Ged Kearney (Cooper, Australian Labor Party, Shadow Assistant Minister for Health and Ageing) Share this | Link to this | Hansard source

I rise to speak on the Health Insurance Amendment (Enhancing the Bonded Medical Program and Other Measures) Bill 2021, and I foreshadow that I will move a second reading amendment. The purpose of the bill is to amend the Health Insurance Act 1973 to improve the implementation of the bonded medical program and the administration of the medical rural bonded scholarships contracts under section 19 of the act. The program is designed to address the doctor shortage across regional, rural and remote areas, a shortage that has grown worse and worse under the Morrison government. Participants of the programs receive a Commonwealth supported place in a medical course at an Australian university in return for completion of a return-service commitment to work in regional, rural and remote areas and areas of workforce shortage.

The bill allows participants in two legacy schemes, the Medical Rural Bonded Scholarship Scheme and the Bonded Medical Places Scheme, to voluntarily opt in to the program, and if the secretary agrees to their participation they also become bonded participants. The program offers a number of advantages to bonded participants, compared with the two legacy schemes, including a shorter, three-year return-service obligation, rather than up to six years. It assures more flexibility in completing the return-service obligation as well. These changes are welcome, but this bill will not address the difficulties Australians in outer-metro, regional and rural areas are having in accessing health care, including seeing a GP.

The Morrison government's decision to remove areas like Newcastle and the Hunter region from the new distribution priority area classification means doctors in the Bonded Medical Program cannot meet their return-service obligations in these areas, making local GP shortages worse. Tightening access to regional bulk-billing incentives, as the government has done, is another policy from the Morrison government that has made regional GP shortages worse. And, of course, there is also the impact of the government's six-year freeze on Medicare rebates and its decision back in 2014 to abolish Health Workforce Australia. At a time when the government should be investing in Medicare and delivering more services to regional Australia, this government is doing the opposite.

I know the government likes to trumpet its rural health strategy, but this is just another announcement from this government that has failed to deliver an end to the regional GP crisis. A lack of doctors and other medical professionals in regional and rural communities across Australia is not a new problem, but it is an even more pressing problem in the context of the COVID pandemic. That's why Labor has established a Senate Community Affairs Reference Committee inquiry into outer-metro, rural and regional GPs and other healthcare services, which will consider the performance of programs such as the Bonded Medical Program. The inquiry will explore the GP crisis in outer-metropolitan, rural and regional areas, including an assessment of government policies such as the rural health strategy, the reforms to the distribution priority areas and the Modified Monash Model geographical classification system. It will also look at GP training reforms and the impact of the coalition's Medicare rebate freeze.

The inquiry has taken off. It has already heard from so many stakeholders confirming there is indeed a regional and rural healthcare crisis and that this crisis also extends to outer-metro areas. So far 43 submissions have been received from stakeholders, including local councils, medical colleges, health organisations and MPs from this place. These stakeholders and outer-metro, regional and rural MPs all acknowledge the challenges to delivering sufficient, high-quality health care to all Australians. These challenges are real, and their impact is only getting worse. Labor wants the inquiry to seek practical, positive solutions to make sure that Australians have access to quality health care regardless of where they live. I encourage all Australians and all MPs to engage with this inquiry.

General practitioners are the backbone of the vaccine rollout across Australia, yet there are regions in which it is near impossible to get a GP appointment. This has obvious implications for vaccination rates, with regional vaccination rates lagging 20 to 30 per cent behind those in cities, and this does nothing but place regional Australians at greater risk from the pandemic. As the member for Macarthur makes clear in his submission to the Senate inquiry, a lack of regional GP access also increases pressure on regional hospitals, as Australians who can't get medical treatment through a local GP are forced to present to regional hospital emergency departments. Of course the same can be said of city hospital emergency departments, which are equally under pressure when people from outer-metro regions simply cannot access a GP. They head into the city based hospital system.

There are other things that regional, rural and outer-metro people are struggling to access when it comes to the healthcare system—for example, obstetrics. Pregnant women can find it very difficult to get the specialist care that they need. They very rarely can access GP shared programs or even midwifery services in outer-metro, regional and rural areas. We were all shocked that the Prime Minister's response to this problem was: the government builds roads, and women use roads. As someone whose daughter had to drive two hours from her regional home to get to the nearest hospital to have her baby, I can tell you that that is no comfort at all.

An area like aged care, where we know that GP access is very short and hard to come by in the cities, is even more desperate in outer-metro, rural and regional areas. Our elderly are not well served by the health system. If there is a shortage of GPs for young people and families, imagine how acute it might be for people in residential aged care or for isolated older people in their homes. They are desperate for good health care from good local GPs, and there just aren't any.

We know that the issue of mental health care is absolutely acute in rural and regional areas, where accessing mental health care is pretty much impossible. Imagine if we had a government that was dedicated and actually put in the time, the energy and the commitment to make sure that people out on farms and living in rural cities and in regional cities could access the mental health care they need: the suicide crisis, particularly amongst our young people, may just be alleviated. We know that some resources are scarce enough, even in the cities, but access is far worse in outer-metro, regional and rural areas.

One policy to support regional and rural access to crucial medical services is to boost the use of telehealth items so that patients can see a doctor regardless of the vast distances that characterise so much of our beautiful country. Everyone, from the medical profession to public health experts and patients themselves, accepts that telehealth is a crucial part of our Medicare system moving forward, but after almost two years of a global pandemic the Morrison government still hasn't made telehealth a permanent feature of Medicare. Some of my constituents who live in the city have told me what a life-changing thing it is to be able to access telehealth, including people with chronic fatigue syndrome, who find it incredibly difficult to leave their home. Trans people, who find it very difficult to access specific health care, have found telehealth to be a saviour. People who, for whatever reason, are finding it hard to get out of their homes and into healthcare services find telehealth to be absolutely revolutionising for their health care. So why is there a delay? Why can't this government simply get on with the job and make telehealth a permanent part of our Medicare system?

Millions of Australians living in outer-metro, regional and rural Australia deserve and are crying out for the same access to medical services as their cousins in the big cities, yet after eight long years of government the Prime Minister has failed to deliver it and has in fact made it worse. Labor will always fight to defend and strengthen Medicare and to make sure that all Australians have access to a GP and to other healthcare professionals. The rural and remote doctors, who I speak with quite a lot in my role as the shadow assistant for health care, have told us that there are many models of healthcare delivery that could be explored and added into the health system to make sure that people in rural and regional areas get good health care. We should be listening to these stakeholders. We should be trialling new models of care that use our entire health force to their full capacity, like midwives, like nurse practitioners, like our allied healthcare practitioners, like physios and like pharmacists who would move to regional areas and who would boost the healthcare workforce. All of this can be looked at, all of this can be added to strengthening Medicare to make sure that all Australians, no matter where they live, can get the health care they deserve. I move the amendment circulated in my name:

That all words after "That" be omitted with a view to substituting the following words:

"whilst not declining to give the bill a second reading, the House urges the Government to do more to address outer-metro, regional, and rural barriers to medical services including GP access for all Australians."

Trent Zimmerman (North Sydney, Liberal Party) Share this | Link to this | Hansard source

Is the amendment seconded?

