Chapter 4Social infrastructure
4.1After housing, social infrastructure was raised in many submissions as the next most common challenge impeding workforce development in Northern Australia. Social infrastructure, in the context of this inquiry, includes:
Health services;
Childcare;
Aged care;
Disability services;
Education (including primary, high-school and tertiary);
Social housing; and
Justice and emergency services.
4.2Health care and childcare were the two issues most listed under social infrastructure or liveability issues affecting workforce development, followed by education and training.
4.3As noted in Chapter 1, the Australian public is anticipated to demand better quality, accessibility and variety of social infrastructure over the coming decades to a greater extent than in the past. In particular, younger people and families may choose not to live in Northern Australia because of a perceived or actual lack of social infrastructure, leading to an ageing population with limited social services such as aged care and health care because of a lack of staff.
Health care
4.4Funding for Australia's public health system is split between the federal and state and territory governments. Public health services are delivered by the federal, state, territory, and local governments:
The federal government sets national health policies, funds Medicare and the Pharmaceutical Benefits Scheme, co-funds public hospitals, funds primary health networks (which include GPs), and delivers some community health and Aboriginal and Torres Strait Islander health services;
State and territory governments co-fund and manage public hospitals, manage public community-based health services, and deliver some community health and Aboriginal and Torres Strait Islander services;
Local governments provide community-based health and home care services.
The impact of national health workforce shortages on Northern Australia
4.5Australia is experiencing a national health workforce shortage, with increased demand from an ageing population and greater incidence of comorbidities, along with sustained pressure and workforce burnout arising because of the COVID-19 pandemic.
4.6This is not just an issue for Australia: the World Health Organisation has projected a global shortfall of 10 million health workers by 2030 and noted global challenges with deploying health workers to rural and remote areas. Given this global shortage, the World Health Organisation has a voluntary code in place to help address the issue of wealthier countries recruiting health workers from poorer nations to address their domestic health workforce shortages.
4.7A key issue with access to health care in rural and remote parts of Australia, including Northern Australia, is the limited number of some health practitioners working outside major cities. Figures from 2018 suggest that while there may be a higher proportion of general practitioners, nurses and midwives working in remote and very remote parts of Australia per 100,000 population compared with cities:
People living outside major cities have higher rates of mortality, chronic disease and increased health risk factors, which in turn require a higher proportion of health practitioners; and
There is a severe lack of other types of medical and allied health practitioners in these parts of Australia.
4.8Mrs Anne Stunzner, Chief Executive Officer of the Cooperative Research Centre for Developing Northern Australia, highlighted that health 'problems in Northern Australia are not the same as those in the south-east'. Mrs Stunzner argued that Medicare levies in Northern Australia do not reflect rates of rheumatic heart disease, syphilis and other health issues. She also noted that ten years ago, the Northern Territory had more than 500 allied health workers. In 2023, that number is less than 50 to deliver allied health services in Aboriginal communities.
4.9Further, despite higher rates of general practitioners, nurses and midwives in rural and remote Australia per capita, population dispersal still means that people living in very remote communities may have to travel many hours to access health care or may only have access to fly-in health care workers once a month. To put this another way, health practitioners may be working across an area the size of Victoria, which then impacts service delivery and their ability to see a large number of patients compared with their counterparts in cities.
4.10Across parts of Northern Australia, there are significant shortages for psychologists, GPs, nurses and midwives, occupational therapists, dentists and speech pathologists. Workforce shortages of allied health practitioners in rural and remote Australia overall are around twice as severe as for medical practitioners.
