HEALTH INSURANCE AMENDMENT BILL (NO 2)
November 1996
© Commonwealth of Australia 1996
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MEMBERSHIP OF THE COMMITTEE
Members
Senator Sue Knowles, Chairman LP, Western Australia
Senator Meg Lees, Deputy Chair AD, South Australia
Senator Helen Coonan LP, New South Wales
Senator Kay Denman ALP, Tasmania
Senator Alan Eggleston LP, Western Australia
Senator Belinda Neal ALP, New South Wales
Participating Members
Senator Eric Abetz LP, Tasmania
Senator Lyn Allison AD, Victoria
Senator Bob Brown Greens, Tasmania
Senator the Hon Bob Collins ALP, Northern Territory
Senator Mal Colston Ind, Queensland
Senator Barney Cooney ALP, Victoria
Senator the Hon Rosemary Crowley ALP, South Australia
Senator Chris Evans ALP, Western Australia
Senator the Hon John Faulkner ALP, New South Wales
Senator Brenda Gibbs ALP, Queensland
Senator Brian Harradine Ind., Tasmania
Senator Sue Mackay ALP, Tasmania
Senator Dee Margetts GWA, Western Australia
Senator Kay Patterson LP, Victoria
Senator the Hon Margaret Reynolds ALP, Queensland
Senator Sue West ALP, New South Wales
Secretary
REPORT
1. REFERRAL OF THE BILL
The Bill was referred to the Committee upon its introduction into the
House of Representatives for report on 7 November 1996 by the Selection
of Bills Committee in Report No 12 of 17 October 1996, for consideration
of the following issues:
The impact of the provisions which limit benefits to services provided
by medical practitioners with formal postgraduate training, and the impact
of the provisions of the Bill which relate to an increase in the maximum
gap between benefits and fees.
The legislation was introduced into the House of Representatives on 17
October 1996 and was passed by the House 6 November 1996.
The Committee was to report on 29 October 1996 however the Committee
sought and obtained from the Senate an extension of time to report, to
21 November 1996. On 18 November 1996 the Committee sought and obtained
from the Senate a further extension of time to report, to 25 November
1996. The Senate agreed on 25 November 1996 to a further extension of
the reporting date to 26 November 1996.
Other developments relevant to the Bill
On 16 October 1996 the Minister for Health and Family Services, the Hon
Michael Wooldridge MP ('the Minister') announced that, as part of the
Government's commitment to improving health and medical services for people
in country areas, new doctors would be allowed to use the provider numbers
of rural GPs on a temporary basis for the purpose of providing locum relief.
[1]
On 29 October 1996 the Minister announced a ten year moratorium on granting
Medicare Provider numbers to newly arrived medical professionals, in a
move which the Minister estimated would cut the numbers of overseas trained
doctors each year from about 600 to about 100. [2]
All overseas trained doctors who have not registered to practise in a
State or Territory or who commence the Australian Medical Council (AMC)
assessment process by 1 January 1997 will not be eligible to receive a
Medicare provider number for billing under Medicare for at least 10 years.
New Zealand trained doctors and overseas students who are graduated from
an Australian medical school are included in this measure. [3]
The Minister stated that he would be asking the Australian Medical Council
to ensure that all applicants for the AMC exam, including those already
here in Australia, will only get two further attempts or two attempts
in total if they have yet to commence the exam, at a maximum of five years
to complete the process, as this is in line with the opportunity given
to Australian students. [4]
Submissions
The Committee received 96 submissions and these are listed at Appendix
1.
Meetings
The Committee considered the Bill at five private meetings; public hearings
were held on 7 and 18 November 1996. Details of these meetings and the
public hearings are at Appendix 2.
2. OBJECTIVES
Medical Practitioners recognised for Medicare purposes
The purpose of these amendments is to set minimum proficiency requirements
which new medical practitioners must meet before the services they provide
attract Medicare benefits. [5]
A number of minor amendments have also been made to improve the administrative
efficiency of the operation of the Vocational Register for general practitioners.
The date of effect is Royal Assent or 1 November 1996.
Financial impact
The financial impact of the above proposed amendments for all medical
practitioners, including overseas trained doctors, will result in savings
estimated at $23.6m in 1996/97; $100.12m in 1997/98; $171.4m in 1998/99
and $241.67m in 1999/2000.
Level of Medicare Benefit
These amendments introduce a number of separate changes dealing with
multiple services rules, the greatest permissible gap and payments for
services of unusual length or complexity. [6]
The multiple services rules allow for fees to be reduced for later services
when multiple services are provided to a patient. The measures are part
of a package to strengthen the incentives in Medicare benefit arrangements
to promote appropriate, quality and cost effective diagnostic imaging
practice. The same multiple services rules concept already applies to
pathology services and its introduction for general medical services aims
to ensure uniformity across all services.
The maximum gap between the Medicare Benefits Schedule fee listed for
any out of hospital service and the Medicare benefit payable for that
service is to increase to $50.
The ability to seek an increase in fees for services claimed to be of
unusual length or complexity is to be removed.
The Date of Effect is Royal Assent or 1 November 1996 for the multiple
services rules and increase in the greatest permissible gap and on proclamation
(or 6 months after the date of Royal Assent) for the removal of increased
benefits for services of unusual length or complexity.
Financial impact
The implementation of the proposed regulations relating to multiple services
rules for diagnostic imaging services would result in Budget savings estimated
at $69.7 m over the period from 1 November 1996 to 30 June 2000 ($9.7
m in 1996/97).
Development costs and on-going administrative costs are estimated by
the Health Insurance Commission (HIC) at $0.8 m.
The increase in the greatest permissible gap is expected to result in
savings of $8.6 m in 1996/97, $15.7 m in 1997/98, $16.5 m in 1998/99 and
$17.1 m in 1999/2000.
The savings to be achieved through the removal of increased benefits
for services of unusual length or complexity are expected to be $2.4 m
in 1996/97, $4.4 m in 1997/98, $4.7 m in 1998/99 and $5.1 m in 1999/2000.
Temporary Resident Doctors (TRDs)
These changes require that Temporary Resident Doctors meet proficiency
requirements equivalent to those for Australian trained doctors before
the services they provide attract Medicare benefits. [7]
The date of effect is 1 November 1996.
Financial impact
Savings for measures in Schedules 1 and 3 together accrue from a reduction
in the overall number of doctors providing services under Medicare - $23.86m
in 1996/97, $100.12m in 1997/98; $171.4m in 1998/99 and $241.67m in 1999/2000.
3. ISSUES
The Committee examined the following issues:
The impact of the provisions which limit benefits to services provided
by medical practitioners with formal postgraduate training; and
The impact of the provisions of the bill which relate to an increase
in the maximum gap between benefits and fees.
The majority of persons providing submissions to the Committee addressed
the first of the two issues. Of the 96 submissions received by the Committee,
only four addressed the 'Gap' issue in any detail those of the Royal Australian
College of Radiologists (RACR), the Australian and New Zealand Association
of Physicians in Nuclear Medicine (ANZAPNM), the Australian Medical Association
(AMA) and the Department of Health and Family Services (DHFS).
The 'Doctor Providers' Issue Benefits related to doctors with post-graduate
training'
The purpose of the legislation as set out in the Department's submission
is to:
- complete the process of recognising General Practice as a medical
discipline in its own right, requiring appropriate post-graduate qualifications;
and
- to deal with structural problems [particularly in relation to the
long-term viability of Medicare] caused by an oversupply and maldistribution.
[8]
The Committee appreciates that these issues have been of concern to successive
Commonwealth governments for a considerable number of years, and certainly
since the 1980s.
The 1988 Committee of Inquiry into Medical Education and Medical Workforce
chaired by Dr Ralph Doherty identified seven main areas in which medical
graduates needed to have more training before they were qualified for
general practice.
In 1992 the general Practice Consultative Committee document launching
the General Practice strategy said '[the] AMA, RACGP and the Government
support the principle that general practitioners should complete appropriate
post-graduate training as signified by the FRACGP or equivalent'.
