Andrew Laming (Bowman, Liberal Party) Share this | Hansard source

It's such an important topic and close to my heart as well, having been a bonded medical practitioner myself. There is a long history of financial incentives to address workplace maldistribution, and Australia leads the world in some of those mechanisms. These tinkerings with the legislation from a couple of years ago address some really important points and, from what I've heard in the debate, there seems to be reasonable agreement on both sides for these changes to occur.

As you know, there are a couple of legacy programs such as the Bonded Medical Program itself and the Medical Rural Bonded Scholarship Scheme. Thankfully, now those categories are also eligible to access the slightly more favourable return-of-service-obligation arrangements that the new system offers. But let's go back a step here and remember this is a mechanism that's been in place for decades now to encourage medical graduates, many of them in their mid-20s already. Many have settled down and have a home in cities. We identified about 10 years ago the importance of rural medical schools to ensure one can grow up in the bush, become a doctor in the bush and stay in the bush. It's certainly a much better way of approaching this challenge than having to increasingly raise the bid until sufficient urban medical practitioners are prepared to relocate, often involving partners and family.

There are no easy answers here. Medicine is complex because of the nature of and the amount of support required for a medical practice, the propensity to seek out further training and promotional opportunities, often in tertiary hospitals, which are not available as you go regional and have a lack of specialist medical training placements. This means that, once you go out of sight of the major hospitals, you lose the ability to be on the crest of the training wave and you lose the opportunity to be close to supervisors and those who are going to select you for medical speciality positions that are highly sought after. So we are working against the economic currents in many ways to find ways to convince medical graduates to go bush.

One option was to increase the number of medical graduates until there was a flow-out effect. That's not a terribly efficient way of doing it, because we are simply creating more and more providers in the Medicare system with potentially urban overservicing as a result. It's very interesting to have a look at Medicare spend by postcode. In theory, it should be based on health rather than remoteness, and to see that Medicare is not equitably utilised in regions and ultimately in remote Australia is a cause for concern. This is particularly the case in the Northern Territory, where there are very few general practitioners working outside of the two or three major centres in the Territory.

So today we recognise the importance of health planning in balancing the GDP spend on health as a proportion of GDP. Just to correct the previous speaker, who I think impugned northern European and Scandinavian health systems for spending between, I think he mentioned, 12 per cent and 14 per cent, that is obviously not the case. He might have been getting confused with the US at 16.9 per cent. Those Scandinavian nations are much closer to Australia and are still firmly in single figures, with the exception of a couple of them—Australia at 9.3 per cent, nowhere near that, and the OECD average of 8.8 per cent. Australia and New Zealand are very similar in their per capita spend.

It is an important question because obviously it's more expensive to deliver services in remote and regional areas. Australia has a high proportion of the population living more than 100 kilometres from a major metropolis and a tertiary hospital and, most importantly, it is extremely expensive to deliver those services. Having worked in Gundagai with Dr Paul Mara AM and also in Goondiwindi, St George, Mungindi and Dirranbandi, I saw firsthand how a small change in an obstetric process, delivering a baby, that might become complicated can lead to massive expense that starts with a phone call for advice and ends with an air retrieval of that mum with her baby back to a tertiary hospital hours away, even when we consider flight times. This is an extraordinary expense that isn't incurred when we have a mostly urban population.

I want to note also that these GPs, many of whom are city people deciding to relocate, become the community glue. It is so important in regional towns of 5,000 to 20,000 to have a general practitioner in the community, not just because they carry the oranges at half-time for the local football team and volunteer at providing first aid health but also because the town is proud of having a thriving general practice. They love having a general practitioner that they confide in and they like not having to travel for services if they can avoid it. Finally, off a strong general practitioner service in community, off a medical practice, there are of course a whole lot of allied health and pharmacy services that hang. To lose that can be catastrophic for communities and for community health. Gundagai was a good example of that. There was a need for a general practitioner, even in that smaller community, because it was located on the Hume Highway, where there was a number of medical emergencies and motor vehicle accidents requiring evacuation sometimes an hour away to Wagga, and that simply wasn't possible relying on paramedics alone.