4.11The Queensland Nurses and Midwives Union pointed to a survey of its members about their experiences living in rural and remote areas, which found:
68 per cent of respondents said that accommodation options played a significant role in their decision-making around their employment in rural and remote areas;
43 per cent of respondents rated transport options as either substandard or poor, with comments from respondents stating that travelling out of town required considerable effort and planning, and transport such as flights or buses are limited and expensive;
Almost half (47 per cent) of respondents reported that internet and Wi-Fi connection was substandard or poor;
Although 76 per cent of respondents lived in employer-provided accommodation, few respondents overall rated the condition of housing facilities as excellent, including maintenance, cleanliness, pest control and working equipment; and
A third of respondents indicated that their requests to accommodate for their personal circumstances were not addressed, with several comments saying it was difficult or impossible to obtain housing for families or couples.
4.12In addition to the above, high turnover of health and allied health staff in Northern Australia may result from fatigue, financial strain, isolation (with limited support from few or non-existent colleagues or mentors), few career options for spouses, resource shortages and limited career development opportunities.
4.13There are also issues with, for example, storing vaccines and essential medicines like insulin, with unreliable power in parts of Northern Australia. Further, adverse weather events may lead to delays in distributing medicines and impede patient travel to medical care or practitioner travel to communities.
4.14Health capacity issues and workforce shortages in other parts of Australia significantly impede the ability of local health services and local governments to recruit and retain the health workforce in Northern Australia. These challenges have led to local communities in Northern Australia offering attractive employment packages to attract health workers. For example, the remote community of Julia Creek in north-west Queensland offered a rent-free house and an annual salary package of more than $500000 to attract a GP. Typically, a full-time GP would earn between $200000 and $350000 a year.
4.15However, the flow-on effect of local community efforts to recruit health workers is that they may end up competing with other communities in Northern Australia for the same staff, given limited interest among medical and allied health graduates in pursuing careers in rural health.
4.16The Queensland Government informed the committee that it has introduced a workforce attraction incentive scheme, commencing 1 July 2023, to attract the health workforce to rural and remote Queensland in particular, including:
Payments of up to $20000 for health workers from interstate or overseas who move to Queensland; and
Additional incentives of up to $50000 for medical practitioners who take a job in regional or remote Queensland.
Aboriginal and Torres Strait Islander health and access to healthcare
4.17The burden of disease for Aboriginal and Torres Strait Islander people is 2.3 times that of non-Aboriginal and Torres Strait Islander people, with Aboriginal and Torres Strait Islanders experiencing disparities across the social determinants of health, such as education, housing, employment and income. Further, rates of disability among Aboriginal and Torres Strait Islander peoples are much higher than the general population—around one in four, compared with around one in six for the Australian population.
4.18Reduced access to health care for Aboriginal and Torres Strait Islanders in Northern Australia arise because of its cost, a lack of accessible or culturally appropriate health services and the remoteness of some communities.
4.19Health care workers, along with social care and education workers, form the core labour force for Aboriginal and Torres Strait Islanders in remote parts of Australia. As with Northern Australia in general, there are issues with attracting skilled workers to remote Aboriginal and Torres Strait Islander communities to provide health services.
4.20Aboriginal Medical Services Alliance Northern Territory flagged that health workforce turnover is significant in the Northern Territory. According to one study, only half of nurses and allied health providers were still working at the same remote clinic 12 months after commencement, with half having left at four months. The Alliance argued that the total number of workforce vacancies in health care in the Northern Territory is much higher than in larger states, such as Queensland. It stated that 'the workforce crisis is already starting to affect clinical performance across the Aboriginal primary health care sector'.
Solutions
4.21Past federal government incentives to encourage more health practitioners to practise in rural and remote areas include:
Location restrictions on overseas-trained doctors and medical graduates which limit where they may practise to be able to access Medicare benefits;
Programs to offer students clinical placements in rural and remote locations;
Financial incentives for health professionals to work in rural and regional areas; and
Training pathways for rural generalists.
4.22The Rural Doctors Association suggested that in areas with wide population dispersal, 'there is a critical need for Rural Generalists and generalist consultant specialists (such as general surgeons and general physicians) and for a broader generalist health workforce' which includes nurses and allied health professionals.
