Rachel Siewert (WA, Australian Greens) Share this | Link to this | Hansard source

I present the report of the Community Affairs References Committee on health services and medical professionals in rural areas, together with the Hansard record of proceedings and documents presented to the committee.

Ordered that the report be printed.

I move:

That the Senate take note of the report.

It is with great pleasure that I present this report. Upfront, I thank my colleagues on the committee. It was a very enjoyable experience—I think that I am allowed on this occasion to speak for all of us and say that—we enjoyed working together. I also thank the secretariat once again for the long hours and hard work that they have put into this report.

This report highlights, yet again, what I think many of us felt very strongly, and that is that there is inconsistent access to the medical workforce in rural and regional areas. In particular, access to medical specialists plummets outside major cities and falls to much lower levels outside large capitals. Also, we are aware of data that is showing higher disease burdens and poorer health outcomes for those living in rural and remote areas. While we acknowledge in our report that there has been work done, we believe, given that we have made 18 recommendations, that there is room for improvement and that more work needs to be done.

As I said, we made 18 recommendations; but in the rest of the short time I have available, other than recommending that people with an interest in this area get hold of the report and read it because there is some very useful information in there—read the recommendations—I point to a couple of key areas. One is that there has been a lot of talk about the classification system for incentives for medical professionals to work in regional areas. Again, the committee received a lot of criticism and input into that discussion and we made strong recommendations about the system needing to be improved—in fact, replaced and improved with some significant improvements.

One of the key areas that was also identified was the fact that the more specialised the medical profession has become—the more specialists we have—the more that has led to the detriment of rural health, because we do not have so many people going into rural generalist programs as in the past, or becoming rural generalists. We were presented with some excellent evidence around the success of programs—which I am sure my colleagues will talk about—and so we made some recommendations around those. We have also identified the need to look at the training places that are available regionally and we made some recommendations on those particular issues, to expand those, and we looked at how we can make improvements there.

We were also very clear that we talk not only about doctors. We are not just talking about doctors; we are talking about nurses and allied health professionals as well. One of the key recommendations that I think is very important—and I am aware that Senator Moore, in particular, will talk about it because it was her who was really focused on allied health and needing to get more focus there—is that a rural and regional allied health adviser be added to the adviser positions in the department.

We also talked about incentives for rural students to study medicine. The overwhelming evidence that we were presented with was very strong: if you want people to go and practice medicine and allied health in the bush then you should be supporting regional students and people from a rural background into studying medicine and as health professionals in particular. The evidence shows that if you come from the bush you have an affinity for the bush and a 'rural-mindedness'—I think that is the right word. We made some recommendations about how we can incentivise that. But there were also some other things we found that were barriers to ensuring more health professionals in rural and regional areas, and so our committee made a number of recommendations.

As I said, there are 18 recommendations. Of course, the Community Affairs Committee could not table a report without talking about the need to improve access to data. We found it quite difficult to pull together the different data sources so we have made some recommendations about data.

I think that this report will contribute significantly to the ongoing work to ensure that we get better health provision in rural and regional Australia.

Claire Moore (Queensland, Australian Labor Party) Share this | Link to this | Hansard source

I want to use this short time to acknowledge the amazing support and commitment of so many people who chose to come before our committee. We had over 130 contributions and a number of supplementary contributions where people put in an original application and talked about their concerns and issues, then, as they individually followed what was going on in the Hansard and through phone calls coming to the committee, they then felt that there were more things they wished to share with us. Whilst it was a trial at times for the committee secretariat to ensure that we had all this information, it is a wonderful acknowledgement of the skills and commitment and dedication of so many people in rural communities to ensuring that their rural communities get the best possible access to medical services.