In 1992, Ms Jenny Macklin, now Shadow Minister for Health and then Director
National Health Strategy, confirmed in the National Health Strategy Paper
on the Future of General Practice that '[t]here is widespread agreement
on the need for vocational training to produce doctors with general practice
skills' (p73).
More recently Professor John Young speaking for the Committee of Deans
of Australian Medical Schools said 'Medicare numbers should only be given
to those who have completed post-graduate courses'. He went on to say
that 'nobody could really argue that it is appropriate for people who
have only done one year's internship to go out and be GPs'. [9]
The Department's submission provides a resume of the post-graduate training
issue and Vocational Registration (VR), introduced by the previous government
in 1989, and notes that 'while VR dealt with the question of appropriate
training it did not deal with other key structural issues facing General
Practice':
- throughout the 1980s there was growing recognition that there was
an oversupply of non- specialists but difficulties in getting non-specialists
into rural areas;
- there was also growing concern about the increasing isolation of GPs
brought about by the increasing specialisation of medicine and GPs being
squeezed out of traditional roles such as hospital work; and
- there were also concerns about the financial impact of a growing number
of non-specialists given the clear relationship between doctor numbers
and Medicare services'. [10]
A joint AMA/RACGP/Departmental strategy document issued for discussion
in 1992 'became the basis for the GP strategy which has been pursued by
the Government since that time' and has been 'progressively refined and
complimented with other measures'. [11]
With reference to the particular issues being examined by the Committee
this strategy implementation includes:
- placing a quota of 400 places on the GP Training Program agreed between
the Commonwealth Government and the RACGP in 1994 and implemented in
1995; and
- commissioning the Australian Medical Workforce Advisory Committee
(AMWAC) to estimate the extent of oversupply and maldistribution (of
doctors).
AMWAC concluded in 1996 that the GP workforce is in considerable oversupply
in the capital cities and major urban areas of Australia and significant
undersupply in rural and remote areas. The urban oversupply is estimated
at 4400 and the rural undersupply at around 500.
- the setting a quota [since discontinued] [12]on
the Australian Medical Council process for new overseas trained doctors;
- efforts being made to reduce medical school intakes; and
- efforts being made via the States to reduce the number of temporary
doctors coming to Australia. [13]
The Committee noted that the success of the previous measures to restrict
the growth in doctor numbers generally, and GP numbers in particular,
has been limited.
Related to the Committee's consideration of the Doctor Providers issue
are the underlying associated issues of the implementation of Vocational
Registration, the role and recognition of post-graduate training providers
and the quality of training provided. These broader issues are not addressed
in detail in this report.
The majority of submissions received by the Committee were from individuals,
particularly current medical students and their families, who are opposed
to the proposed changes to the legislation.
The Committee identified a range of common sub-issues arising out of
the restriction of provider numbers addressed in the submissions placed
before it. These include:
- Policy goals underpinning the government's changes;
- Access to employment of choice after graduation by current medical
students, new graduates and Junior Doctors; including considerations
of the effect of the changes on the public hospital system;
- Effect of the changes on the maldistribution of doctors between
urban and rural areas, in particular locum arrangements and deputising
services;
- Effect of the changes on female graduates;
- Roles of Temporary Resident Doctors and/or Overseas Trained Doctors
(OTDs);
- Cost issues, in particular whether all aspects of the measures
implemented have been taken into account in savings estimates; and
- Quality of the workforce data upon which the decisions associated
with provider numbers have been made.
Policy goals underpinning the Government's changes
The Government reiterated the vital importance of the changes to the
Committee, supported by the following reasons:
First, they will increase the quality of health care available to the
Australian Community by making sure that, in future, all general practitioners
have been properly trained. It recognises the current reality that a
basic medical degree is no longer adequate for a doctor to practise
unsupervised in the community;
Secondly, they will help correct some of the distribution problems
with the medical workforce, where we have the absurd situation of having
to import more than 500 overseas trained doctors on temporary visas
each year to work in our public hospital system, even though we have
something like 4000 more doctors than our population would require;
and
Finally, they will reduce one of the major growth pressures on Medicare,
making it more sustainable in the longer term. There is widespread agreement
that the increasing number of medical practitioners is one of the main
growth pressures on the health costs in Australia. [14]
The majority of submissions and evidence received by the Committee supported
the concept of post-graduate training for general practice.
The Royal Australian College of General Practitioners (RACGP) applauded
the initiatives in the Budget which aim to correct the maldistribution
of GPs between rural and urban areas and to increase the availability
of locums to rural General Practice, however cautioned that it would be
a retrograde step if the effects of the current government initiative
(restrictions on provider numbers) in fact worsened the scarcity of permanent
and locum GPs in rural and remote areas. The College proposed a wider
range of incentives for both rural and urban practices to encourage a
more rational distribution as well as a more viable basis which must involve
more than monetary incentives and be relevant to families. The RACGP indicated
its willingness to be involved with government in setting up the structure
of these packages. [15]
The Australian Medical Students Association (AMSA) also pointed to the
positive initiatives of the Government - the John Flynn Scholarships and
initiatives to increase the medical profession's reliance on Temporary
Resident Doctors (TRDs) and to initiatives of its own. [16]
Access to employment of choice by current medical students, new
graduates and Junior Doctors
The majority of individual submissions from current medical students
and practitioners, recent graduates, parents and friends of medical professionals
were critical of what was perceived as the potential immediate loss of
some of the best trained young Australian professionals who would not
be able to access the employment of their choice.
The RACGP in its submission supported the restriction of access to provider
numbers under Medicare to those doctors who have been trained or are training
for a particular medical discipline 'because it is consistent with RACGP
policy and community expectations'. [17] In
doing so the RACGP recognised that the initiative will 'have consequences
for Australian Junior Doctors who are currently in hospital training and
for overseas trained doctors wishing to immigrate to Australia and to
practise medicine'. [18]
The RACGP did, however, refer to the' changing of the rules' by government
and stated that it is crucial that the career options open to Junior Doctors
be quickly clarified. The College noted the information provided by the
Minister on such career options, however 'it is essential that much clearer
information is available concerning the numbers of approved training posts
and hospital positions'. [19]
AMSA claimed that the effects on public hospitals of a possible influx
of 400 graduates per year to the proposed new positions of Hospital Medical
Officer (HMO) or Career Medical Officer (CMO) would lead to oversupply
and unemployment. The Committee explored this claim in evidence with AMSA,
raising the issues of the current undersupply of doctors in hospitals,
for example that there are 365 unfilled positions in New South Wales and
Queensland; and the effects of bringing doctors back to reasonable working
hours.
AMSA also claimed that graduating medical students are not in the same
situation as other university graduates not assured of employment, in
that they are required to undertake further postgraduate study.
Doctors in Training did not dispute that post-graduate training should
be encouraged to ensure the highest quality care is available to the community
and stated that this remains a policy of the AMA and the DIT group. DIT
however if we are to consider legislation which makes post-graduate training
compulsory prior to medical practice then we have an obligation to ensure
this training is available to every Australian Graduate. [20]
DHFS stated that it considers that the suggestion that there should be
an increase in the number of training places is an incorrect focus. Not
only is there overwhelming evidence of an oversupply of general practitioners,
there is equally strong evidence of a substantial undersupply of specialists.
The current limit of 400 places is supported by the RACGP. [21]
AMWAC has concluded that there is a shortage of specialists in no less
than 18 specialities. DHFS stated on the basis of this shortage that if
it was to be proposed to increase the number of training places, the area
to make such an increase would be in those areas of specialist undersupply.
AMWAC is systematically undertaking analysis for each speciality and then
negotiating an increase in the number of training places with the relevant
college. To date AMWAC has completed this exercise in respect of four
specialist colleges with the result that more than 50 additional training
places have been negotiated. Negotiations with the remaining colleges
are continuing. [22] Details of the training
places now available are reproduced as Appendix 3 to the Committee's report.