4.23However, the Rural Doctors Association did note the importance of ensuring that any workforce development planning for the health workforce in Northern Australia 'is realistic about the tenure of doctors in rural areas and manages community expectations accordingly'. That is, although people may expect their doctor to practise in their community for a long time, if not their entire career, 'this is not a realistic expectation for many Northern Australian communities' given 'the significant physical and mental toll on doctors working in isolated places'.
4.24The committee received many proposals to address health workforce issues in Northern Australia. This extensive list included:
Sufficient funding for the full implementation of the National Rural Generalist Pathway;
Advanced skills training in areas of medicine needed in Northern Australia, including:
- Aboriginal and Torres Strait Islander health;
- Internal medicine;
- Public health/tropical health; and
- Mental health;
Multi-disciplinary team models of care, allowing all members of a team to work at the top of their scope of practice;
Increased funding for medical training and supervision, health infrastructure, professional networks and community liveability, including for education and employment of the families of health care workers;
Increased number of medical student rotations and pre-vocational junior doctor positions in rural areas;
Funding for rural medical practices to train local Aboriginal and Torres Strait Islander people as Aboriginal Health Workers;
Financial and non-financial incentives that increase with degree of remoteness;
Initiatives aimed at ensuring the protection and safety of health workers, including providing safe housing and security for facilities perceived to have drugs;
Providing social infrastructure to support doctors' families, including childcare and quality schooling;
Long-term rather than short-term funding commitments in areas where future demand and supply needs are a given, such as in health workforce and service capacity;
Expansion of:
- The Allied Health Rural Generalist Pathway, into private and community settings; and
- The Building the Rural and Remote Allied Health Assistant Workforce program;
Joint state/territory government approaches to health workforce issues, given current state/territory-based approaches encourage competition;
Other incentives and subsidies for health care workers, including:
- One-off payments;
- Subsidies for housing (for both renters and home ownership);
- Subsidies for professional development, including transportation costs;
- Free training in healthcare for high-school students, such as cadetships; and
- An urgent review of current fringe benefit tax (FBT) arrangements to ensure these do not exacerbate recruitment difficulties in rural and remote areas;
Incentives to retain the existing local workforce already living in Northern Australia, given high accommodation costs;
Better data on graduate placements, including how many graduate contracts are transitioned into permanent contracts;
Grants to employers in Northern Australia to support upskilling of health staff, as well as scholarships for nurses and midwives;
Support for students to commence vocational training in health-related studies close to home;
Initiatives to address significant differences in remuneration for rural GPs and GP registrars versus state-employed, hospital-based rural doctors, which is also an issue for allied health and nursing;
Applying models of health care that have not traditionally been used in the Australian context, such as health care teams and 'hub and spoke' models of care delivery;
Blended funding models across health, disability and aged care;
Increased holistic approaches to retain GPs, with non-monetary incentives including:
- Supports for GPs' families;
- Orientation and integration; and
- Other mechanisms to increase connectedness to rural communities;
Local planning for health services to include Local Hospital Networks, Primary Health Networks, Rural Workforce Agencies and community representatives, particularly Aboriginal and Torres Strait Islander people, with funds pooled and distributed accordingly; and
Working with universities to identify and prioritise students interested in long-term placements and to expand support for remote and rural student placements in Northern Australia.