Tim Watts (Gellibrand, Australian Labor Party, Shadow Assistant Minister for Communications and Cyber Security) Share this | Link to this | Hansard source

I second the amendment and reserve my right to speak.

Rowan Ramsey (Grey, Liberal Party) Share this | Link to this | Hansard source

I rise to speak on the Health Insurance Amendment (Enhancing the Bonded Medical Program and Other Measures) Bill 2021. The amendments in this bill will make welcome changes, as the member for Cooper said, to a scheme that is designed to attract more doctors to work in rural and regional areas. Anything that can attract more doctors to rural and regional areas must be welcomed. Although it's unlikely to be the silver bullet that will fix up all the problems of the past, it's certainly designed to make things more flexible. We know that it's a great concern to young people in particular that they're having to tie themselves to a particular area for a long period of time, and that makes them uncertain about signing up to work in a rural or regional area. I thought about when I first went on a hospital board and decided it was in about 1980; it may have been 1982 but it was certainly at least 30 years ago, although that would make it almost 40 years ago. One of the first issues we had in the days when hospital boards existed in each hospital in South Australia was the lack of doctors in regional areas. I watched the whole episode unfold as the numbers of trainee doctors entering universities was curtailed because we had a problem in Australia, and that problem was overservicing in the cities—in fact, chronic overservicing in the cities. At the time a decision was made to cut the universities' intake of trainee doctors with the eventual aim to dry up the surplus of doctors, as it were.

Even at that time we had great difficulties in attracting doctors to rural areas. It certainly was not as difficult as it is now, but it was difficult enough. As a local hospital board we would manage the advertising for medical staff and we would do the interviews. We would chase people from one end of Australia to the other, and at times we would seek to bring trained doctors to Australia. But with the training stream drying up, the foot was kept on the neck of the intake for too long, I would have to say, and eventually we had a shortage of doctors in Australia. Then we began bringing large numbers of overseas trained doctors in to meet that shortfall. As someone who comes from the country and represents a part of remote and regional Australia, I would have to say that those doctors saved our lives. Is it the perfect solution? No, it most certainly is not. But the great advantage of bringing doctors in from overseas is that you can place limitations on where they practise as part of their immigration process. You can ensure that they go to a remote service or a regional service for a certain period of time and so receive the service you need for that population, which is not the case for our local trainees, who maintain that they are private businesses and can go and set up virtually whenever they like.

It takes a long time to become a doctor. There has been a great emphasis over the years on trying to recruit an oversupply or to tilt the scale in favour of regional students because we know that more of them are likely to end up in the regions, but it's far from an ironclad solution. In fact, many regional students, particularly if they've done a couple of years of senior secondary education in a major city, with maybe eight years of training to get their standard doctor's certificate and then GP training after that, might be away from the country for anywhere up to 15 years before they actually qualify to the state where they can come back and serve. By that time, so many things can have happened in their lives—they could have formed partnerships and relationships and may have had children. The whole world can change in that time, and I'm very grateful for those who do decide to return to rural Australia.

In fact, there are a whole host of programs that the government is already running to help bring doctors to rural Australia, including rural bulk-billing incentives. I might point out that under the Monash model it's not uncommon for an extra $10 to be delivered on a bulk-billing incentive package for the needy or for those on pensions, health care cards or whatever. In some places it might be well over a 100 per cent increase in the amount of money per Medicare item for a service in rural Australia. There's the Approved Medical Deputising Service Program, a heath workforce, a scholarship program providing anything up to $10,000 a day, the Medical Outreach Indigenous Chronic Disease Program and the Rural Locum Assistance Program. We have the More Doctors for Rural Australia Program, the Rural Health Outreach Fund, the Rural Health Workforce Support Activity, the Remote Vocational Training Scheme, the Remote Vocational Training Scheme extended targeted recruitment pilot—and there's up to $200,000 a placement available on that one—the Practice Incentives Program and the Workforce Incentive Program. It goes on; there's more there.

The point I make is this. Many doctors don't like to publicly express how much they're earning, but it's not uncommon for them to be earning in excess of $400,000 or $450,000 a year. I don't know how much extra money makes a difference, but I've come to the conclusion that it's about the only tool we've got, quite frankly. We need to recruit more doctors to rural and regional Australia. Statistics will tell us that, on a per capita basis, Medicare item numbers are accessed in regional Australia at roughly half the rate that they are in the city, and this is a really interesting statistic. I live in regional Australia. I live in a small country town that has an irregular doctor service. We have struggled to recruit and retain doctors. We have a hospital, and it's a struggle to keep services up in the hospital unless you have a doctor. It's a struggle to recruit workers in other industries to the town unless you have a doctor. It is absolutely essential that we have a doctor, and yet we don't need twice as many doctors as we've got. This overservicing in the city is already a large problem that is eroding the sustainability of the federal health budget, and I think it's something that requires some deep analysis.

I think we need to understand what a fair shake is in Australia. We don't need more doctors in eastern Adelaide. We need more doctors in northern and southern metropolitan Adelaide and we need a lot more doctors in remote South Australia. We don't have a shortage of doctors in Australia. What we have is a distribution problem. I have argued for some years that we should have a postcode-specific Medicare provider number. I've come to the conclusion in this place—I've been here 14 years now—that I'm not going to get my way. That is not going to happen. I think it probably should, and I know there are some difficulties that surround it, but I take it that we probably won't see progress in that area.

I have reached the conclusion that money is a blunt tool but it's about the only one we've got. I think we need an increased rate, even over all the incentive programs I just read out, for service in remote Australia. It could be worked out based on the Monash model, and that's not a bad idea. I actually prefer postcodes because then we can really drill down and find out which communities are not getting the service they require, and it's very easy to identify those that are getting more service than they require.

Once again, this is not a policy that the coalition government has adopted, but I have suggested that what we should be doing to fund those extra payments in rural and remote Australia is reducing the payments from the places where we've got overservicing. If we don't address the overservicing, eventually it will swamp the budget. If we don't start putting parameters on where extra doctors can provide extra services—it's not hard for doctors to generate extra income: 'Mrs Jones, I've just changed your drugs; I want you to come back next week; I'm not going to issue a repeat.' And when she comes back next week: 'I'm going to send you to my friend the pathologist down the road, and once you've got that report, you come back to me and then we'll analyse it and I'll put you on something else.' It goes on and on and on, and it's very hard, on an individual basis, to call that out. In fact, I don't think anyone would want to call it out. But it's not hard to do on a postcode basis, where you can see that one area is getting so many more services than, say, the little town where I come from, where there's an absolute imbalance in the health budget. Rural and remote Australia deserves a better deal.

So I've come to the conclusion that's the way to do it. I'm not sure I'm going to win that argument, either.

I think the learned member on the other side is incorrect, let me say. What we need to do is make a change. This legislation today is a small step in trying to do other things.

I've also been championing a proposal—a rural and remote medical academy, to be based around a number of centres in Australia that will train doctors for the remote areas in combination with the RFDS, with the Aboriginal doctor workforce and with the University of Adelaide. I hope we can find our way, as a government, to funding a number of these positions. One such academy in my electorate would be at a place called Port Augusta. Although Port Augusta has a population of 14,000 people and services a larger area, even areas like that don't have enough doctors. In Port Lincoln—I don't know how many House of Representatives members have been to Port Lincoln, but it's a very attractive community on a beautiful harbour and it's got a lot going for it—even there we struggle to attract doctors to regional areas. It's got a good hospital—a lot going for it.