On consideration of the evidence, the Committee concluded that, while
application of the measures will have some effect on the career choices
available to junior doctors and medical graduates, the choices of a career
will not be cut off for others. The Committee noted that there would the
prospect of additional specialist training positions as well as opportunities
in rural/locum areas, salaried medical officer positions, government,
the private sector and research. The evidence available to the Committee
indicated there should be, in the future, sufficient such vacancies to
provide opportunities to Australian medical graduates.
Effect of the changes on the maldistribution of doctors between
urban and rural areas, in particular on locum arrangements and deputising
services
While generally supporting the changes, the RACGP pointed out that it
is aware that there may be a decreased availability of locums to rural
General Practice. The RACGP regarded this consequence as serious as access
to locums is 'essential for rural GPs to be able to take leave and to
undertake continuing medical education'. [23]
AMSA applauded the government's initiative with projects such as the
John Flynn Scholarships and the funding of rural Medical Faculties. The
Association viewed the lack of locum relief, 24 hr service workers, other
relief work filled by a majority of younger doctors and non VR GPs (OMPs)
as factors most likely to have an effect on those areas of Medicare service
provision in a fashion contrary to Government predictions. [24]
The National Association of Medical Deputising Services (NAMADS) claimed
that there were possible adverse effects of the legislation, in particular
'the crucial locum and deputising sectors of general practice' and presented
a package of alternative proposals for government to consider. [25]
The Department's evidence to the Committee indicated that the Government
would discuss these proposals with the Association.
In its Supplementary Submission DHFS provided a detailed statement pointing
out that the Bill was never intended to be the Government's sole response
to these (the rural mal-distribution) problems. The government has adopted
a multiple strategies approach, consisting of the General Practice Rural
Incentives Program and a range of other measures, including:
$20,000 one-off grants to doctors relocating to more remote locations
where there is an undersupply of GPs. (236 approved since the Rural
Incentives Program began, 99 in 1995-96);
up to $78,000 for training to assist in improved skills levels of rural
GPs (138 training grants approved since the start of the Program, 75
in 1995-96);
up to $50,000 annual income supplement for GPs in the 59 identified
very remote practices where practice viability is limited;
infrastructure support to coordinate rural recruitment and retention
through State/NT panels (includes family support);
$5m per annum for continuing medical education and locum support initiatives;
and
initiatives at the undergraduate level to encourage students to take
up rural practice and to improve the focus in medical schools on rural
practice teaching ($2.5m per annum).
Other measures:
John Flynn Scholarships for medical students rural vacation scholarship;
tax relief for communities supporting students to undertake rural
practice;
rural locum support for specialists;
Departments of Rural Health - six;
rural loadings through the Better Practice program, with around $15,000
per full-time equivalent GP, which is $3500 higher than in metropolitan
areas; and
support for rural practitioners through rural divisions and the rural
division coordinating units ($25m in 1995-96). [26]
The Government believes that the Budget measures will improve the position
for rural Australia by allowing the essential structural change to complement
the extensive range of incentive programs. Despite claims to the contrary,
the number of new doctors going into rural areas without undertaking further
training (ie the group affected by the proposed measure) has traditionally
been very low.
The Department also outlined the arrangements approved by the Minister
whereby new doctors will be allowed to practise in a rural or remote area,
by issuing them with temporary provider numbers (under the approved placement
arrangements on S 3GA of the Bill) on condition that they are working
in appropriately supervised arrangements such as an approved rural locum
service or an Aboriginal Medical Service. As these doctors will not have
undertaken post-graduate training appropriate supervision arrangements
are essential.
The Minister has also announced that doctors completing approved assistantships
in rural hospitals will have privileged entry into the General Practice
Training Program. This means that provided they can meet the minimum standards
required by the RACGP they will be guaranteed a place in the College Training
Program. This is seen as a significant incentive for young doctors to
work in rural Australia. [27]
The Committee believes that, on balance, the Rural Incentives components
of the changes will improve the prospects of doctors working in country
areas either in locum services or in full time practice.
Impact of the changes on female graduates
A majority of submissions from peak bodies including AMSA, the AMA and
Doctors In Training and individuals, drew attention to the adverse effects
on female graduates of restrictions on provider numbers.
The Committee notes however that the Bill does not have any specific
provisions within it which change the way in which women doctors in training
are treated. AMWAC is reviewing the issue of increased flexibility and
part-time work in relation to hospital career positions. Issues around
fairness and gender equity in post-graduate training have always been
of concern but are not directly related to this measure. The Minister
has indicated that he will vigorously pursue these issues with the medical
colleges should it be demonstrated that a problem really does exist. [28]
The Committee welcomed this initiative.
DHFS addressed the implications for female doctors in its Supplementary
Submission, stating that it 'does not have any evidence to suggest that
women will be disadvantaged by the measure'. If it were true that women
were disadvantaged by the requirement to undertake training before entering
general practice then [the Department] would expect to see female non-specialists
over-represented in other medical practitioners (OMPs). The figures produced
by the Department indicate that there is a similar spread of females between
the non-specialist categories, at about 30% in each. The Department also
points out that the proportion of women entering medical schools has increased
dramatically in recent years and the representation of women in the workforce
is improving. For women doctors who choose not to become GPs there will
be as wide a range of alternative options, as there is now.
The roles of Temporary Resident Doctors (TRDs) and/or Overseas
Trained Doctors (OTDs)
As outlined in the introduction to this report the Minister has made
a decision in relation to new Temporary Resident and/or Overseas Trained
Doctors, which, in the Committee's view is widely supported in the submissions
and evidence. The number of OTDs coming into Australia in a year is the
equivalent of three medical schools' student bodies combined. To allow
this situation to continue will have a deleterious effect on Australian
medical graduates.
The Australian Doctors Trained Overseas Association stated that it recognised
the problems associated with Medicare and the Health system, understood
that the continued migration of overseas trained doctors contributes to
a more complex problem and recognised the Government's need to take measures
to cap the flow of overseas trained doctors into private practice. The
Association generally supports the measures proposed. [29]
The Association however highlighted three issues it felt consideration
could be given to:
the proposed changes to the examination structure for OTDs to further
restrict the number of attempts at the Australian Medical Council examination,
which, in the Association's view, will make an already restrictive system
even more difficult;
hostility directed at OTDs which it is claimed is 'being whipped up
by vested interest groups, including the AMA'; and
a need for confirmation that Australian Doctors Trained Overseas will
be given priority for use in areas of need positions over TRDs on visa
422 who, like ADTOs, are not eligible to be registered in Australia.
The RACGP, in noting the distinction made by the Minister between those
OTDs already in Australia and those arriving after 1 January 1997, drew
attention to the need to be aware of 'exceptions', such as the recognised
equivalence of the vocational training for general practice of the Royal
New Zealand College of General Practitioners, which it saw as being exempt
from the changes for OTDs.
The Committee has considered the submissions and evidence placed before
it relating to OTDs and on balance does not intend to recommend any further
amendments in this area.
Cost issues
DHFS states that an underlying premise in the changes proposed is that
there is a relationship between doctor numbers and Medicare services.
In the Department's view the relationship is clear, illustrated by the
growth in Medicare attendances relative to population and doctor numbers
for the period 1984 - 1995 and stated that a similar relationship can
be demonstrated at State and local levels. [30]
The Department quoted examples of patient visits to doctors in Forbes
in rural NSW, compared with Ryde in urban Sydney where the average number
of visits per year are respectively four times and 7.3 times. The only
factor this can be correlated to is doctor numbers. [31]
DHFS in its supplementary submission noted that various witnesses had
challenged the Government's estimates of the savings likely to be achieved
from the proposed Budget measure and pointed out that the estimates have
been agreed by the Department of Finance and the Department.
A number of groups including, for example, the Australian Medical Association
(AMA), questioned the costings prepared by DHFS and the Department of
Finance.