4.25Proposals to address challenges with the provision of health care in Aboriginal and Torres Strait Islander communities included:
Expansion of the National Aboriginal and Torres Strait Islander Health Academy, a community-led model intended to increase Aboriginal and Torres Strait Islander high school student engagement, retention and successful completion of Year 12 with a Certificate III in Allied Health Assistance;
Funding for Rural Workforce Agencies to develop international recruitment campaigns and to recruit from developed nations (Europe, the United Kingdom, New Zealand, Canada and the United States), to avoid the ethical challenges of recruiting from developing countries with their own healthcare needs;
A national campaign aimed at encouraging Australian health professionals to commit long-term to working in remote Aboriginal primary care;
Funding for a retention system for nurses in very remote areas, similar to incentives for doctors, including a sliding scale of bonuses for remote area nurses who work in the same community for at least 12 months;
Financial incentives to attract GP registrars to the Northern Territory;
Funding for an additional 40 medical school placements in the Northern Territory;
Expansion of a two-year graduate nurse program at the Central Australian Aboriginal Congress to other, large, Aboriginal Community Controlled Health Services, given the popularity of the program and demand from applicants who had to be turned away;
Additional support for on-country education, training and mentoring to increase Aboriginal employment within the Aboriginal community-controlled health care sector;
Commonwealth funding for housing for local Aboriginal health staff, given staff from outside communities are provided with quality housing at little or no rent, while local staff may be living in overcrowded houses and may be approached ahead of external, non-Aboriginal staff;
Further investment to support empowering and upskilling local Aboriginal and Torres Strait Islander people and organisations, and training pathways for Aboriginal and Torres Strait Islander doctors, allied health professionals and allied health assistants; and
Better utilisation of the Aboriginal and Torres Strait Islander Health Practitioner role.
Questions – health
(a)Given the global and national shortfall of health workers, how could Australia ethically introduce targeted migration to help reduce severe health workforce shortages in Northern Australia?
(b)Despite decades of government initiatives, health workforce shortages remain in Northern Australia. What government policies have been most effective and what have not been effective?
(c)What reforms are needed to ensure there is a greater number of health graduates willing to work in Northern Australia?
(i)Have financial incentives at the tertiary level and clinical placements had a positive impact?
(ii)What reforms are needed at the College level to recognise qualifications or increase the number of health practitioners?
(d)What does evidence suggest most incentivises medical and health professionals to work in Northern Australia? For example, training pathways, accommodation subsidies, guaranteed employment for spouses, large salary packages.
(e)Which models of health care are working best in parts of remote Northern Australia, particularly in remote Aboriginal and Torres Strait Islander communities?
(f)What needs changing in the delivery of primary health care in Northern Australia as a matter of urgency?
(g)Of the solutions proposed above, which do you consider have merit and should be adopted immediately?
Childcare
4.26While too extensive to list in detail here, evidence from many submitters indicated that access to early childhood education and care services is impacting workforce development in Northern Australia. Access issues are largely a result of staff shortages in childcare.
4.27Workforce shortages in the childcare sector are a nation-wide issue. It was estimated in October 2022 that Australia will need 16000 new educators to fill workforce shortages in the sector. Staff shortages are leading to centres capping enrolment numbers, with staff in the regions in particular deciding to leave the sector because of low pay, burnout and lack of professional recognition.
4.28The primary source of overall funding for childcare services, largely through partial fee subsidies, is the Australian Government. State and territory governments regulate childcare providers and set quality standards. Childcare services for pre-school aged children include centre-based childcare and family day care. Childcare is also provided for school-aged children through outside-school hours care in childcare centres and schools, before and after school finishes. This section focuses largely on childcare for pre-school aged children.
4.29Childcare staff working in centres must hold or be actively working towards a Certificate III in education and care. At least 50 per cent of educators must be diploma-level qualified or higher in centre-based services with children pre-school age or under, and services must engage or have access to an early childhood teacher at least part of the time, with this proportion determined by the number of children attending the centre.
4.30The Fair Work Ombudsman sets award rates for childcare workers. While rates differ according to the level at which staff are employed, on average, childcare workers are paid between $55,000 and $65,000 per year.
4.31Two federal inquiries are currently underway into the provision and cost of childcare in Australia:
An Australian Competition & Consumer Commission inquiry into the market for the supply of childcare services, including the cost and availability of labour, which is due to provide an interim report by 30 June 2023 and a final report by 31 December 2023; and
A Productivity Commission inquiry into early childhood education and care, including cost and availability barriers that affect access to childcare (along with preschools and outside school hours care), which is due to hand a final report to the Australian Government by 30 June 2024.