This legislation today helps. It's another program. As I said, it won't be a silver bullet. As a parliament we need to make an absolute commitment to rural and regional people that this imbalance in health services in Australia is not going to continue, that we're going to do something fair dinkum about fixing it. I don't think we can do something fair dinkum about fixing it unless we tread on a few toes. We've been dangling carrots in front of people for a long, long time. I think we're going to have to take a bit of stick. If that's what it requires then I think that's what's required. But we certainly do owe it to that constituency to provide a better service than they're getting at the moment.

Mike Freelander (Macarthur, Australian Labor Party) Share this | Link to this | Hansard source

The member for Grey raised several very valid points. One of the points he raised, however, for which there is very little evidence, is that there is, at least in part, an epidemic of overservicing in city areas. That is fundamentally not the case; there is no evidence for that. The problem is, of course, access to proper medical care in outer metropolitan, rural and regional areas. That's why, by whatever measure you care to take, health outcomes in outer metropolitan, rural and regional areas are much worse than in the cities. Whether you take rates of bowel and lung cancer, rates of smoking and cardiovascular disease, death rates or age of death, male or female, they're all much worse in outer metropolitan, rural and regional areas. The further people move from access to medical care the worse those statistics are. So what the member for Grey was saying—that overservicing in the cities is affecting servicing in rural and regional areas—is not true.

Yes, what you said was rubbish. That's quite right.

Well, we need the appropriate number of doctors and you need more. I don't particularly want to be distracted with this argument. I'm happy to have it later on. But, if the member for Grey is making these statements, he should be able to produce the evidence, and there is no evidence for that.

I've discussed the Bonded Medical Program many times because I've had to deal with medical students who signed up to this program when they were 17 or 18 and in full flight of getting a good HSC mark and getting into medicine. They signed up for something that may have looked good, but, as the member for Grey and others have pointed out, as their circumstances changed, their priorities changed. I've had to act for a number of people trying to get out of these bonded programs because their lives had changed, because of partners, children et cetera. They haven't worked. They haven't really made much difference to the medical workforce in rural and regional areas. They don't affect the outer metropolitan areas, which also have huge difficulties in attracting general practitioners. I'll just explain to you why that's the case.

If you work in disadvantaged areas—in outer metropolitan areas and in rural, regional and even remote areas—the work is very hard. If you're a doctor working in these situations, you're expected to deal with everything from an obstetric emergency to an acute cardiovascular event, a stroke or a severe seizure disorder. Our standards of medical care have improved a lot over the years and expectations have risen. Providing care in an outer metropolitan hospital, which may not have access to specialist care, may not have access to a range of interventions, like MRI scanning and cardiac catheterisation, and may not have access to the range of specialists that could support you in an inner city hospital, makes the work far more difficult, far more time-consuming—because the work is generally put on the one practitioner only—and much more stressful. If you happen to be on call in these communities, the work is far more difficult than if you were a general practitioner working in an inner city practice with multiple doctors with multiple cover, either not on call at all or only on call one in 10 or one in 14. So the work is much more difficult in these areas and it has proven to be much more difficult to attract people to these areas.

For those reasons and others it's difficult to get ongoing education, even though there are some programs that support rural and regional education. It's more difficult to access specialists and subspecialists in rural and regional areas. As the member for Grey has pointed out, there have been multiple schemes and multiple programs put in place to try to support doctors in rural and regional areas. There has been very little in outer metropolitan areas, like my electorate, but in rural and regional areas there have been lots of schemes put in place. To date they have not been successful in stimulating an influx of medical professionals to the rural and regional areas, and neither have the bonded scholarships, as we've mentioned. I think the financial rewards are not so great as to compensate for the lifestyle and the hours required when working in these practices.

I have approached the health minister on a number of occasions to make sure that they can review these areas of workforce need, the distribution priority area classifications. That has had very little effect, in spite of me approaching the minister on a number of occasions. It's not an issue that's new to the government. I've certainly been doing it since I've been in parliament—for six years. Countless times, I've written to the minister and I've spoken in this chamber about this very thing.

In my own electorate, which is an outer-metropolitan electorate, some of our general practices are having trouble recruiting and retaining quality local medical people. These are the very family practices that we've relied on and that have been on the front line of the pandemic. They play a vital role in our national immunisation program, yet the government has ignored their concerns. Because they've had trouble recruiting general practitioners, it has put far more pressure on our public hospital, which is already overstretched because of the pandemic.

On countless occasions, on behalf of these medical practices from not only my electorate but also the rest of the state, some of whose principals have contacted me, I've urged the government to review its distribution priority area classifications. I have been fobbed off by the government using the bureaucracy as a shield, without any meaningful change. It's not the same trying to access a general practitioner in my electorate as it is in the eastern suburbs or on the North Shore of Sydney. Many of my patients have huge difficulty getting access to a general practitioner. They tend to use the public hospital as their general practitioner, and that puts added pressure on an already-stretched system. I suggest that the junior coalition partner also listen very carefully to what's happening in their electorates, because their constituents have similar problems to mine with access to primary care through a general practitioner.

The partial schemes that have been put in place have been put in place without much evidence and without much forethought about how this is going to work and how we're going to keep general practitioners in these rural, regional and outer-metropolitan areas. The health outcomes demonstrate the difficulties in accessing medical care in outer-metropolitan, rural and regional areas. The bonded medical scholarships have not changed it. Neither has setting up rural medical schools, and neither have some of the supports put in place through medical education.

I believe that people are forgoing medical treatment through the pandemic, and this has become much, much worse in outer-metropolitan, rural and regional areas. Lack of access to general practitioners is the primary problem. My personal view is that we need to engage better with the departments of health of all the states to make sure our teaching hospitals have more of a role in providing medical workforces to outer-metropolitan, rural and regional areas. That will require a total rethink of how health care is managed in previously disadvantaged areas. But it is important that we do that; otherwise health care in outer-metropolitan, rural and regional areas will fall further and further behind the inner suburbs of our wealthy capital cities.

We already see different advances in the medical management of, for example, coronary artery disease and heart attacks, with acute intervention which can be life saving and lifestyle saving. Stroke management is changing dramatically, with acute clot retrieval through neuroradiological techniques. There have been huge changes in medical care, and our provision of medical care to these outer-metropolitan, rural and regional areas has not kept pace with those changes in medical care. This bonded medical scholarship scheme will do little to redress those needs. The gap is widening, and the increasing cost of health care is only perpetuating the inequality that is occurring.

Australia's spend on its health budget is much less than many other countries in the developed world, such as the Scandinavian countries, the United States of America, Great Britain et cetera. Where we spend around 10 per cent of our GDP on medical costs, they're spending 12 per cent, 14 per cent or 16 per cent. We need to fund our health care better. We're now approaching a time similar to the time of the advent of the Whitlam government, when healthcare costs were out of the reach of average Australians. We need to rethink our access to medical care for those disadvantaged areas. We need to rethink Medicare on that basis, we need to fund Medicare properly and we need to make sure that our major teaching hospitals that provide the highest level of care can provide that level of care throughout the country. We need to rethink how we engage with them.