The AMA stated that the estimated Budget savings are 'implausibly high'
for the following reasons:
the estimates incorrectly assume that, in the absence of the
restrictions, the newly registered doctors would immediately be in a
position to earn income as a result of Medicare rebates paid to patients.
The AMA described this assumption as 'patently wrong' as many doctors
completing their intern year would work as a junior Resident Medical Officer
(RMO) for a further year upon registration and many would continue on
as a senior RMO for a second year before either obtaining a training position
(as a hospital registrar or GP in training), taking a general RMO position
or entering private practice as an OMP. The AMA claimed the effect is
to bring forward the savings by a year or two.
The implied annual benefit earnings is well above the average Medicare
benefit earnings of a full-time GP within three years of registration.
The Association claimed that the estimation is based upon an assumption
which holds that the only determinant of doctors' Medicare benefit incomes
is the number of doctors.
DHFS described the AMA's independent costings as 'deficient in a number
of areas', in that:
flow-on costs are ignored;
the effects on TRDs are ignored; and
the effects of prohibiting trainees moonlighting are ignored.
These effects, after being discounted, add almost $150m to the savings.
[32]
The Government has used the figure of $176,000 per annum as a combined
total of Medicare earnings, pharmaceutical and other flow on costs for
a full time equivalent doctor, as evidence available suggest that the
true figure for existing full time doctors in terms of Medicare income
and other costs is well over $300,000. [33]
The Government acknowledged that not all of a new doctor's patients would
be the result of supplier induced demand by that practitioner, or others.
The OECD suggests that between 40% and 75% of increased demand is due
to supply factors.
The calculations made by the Department also assume that each new doctor
prevented from accessing Medicare would have been 0.8 of a full-time equivalent.
The Department stated that 28-30 year old doctors work well in excess
of an average full-time load; on average 36% higher - again reinforcing
the conservative nature of the savings.
GP trainees work an average of 0.16 of a full-time equivalent outside
of their training program, working predominantly in bulk-billing super-clinics.
This measure will not allow this, so that trainees can concentrate on
their studies. Likewise specialist trainees undertake this work at an
average FTE of 0.17. Half of the savings for these effects on trainees
and TRDs have been discounted, reflecting the conservative bias of the
estimates.
Quality of workforce data
A number of groups and organisations raised issue concerning the quality
of the workforce data used to support the changes.
The Department of Health and Family Services provided detailed statistical
workforce information from 1996/97 projected through to 1999/2000 in its
main submission, and, attached to its supplementary submission provided
available estimates of specialist training place numbers, based on advice
to date from specialist colleges. [34]
The Committee noted from the Department's main submission that the GP
Training Program has a quota of 400 places, covered by specific Commonwealth
Government funding and that the specialist (training) places, estimated
at 800, are determined by specialist Colleges and State hospital funding.
DHFS indicated further that it had commissioned the Australian Medical
Workforce Advisory Committee (AMWAC) to quantify the oversupply and provided
the Committee with a copy of the AMWAC report. In addition the Committee
obtained further statistical information from DHFS in answer to queries
from the Deputy Chair, Senator Lees. The Committee had earlier (7 November)
heard evidence which cast some doubts on the validity of some of the AMWAC
data and followed up these and other matters at its public hearing on
18 November with the Department. [35]
Notwithstanding the claims, the Committee noted that the estimation of
training place numbers provided by the government was not rejected by
any of the witnesses. Similarly it was noted that the general assumption
of the government's measures, that there is an over-supply, was not challenged
by nearly all of the submissions, although there are some differences
of opinion about the validity of data in general.
The 'Gap' Issue
The purpose of the legislation is to reduce government outlays by adjusting
the amount above the Medicare rebate (but less than the Schedule fee)
that is payable by patients. [36]
Medicare rebates for out-of-hospital services are currently payable at
85% of the Schedule fee, with a maximum payment of $30.20 (indexed annually)
where the Schedule fee is charged. Under the indexation arrangements the
maximum patient gap increased to $30.20 on 1 November 1996. The measure
will increase the maximum gap between the Schedule fee and the Medicare
rebate for any out-of-hospital services to $50.00 (indexed annually).
[37]
The Committee in evidence explored with the College and the Association
the safety net provisions which apply and noted that the maximum additional
amount any patient would pay, irrespective of the number of services they
received, over a twelve month period was $270.00. [38]
The Committee also notes that the measure affects only 0.5% of Medicare
services and those who are most vulnerable will be bulk-billed. The Committee
is mindful also of the ethics and time-honoured practices generously followed
by the vast majority of members of the medical profession whereby patients
with a demonstrated incapacity to pay will invariably be bulk-billed.
In its submission the Department stated that ' a significant proportion
of the items affected by this measure related to diagnostic imaging services.
Services affected are mostly computerised tomography scans, nuclear medicine
imaging services and to a lesser extent, certain ultrasound and angiography
services.' [39]
The Department points out that budget savings were developed in cooperation
with the RACR and ANZAPNM and states:
To avoid a double impact on diagnostic imaging services, the
savings target for diagnostic imaging was reduced by an amount equal
to the component of savings from the increase in the maximum gap attributable
to diagnostic imaging services bulk-billed services. This was estimated
at $29.4 m over four years.
If the measure is passed this amount will be made available for use within
the diagnostic imaging parts of the MBS. The precise way in which the
funds will be used will be determined in consultation with the RACR and
the ANZAPNM. [40]
RACR stated in its submission that since early 1996 the College of Radiology
and ANZAPNM have worked in close consultation with DHFS to restructure
the Diagnostic Imaging Services Table ('the Table') through a specially
convened Diagnostic Imaging Task Force. [41]
The purpose in setting up the Task Force was to reduce Medicare outlays
in those sections of the Table which were growing faster than the other
areas of expenditure in the Medical Benefits Schedule (MBS). The restructure
was also targeted to remove incentives for inappropriate itemisation and
to allow description of item numbers in the MBS to reflect current practice.
The range of proposals produced by the Task Force were designed to deliver
the government's required savings of $254.7 m over a four year period
and restructured the Table. As part of the cooperative arrangements, the
RACR and ANZAPNM are committed to an on-going monitoring role.
RACR and ANZAPNM held the belief that diagnostic imaging was to be quarantined
from the effects of any other measures introduced in MBS during the period
of the agreement. In a letter dated 3 October 1996 the Minister's Chief
of Staff had confirmed the government's agreement to quarantine diagnostic
imaging from other budget measures. [42]
One measure which was not included in the agreed package and which would
have an impact on diagnostic imaging, the RACR had been assured, it would
be fully compensated for. [43] This inclusion
was the proposed increase in the maximum gap between Medicare rebates
and MBS fees for Medicare patients for non in-patients from $30.20 to
$50.00.
The College expressed reservations at the manner in which this proposal
was introduced and the significant consequences for the patients of medical
imaging practices. In its view the major effect of the change will fall
on the Diagnostic Imaging section of the Schedule.
ANZAPNM supported the College's views pointing out in its submission
that:
The increase in the maximum gap payment was presented as a "general
measure", affecting all relevant items in the Medicare Benefits
Schedule. However the Department has subsequently indicated to the Task
Force that approximately 70% of the items affected by this measure are
in the diagnostic imaging services section of the Medicare Benefits
Schedule. Ninety percent of Medicare benefits for nuclear medicine services
are affected. [44]
In answer to queries from the Chairman as to why these patients (for
example the elderly or seriously ill) would not be bulk-billed the College
stated:
[We] do not believe that that is necessarily the way it works outside.
The bulk patients who are on benefits are all bulk-billed but different
practices have different ways of practising. I guess many of them charge
the schedule fee. If they charge the schedule fee the patient will still
be up for the $50.00 gap. [45]
The College acknowledged that 'in an ideal world they would all be bulk-billed,
but the economics of the situation are that it is the schedule fee which
is the viable amountI do not think it would be viable to bulk-bill everyone
in a radiology practice at the moment.' [46]
It was pointed out, however, that not everyone who utilises the facilities
on a fee-for-service basis is either elderly or seriously ill. There are
a lot of people who have one or two tests in three or four years. In acknowledging
this the College stated:
I think we are saying with the Task Force we have already made
$250m of concessions in terms of reduction in income to the radiology
and nuclear medicine practitioners in this country. This is an extra
measure which adds strain on income levels. [47]
In its Supplementary Submission, DHFS stated that there has been no breach
of faith with the RACR and/or the ANZANMP. There has been some disagreement
about the Department's calculations and about the patient billed component.