As Senator Siewert said, a core aspect of our committee was to make sure that we were looking at the range of medical support. Too often we get into a debate about the number of doctors in rural areas. That is a worthy debate and no-one is moving away from that and it will continue to be problematical, as our committee found in terms of making sure that we have appropriate training. My personal favourite, as Senator Siewert has mentioned—and I think that most of our committee members will mention—is the issue around ensuring that we have people who want to work in the bush, people who want to have the chance to have training to receive professional skills so that we can make an effective link for those who want to work in the bush to get their skills and then return to the bush, and that was the aspect of 'rural-mindedness'. I believe that everyone who was on this committee is rural-minded, and I think all the people who came to give us a evidence are rural-minded. We think that should be valued in the way students are selected and the way assessments are done and, most particularly, the way training is actually executed. People need to have the opportunity to work in a rural setting to see the wonderful range of opportunities there in order to find out whether that is the place where they are best able to use their skills.

We saw through the evidence the range of issues that have come in by a series of governments. This is not a problem peculiar to one government or another. This is not a new issue. In fact I did say during the committee hearings that I think sometimes we get a degree of 'rosy-glassedness' when we look back on the past—and I apologise to Hansard for how you are going to spell that one! Nonetheless, I think that sometimes we look back and think that things were much better than they really were. If you look at the number of professionals working in the medical sphere that were available in some of these rural centres in the past, they were not well serviced all the time. I think that what we are doing now is balancing a situation where people have a greater expectation of their rights to have effective medical services, and that is appropriate. In the past they may have been prepared to put up with one doctor with extensive working responsibilities and no time off and with no Allied Health—and I do acknowledge the point made by Senator Siewert—I am unabashedly a proponent for Allied Health Services. When you are talking about medical services, you are talking about the range of wonderful professional help that we should be able to access no matter where we live.

We heard about the number of recommendations. I particularly want to acknowledge the work of the Rural Health Alliance. Their professional commitment to this area over many years was really the basis for much of the evidence that we received. Not only did we receive it from the alliance, we received it from a number of their component parts. So thank you very much to Gordon Gregory for his resilience, his commitment and his professional knowledge. He was so valuable in working with our committee, ensuring that we knew what the background knowledge was.

Before I sit down, I particularly want to acknowledge Senator Judith Adams. One of the things that was with us all the time was the fact that this was a committee that Judith was dedicated to, and I felt at times that she was there giving evidence. I think we need to see that the work of women like Judith, countrywomen, strong professional nurses who have knowledge of their community and a desire to ensure that their communities are well serviced, is valued. We need those people. We need to acknowledge them. We need to respect them and we need to fund them well, because no community can exist without people who have that knowledge and dedication.

I commend all our recommendations and I think that in the future we will have more things to say. This was a committee on which it was a joy to serve. We met people that had the same sense of commitment we had, and the recommendations of this committee can make a difference. Thank you for being part of it.

Fiona Nash (NSW, National Party, Shadow Parliamentary Secretary for Regional Education) Share this | Link to this | Hansard source

Some time ago Dr Paul Mara from Rural Doctors Association had a conversation with me about the inequities that he saw with the incentives to try to get doctors out to regional areas. That was, I guess, the seed for this inquiry; it grew from there. It certainly created the drive for it.

I thank my Senate colleagues for agreeing to hold this inquiry. I think that it has been one of the most important pieces of work we have seen for regional health for quite some time and I really do thank them for their agreement to initiate this inquiry in the first place. I thank also my colleagues the shadow minister, Peter Dutton, and the shadow parliamentary secretary for regional health, Andrew Laming.

There is no doubt, as everybody knows, that there is an enormous inequity when it comes to health between regional communities and the cities. We have just reflected in this committee the solutions that people have brought to us. We have just reflected in this committee the thoughts that are out there, the extremely good commonsense thinking that is going to create a better future for health in regional communities.

But it is going to take commitment to change. There are so many good solutions out there that hit a wall and go nowhere because we have not seen enough commitment to change, and that, I think, is one of the key things that we need to take out of this entire inquiry. We have made, I think, 18 excellent recommendations, but we need from both sides of parliament a real commitment to change.

Initially, the driver was the issue around the workforce incentive programs.