I think it's very unfair that someone who lives in, for example, North Sydney, should get far better care than someone who lives in Campbelltown, Minto, or Airds; someone who lives in Temora; someone who lives in Armidale; or someone who lives in Broken Hill. I think we need to look at a more equitable approach to health care.

I think that the government needs not just to pay lip service to these complaints; there needs to be a real review of how we provide health care in Australia. I welcome the recent announcement that a new appeals process will be installed to existing DPA classifications—I think that's very important—but there's a lot of work from making that possible to getting it right and allowing our practices to recruit medical practitioners on a DPA basis. It's not a new issue, as I've said.

I want to thank my friend and colleague the member for Dobell, who has worked very hard on similar issues on the Central Coast. The member for Chifley also has worked hard to get GP recruitment in his outer metropolitan electorate. I know the member for Macquarie has worked very hard in her electorate to see what can be done to get better GP recruitment in her electorate. Labor has consistently been trying to get the government to address the GP shortages. These shortages have made the pandemic problems even worse in disadvantaged electorates, and it's time the government actually took notice and did something about it. This small change to the bonded medical scholarships will not make much difference at all, I'm afraid, and we really do need to see meaningful action from a government that's been prepared to sit on its hands for far too long.

I am constantly being contacted by general practitioners in my electorate and others around the country to see what can be done to improve recruitment of general practitioners, because primary care is the basis of all good medical care. If you can't get your primary care right, you will not have good health care. This is across a whole range of issues, be it paediatrics, obstetrics, immunisation programs, public health campaigns and even dental health and other preventative health measures. Unless we can get our primary care right, we will not get decent primary health care across the country.

What's happening is very inequitable. This is a government that for eight years has sat on its hands, and it's time we had a consistent program from the government to improve the whole system.

Andrew Laming (Bowman, Liberal Party) Share this | Link to 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.

Susan Templeman (Macquarie, Australian Labor Party) Share this | Link to this | Hansard source

Well, there is some agreement and recognition that there is a GP shortage—for electorates like mine it's a very serious shortage—and the Health Insurance Amendment (Enhancing the Bonded Medical Program and Other Measures) Bill 2021 will have our support. But it doesn't go nearly far enough to address the issue. The complex problem of the provision and retention of GPs has been a challenging issue since I first sought office in 2010, and I've advocated for changes at various times over those 11 years. We were able to secure special support to attract GPs to our area through some of that time, but in the past eight years there have been big changes. The Nepean Blue Mountains Primary Health Network and its predecessor have been active on this matter throughout that whole time as well. GPs have spoken to me about the strain of the shortages that they and their teams experience. Residents of my electorate, particularly new residents, have told me of their challenges in being accepted as a patient at a local practice. It plays out for a lot of people.

The Macquarie electorate covers all of the Blue Mountains and all of the Hawkesbury local government areas on the western edge of Sydney. So, some people think of us as Western Sydney, but in fact we have some very remote areas, and a lot of rural. We have a lot of distance between us and the major teaching hospitals. So these changes are welcome, but the bill will simply not address the difficulties that peri-urban areas like my electorate experience. The Morrison government's decision to exclude most of the Blue Mountains and the Hawkesbury from the new Distribution Priority Area classification means that doctors in the Bonded Medical Program can't meet their return-of-service obligations in my area, and that makes the local GP shortage worse. Often it's not just an issue of attracting the GPs; it's also an issue of attracting the bulk-bill incentives. That's another policy that the Morrison government took action on that makes the regional GP shortage worse. And of course there's also just the general impact of the Morrison government's six-year freeze of the Medicare rebates and the government's decision back in 2014 to abolish Health Workforce Australia—all these things at a time when we should be investing in Medicare and delivering more services to peri-urban, regional and rural areas. This government has been doing the opposite.

The COVID experience has obviously made things harder. That's why Labor established a Senate Community Affairs Reference Committee inquiry into outer-metro, rural and regional GP and other healthcare services. The inquiry will consider the performance of programs such as the Bonded Medical Program, and I was very pleased to make a submission to that inquiry. We want this inquiry to seek practical, positive solutions so that Australians have access to quality health care, regardless of where they live. You shouldn't have to live in Double Bay to get the best health services; you should be able to get those if you in Bullaburra. I encourage others who have views around this and have experienced the impact of shortages and difficulties accessing primary health care to make a submission to the inquiry. It can be as simple as an email and a letter. I want to acknowledge the efforts of the Nepean Blue Mountains Primary Health Network. They and their predecessor have worked hard on this and I'm very grateful for their ongoing interest in the issue.

I want to talk about the things we experience in the electorate. Residents in the upper Blue Mountains and parts of the Hawkesbury find that it can be difficult to get an appointment with a local GP in a timely way. Many new residents to the area are advised by multiple local general practices that their books are closed to new patients; they simply cannot become a patient. And a lot of our GP practices are relatively small. We don't have massive centres, so we have smaller practices scattered across a lot of towns and villages. The real challenge is in attracting GPs to live and work in the area. There are no financial incentives to attract GPs from inner metropolitan areas to the Blue Mountains, unlike designated rural areas. And GPs will not choose to commute on a daily basis from Sydney to Katoomba when there's local work available closer to home. Early-career GPs are increasingly reluctant to venture beyond inner-metropolitan areas, I'm told, or to relocate to regional and rural areas.

Let's put this in perspective. Katoomba is 55 kilometres from the nearest tertiary hospital and metropolitan centre, which is Penrith, and it's more than 100 kilometres from the CBD—probably closer to 150. Yet this peri-urban status is not reflected in GP workforce schemes and initiatives. It's still considered part of metropolitan Sydney. This is a place people go to for a long weekend to escape Sydney, yet we're classified as Sydney for the purposes of GPs. It makes no sense and is completely inequitable. This has to change. You have to travel to Black Heath, a bit further up the mountain, before you get to an area that is considered to be slightly outside Sydney.

The two major general practices in Katoomba have been under significant stress for several years. GP positions have remained vacant and demand for GP appointments has increased. Local residents report absolute distress at the impossibility of getting a timely appointment, and that means that they can end up having to go to an emergency department to get the medical assistance they need. All of this has been an issue for a long time but has been heightened ever since the Blue Mountains LGA was not deemed a distribution priority area in 2019. The primary health network informs me that, for example, in November 2020 one of these practices reported turning away more than 100 patient appointment requests a week. That's a lot of people who are reaching out to get medical assistance and advice, or to have their usual check-ups, but are not able to get it.

Coupled with the difficulty for residents in accessing appointments is the fact that there is no 100 per cent bulk-billing general practice in the mid- to upper-Blue Mountains. There's no general practice open on evenings, Saturday afternoons, Sundays or public holidays. This is a contrast to other areas closer to Sydney, where bulk-bill services are available until 10 o'clock every night of the year. That has led to a strain on the emergency department at the local Blue Mountains District Anzac Memorial Hospital. The cost factor is an issue as well as the difficulty in securing a doctor's appointment. It means that residents in the area who have chronic and complex health issues frequently present at the hospital with what are probably inappropriate presentations that could be seen by a GP rather than taking up time in an emergency department. But they're thinking about the out-of-pocket, the cost of the appointments that they would have to pay.