The Government has made it clear that it will provide an amount equal
to the effect of the $50.00 measure on the bulk-billed component of diagnostic
imaging and that the calculations will be verified with the RACR and the
ANZANMP. However it is not appropriate to compensate radiologists for
increased costs borne by patients. [48]
The Committee is of the opinion that the Government has taken steps to
ensure, as part of its Budget measures, that radiologists and diagnostic
imagists, are not disadvantaged. The Committee noted that discussions
between the government and the profession, about implementing these measures,
is ongoing.
4. ISSUES FOR ON-GOING MONITORING
The Committee has identified a number of areas that require further clarification
and ongoing monitoring to assess the impact of the changes.
In evidence to the Committee, a number of witnesses expressed concern
that there may be a decrease in the availability of locums to rural, metropolitan
and deputising services. The Committee believes that there needs to be
a system established by the Government to monitor the effects of the legislation
on availability of such services so as to ensure that there is no diminution
of services to patients.
The Committee considers this is a matter for legitimate concern. Although
the Department has stated that there is an excess of some 4,500 General
Practitioners in Australia at the present time, the Committee notes that
the National Association of Deputising Services submission referred
to the difficulty in filling locum positions at present. [49]
The Committee does not consider it to be in the interests of the community
were the situation to be exacerbated.
The Committee received no cogent evidence as to the optimal number of
medical practitioners per head of population, nor whether increasing the
numbers of trained medical practitioners alone would ameliorate the shortage
of locum placements. Obviously, other initiatives, beyond the scope of
this Report, including perhaps collaborative night care arrangements with
General Practices, in association with local public hospitals, need to
be further investigated.
Graduates taking up rural placements with approved supervision will be
guaranteed a place in the General Practice Training Program ('GPTP').
The Minister has referred to the time frame for this option to be available
as being 'after a period of time'. [50] The
principle of offering medical graduates guaranteed access to the GPTP
by means of a credit for prior learning, lends itself to consideration
of the possibility of an accreditation system which could be worked out
on a sliding scale and available to ALL medical graduates.
If this is a viable option, all graduates who are unable to access a
training program would go onto a waiting list and be offered credit points
towards the GPTP for relevant work experience. There would possibly need
to be an appropriate caveat as to suitability of applicants to meet RACGP
standards, such as observance of guidelines on relevant work experience
in accordance with the sliding scale. While the incentives for rural placements
would need to be highlighted, a sliding scale would enable all graduates
to progress towards registration in the event of training places being
available.
The Committee is anxious to ensure that new graduates who go to country
hospitals be assured of proper supervision, and that the hospital must
meet adequate training standards. To do otherwise is to provide patients
with inferior treatment by untrained doctors and for there to be adverse
long term consequences for medical practitioners thrust into difficult
areas of practice without having been effectively supervised or trained.
Rural training incentives and schemes in some States to encourage and
assist rural doctors in a variety of ways are welcome, but the Committee
believes that the effectiveness of the multiple strategies approach in
the Government's General Practice Rural Incentives Program, and
the range of other methods identified in the Report, [51]
will need to be critically evaluated as measures to improve the prospects
of doctors working in country areas, either in locum services or in full
time practice.
The question of the number of actual training places available, and in
what specialties and in what geographical distribution, remains unconfirmed
as at the time of the tabling of this Report. [52]
This exacerbates the concern about what happens to training place availability
when, for example, doctors who have accepted placements in country hospitals
(thereby guaranteeing them entry into the GPTP) actually enter the program.
Do they then take positions of new graduates who would otherwise have
filled those vacancies?
The Committee considers that it would be desirable for there to be a
National body responsible for supervising and setting strategies and policies
for medical training at all levels in Australia, including
monitoring the number of available training places, assessing barriers
to entry and issues of maldistribution of medical practitioners throughout
Australia; and whether there is an oversupply of medical practitioners,
and if so, in what areas of practice.
A survey carried out by the Australian National University, National
Centre for Epidemiology and Population Health, entitled 'The Future Role
of Operation of Australian General Practice, General Practitioner Survey',
conducted in August 1995, concluded that since the introduction of the
Vocational Register, the number of years of hospital training of medical
graduates prior to entry into general practice, currently stands at a
mean average of 3.6 years. [53] Evidence before
the Committee failed to establish the number of medical graduates who
would wish to enter general practice before undertaking graduate training
in any event.
It is therefore difficult to accept that in effect, placing a cap on
availability of General Practice Provider Numbers to new graduates, materially
differs from the position which has obtained since introduction of the
Vocational Register by the former Government in 1992. In effect this proposal
formalises the present position with respect to training time spent before
entering general practice.
Given that there is universal acceptance by witnesses appearing before
the Committee that undifferentiated medical graduates require post-graduate
training in the public interest, and that the practical effect of the
requirements for the Vocational Register imposes the need for further
training, in any event; the Committee considers that concerns expressed
by various witnesses will be addressed by ensuring the availability of
adequate training places on a national basis, and that the other areas
of concern identified herein be properly monitored on an ongoing basis.
Recommendation
| The Committee reports to the Senate that it has considered
the Health Insurance Amendment Bill (No 2) 1996 and RECOMMENDS that
the Bill proceed. |
Senator Sue Knowles
Chairman
November 1996
DISSENTING REPORT BY THE LABOR OPPOSITION
Introduction
The Labor Opposition dissents from the majority report on the Health
Insurance Amendment Bill (No 2) 1996.
The Opposition believes that this Bill will have an unfair and retrospective
effect on current medical students and interns. We are concerned that
it may aggravate the shortage of doctors in rural areas and severely restrict
the options of medical students and interns who are seeking to postpone
their postgraduate training or undertake that training part-time.
The Opposition also does not support the increase in the maximum permissible
gap for an out-of-hospital Medicare services from $30.20 to $50.
The Committee examined the issue of removing the Medicare Benefits Advisory
Commission's power to award higher fees for services of unusual length
or complexity. The Opposition does not support this change because patients
who receive services of unusual length or complexity will face very high
out-of-pocket costs.
Workforce Issues: Provider Numbers and Post Graduate Training
The Opposition understands the necessity of managing the medical workforce
and in particular of managing access to Medicare to ensure the best possible
value for the money for the Australian people.
The Opposition also understands the need to ensure that those practising
medicine in Australia are of the highest possible standard and are appropriately
trained.
In recent years it was the Labor Government which took a number of decisions
aimed at limiting the number of overseas trained doctors coming to Australia
and who worked with the medical profession to improve the standing of
General Practice and to develop a system of postgraduate training for
general practitioners.
The Opposition cannot support this legislation however because of its
unfair and retrospective nature in adversely affecting the careers of
medical students and interns who are already in the system.
Parents and Friends Supporting Medical Students said in its submission
that:
'Current medical students and interns will be denied their rightful
expectation, under training requirements existing at the commencement
of their training, of eligibility for a medicare provider number at
the end of their internship year.' [54]
The Opposition believes the Government should have paid greater attention
to lowering medical school intakes and restricting access for overseas
trained doctors rather than reducing medical students' options half way
through their degrees. This is a view supported by the Australian Medical
Students' Association. [55]
Though the Opposition welcomes Dr Wooldridge's belated announcement of
a 10 year moratorium on overseas trained doctors, the Opposition remains
concerned that this measure has not gone far enough to ensure that current
Australian medical students and interns are given priority in relation
to the provision of provider numbers.