The other point to make is that there are always going to be unique and exceptional circumstances with the bonding placements. So I'm really glad to see that they're a little bit more flexible now than they were in the 1990s when I was an applicant. There are arrangements here for special circumstances where there might need to be an extension of time to meet a service obligation, return of service can also be done over a longer period and there can be up to a six-year extension, which is also very promising.

We know that having adequate general practitioners in the bush is critical—that goes without saying—but we also know that, by having GPs in the bush, we can actually support a whole lot of other health services provision. I want to make the obvious statement in this debate: what is the point of having private health care if you live in a remote area where there is no GP?

We don't think about that very often but, in many cases, we rely on having a GP to support private health insurance levels so that people can get value for money for their insurance, because with the general practitioner come the optical and pharmaceutical benefits as well as the allied health services that they need. If those allied health workers drive out from a central location only once a week, it's very hard to get value for money from your private health insurance, and we know that it falls away in regional areas for that reason.

The bonded medical placements that are offered here play multiple roles, as I've pointed out. It's not just community cohesion. It's not just being able to turn up at a school and give a public health talk that otherwise wouldn't happen. It's that you no longer rely on rotating services—seeing different practitioners every time and different providers and people not keeping notes up to date. You can always count on a local GP to do that. These bonded placements are important because they offer this tantalising opportunity to work in the bush where it would otherwise never happen. I can tell you that there is no shortage of GPs who were dragged screaming to paradise, as one would say, to work in regional areas, and who fell in love and stayed. I'd obviously dispute the previous speaker saying that there are lifestyle issues with working in the bush. In most cases, the lifestyle is utterly brilliant; it's the isolation that's the problem. It's not just social and professional isolation; obviously there were times when there were almost no online services and continuing medical education available. That's now a thing of the past. Internet connection is far better, so the support from colleges and from the AMA for further education is there in a way that it wasn't before.

I continue to push the medical speciality colleges to start to accredit more of their fellows who work in regional Australia—for that work to be an accredited part of a training scheme. What I mean by that is, if an eye surgery trainee were to go and spend a few months in a smaller community where there is an ophthalmologist—say, Rockhampton, Bundaberg or Gladstone—then there really is no reason why that shouldn't be accredited training for their speciality, up to a cap of, say, six to 12 months. If you do that, you're not only rewarding the fellow and giving the fellow a chance to educate but also attracting to the town GPs who can learn more about eye surgery. And, if the trainees come and visit as well, then we increase the odds that, when they graduate, they're more likely to serve regional Australia.

I'm obviously very proud of having been a former participant of a scheme that offers a carrot and not a stick. It's sad that many will forget that, in the early nineties, there was a push to geographically allocate provider numbers in a way that, effectively, recruited, rather than having GPs move to regional areas as willing volunteers. That was stopped in the early nineties. It was one of the great debates at a time when the easy solution was to mandate and basically have the government putting GPs where they felt they should be put. There's no doubt that having GPs that move somewhere because the incentives are right—and when they get there they love it and they stay as a result—is an enormous and rewarding success for the system. Very few other countries can say they have a similar challenge. Australia's unique solutions to this challenge are something we can all be very proud of. I know, as I'm speaking tonight, that there may not be many people in the gallery nor even in the chamber, but there will be hundreds of remote and regional Australians listening to this debate and knowing that tonight, for a change, both sides of this parliament are fighting to support these modest amendments that continue a very, very important strategic attempt by a rural commissioner—the additional investment of a $550 million, 10-year Stronger Rural Health Strategy. That is all a legacy of the Morrison government from 2018-19, and it continues to roll out successfully.

These incentives are vitally important for the reasons that I have given. They have spin-off benefits to the community and spin-off benefits to allied health, who are supported by the presence of a general practitioner in these communities. And it's fair to say that, if you're in a community of 5,000 or more people, there's a reasonable expectation that there should be an Australian GP there to look after you and your family, to be the care navigator and to provide the services you need that range from allied health through to access to specialist referrals at your doorstep or nearby in your local community. It's a challenge that Australia, with its sparse population density and large distances, faces quite uniquely, and I'm proud to say that, as a result of legislation like this, it's one that we have not only negotiated but also achieved.

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