I received similar feedback to this from GPs in the Hawkesbury. Remember that the Blue Mountains is an area of about 1,000 square kilometres and the Hawkesbury is an area of about 3,000 square kilometres, with people living up little country roads, stretching halfway up to the Hunter. Their medical services are delivered in small towns and cities like Richmond and Windsor. I raised this issue recently in a Zoom with GPs, in which I was getting an update from them around how the vaccination rollout was going in the Hawkesbury. I asked them, 'How are you feeling about GP shortages?' And there was just a complete, unanimous response of, 'Oh my goodness, it is a massive issue!' They had a totally unanimous view about it, particularly when they talked about the area across the river—not the Sydney side of the Hawkesbury River but the north and western parts of this very large LGA.

Historically, we have had a proportion of the district covered by workforce shortage provisions. In the past this has enabled GPs to recruit from a wider pool of doctors, because it allowed for overseas-trained doctors and those on the Bonded Medical Places Scheme to work in the region. Under the Commonwealth's Stronger Rural Health Strategy, and in an effort to shift inequity in the distribution of GPs, the distribution workforce system was replaced in 2019 with this new Distribution Priority Area scheme. It might have benefited some very rural and remote areas—I don't argue that—but peri-urban areas like mine are worse off as a result. The suburbs of Blackheath and Mount Victoria—and anyone who knows the Blue Mountains knows they are small areas right at the top of the mountains—are the only areas now classified as being distribution priority areas. That's in contrast to the entire Blue Mountains and most of the Hawkesbury local government area previously being considered a DWS.

A high and growing proportion of GPs who work in the broader Nepean Blue Mountains PHN are overseas trained doctors. In 2017, about half of GPs in the region had gained their qualifications overseas. The loss of the DWS-DPA status has had a detrimental effect on general practices' ability to get those GPs to work there. I will give you one example of that, Mr Deputy Speaker. When the area was ruled a DWS, under the old scheme, we were able to help at least 25 doctors, in a 4½-year period, secure work in a general practice in the region. Afterwards, that changed. The only place you can do it is Blackheath, so we're down to pretty much zero. There are a few exceptions. The establishment of the medical practice in Glossodia, in the Hawkesbury, was helped only due to the fact that it was in a DWS-DPA area and the owner of the practice was the first doctor they recruited. That has not been possible since the changes were made. These are two things that were possible before but are not possible now, and the consequences of that are really profound.

One of the really serious consequences I'm seeing is GP burnout. I think we've probably all seen GP burnout during COVID. They have been asked to administer vaccines to thousands and thousands of people. In my electorate there is no hub. The only place you can go is to a GP practice or, now, to a pharmacy. The hubs are outside the electorate, so people have leaned really heavily on their GPs. They have stepped up amazingly, but they are burning out. They are carrying a large and complex case load. I'm advised that several GPs from the upper Blue Mountains have resigned in the last 12 months because the patient complexity and workload volume were simply unsustainable.

In peri-urban areas like mine there are fewer opportunities for GPs to link patients with the types of health services and support that residents in metropolitan areas have, so they carry a big load on their own. They're coordinating far more of the care of patients with chronic conditions than are their urban counterparts, who can simply refer on. My rural and regional colleagues will know this.

My GPs also report that they feel less connected to a collegiate professional network. They draw a lot on each other, as GPs, but there's not necessarily the wider ecosystem. Interestingly, I've had a number of conversations with overseas trained GPs who aren't able to work in my electorate. They live in Sydney's west, so they live close. We're not asking them to drive long distances to get to us. They would love the opportunity to finish their Australian training and be supervised, and we have such experienced GPs within our practices that the supervision would be of a very high standard. With the right incentives it would actually be a perfect match. These are the sorts of things that should be considered to provide long-term, sustainable services to my community.

At a systemic, policy level we need to see the methodology for determining distribution priority areas reviewed; we need to see more incentives for GPs to work in lower socioeconomic, peri-urban areas; we need stronger measures to support collegiate professional networks; and we need to consider new models for funding primary health care that might support our GPs and their work. We really do need to draw on the experience of long-serving GPs to train the next generation.

There's one other thing that I think this parliament needs to push. We all accept that telehealth will be an absolutely crucial part of our Medicare system going forward. It has saved lives during COVID. The medical profession, public health experts and patients themselves all agree that it should be made permanent, but after two years of a global pandemic it still isn't a permanent thing. I cannot understand the delay. That is something that needs to be done and it's something Labor will be fighting for, to defend Medicare and improve health services.

Mark Coulton (Parkes, Deputy-Speaker) Share this | Link to this | Hansard source

I take great pleasure tonight in speaking about the Health Insurance Amendment (Enhancing the Bonded Medical Program and Other Measures) Bill 2021. The bonded placement scheme is very important in distributing doctors across this country to where they are needed. I understand the need for this bill to iron out some problems, but we also don't want to take it away. If someone has an obligation to work in a regional or rural area, they should, unless there are exceptional circumstances, fulfil the obligation they have agreed to.

I've been listening to the debate here and I've heard a lot of talk about the problems, but there haven't been too many solutions coming forward. The member for Macarthur, who's obviously highly regarded in his field, could have gone into some of the programs that are now in place but for some reason chose not to. I'd like to touch on the complexity of the shortage of doctors in regional areas. In listening to the member for Macquarie, I have a degree of sympathy for her issues in being 100 kilometres from a tertiary hospital, but I've got constituents who are 300 or 400 kilometres from their obstetrician and have to relocate a long way from their homes for several weeks before their baby is due and then for some time afterwards for antenatal care, so it's all relative.

In my time as regional health minister I found that everyone believes they live in a disadvantaged area and has special circumstances, but it's important that we put the resources and the support where they are really needed. Over a period of time various schemes have come about. One of them, which paid locums higher rates to fill those workforce gaps, did in one way fill some of those shortages in the workforce, but in another way it actually exacerbated the problem, because why would someone commit to working full time in a regional centre when they could go and work part time in several regional centres and earn double the income of someone who had committed to the area? So the locum scheme actually created part of the problem.

When I was minister, up until quite recently, we put in five trial sites to encourage a different model of workforce. One of the partners in that was Western NSW Local Health District, because they are paying millions of dollars a year in locum fees to fill short-term gaps. They agreed to put some of those funds into creating a work environment that is more conducive for people to work there. They are paying a salary to a doctor to go and work in an area, because they're competing with the larger hospitals in the city, where you can work on a salary, have regular shifts and get holiday pay and maternity leave. With the feminisation of the medical workforce, it's a difficult decision for a younger doctor to go into a regional area, knowing that if they want to have a family they are not actually paid for that particular time.