It was and is—this issue still exists—completely stupid to have the same incentive for a doctor to move from the city to a small town like Gundagai, which is under huge pressure when it comes to GPs, as the incentive for a doctor to move to a place like Wagga, which has around 60,000 people and has a specialist support network. To have the same incentive applying to doctors moving from Sydney to Gundagai or to Wagga is just completely stupid. It is bleedingly obvious—pardon the pun—that that needs to be changed, and that very much came through during the inquiry.

Also, for rural generalists, we need to have GPs who can do the general procedural things as well. All the evidence showed that that has really slipped away. We have got to get a focus back on those medicos who obviously provide a great GP service but who also have the training so that they have the procedural skills to be generalists. It is vitally important that we do that.

We also noted very clearly that there is an inadequate supply of rural placements for medical interns. This needs to be addressed. There is no point getting all these students through the system if, once they get to that point, they cannot get an intern place. The quota that is currently required is 25 per cent of students from a rural background. The definition needs to be changed. Currently you have to have spent five years of your life in a rural area somewhere. We figure that is not good enough. We want it to be students who spend either four of the last six years of secondary school in a rural area or four of the last six years with their home address in a rural area, or city students who show rural-mindedness, that being an orientation to work in a rural area, which they would support by a willingness to be bonded.

We also need to look at the 25 per cent rural medical student intake and make sure that we have clarification of where that is not being met. It is vitally important that universities are not allowed to slip that under the radar. It is a requirement, it should be shown to be requirement, and we need to have clarity around those figures. We also need to support rural GPs who provide training. That is vitally important. It should be support both financially and by providing locums to help them. We need incentives to ensure that medical students are encouraged to study at regional universities.

We have done a lot of work around allied health, and it is big-picture stuff. We need to look at the interprofessionalism, if you like, of how health in the regions works. We were looking for things outside the square and we were particularly impressed with the Charles Sturt University proposal for a full-scale medical school. Obviously, students from a rural background studying in a rural area are far more likely to stay in a rural area to practise their profession.

I thank my colleagues. I commend the report. I certainly hope that the government pays attention to it. This is not a report to be thrown under the carpet. There are some very good recommendations in this and we absolutely hope that they are acted upon.

Sue Boyce (Queensland, Liberal Party) Share this | Link to this | Hansard source

I would like firstly to congratulate Senator Nash for being the person who initially suggested this inquiry and, in particular, looking at the Australian Standard Geographical Classification Remoteness Areas, which clearly has not been working properly. But it was the entire Community Affairs References Committee which broadened this out into what has become a very meaningful assessment of the health services available in rural and remote Australia.

I was somewhat surprised to discover that the number of health professionals across Australia is spread evenly across the country on a per capita basis. Clearly, 'on a per capita basis' when you live in a town of 100 people is not quite as helpful as it might be when you live in a city of a million people. So we need to think about accessibility and many other issues at the same time as we are thinking about whether we have enough health professionals on a per capita basis. We have suggested not only that the Australian Standard Geographical Classification Remoteness Areas should be reassessed and changed to be far more flexible and to reflect much more the needs of people in remote areas and the incentives for doctors to actually go to those areas; we have suggested also that there should be a proper evaluation or assessment conducted at the same time as any new system is put in place. The problem for people who use the scheme is that whether you are in Gundagai or Newcastle, as Senator Nash said, or whether, in my state of Queensland, you are in Longreach or Townsville—both of which have the same classification—is clearly a significant factor in the ease with which you are going to get doctors to work in those areas.

One of the other things that came up, and I must congratulate Senator Moore on this, was the fact that there is a huge amount of data being collected, there is a huge amount of research going on and there are many good programs going on, but the communication of these, the sharing of information and the correct use of material are lacking in almost every area. You only have to look at the evidence from the Australia Bureau of Statistics about the geographical classification for remoteness areas, which said:

… it is well known that some policy makers use ABS definitions, both geographical and others, to directly target policy. For example, some organizations paid an additional allowance to staff stationed in 'rural' areas… The validity of using ASGC in this way depends entirely on the relevance of the geographical concept to the desired policy outcomes. It is vitally important that anyone developing policies, funding formulae or intervention strategies understands the alignment, or lack of alignment, between … classification and their business objective.