4.32Workforce shortages in childcare are impacted in Northern Australia by housing availability and affordability, as well as the high cost of living. To put this another way, the pay offered to childcare workers may not be attractive to those living in metropolitan or regional areas with lower living costs, let alone in parts of Northern Australia with higher living costs and limited housing availability and affordability.
4.33Hours offered by childcare centres and family day care centres may also not take into account the shift work required of, for example, workers employed in the healthcare, mining and agricultural sectors, which are key employers in Northern Australia, and the remoteness of parts of Northern Australia mean leaving young children with family is impossible for those migrating from other areas.
4.34A lack of affordable or culturally appropriate childcare also impacts the workforce participation of Aboriginal and Torres Strait Islander people in Northern Australia.
4.35The flow-on effect of workforce shortages in childcare is that essential workers may be unable to return to work after having children, or only be able to return at reduced hours—and, as a result, choose to leave Northern Australia.
4.36In one example, the Chief Executive Officer of the Cooperative Research Centre for Developing Northern Australia told the committee the town of Kununurra in Western Australia had been unable to fill nursing shortages because of several compounding factors, including a lack of childcare:
The township of Kununurra just advertised and filled two positions for nurses in the town, but they have nowhere to live because there's no housing. They can't build any more housing in Kununurra because the state government hasn't approved their main sewerage plan in terms of their town development. Those two nurses have kids, and they've got no childcare for their children to attend in the same space.
Solutions
4.37Proposals presented to the committee to address workforce shortages in the childcare sector in Northern Australia included:
Additional funding for early childhood education and care centres to help them attract, retain and upskill staff;
Tax benefits for people working in key occupations in the care sector in Northern Australia, including childcare;
Government investment in more jobs and skills training for Aboriginal and Torres Strait Islander childcare workers, with governments to develop guidelines mandating the level of cultural training required by non-Aboriginal and Torres Strait Islander staff working to provide culturally appropriate childcare;
Requirements for the Certificate III minimum be amended in certain regions to instead recognise local training initiatives;
Incentives for new family day care providers;
Reconsideration of current regulation of family day care providers;
Funding for placements and face-to-face learning to upskill people from local communities; and
Changes to fringe benefit tax (FBT) benefits, given the inclusion of childcare services in salary sacrificed employment packages currently attracts the highest marginal rate of tax, with:
- Children's education costs for employees required to live in remote areas to be treated as a living away from home allowance that is exempt from FBT.
Questions – childcare
(a)What are childcare services in Northern Australia currently doing to address workforce shortages?
(b)Given current workforce shortages in childcare, to what extent are early childhood providers:
- relying on migrants to fill vacancies;
- drawing on and upskilling a local workforce; or
- recruiting childcare workers from other areas; and
Which of these approaches has been most effective?
(c)What major initiatives from all levels of government would help to address current childcare workforce shortages for Northern Australia?
(d)With a national childcare worker shortfall, what can governments do to increase the number of childcare workers nationally?
(e)How have childcare workforce shortages affected the cost of childcare services in Northern Australia?
(f)Are childcare workforce shortages a recent issue, or one that has developed over the last few decades?
(g)What current state and federal government initiatives to attract more people to careers in childcare are working the best?
(h)What flexible options could childcare centres consider implementing to provide services for shift workers, and how could governments support these efforts?
Education and skills training
4.38The committee received submissions from several universities about higher education in Northern Australia but limited evidence about primary and high school education or from vocational education providers. In short, evidence pointed to issues such as remote delivery and students leaving to obtain qualifications and not returning to Northern Australia. This evidence aligns with the 2022 Regional Strengths and Infrastructure Gaps report, which flagged access to further education and skills training as one of the most frequently highlighted gaps in regional Australia.