There are five trial sites. One of them, known as the '4Ts', is four small towns in the Central West of NSW: Trangie, Tottenham, Tullamore and Trundle. Those four towns are working as a network so that there's a collegiate atmosphere and so that they're supporting each other. They know that they are not going to be swamped, given the 80- or 100-hour weeks. They know that there's other backup if they need it. But they also know that, if they're part of a generalist pathway, they will be able to work shifts in, say, Dubbo hospital as an anaesthetist, as an obstetrician or as one of the other specialists that goes with the generalist pathway. In the early stages this seems to be having some effect. They've been quite popular. People are being recruited to these models, because one of the disincentives—and it's been raised here by others on both sides—is that feeling of isolation and lack of support. To overcome that, the generalist pathway that's been funded by this government will give those doctors who are going into those regional areas a broader skill set—knowing that you might be doing primary health care, general medicine, all day, and then a carload of teenagers hits a tree that night and you need to have that extra skill set to be able to manage an emergency of that scale. That can be a daunting process for young doctors. Doctors in my home town of Warialda were the rural doctors of the year in Australia some years back because in 2007, on the last day of the school holidays, a ute with eight 13-year-olds flipped over. All except one were critically injured. Sadly, three passed away, but the others' lives were saved because of the skill set of those doctors. So we are training another cohort of doctors to come through with the skill set to handle that.

Probably at the core of the issue is the fact that general practice as a discipline is falling from favour among our graduates. Part of the reason is that during their training time in the metropolitan hospitals they are actively discouraged from going down a pathway in general practice because working in a specialty can be more financially rewarding, it can have a better work-life balance and people can work closer to the city. So one of the big shifts was the establishment of the Murray-Darling Medical Schools Network, where we are training country people in country areas to be doctors. Earlier this year I was at the first intake in Orange. Every one of those students comes from a regional area. I was speaking to some of them from my electorate. One ultimately wants to be a dermatologist because of the high rate of skin cancer in country people. Every one of those young people was committed to practising in the region.

Next year will be the first intake into Dubbo. Sydney university's campus for Murray-Darling is very, very popular. Sydney university have been recruiting locally from, probably, a more mature group—people who are already established in the community and want to advance their career into becoming doctors. They can do it in their local area. With the establishment of the Western Cancer Centre, which has recently opened, you can do your specialty in oncology or surgery or obstetrics in a regional area, rather than having to be drawn into the city. Because it's such a long process to be fully qualified as a doctor, quite often other life issues come into play. By the time you're fully qualified, you have generally found a life partner. In some cases you want to start a family. So it's important that those decisions are made where people might ultimately be established, rather than having to move a family. One of my daughters is a GP. She practises in a regional area. When she moved from Sydney to that regional area she could find work, but it took some time for her husband to find a position that was suitable for his skill set.

One of the changes in the last budget, a change that comes into effect on 1 January, is that for the first time there is a graduated rebate payment for general practice under the MBS for bulk-billing. On the Modified Monash Model, the further remote you are the higher the rebate you will receive. Understanding a lot of the smaller and more remote communities do have a higher bulk-billing regime, it's important that we reward them. It's the first time that the MBS has been altered in that way. It comes into effect on 1 January. Dr John Hall, the President of the Rural Doctors Association, said this was 'a game changer' for rural medicine.

When I was minister, we also doubled the training places in regional areas for junior doctors. Quite often, for doctors that spend part of their training program as doctors, the more time they are exposed to rural and regional medicine the more likely they are to be established in the areas they've come from.

This is a very complex issue. It is a big issue; there's no doubt about it. It's probably the biggest issue in my electorate. It's not universally the same right across it. At the moment, it's a big issue in Gunnedah, a community of 15,000 people with two practices and two or three doctors servicing that community. Others towns are doing better. It's a bit cyclical. Quite often the problem comes when a senior practitioner wants to retire. That transition to someone else coming through is quite often the difficult part.

These innovative models, I think, will very much help with that. It's the idea that people can come into a system where they'll work with and have the support of a cohort of medical professionals—allied health workers and Indigenous health workers as well—but where there's also the understanding that they're going to have some work-life balance. The days of a doctor coming to town, buying the practice and staying there for 40 years are of an era past. That's just not happening now. The cohort of junior medical professionals who are coming through at the moment want to have that work-life balance. They want to be able to have other skills or go into a more generalist pathway, and we need to recognise that. We need to know that, when that older doctor or those couple of doctors retire, it's probably going to take three or four junior doctors to replace them.

The number of medical graduates coming through is encouraging. There were over 700 applicants for 40-odd places at the Orange campus of the Murray-Darling Medical Schools Network. There is a desire. It is a slow process to go from a first-year medical student to a fully qualified practitioner. I met three third-year medical students on Friday in a little village called North Star, in my electorate. They were out helping the Royal Flying Doctor Service with the vaccination program in regional areas, and they were quite enthusiastic about the experience they were having—flying around in an aeroplane and going into smaller, remote areas. Hopefully, the positivity of that experience might get them to think about maybe enhancing their career.

We just need to be wary of short-term fixes, because quite often the short-term fix actually exacerbates the problem and doesn't solve it. I acknowledge some of the comments made by earlier speakers on both sides. We owe a great debt of gratitude to our doctors and medical practitioners for their work over the last 18 months. They've got Australia through a very difficult time. In my electorate there were over 1,000 cases of COVID but there was a very low death rate, largely because of the dedicated staff of the Aboriginal medical services, the Royal Flying Doctor Service, the health districts and the local GPs doing a fantastic job.

I support the changes in this bill and I look forward to seeing some of the other policies that this government has in place coming to fruition over the years to come as we tackle—in a methodical, professional and thoughtful way—the issue of workforce shortages in medicine across regional Australia.

Peta Murphy (Dunkley, Australian Labor Party) Share this | Link to this | Hansard source

I start by joining others in this place in thanking all of the medical staff and people who have supported medical staff through the pandemic, from nurses doing COVID testing to the administrators helping the nurses as we go through the mass testing sites to have everyone registered for their testing; to the pathology service who have processed the tests; to the doctors, the nurses and the administrators in our hospital systems who have been under such pressure dealing with COVID; to the GP clinics and the people that work in those clinics, be they the GPs, the practice managers or the people at the front desk. You have been the front line of our fight against COVID and will continue to be as we open up. All of those people deserve the support of their government—not just words of thanks, which I'm sure are welcome, but the funding that's needed to make sure our public hospital systems can continue to operate not just for the sake of people who have COVID but for everyone else who needs to access a public hospital, which is often overwhelmed at the best of times and certainly has the extra burden of COVID. For the Medicare system, for the GPs who are now seeing people for their health check-ups, for their ongoing treatment, for getting the vaccine, sometimes then for treatment of COVID—their workload has increased. Sadly, we haven't seen enough funding guaranteed going forward to help these people.

The Health Insurance Amendment (Enhancing the Bonded Medical Program and Other Measures) Bill 2021 brings forward some changes that are welcomed, but it doesn't address some of the specific issues that Australians have in outer metro seats like my seat and my community of Dunkley and in regional and rural areas in accessing health care and, in particular, in seeing a GP.

Tightening access to regional bulk-billing incentives that the government has brought in is a policy from a Morrison government that's made regional GP shortages worse, and we feel those shortages in outer metro seats like mine; it's not just in the regions. There's also the impact of the government's six-year freeze in Medicare rebates and the decision back in 2014 to abolish Healthcare Workforce Australia, the consequences of which we are still feeling today.

This is the time that the government should be investing in Medicare and delivering more services to people, not fewer. October is Breast Cancer Awareness Month, and the Breast Cancer Network of Australia and other organisations dedicated to helping women and the smaller number of men who have breast cancer have been ringing the bell loudly and clearly for at least 18 months now about drop-off rates of women getting checked—having mammograms—and the consequences of later detection of cancers for survival rates and for the sort of treatment that you have to go through.

