Wendy Askew (Tasmania, Liberal Party) Share this | Link to this | Hansard source

I rise again to continue my contribution on the Health Insurance Amendment (Bonded Medical Programs Reform) Bill 2019, which will amend the Health Insurance Act 1973 by introducing a statutory scheme to administer the reformed bonded medical programs from 1 January 2020.

There are currently 9,406 program participants studying at medical schools or in prevocational training under the older programs—the Bonded Medical Places Scheme and the Medical Rural Bonded Scholarship Scheme—with a further 623 participants undertaking their return-of-service obligations. These participants will have the option to opt in to the new arrangements from 1 January 2020, and those who choose to stay under the existing arrangements will also be able to do so.

As the program matures, up to 700 doctors are expected to commence their return-of-service obligations in rural, remote and regional Australia each year over the next five to seven years. To be eligible to participate in the reformed bonded medical programs, a person must have accepted a bonded Commonwealth-funded place in a course of study in medicine at an Australian university. They must be an Australian citizen or permanent visa holder and agree to participate in the program using a web portal maintained by the department.

Under the new statutory scheme, participants will be required to work as a medical practitioner in eligible locations for a total period of three years. The three-year return-of-service obligation is half of the six years required under the previous Medical Rural Bonded Scholarship Scheme and a reduction of between one and three years for previous bonded medical programs scheme participants who entered the scheme in 2015 or earlier. Participants in the bonded medical programs scheme who entered the scheme in the years 2016 to 2019 agreed to a 12-month return-of-service obligation. These participants will retain their 12-month return-of-service obligation under the new statutory scheme should they voluntarily opt in.

Under the new scheme, the return-of-service obligations must be completed within 18 years from when the participant completes their course of study in medicine at an Australian university, but they may be completed by a series of periods. The period of 18 years to complete the return-of-service obligation may be extended in limited circumstances only where a participant or a family member has a medical condition that prevents that participant from completing their return-of-service obligation within the time frame. A participant will be subject to a number of conditions, including that they must complete their course of study in medicine at an Australian university. The return-of-service obligation must be completed in accordance with the rules, and the participant must give their information or documents to the department in particular circumstances. These are necessary safeguards to protect our investments in these participants.

Should a participant withdraw from their course of study in medicine after the census date for the second year of study, that participant will be liable to pay the Commonwealth the cost of the participant's course of study for the year or part year—semester—of study undertaken, plus interest. Where a participant does not complete their return-of-service within 18 years from completion of their course of study or an extended period, that person will be liable to pay the Commonwealth the cost of the person's course of study that was funded by the Commonwealth, less a pro rata proportion of the return-of-service completed.

Under the new statutory scheme, medical benefits will not be payable to an MRBS participant who becomes a participant under the new statutory scheme and does not complete their return-of-service within 18 years. Medical benefits will not be payable for six years from the day that breach occurs. Further, under the new statutory scheme a participant may be liable for an administrative penalty of $10,000 if the person fails to comply with the condition to provide the department with information or documents. This administrative penalty is considered to be a debt due to the Commonwealth and may be recovered, if needed, by the Commonwealth.

A participant will be able to withdraw from the bonded medical programs at any time by notifying the department using the web portal maintained by the department.

As I said earlier, these are necessary safeguards to protect our investment into these doctors, and they will protect the integrity of the scheme. However, the changes being made to the bonded medical programs are welcome. They will encourage young people interested in a career in medicine to work in more remote, rural and regional areas of our beautiful country. It will expose them to a different kind of medical practice and give them valuable experience for wherever their career may take them.

Doctors in rural and regional areas often become integral members of their communities, particularly in those small towns, often many kilometres from the nearest hospitals. Their families live in the community. Their children go to the school in the local area, and they go to the local church. They are members of the local sporting teams. They get involved in their community. Their days are not just nine to five working days; they work long hours and they're always on call. They can be exposed to situations where their patients are suffering serious life-threatening conditions and it may be some time before emergency service personnel can assist them. They are often the unsung heroes of their town. In the small regional and rural towns in my home state of Tasmania—Deloraine, Westbury, Bicheno, Smithton, Ross, Strahan, Wynyard; the list goes on—they understand this and they truly appreciate and value their local GPs.

Through the return-of-service obligations, this bill will provide doctors with exposure to a regional, rural and remote location. My hope—and I am sure the intent behind this bill—is that these doctors will settle into their community and find a love for their community. The ultimate outcome may well be that they will understand and enjoy the value they bring to the people within the community and will then decide to stay and put some roots down for many years to come.

I referenced Senator Brockman's contribution earlier in my contribution last night, and I note his comment:

In Western Australia alone there are just over 300 medical vacancies, 115 of them being GP positions, in regional areas.

This situation is reflected across the country, with similar statistics in most states and territories. He also acknowledged:

GPs in those country towns are of absolutely vital importance. They're such a central part of a small town's life and existence. In the city it is easy to ignore or forget or not realise what a central component to life in the bush those GPs are.