The Opposition is also deeply concerned that this Bill was not introduced
to the Parliament until four sitting days before its date of effect (1
November 1996). Indeed the consideration of this committee is taking place
after the date of effect of the Bill. Moreover, the Government has indicated
that if it is unable to secure passage of the Bill during this session
of the Parliament it will take back provider numbers from doctors who
receive them from January next year. The Opposition does not support this
retrospectivity.
The Opposition is also concerned about the apparent contradiction in
the Minister's recent statements on this Bill. He has given public assurances
that no Australian graduate will miss out on a training place - though
he has failed to offer a guarantee of a training place to existing students
and interns. However, he has also asserted that the effect of the Bill
will be to force graduates into rural training positions and rural hospitals.
These statements do not appear to be consistent.
A major problem of the provision of medical services is still the maldistribution
of doctors and the shortage in rural areas in both hospitals and in general
practice. This legislation provides no solution to this problem.
The Opposition remain concerned that Dr Wooldridge's proposal may also
have an adverse effect on the provision of medical services in rural areas
and on the options available to young doctors, particularly women, who
do not wish to proceed immediately after registration to full-time training.
The National Rural Health Network said in its submission that the 'the
proposed restrictions on provider numbers will discourage junior doctors
and medical students who are considering practicing in a rural area'.
[56]
Several of the submissions and a number of the witnesses, particularly
women, have expressed their concern about the practical difficulties in
getting a deferred or part-time training place.
Ms Janine Manwaring, an intern at the Bairnsdale Regional Health Service
Hospital, said, 'It will no longer be possible for women to combine their
child-rearing responsibilities with part-time employment. The inflexibility
of many training programs will mean that many women will have to make
a choice between family and career. This is occurring at a time when Medical
Schools have over 50% female intake.' [57]
Other submissions have expressed concern about the effect of this measure
on the provision of medical services in rural areas, particularly locum
services.
The National Rural health Network pointed out that the decision will
reduce the pool of locums, preventing rural doctors from getting locum
relief. [58]
The Opposition is also concerned that a proposal of such far reaching
consequences was not given adequate and extensive enquiry and that some
key stake holders were not heard by the Committee. The Committee received
96 submissions and only five organisations, including the Department of
Health and Family Services, were given an opportunity to address the public
hearing.
Increase In The Maximum Permissible Gap from $30.20 to $50.00
The Opposition does not support the intention of this Bill to increase
Medicare's maximum permissible gap payment from $30.20 to $50.00. This
measure effectively reduces the Medicare rebate for out-of-hospital services
with a value in excess of $202.
This measure represents a fundamental breach of the Coalition's election
promise to "maintain Medicare in its entirety" and is a regressive
measure through which the Government intends to raise $60m from a group
of people whose only distinguishing characteristic is that they require
high-cost medical treatment.
The Royal Australasian College of Radiologists has described the calculations
of savings as 'grossly flawed' and that the non-bulk billing patient,
many of whom are elderly and seriously ill, will bear the brunt of these
savings. [59]
The Opposition is also concerned that the Government appears to have
originally breached its commitments to the Royal Australasian College
of Radiologists in relation to this measure and in trying to undo the
damage caused by its mishandling of this issue may introduce undue complexity
into the fee structure for the affected items.
Limitations of the Powers of the Medical Benefits Advisory Committee
The Opposition is concerned that this measure is typical of a number
of the Government's arbitrary Medicare cuts.
The Government's figures indicate that this measure will save around
$5 million in a full year by removing doctors' rights to claim higher
benefits for services of unusual length or complexity.
The Opposition opposes this measure as being unfair and highly likely
to lead to significantly higher out-of-pocket costs for patients who are
unfortunate enough to require these services.
Recommendation
The Opposition recommend that
- Schedule 1;
- those parts of the Bill which give effect to the increase in
the maximum permissible gap payment; and
- those parts of the Bill which remove the MBAC's power to award
higher fees for unusually long or complex services;
be opposed.
|
Senator Belinda Neal (ALP, New South Wales)
Senator Kay Denman (ALP, Tasmania)
Senator Sue West (ALP, New South Wales)
DISSENTING REPORT BY THE AUSTRALIAN DEMOCRATS
The Health Insurance Amendment Bill (No. 2) 1996 seeks to
require medical graduates to undertake additional post-graduate training
before the services provided by them attract Medicare benefits. It seeks
to achieve that aim by restricting access to Medicare provider numbers
to those medical graduates in recognised formal training positions. This
move has now been fully explored before the Senate Community Affairs Committee
and in Estimates hearings.
The Australian Democrats' position
The Australian Democrats support the premise that medical graduates wishing
to enter general practice should undertake additional training.. We accept
the evidence that undergraduate medical education does not prepare graduates
for unsupervised general practice (although we note that such evidence
raises questions about the content and structure of undergraduate medical
courses). We also note this is not a requirement exclusive to medical
graduates - law graduates, for example, are required to undertake additional
training before being allowed to practice as solicitors or barristers
We do not believe that access to a Medicare provider number is a 'right'.
It is a privilege bestowed by the Australian taxpayers. It is a privilege
which attracts a significant amount of taxpayers' funds and, as such,
the taxpayers (through the government) are entitled to place conditions
upon the receipt of those funds.
The Democrats also accept the benefits to the overall health system in
having medical graduates fill vacant work and training places in less
popular disciplines and places, rather than using their Medicare provider
numbers to practice medicine as under-trained and unsupervised doctors
in areas of oversupply. We also support the Government's stated desire
of addressing the maldistribution of general practitioners.
Accordingly, we support the intention behind the Government's move to
restrict access to Medicare provider numbers to graduates in recognised
formal training positions. However, we are concerned about the impact
of this proposal on medical graduates - especially over the next three
years.
The Democrats have the following concerns about the Government's proposal.
1. Inadequate medical workforce data
Australia does not have accurate and comprehensive data about its medical
workforce. The shortage and unreliability of the available data in this
area is alarming. The absence of reliable data makes it difficult to verify
the Minister's assertion that no medical graduate will miss out on a training
place. It also makes it difficult to verify the claim - made by those
opposed to the legislation - that 300 to 400 graduates will miss out on
training places.
It should be noted that neither the Minister nor the Department have
been able to precisely state the current number of training positions
which are available or which are likely to be available in the future.
The Department could provide accurate figures only for the RACGP Training
Program: 400 places per year.
In its evidence to the Committee, the Department provided a list of the
number of first year places available through the specialist medical colleges
(based upon verbal advice from the colleges): 722 places in 1997. Information
on the number of places available in previous years and in 1998 is not
available, making it difficult to accurately determine any trends in training
places or in particular specialities.
However, the Committee was also told of many training positions in 'unpopular'
disciplines which are simply not being taken up. These areas include accident
and emergency medicine, rehabilitation and psychiatry. Once again, inadequate
data makes it difficult to ascertain the number of places which are not
being taken up.
In addition, there are medical specialities which are facing shortages
and which could make more training places available.
The difficulty in accurately assessing the appropriate number of future
specialist training positions is compounded by the fact that the Australian
Medical Workforce Advisory Council's investigation into the supply and
requirements of particular specialities remains incomplete. AMWAC's
work to date has covered four specialities - the orthopaedic, anaesthetic,
urology and opthamology workforces - and in each of those areas AMWAC
has found there will be significant shortages unless graduate output in
increased.
While acceptance of AMWAC's finding by the Australian Health Ministers
Advisory Council has resulted in 50 additional training places being negotiated,
it remains unclear where those places will be located and how other areas
of shortage will be addressed as the AMWAC review progresses.
We also note that there is dispute about the precise number of GPs
currently practising in Australia and about the extent of the 'oversupply'
of GPs. While the Minister and the Department continue to maintain
there is an oversupply of GPs, the data upon which this assertion is based
is far from convincing. For example, simple per capita calculations do
not take into account the number of GPs practising part-time or the ratio
of 'core' GP work to special interest work (such as sports medicine or
women's health). Nor do they consider the specific or 'special' health
needs of particular communities.