There is so much to be done in the healthcare system on top of COVID, and we can't afford a government that is not just asleep at the wheel but failing to look after people in their time of need. If we can't properly train up enough people to be GPs in Australia, if we can't devise a system that incentivises GPs to get to outer metro seats like mine, we're going to continue to be reliant on GPs coming to Australia from other countries. We've seen that something like this pandemic really impacts the ability for GPs to come from other countries. We welcome medical practitioners from around the world, and they bring so much to the profession and also to our community. We of course should continue to actively recruit people—the best and the brightest—from all different parts of the world to come and work in Australia, but we have to skill up Australians. We have to give Australians the opportunity to be the best medical practitioners that they can be.

We have to have a system that doesn't make it almost impossible for GP clinics in outer-metropolitan seats to recruit GPs. That's why Labor established a Senate Community Affairs Reference Committee inquiry into outer-metro, rural and regional GP and healthcare services. That inquiry is also going to consider the performance of programs such as the Bonded Medical Program. There is a crisis in outer-metro seats. There is no doubt about it; there is a crisis in being able to recruit and retain appropriately trained GPs. It is unfortunate that we have to have a Senate inquiry to push for reforms in this area. It should be something that is done as a matter of course by a good government, but it hasn't been done.

The inquiry happening in the Senate, I understand, has heard from numerous stakeholders. If you look at the committee's website, it says that some 40-odd submissions have been received so far. I thought that was a bit strange, because I made a submission on behalf of my community in Dunkley and it's not on the website. So my office contacted the committee today. Apparently there are so many submissions to this inquiry that they're overwhelmed trying to get them all up onto the website. So those 43 or so submissions that are on the website don't reflect the huge number of stakeholders, MPs, local councils, medical colleges, individuals and GP clinics who have made submissions. The point of this inquiry is not simply to hold an inquiry; it's to get practical, positive solutions to make sure Australians have access to quality health care regardless of where they live. I've made a submission on behalf of Dunkley, and I encourage everyone who lives this issue or is concerned about this issue to get engaged in the inquiry.

This issue was first brought to my attention shortly after I was elected in August 2019. Dr Chung and Lucina Wilk from the Total Care Medical Group in Frankston came to me. Dr Chung, 72 years young, wants to retire. He wanted to retire in August 2019 but he couldn't—and still can't—recruit enough replacement doctors to be able to do so. I've raised this issue with the minister and I've raised this issue in the parliament, but the barriers to employing doctors at Dr Chung's clinic remains and he continues to work. In November 2019 I met with Rachael Hatzopoulos, from the St Mary Medical Centre in Carrum Downs, because of the serious barriers to employing new doctors that that clinic and other clinics associated with it have been experiencing. Ms Hatzopoulos said to me at the time that it is a common problem across bulk-billing, outer-suburban clinics. It was then and it is now. Ms Hatzopoulos has put in a submission to the committee, which I helped her to submit.

Recently, I had a roundtable discussion with local clinics and Labor's shadow minister for health. Here is a summary of what was clear from that roundtable. As an MM1 location, the Dunkley electorate is not listed as a distribution priority area. From 2022, all doctors require a 3GA program placement; however, there are no programs available in the local area. The only program is the AGPT, which has been closed for several years in metropolitan locations. Health workforce certificates are not granted in MM1 locations, resulting in local clinics being unable to recruit an international medical graduate. Clinics with GP shortages have used locum doctors to fill the gaps, but these placements are only available after they've passed their FRACGP exam and for a maximum of six months. So patients and clinics are consequently subject to frequent GP changes, which is not good for people who need ongoing care. Multiple GP clinics with active patient lists of over 6,500 have reported having only one full-time doctor, with some part-time assistants to manage their patient load. Additional pressure is being put on hospital emergency departments. Patients who can't be seen by a doctor in a timely manner are being referred to hospital for primary care matters.

It's just not good enough. It's not good enough for my community of Dunkley and it's not good enough for people across Australia. We are constantly putting out a positive message to people to look after their health: engage actively in preventative health, go and see their doctor if they have concerns about anything, get tested and carry out courses of treatment in the way that they are prescribed to them. It's really, really hard for people in outer suburbs who rely on bulk-billing GP clinics if they cannot engage a GP to help them to do all of those things. It shouldn't matter what your socioeconomic status is. It shouldn't matter where in Australia you live. You should have access to superb, top-quality care and you should be able to get that care at a bulk-billing GP clinic. When the clinics in my electorate can't recruit doctors and can't get them to stay at their clinics, that undermines the care that is given to often the most vulnerable people, and it's not good enough. I call on the government to actively participate in the Senate inquiry, to look for positive solutions and to implement those solutions. It's actually urgent and it really needs to be done.

Anne Webster (Mallee, National Party) Share this | Link to this | Hansard source

In my maiden speech I made the statement that your health status should not depend on your postcode. I adhere to that statement. I committed then to fighting for my regional communities to improve access to health care and an increased professional workforce, and I continue to do so. I moved to the country 44 years ago, as an 18-year-old bride married to a young intern who began his internship and junior residency at the Mildura Base Hospital, undertaking training in anaesthetics. He then became a GP and completed additional training in obstetrics. Phillip was a very busy GP, with over 1,000 births in just a few years. He spent 44 years in a country practice where doctors shared after-hour calls and obstetric calls and had alternate weekends on duty—it was a heavy workload. Today, things are different, though I will say that rural GPs, such as rural generalists, can work just as hard. In places such as Mildura, GPs choose to take on registrars, resulting in some staying and therefore increasing the workforce in those areas. Not all towns and practices have that option.

This government recognises the need to invest in our regional communities to ensure we get the health care we need when we need it. Many of the challenges relating to healthcare service delivery, particularly in my electorate of Mallee, relate to workforce. We simply do not have the people to deliver the services we need in our communities. The workforce we do have is stretched to the limit, especially now, during the pandemic. The commitment and sacrifice shown by frontline workers in my electorate through this difficult period are a demonstration of why our regional areas are such a wonderful place to live. But we cannot dodge the key issue: we need more people. We need highly trained doctors, nurses, radiologists, physios and other allied health professionals. The problems facing healthcare delivery in regional areas are not going to go away until we get the right people. That's where the government's initiatives to train, attract and retain medical professionals in rural communities become so important.

For example, from 1 January 2022 the Morrison-Joyce government is investing more than $65 million in boosting bulk-billing rebates and providing more affordable health care for patients in regional areas. We are introducing a new progressive incentives schedule that increases the value of the rural bulk-billing incentive based on remoteness. This will enhance the financial viability of practices in rural and remote areas as well as reduce the gap paid by patients. The more remote the area, the greater the incentive payment. This will be done to recognise the greater challenges and cost pressures of providing health care in regional areas. The new rural bulk-billing incentive will support those GPs providing services to people in greatest need and those who have the lowest capacity to pay for health care. The new rural incentive rates are a key reform we have delivered to attract more doctors to the bush.