I cannot agree more with Senator Brockman's sentiments. Those of us who are fortunate enough to be able to pick up the phone and ring the doctor's surgery and get an appointment that day and feel a huge sense of disappointment if we can't get in for a couple of days should reflect on the experiences those in the rural and regional areas of this country experience.

The coalition government has clearly demonstrated its support for the rural and regional communities of this country, particularly those in drought and flood affected regions. As I mentioned yesterday, the public health system in Tasmania is struggling under the increasing demand and increasing cost of delivering medical services. The coalition government is clearly working hard to make sure that we are helping people in the rural and regional communities of this country, and the changes to the bonded medical programs reform is a great initiative. I strongly urge all senators in this chamber to support this bill.

Pauline Hanson (Queensland, Pauline Hanson's One Nation Party) Share this | Link to this | Hansard source

Australia's Bonded Medical Places Scheme is a sensible system because it benefits the Australian people in rural, regional and remote areas that often, as a result of their distances from capital cities and major services, struggle to attract doctors. It also benefits the new doctors themselves by allowing them to attract government funding support for their studies by promising to work for a period for the people in those needy communities. On the face of it, it is a really sensible arrangement that has various beneficiaries, but I do think it can be improved.

Unfortunately, the lure of the bigger cities and the services they provide—the shopping, entertainment, restaurants and convenient access to professional services, as well as being near to family and friends—often outweigh the apparent attractiveness of the smaller country towns and communities. I think graduate doctors who are supported by the Bonded Medical Places Scheme should be more open to creating a life in rural, remote and regional areas and enjoy the unique offerings of country living and the people that call these places home, who deserve just as much access to professional medical and health services as those in the cities.

However, it is also important to recognise the professional aspirations of these doctors, who have often spent many years in study and professional development to become, for example, a GP. The pathway to becoming a doctor that is able to provide GP services and more in a remote community is not an easy one. The whole doctor training pathway sphere is demanding. It is very time-consuming in terms of the years that it takes from when a first-year medical student finishes their medical training, spends time in a training hospital and then completes his or her area of speciality. It's a significant commitment of at least a decade or more to become a fresh GP who can stand alone in a small community as their local doctor.

The bonded scheme has, since 2016, applied to about 28.5 per cent of first-year medical students in Commonwealth-supported places. It's a significant proportion of all medical students in Australia, and it should, on the face of it, result in good outcomes for country areas. Currently, in exchange for the support the students receive to achieve their medical qualifications, they are required to then work in an eligible non-metropolitan location in Australia for a total of 12 months, with that time to be completed within five years of attaining that fellowship. The Commonwealth provides 850 of these bonded medical places each year. It offers a subsidy of $22,000 per year of HECS or HELP support that does not need to be repaid if the terms of the scheme under which the bonded place was offered are met. The scheme should provide a win-win for the new doctors and also for the needy communities which otherwise would struggle to receive access to health services that are taken for granted in the cities.

However, a problem with this scheme is it's been apparently unable to come to a satisfactory time period for how long the medical graduates should spend in the remote locations and over what time frame that service should be fulfilled. In the past, there has been a requirement that graduates spend a period equal to the period of the medical studies, either four or six years, in these needy communities, but that wasn't successful. It's been turned back to now require graduates to fulfil a 12-month commitment in a needy community, with that service to be completed within five years of graduation. The shortcoming of this arrangement is that it could realistically mean that the new doctor could come and go from the community or communities, spending short times here and there and subsequently fulfilling the requirements of the bonded medical scheme but proving to be of no long-term benefit to the community, the local residents and their health needs.

The value of the Commonwealth support for the medical qualifications is of some $88,000 to $132,000, depending on whether it is a four-year postgraduate medical degree or six-year undergraduate degree. It's unacceptable that, after receiving so much financial support from the Australian taxpayer for a qualification that is well regarded and will lead to significant earnings in the private sector over the length of their career, the graduate spends such a relatively short period of time in a haphazard way repaying the Commonwealth and the taxpayer for their financial support.

This bill makes a further change by initiating a compromised time period, increasing the required payback service to three years to be completed within 18 years from when the formal medical studies are completed. This change would also fail in providing continuity of support for the needy communities. It fails to encourage the development of relationships between the members of the community and their doctor. We all know how important it is to have longevity of relationship with your doctor and to develop trust over time. The doctor-patient relationship is one that is intimate, very personal and vital as the patient negotiates the many ups and downs and challenges of their health and family relationships over time. It is absolutely more desirable to have a doctor in a community who has taken time to become part of the community, to develop relationships and to build trust. In some cases, they meet a local, fall in love, buy a house, get married and maybe start a family. To require just three years of payback service completed over 18 years is rather counterproductive.