I think that unfortunately what we have discovered is that there really has been very poor alignment in the past on this topic.

As I said, the government, every government, is spending significant amounts of money to try and ensure adequate health services in regional Australia, but the evidence that we received as a committee during the inquiry has highlighted the deficiencies in both the development and evaluation of the programs. We have an urgent and fundamental need to better understand what works, where it works and where we have significant gaps in the system.

I would very much like to commend this report and, like Senator Moore, I would also like to acknowledge our former colleague the late Senator Judith Adams, who would have revelled in the opportunity to be involved in this inquiry and whose work in the Senate paved the way in many ways for the work that we have done in this inquiry.

Bridget McKenzie (Victoria, National Party) Share this | Link to this | Hansard source

For almost 12 months now the Community Affairs References Committee has been looking into the factors affecting the supply of health services and medical professionals in rural areas. This inquiry started with the knowledge that people from regional Australia experience poorer health outcomes than their urban counterparts. It was the Nationals' very own Senator Fiona Nash who brought these terms of reference to the committee.

Research tells us that people who live outside major cities are 20 per cent more likely to have had asthma and 16 per cent more likely to report mental or behavioural problems. The Australian Institute of Health and Welfare reports that people living outside major cities are 1.2 times more likely to engage in behaviours associated with poorer health, such as smoking and binge drinking, than people living within major cities. Life expectancy in regional areas is one to two years lower and in remote areas it is much more—seven years lower. Part of that could be because of the difficulty country people have had in accessing health services. We know that to be the case—because there is not a doctor's surgery 10 minutes down the road; there are no specialist staff in the local small hospital there ready to assist.

We wanted to find out exactly what the issues are so that we can look at how the government and community can work together to solve the problem. As others have mentioned, there was no shortage of people assisting us with the task—from academics and the medical fraternity, both retired and current, to local community members. As part of that process we have heard from stakeholders right across Australia and built up a picture that shows that the problems being faced by those in country areas are quite consistent throughout the country.

For a start, the Australian Standard Geographical Classification Remoteness Areas model used by the government to determine what is classified as regional, rural or remote is flawed. It is the same model that is being used to determine a whole host of incentives and policy settings which I will not detail now for the sake of time. But it is the classic one-size-fits-all policy: it does not work, especially for the regions. It is particularly relevant in my patron seat of Bendigo, a large regional centre that serves the surrounding area with a soon-to-be-built, world-class $630 million hospital. We heard examples from Central Victoria General Practice Network and the Murray Plains Division of General Practice regarding the crude application of the RA classification, which gives communities with population bases ranging from 2,000 to 100,000 the same relocation and retention grants. There is a big scope of difference there in reality. Tiny towns in the region surrounding Bendigo, such as Elmore, do not receive any additional recognition for their particular situation.

The Centre of Research Excellence in Rural and Remote Primary Health Care, based in my patron seat, has done some excellent work in this area. It is referenced throughout the report and commended by the committee. I suggest that anyone with an interest in this area read the work of Professor Humphreys. Additionally, we found that a problem in country areas is that GPs are becoming increasingly rare as more medical students opt to specialise; yet rural GPs need a well rounded, complete set of skills. One day you have to set a leg, the next day deliver a baby, do the stitches and dispense some antibiotics for a cold—and that is just for the animals. Jokes aside—that is for the community members. We need really well rounded medical graduates in regional areas. These skills are just as important as a specialisation in other areas. Indeed, these days general practice can be a specialisation in its own right. We have mentioned Queensland Health's efforts in this area and I would particularly like to highlight those. It is quite an exciting approach to the problem.