The legislation currently before the House builds on the coalition government's workforce training and primary care reforms. The Health Insurance Amendment (Enhancing the Bonded Medical Program and Other Measures) Bill 2021 provides additional flexibility to enhance the implementation of the bonded medical program. The bonded medical program is a key policy which aims to provide more Australian doctors to areas of need, particularly in regional and remote Australia. The proposed amendments will address unintended consequences in the interests of participants and will also support achievement of the program's objectives. The proposed amendments will provide the necessary flexibility to administer the program and to address issues that are having a direct impact on participants. If the bill is not passed in the 2021 spring sittings, the issues directly affecting participants—most of whom are medical professionals providing crucial health services in regional, rural and remote Australia at this critical time—will remain unresolved. This is unacceptable. The additional flexibility provided for by this legislation will enhance participation in the program and will therefore improve health outcomes for regional Australians. Increasing the availability of appropriately trained doctors is a key factor in improving our health outcomes.

While we are delivering these key amendments, we also need to look to the future. Retaining skilled people is a key challenge in the bush. We know that training people in the regions significantly increases the likelihood that a student will live and remain in the regional area. Train local; stay local. That's what I'm focused on, particularly for my electorate of Mallee. Training home-grown talent to meet our health needs is the most sustainable solution to the problems we face. One of my key aims is to assist in the establishment of an undergraduate biomedical degree at our local La Trobe University campus in Mildura. The idea is then to link the undergraduate biomed degree to a postgraduate medical degree at Melbourne university's Shepparton campus or, alternatively, Mildura. This would create a pathway for rural students to complete end-to-end medical training in regional Victoria. I'm fully behind this proposal and have taken it directly to the Minister for Regional Health, whom I know is on board. I've also spent many, many Zoom meetings with the Vice-Chancellor of La Trobe University, Professor John Dewar.

Within the first six months of taking up the role as the member for Mallee, I held stakeholder meetings with health service providers across Mallee to seek to understand where they saw the gaps and the issues. It became very clear that an innovative model would be necessary to meet the health needs of our rural, regional and remote communities. I put together a healthcare policy document which addressed the gaps and provided solutions. As such, an integrated model, which reaches out to rural towns, appears to be the ultimate solution—a heart and artery model or a hub and spoke model of primary and allied healthcare. Mallee Track in Ouyen provides such a service and reaches out to small, rural towns in that region. Lois O'Callaghan is the CEO of Mallee Track, and I've spent many sessions talking with her about how it could be improved. At the moment, they struggle to get a GP—to simply get a doctor to work at that practice. It puts a tremendous load on the service delivery.

The team approach is working very well in other states, and I have spoken with the Minister for Health and the Minister for Regional Health about this concept for Mallee. I've discussed with them the need for a mix of block funding and Medicare funding to provide services by allied and primary health professionals who work together as a team. The benefit of a team approach is that it shares the load of health delivery. A team that communicates and plans and that manages patient needs, whether that happens under one roof or over several locations, would bring an enhanced healthcare model and, undoubtedly, increase our workforce at the same time.

The health space in my electorate is continually expanding, and this government is backing us to deliver more of the services we need locally. The coalition government invested $6.5 million to purchase new equipment for a radiation oncology service in Mildura. The service will be established at the Mildura Health Private Hospital and will be open to both public and private patients. A radiation oncology centre in Mildura is another step towards improved health outcomes for regional Victorians. Thankfully, cancer patients in Mildura and surrounds will no longer have to travel long hours away from home in order to receive life-saving radiation cancer treatment. Of course, the pandemic has exacerbated this issue, and there have been many patients who have had treatments delayed or have had an inability to get the treatment that they need. This would be solved with the implementation of this radiation bunker.

It comes down, however, to workforce. In Mallee we are ambitious and we see a bright future for Mallee as a tri-state health hub. Discussion and planning for a new hospital in Mildura has begun at the state government level, which is greatly appreciated. A new hospital is undoubtedly necessary to keep pace with our population growth and greater demand for services. We need the new hospital to be a tertiary training hospital, with capacity for specialist referrals. We can't keep shipping our most sick patients off to Bendigo, Adelaide and Melbourne. People in the region deserve the best quality healthcare close to home.

This is an ambitious goal but a critical one. This is why we need to implement measures now to secure the workforce for the future. We need to have new local training opportunities. We need to continue incentivising doctors to work in the bush and to create innovative models of healthcare delivery to address workforce shortages. This government is getting on with the job. Measures contained in this bill will work towards a brighter future for healthcare delivery in the regions.

Emma McBride (Dobell, Australian Labor Party, Shadow Assistant Minister for Mental Health) Share this | Link to this | Hansard source

Firstly, I'd like to join others in this House who have recognised and acknowledged the critical work of healthcare workers across Australia during the pandemic. I'd like to especially acknowledge those on the Central Coast in the electorate I represent. As we faced COVID-19 it was a privilege as a volunteer pharmacist immuniser to help boost vaccination rates in our community.

I rise to speak on the Health Insurance Amendment (Enhancing the Bonded Medical Program and Other Measures) Bill 2021 and to support the amendment moved by the member for Cooper. The purpose of the bill is to amend the Health Insurance Act 1973 to enhance implementation of the Bonded Medical Program and the administration of medical rural bonded scholarship contracts under section 19 of the act. The program is designed to address a doctor shortage across rural, regional and remote Australia, but this shortage has only gotten worse under the Morrison government.

I have spoken countless times about the acute GP shortage that we're facing in Australia, particularly in the outer suburbs and the regions—as soon as you live anywhere outside a big city. But, despite the growing crisis, this government has been slow to act. That's why we have been forced to establish a Senate inquiry into the provision of GPs and related primary health services in outer metro, regional and rural Australia. The inquiry will consider the performance of programs such as this one. Many submissions have been made from my electorate so far—from the Central Coast Community Women's Health Centre; local GPs, like Dr Brad Cranney; and local surgeries. They know that the problem is real and that it is only getting worse.

In my community the GP shortage is now a crisis. On the coast getting in to see a GP has never been tougher. The government's distribution priority area classification—and I've spoken to the minister about this myself—excluding most of the Central Coast, particularly the northern part of the Central Coast that I represent, is making it harder to get an appointment. Unfortunately, this is true for many communities in outer metropolitan, rural and regional Australia. We're now seeing a two-tiered health system in Australia, where care is increasingly determined by where you live and how much you can pay. This means that people living outside big cities are finding it much more difficult to access care and access critical care close to home, leading to poorer health outcomes in rural and regional communities, which is made worse by longer wait times, higher out-of-pocket costs and a shortage of healthcare workers.

The Morrison government's DPA classification has had a significant and detrimental impact on my community. It means doctors in the Bonded Medical Program can't meet their return-of-service obligation in our community, making the local GP shortage even worse. It has made it extremely difficult for local practices to recruit and retain GPs. I've spoken to so many GPs who are struggling to get through the COVID-19 pandemic and be able to meet the needs of people who want to get a jab, who need critical health information and who need routine care. Regular health screening has been delayed.

This is a crisis in our community. In a community like mine—where one in five people are aged over 65 and, at the other end, there are lots of young families—people can't get a GP. They can't find a GP. The books are being closed. To get an appointment they're being forced to travel back to where they were before. It's just not good enough. I have heard from countless GPs working in local practices. They have reported increased waiting times since we lost our DPA status. Not only is it frustrating that people in my community must wait weeks to see a GP but also it is risky.

Debate interrupted.