To overcome this problem, the Rural Doctors Association of Australia
(RDAA), the Australian Medical Association (AMA) and the Royal Australian
College of General Practitioners (RACGP) have proposed a mapping exercise
to establish how many GPs and GP practices really exist and the hours
those GPs are actually working. The Democrats share the RDAA's view that
such an exercise is essential for the future planning of both the rural
medical workforce and the wider GP workforce.
2. Crucial medical workforce reviews are yet to be completed
Two reviews are currently underway which should provide the Government
and the Department with much firmer data and material upon which to base
future medical workforce planning. These are a review of the General Practice
Strategy (recently initiated by the Minister) which includes a review
of the Rural Incentives Program and the AMWAC investigation into specialty
areas (see above). The Democrats believe the Government should be prepared
to be much more flexible in its approach to provider number restriction
until the results of these reviews (and the mapping exercise proposed
by the RDAA, the AMA and the RACGP) are known.
3. While the proposal could be a further important step in addressing
the shortage of qualified doctors in rural and 'difficult to staff' salaried
positions, it does not go far enough
The Department believes that salaried positions in rural and 'difficult
to staff' areas will be easier to fill as a result of this measure (as
untrained graduates will no longer be able to ignore or reject these positions
in favour of working in cities in medical clinics and "billing Medicare
in already oversupplied markets"). While there is an element of truth
in this assumption, it raises questions as to why these areas and these
services should have to rely upon 'untrained' doctors (most of whom are
simply marking time waiting for a training place to come up) to fill their
vacant positions. A better approach may be to increase the availability
of formal training places in these services and areas and improve the
conditions and career structures associated with these positions.
We acknowledge the initiatives currently underway through the Rural Incentives
Program and we welcome the Government's decision to allocate an additional
$20 million per year into rural areas and hospitals to address medical
workforce issues.
We also support the Minister's announcement that doctors completing approved
assistantships in rural hospitals will have privileged entry into the
General Practice Training Program. However, at this early stage, it is
difficult to ascertain the impact of these initiatives upon GP shortages
in rural areas. It may be equally effective to ensure all RACGP trainees
are required to undertake work in a rural area. The Democrats believe
the Government should also explore the possibility of establishing additional
GP training places in rural areas, possibly under the auspices of the
recently established Australian College of Rural and Remote Medicine .
The Minister's decision to provide new doctors prepared to practice in
a rural or remote area with a temporary provider number - provided they
are working in appropriately supervised arrangements - is an unsatisfactory
response. It clearly implies that doctor shortages are an acceptable reason
for allowing an untrained doctor to practice in a rural area, while training
will be required in an urban area. Again, a better solution may be to
provide more rurally based training places and to take up the suggestions
of the National Association of Medical Deputising Services Australia (NAMDS)
to improve locum services. These suggestions include: recognising deputising
practice and locum work as an Area of Medical Service Disadvantage within
the RACGP Training Program and the establishment of a postgraduate diploma
course in Emergency Primary Care Medicine (which can also be accredited
as part of GP training).
4. The impact of the proposal on the public hospital system is unclear
and it fails to resolve the current problems with the structure and career
paths of hospital or resident medical officer positions
The Democrats believe problems in this area must be urgently addressed.
There is clearly a problem in meeting the demand for RMOs in Australian
hospitals. The Department advised the Committee that around 400 medical
positions in public hospitals are currently vacant throughout Australia,
confirming evidence given to the Committee that these positions are unattractive
to many graduates. RMOs tend to stay only a short time in a hospital situation,
with many feeling they are little more than 'hospital fodder', working
long hours with often inadequate supervision or support and a lack of
any defined career structure.
The restriction on access to provider numbers does nothing to improve
this situation. It may, in fact, exacerbate the situation by turning hospitals
into a 'dumping ground' for those graduates who are unable to get into
a training position and who would previously have gone into GP practice.
However, it could be argued that it is preferable to have disgruntled
graduates working in hospitals where there is at least some level of supervision
than having them practising as untrained and unsupervised GPs.
AMWAC has reported that in 1994 male hospital non-specialists worked
on average 56.2 hours per week and females 53.2 hours per week, while
male specialists worked on average 61.8 hours per week and females 55.8
hours per week. AMWAC indicated that a reduction in hours to around 4o
per week would require an increase in the workforce in the order of 15%
or 1,160 persons.
Those figures suggest there is considerable room for additional specialist
and non-specialist positions to be created in public hospitals - provided
an attractive and appropriate career structure is in place.
The Democrats also note the pressure on graduates to 'stream' into specialities
as early as possible. Those graduates who don't 'stream' early (or those
who drop-out of specialist training) often find themselves with little
option but to practice as GPs. A much better outcome - for both the individual
doctors concerned and for the overall health system - would be to offer
those doctors improved post-graduate training opportunities through the
public hospital system (perhaps along the lines of the General Medicine
Training Program currently being developed at Toowoomba Hospital). Such
opportunities would encourage RMOs to remain working in a hospital environment.
They would also provide a unique and valuable training experience while
still enabling RMOs to take up specialist training at a later point in
their careers.
The Democrats believe very strongly that instead of increasing the pressure
of competition for training places among RMOs, the Government needs to
give priority to ensuring RMOs and career medical officers in general
are given strong incentives to remain working in hospitals and the public
health system.
The RACGP - in a letter to all Senators - suggested that adequate work
and training places are available for junior doctors, but "in disciplines
and places which are unpopular. These posts are either unoccupied or filled
by doctors on temporary visas doing work our own graduates will not do,
as long as they have access to a provider number and can make a living
practising 'triage and referral' medicine without further training in
major cities". While this assertion sounds reasonable (and is supported
by anecdotal material), it is - once again - difficult to verify in the
absence of accurate data about the availability of work and training places.
It also suggests that, unless these 'unpopular' places are made more 'popular',
restricting access to provider numbers will not change the situation and
these places will continue to be 'holding stations' for disgruntled graduates
waiting to get into a more 'popular' course or position.
While the Democrats acknowledge the work being done by the Department
in this regard, there is a considerable way to go before this problem
is resolved.
5. The effect upon graduates
As previously stated, it is difficult to determine with any certainty
the impact on medical graduate over the next five years. While the Minister
believes there are sufficient training places for all graduates who want
them, opponents of the proposal argue around 300 to 400 graduates may
miss out on places. On the basis of the evidence provided to the Committee,
this appears to be an exaggerated claim.
What appears more likely is that, after an initial round of take-up of
training places, there will be a number of graduates who will miss out
on their 'first choice' of place. Those graduates - who in the past may
have opted for general practice - will now have to look at taking up training
places in undersubscribed areas. Graduates who still don't have a training
place after those positions are taken up will have the option of working
in a hospital or some other salaried position.
The Democrats do not see anything wrong with some medical graduates having
to take up 'second option' places. Many graduates from other disciplines
have to opt for post graduate training or employment in areas which are
not their first preference. Still other graduates are considerably less
fortunate.
However, because of the gaps in the available data, the Democrats believe
the Government must put a 'safety net' under its proposal for at least
the next three years to ensure graduates do not miss out on either a training
place or a salaried position which does not limit their future training
options.
Several submissions to the Committee also referred to the adverse effects
upon female graduates of this measure. The Committee received very little
in the way of concrete evidence in support of these claims. However, there
is evidence that female graduates are already disadvantaged by current
selection practices and training requirements in both GP and specialist
training. The Democrats believe this disadvantage must be addressed and
we note the Minister's statements that he intends to vigorously pursue
this issue with the colleges.
Recommendations
In light of these shortcomings with the current proposal, the Democrats
make the following recommendations.
The aim of the Democrats' proposals is to establish a 'safety net'
under the legislation for the first three years of its operation to ensure
graduates are not disadvantaged should the Government's figures and predictions
prove wrong. We believe it is fair for the cost of being wrong to be borne
by the Government. On the other hand, if the Government's figures are
accurate, the costs of these proposals will be minimal.. By the end of
1999, the Government should be in a position to accurately demonstrate
the impact of the legislation and to make any necessary adjustments.