Medical specialist numbers plummet outside the major cities to levels as low as one-sixth of those in large capitals, hence the need for better access to specialist services whether through transport assistance or even through specialists travelling to regional areas for one or two days a month to enable locals to access their services. The committee is encouraged by the steps already taken and wants to see the progress of the Rural Clinical School programs continue to ensure that students have access to support at all stages in the training and placement program. There is a great quote that I would like to be able to deliver here but for the sake of time I will not be able to. It was a key factor in supporting the training out there. The evidence suggests that we have seen the need; we are training more medical graduates but they do not have the funded places to go to, to complete their training. We would like that to happen in the regions so they can get on board with what a fantastic experience it is outside capital cities—and hopefully join us there for their long careers.

I would like to thank Senator Siewert, Senator Nash, Senator Moore, Senator Boyce and Senator Fawcett for great work done on a great report.

David Fawcett (SA, Liberal Party) Share this | Link to this | Hansard source

I rise to support the comments of my colleagues on this report, which is a very important report for people living in rural, regional and remote Australia. I am not going to repeat all of their comments in detail except to say I strongly support the comments around classification systems. Statistics do indeed lie. They do not necessarily reflect the reality on the ground and we need those improved systems such as the ones identified and recommended in the report. I support the comments on specialisation and the lack of incentives that are available for allied health professionals compared to GPs.

I would like to touch on a couple of things that have come up during the inquiry from a South Australian perspective specifically. Firstly, states are different, particularly if you look at demographics and the distribution of population. Policy that is developed at a national level that may well suit the larger east coast states, with larger populations and larger regional centres, may not suit South Australia. A number of pieces of evidence came to light during the inquiry that highlighted that sometimes things occur quite differently because of the different arrangements within states.

For example, in South Australia the largest regional town, Whyalla, is around 21,000, Port Augusta is around 13,000, and Port Lincoln is around 14,000; then we have a number of other smaller places. So in South Australia there is no regional university. Flinders University, for example, has taken a great initiative with the Parallel Rural Community Curriculum in Renmark and Mount Gambier. They are having terrific success and there is good longitudinal evidence showing that students who spend a long period of training as an undergraduate in country areas do in fact have a higher probability of returning and remaining in the country as a GP.

What is important, though, is that we look at it as a whole system. It is not just the universities; it is also the training placements for interns and people in their second year after graduation. What we see in South Australia is that there are only some six places available in the country and yet we need some 56. Allowing for international medical graduates, perhaps we only need 24; but that is still a fourfold increase in what is available at the moment.

So there needs to be alignment between the state government as well as the federal government and the providers, such as universities and colleges, to find a way to make this transition smooth and effective so that the communities who need the support get it, as opposed to the buck being passed or just reaching dead ends in trying to get people to flow between the various stovepipes.

The federal government also has a role to play in looking at how they work with the state government around things like incentive payments for GPs or the provision of locum services to support GPs in country areas who wish to provide training for medical students or, indeed, for interns. I note the trial that is occurring in South Australia—for example, in Kapunda—where people can come as an intern and GPs can provide a level of training for them post their graduation from medical school. In a state like South Australia, where we do not necessarily have large enough communities to have training hospitals in the community, that is a model that is viable. It is starting to work, but we need the federal government to look at ways to adequately compensate GPs for the time taken away from their business—because at the end of the day it is a business; it pays their bills—to provide that support.

I thank a range of people for their support in South Australia and for making me aware of the issues in South Australia. Steve Holmes, you can take your stockwhip and put it back on the wall. I think this inquiry has done a fair bit to round up of some of the issues. Dr James McLennan at the Clare Medical Centre showed the way in terms of sustainable rural practice. Dr Anthony Page in Gawler highlighted a number of the areas of difference between state and federal policy that can have an impact. I also thank Scott Lewis from the RDAA, as well as my federal colleagues Rowan Ramsey, Patrick Secker and Senator-elect Anne Ruston who helped out with the inquiry.

One of the recommendations that has come out of a lot of the work in South Australia is to look at having a function within DoHA that aggregates the information collected by Medicare locals so that on a regular basis we assess the gaps that are emerging between federal and state policies and very deliberately put those onto the COAG agenda so that they can be dealt with in the interests of sustainable health care for people living in rural and remote Australia.

I seek leave to continue my remarks.

Leave granted; debate adjourned.