If the three years are locked in as acceptable for the payback of financial support, I would prefer to see that time completed in one three-year stint, not a broken-up mishmash of some days here and a few weeks there. I personally would like to see the graduate spend a full five years in the community once again, but that may be difficult to introduce again. The reason I suggest these stricter ideas is that these medical graduates have been given a massive opportunity courtesy of the taxpayer. It's a support mechanism that is very generous and provides valuable support towards qualifications that can reap considerable career and financial benefits into the future. It doesn't seem unreasonable that there should be a fair contribution made to the needy rural, remote and regional communities in recognition of the support given.

If police are required to be posted in remote areas for at least two years after they graduate and teachers also have a similar program, with those who spend at least four years teaching in a very remote location over a six-year period also eligible to have their Higher Education Loan Program debt remitted, these should be taken into consideration.

As I have travelled around the country, I have spoken to many councils, mayors, communities and people living in those rural and regional areas who are crying out for doctor services. A lot of these communities are dying because they don't have the services available to them and they can't have access to health care, especially having doctors in their communities, or are spending an enormous amount of money with fly-in, fly-out doctors. Yes, something needs to be done about it—drastically. As I have said here, the taxpayer is going to be paying an enormous amount of money of between $88,000 and $132,000 in HECS fees for these medical students to get their practice. Surely it is reasonable to expect them to sign this contract in return, to give something back to Australian taxpayers by giving of their services.

It is a shame that the five-year scheme didn't work and a lot of people didn't sign up to it. But it is about working together to keep these communities alive, because when the older generations who live in these rural and remote areas can't get the health services they need they move out. They move to the cities, where they can get their health services provided to them. You have got less people living there. Less services will shut down because of less people living in the areas. It is going to have a flow-on effect. I do believe that extending it to a three-year period, from one year is more favourable. One Nation will be supporting the bill.

Michaelia Cash (WA, Liberal Party, Minister for Employment, Skills, Small and Family Business) Share this | Link to this | Hansard source

I rise to sum up the debate on the Health Insurance Amendment (Bonded Medical Programs Reform) Bill 2019. This is one of the targeted strategic responses under the Stronger Rural Health Strategy, which responds to the challenge of ensuring primary health care is accessible and available to all Australians, no matter where they live. Under the strategy, a total of $20.2 million was committed to reform the bonded medical programs. The bonded medical programs are a long-term investment in the health workforce by the Australian government. These schemes are designed to address doctor shortages across regional, rural and remote Australia and in areas of workforce shortages. Participants receive a place in a medical course at an Australian university in return for a commitment to work in underserviced areas.

The bill introduces a statutory scheme, known as the Bonded Medical Program, which will come into effect from 1 January 2020. The statutory scheme consolidates the existing bonded medical places and rural bonded medical scholarship schemes under a single legislative framework to progress the government's long-term view to move towards a single bonded medical scheme. The statutory scheme is clearer about the conditions applied under the program and provides greater flexibility for participants to complete their return-of-service obligation. Participants of the statutory scheme continue to have the right of internal review and now will be able to seek review of administrative decisions by the Administrative Appeals Tribunal. From 1 January 2020, new participants will enter the program under the new statutory scheme, and existing participants will be able to opt in. The statutory arrangements will eventually replace the myriad complex contractual arrangements currently in place with individual participants. Statutory provisions will ensure that existing participants and future participants have access to the same suite of options and opportunities going forward. Legislative amendments will enable entrants to opt in to a statutory scheme without the need for individual contracts. It will make it significantly easier for bonded students and doctors to complete their return-of-service obligation by reducing and streamlining administrative requirements and giving more options as to when, where and how it can be completed. The reformed arrangements will provide earlier and stronger links with key professional support agencies for doctors.

These improvements to the program will encourage doctors to stay working in the community where they are undertaking their return-of-service obligation beyond their obligations and ensure there are more fully-qualified Australian trained doctors working in regional, rural and remote Australia and in areas of workforce shortage. More importantly, the reforms will also better target the future bonded workforce to locations of need as demographic and workforce demands change over time. The statutory scheme will enable the collection of data for reporting and effective evaluation of the programs. At this stage, it is too early to evaluate the program's success; however, it is critical that the government, the medical profession and the Australian public have access to robust evaluation of the program outcomes to inform policy decisions into the future.

Without legislative reforms, existing administrative arrangements will remain outdated and contractual provisions will continue to be required and will continue to obstruct the delivery of effective and responsive targeting of the bonded medical workforce into the future. The program will become increasingly outdated, with growing frustration experienced by participants and the key stakeholder groups which support them. It questions the benefit of retaining a program which, due to its administrative arrangements, is unable to maintain currency or prepare for the future needs of participants and workforce distribution.

It is the government's long-term view to rationalise the bonded medical programs to a single bonded medical scheme once all existing schemes have expired. It is envisaged this will occur around 2035, when all participants under the existing schemes have either completed their obligations under the program or have chosen to opt in to the new statutory scheme. The government is committed to implementing progressive and responsive administrative arrangements, which support both current and future-bonded doctors keen to make a substantial contribution to better access of medical services across Australia, and I commend the bill to the Senate.

Question agreed to.

Bill read a second time.