In the interim, these proposals should ensure no medical graduate
is disadvantaged.
1. The Government should postpone the start-up date of the legislation
until 1 November 1997.
Given the widespread concern about these proposals, it would be
preferable for the Government to defer the start-up date to enable
further discussions to take place with those most affected by these
changes, to commence negotiations with the States on their role
in medical training opportunities, to gain a clearer picture of
the numbers of training places and hospital positions, and to ensure
the measures suggested below are initiated.
|
2. The Government should set up a 'safety net' for medical graduates
for the first three years of the operation of the legislation. This
'safety net' should consist of:-
(i) the establishment of a Medical Training Review Panel to oversee
the take-up of training places
The Panel's task would be to monitor the progress of graduates
in finding training places, advise graduates of where vacant places
are available and report to the Minister for Health and Family
Services on the numbers (if any) of training vacancies still current
and the numbers of graduates genuinely unable to find places.
The Panel would not set policy. Nor would it have any powers
to compel graduates to take up positions. The Panel's brief would
be to provide the Minister with an accurate picture of where graduates
are taking up training places or employment, how many graduates
are without training places or employment and the reasons why
those graduates have not found a training place or employment.
The Panel should consist of no more than 5 members nominated
by the Minister after consultation with the major organisations
involved in post-graduate medical training.
(ii) an agreement to make available up to 200 additional training
places per year for those graduates who are unable to find places
These places should be made available in rural, remote or 'difficult
to staff' areas, through either the RACGP, the Australian College
of Rural and Remote Medicine or the specialist colleges.
The Government should agree that if the Panel reports there are
more graduates than available places, the Minister for Health
and Family Services will immediately make available the additional
places.
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3. A sunset clause should be inserted into the legislation causing
it to cease to operate on 31 December 2001 unless its operation
is formally extended by the parliament. The Minister should also
be required by the legislation to report to the parliament by 30
June 1999 on the impact of the provider number restriction, the
take-up of the additional training places and the current state
of post-graduate medical training.
This gives the parliament two opportunities to evaluate the impact
of the legislation - in June 1999 and at the end of 2001.
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4. Additional requirements should be placed on RACGP trainees.
All 500 RACGP trainees should be required to undertake a period
of at least 6 months' work in a rural or remote area (either in
a hospital or a GP practice) and a subsequent mandatory period in
a `difficult to staff' area (such as drug and alcohol rehabilitation
services, community health centres, locum services and Aboriginal
medical services).
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5. The time in which GP training can be completed should be extended
from 4 years to 6 years and provision should be made for more part-time
training opportunities in GP and specialist training.
The Democrats believe this is a necessary step in achieving approved
access to GP training for women.
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6. As AMWAC's investigation into the speciality areas proceeds,
the Government should make available at least another 100 specialist
training positions in areas of specialist shortages. At least 30
per cent of these positions should be available part-time.
The Democrats understand the difficulties in negotiating funded
specialist training positions with the States and the specialist
colleges, but believe the Commonwealth must show leadership in this
critical area. In order to ensure additional training opportunities
are made available, it may be necessary for the Commonwealth to
enter into negotiations with the States and to explore specialist
training options beyond the control of the colleges. In any event,
the Democrats believe additional specialist training positions can
- and should - be made available over the next three years as AMWAC
works its way through the various specialities.
The Minister should also undertake to begin further discussions
with the specialist colleges on opening up the specialist selection
and training processes, with a view to developing a package of reforms
in surgical and specialist training by 1 January 1998.
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7. Additional requirements should be placed on medical undergraduates
The Minister should undertake to discuss with the Deans of Australia's
medical schools a requirement for the undergraduate curriculum to
include a placement of 4 weeks a year in a rural area.
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8. The Minister should undertake to develop in conjunction with
the States by 1 January 1998 a package of reforms for RMO and other
salaried medical positions.
These reforms should include: agreed national standards on expected
hours of work and spread of shifts; improved access to post-graduate
training; and a clearly defined hospital career structure (with
facilitated access into specialist training).
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9. The Commonwealth should establish a medical 'Training Pathways'
program.
The program should include: the establishment of an independent
central body to whom complaints about training positions can be
directed and which can advise the Minister on GP and specialist
training issues; and the setting up of post-graduate diplomas for
medical graduates in specific areas such as Emergency Primary Care
Medicine (as suggested by NAMDS), drug and alcohol treatment and
rehabilitation, and environmental medicine. Completion of these
diplomas should go towards accreditation as part of GP training.
The Democrats suggest the Medical Training Review Panel (see Recommendation
1 above) could form the basis of the Training Pathways program.
For example, it would be possible to add to the Panel and extend
its functions to include a complaints and advisory role.
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Senator Meg Lees
Deputy Chair
(AD, South Australia)
FOOTNOTES
[1] Ministerial Press Release MW 81/96.
[2] Hon M Wooldridge, MP, Minister for Health
and Family Services, Press Conference 1545 (Media Monitors) 29 October
1996.
[3] Hon M Wooldridge MP, Minister for Health
and Family Services, Second Reading Speech, House of Representatives Hansard
4 November 1996.
[4] ibid.
[5] Explanatory Memorandum p.1.
[6] Explanatory Memorandum p.1.
[7] Explanatory Memorandum p.2.
[8] Submission No. 89 p.1.
[9] Supplementary Submission No. 89 p.1.
[10] Submission No. 89 p.2.
[11] ibid.
[12] Hon M Wooldridge, MP, Minister for Health
and Family Services, Press Conference 1545 (Media Monitors) 29 October
1996 p.19.
[13] Submission No. 89 pp.2-3.
[14] House of Representatives Second Reading
Speech.
[15] Submission No. 66 pp.5-6.
[16] Submission No. 6 p.5.
[17] Submission No. 66 p.2.
[18] Ibid.
[19] Submission No. 66 p.4.
[20] Submission No. 90 p.1.
[21] Supplementary Submission No. 89 p.5.
[22] ibid.
[23] Submission No. 66 p.5.
[24] Submission No. 6 p.1.
[25] Submission No. 21 pp.9-12 and Appendix
3.
[26] DHFS Supplementary Submission No. 89 pp.5-6.
[27] DHFS Supplementary Submission No. 89 p.6.
[28] DHFS Supplementary Submission No. 89 p.9.
[29] Submission No. 94 p.1.
[30] Submission No. 89 p.3.
[31] ibid.
[32] DHFS Supplementary Submission No. 89 p.8.
[33] DHFS Supplementary Submission No. 89 p.8.
[34] See DHFS Supplementary Submission and
Appendix 3.
[35] Submission No.44 p.5 and Transcript
of Evidence, 18 November 1996
[36] Submission No.89 Part B p.1.
[37] Explanatory Memorandum, p.1.
[38] Transcript of Evidence p.43.
[39] Submission No. 89 Part B p.2.
[40] Submission No. 89 Part B p.2
[41] Submission No. 29 p.1.
[42] Submission No. 29 Appendix B
[43] Submission No. 29 p.1.
[44] Submission No. 43 p.4.
[45] Transcript of Evidence p.45.
[46] ibid.
[47] ibid.
[48] DHFS Supplementary Submission No. 89 p.9.
[49] Submission No. 21 p.4 and pp.6-7.
[50] House of Representatives Hansard 15 October
1996 p.5252.
[51] See pp.9-10 above & DHFS Supplementary
Submission No. 89 pp.5-6.
[52] See Appendix 3.
[53] See Senate Hansard 5 November 1996, p.4939
(Document tabled by Senator Alan Eggleston).
[54] Parents and Friends Supporting Medical
Students, submission 68, p. 2.
[55] Australian Medical Students' Association,
submission 6, p. 7.
[56] The National Rural Health Network, submission
72, p. 1.
[57] Ms Janine Manwaring, submission 31, p.
1.
[58] The National Rural Health Network, submission
72, p. 1.
[59] The Royal Australasian College of Radiologists,
submission 29, p. 2.