctors, maximising the workforce participation of existing general practitioners and the introduction of new models of care.

Despite this response, the maldistribution is still occurring. The medical practitioner supply between 2000 and 2004 was found to have risen in metropolitan regions and again demonstrated a shortfall in non-metropolitan regions. The current situation, despite all efforts, still demonstrates a maldistribution between rural and urban areas, although there are some improvements in some areas. It is obvious, therefore, that many rural communities must struggle in the recruiting and retention of basic medical services through the attraction and retention of staff necessary to run a general practice or a local hospital.

Prior to its shutdown in 2014, HWA's efforts delivered an additional 446 nurses and allied health professionals in rural and regional communities. In their submission to the Senate inquiry into the abolition of HWA the National Rural Health Alliance noted that many people in rural and remote Australia have poor access to many types of health professionals and the services they provide. Further, the alliance emphasised that HWA had been investigating the need for integration of education, training placement and hospital training activity for medicine and other health professions with a view to improving access to a range of medical professionals and services for regional communities.

I would note that, since the Turnbull government abolished HWA, there has been a general decline in the number of full-time equivalent general practitioners in remote and regional areas. Nevertheless, this legislation seeks to address this issue with the establishment of a commissioner to provide advice to the relevant minister on the role of the rural generalist general practitioner, to develop a national rural generalist pathway and to provide advice on rural health reform generally.

The role of a rural generalist is to recognise as a matter of policy that medical practitioners in rural and remote areas are required to have a broad range of skills in order to serve their local communities. It is said that today a rural generalist is likely to be a GP who works in community based primary care but also in an acute care setting and has specialist skills in particular areas—typically obstetrics, anaesthetics and/or surgery. Many years ago GPs may have routinely delivered obstetric and/or anaesthetic services and/or minor surgeries, but specialisation has led to a reduction in this and a preference to deliver more specialised services in larger centres. The rural generalist model has been extensively analysed in a systematic review conducted in 2007 and subsequently in a Senate Community Affairs Committee inquiry in 2012. Importantly, there is also an existing model, which is the rural generalist pathway developed by Queensland Health.

There are, no doubt, areas in which specialisation will be the most effective and efficient way to deliver health care. Nevertheless, there are areas in which specialisation is inappropriate, particularly for those who demand access to safe, efficient and effective health care near where they live. However, the adoption of a rural generalist pathway is not without challenges. Whilst it might be argued that a medical practitioner choosing to adopt a pathway as a rural generalist might be treated in the same way as a form of specialisation, there is still some publicly expressed concerns that safety and quality issues may determine that certain procedures are not appropriate for a rural generalist. For example, there are some procedures which are of such complexity that a practitioner is required to demonstrate proficiency through exposure to a sufficient number of procedures over the course of a year.

Specialisation facilitates the concentration of types of work in the hands of those who possess particular skills. There may be concerns as to safety when there are low volumes of procedures to be performed by a particular practitioner, notwithstanding that that person may be otherwise well qualified and experienced in general practice. The review undertaken in 2007 noted that there are other structural barriers to the delivery of generalist services, including the growth of fly-in fly-out specialist services, improved retrieval services, role delineation of hospitals, rising medical indemnity costs and litigious populations. Overall the 2007 review concluded that the generalist model is a practical and cost-effective means of meeting the comprehensive health needs of rural and remote communities, which have lower population densities.

See this speech in context