4.39Some witnesses also argued there are issues with the quality of education in parts of Northern Australia and there had been a 'long-term under-investment in education in remote Australia'.
4.40The states and territories are responsible for the provision of public school education, while the Australian Government leads national policy initiatives and reforms. Public schools are funded by the Australian and state and territory governments and through fees, family, and private contributions. The Australian Government funds universities through subsidies for course fees for eligible higher education students as well as supplementary grant programs that support higher education learning and teaching. The Australian Government and state and territory governments share responsibility for vocational education and training (VET) policy and funding.
4.41While issues with education are far too complex to go into detail in this issues paper, particularly given the different levels of education and differences across jurisdictions, submitters noted the following issues with education in Northern Australia, focusing particularly on higher education and vocational education:
Higher training delivery costs, compounded by unique needs of remote communities, leading to higher costs for VET programs;
Many local markets for VET courses are not viable for more than one provider, if any;
'Brain drain' from Northern Australia, with government programs designed to increase the participation of regional, rural and remote students indirectly incentivising competition from metropolitan universities for students from Northern Australia; and
Issues with attracting skilled workers to remote Aboriginal and Torres Strait Islander communities to provide education.
4.42Submissions pointed to low educational attainment rates for Aboriginal and Torres Strait Islander peoples, in large part because of the remoteness of many communities away from training facilities, and limited access to culturally appropriate training.
4.43The Northern Territory Government noted the high cost of delivering training in remote communities, with an unpredictable number of students attending training courses. As a result, there are a limited number of registered training organisations willing to deliver services in remote locations. Recognition of the challenges involved in VET service delivery is recognised in the VET funding model in the Northern Territory, which has a 15 per cent loading for regional delivery, and a 70 per cent loading for remote delivery.
4.44Average educational attainment levels in schools in Northern Australia are less than Australian averages, which then also limits the progression of students into vocational and higher education pathways.
4.45In the Kimberley, school attendance is an average of 68 per cent, compared with the Western Australian average of 91 per cent.
4.46The Northern Australian Universities Alliance argued that 'training and education for the current and future needs of the north's workforce must be done in the north, for the north'. The Alliance and the Cooperative Research Centre for Northern Australia both argued that 'students who study in the north, stay in the north'.
4.47The 2014 Interim Report from the Joint Select Committee on Northern Australia noted workforce pressures arising 'with difficulties retaining qualified staff aged 30–50 because of the quality and range of educational opportunities at pre-school, school, TAFE and universities'. The committee's Final Report also emphasised that 'a major impediment to development in the evidence presented to the committee' was limited educational opportunities, with one submitter suggesting 'a whole generation of people… are being lost' because 'Our best and brightest… are going back to the capital cities because they cannot get an education, and we lose a lot of those people'.
Solutions
4.48Proposals made by submitters to address issues with education in Northern Australia included:
Contributions to or assistance with paying Higher Education Loan Program debts;
A national program in skills development for young people leaving school without an education, training or employment pathway;
Additional support for regional, rural and remote apprentices and trainees who have to travel to access training;
A wage subsidy scheme to support employers who take on apprentices and trainees;
A review of current Northern Australia Aboriginal and Torres Strait Islander Australian education standards and approaches;
Family assistance payments to be impacted if parents do not ensure their children are attending school;
Tailored training and education for Aboriginal and Torres Strait Islander people in Northern Australia, with services to be flexible and tailored to individuals;
Education and training for Aboriginal and Torres Strait Islander communities to be delivered by Aboriginal and Torres Strait Islander owned and controlled organisations and initiatives;
A TAFE college for remote western Queensland teaching skills relevant for the area, such as station work, welding and cattle management; and
Funding for universities and TAFEs to reflect the costs of delivery in Northern Australia so that public education providers can provide the same standards of education, vocational training and amenity as those in the south.
Questions – education
(a)What are the key issues in Northern Australia for:
(i)The provision of school-based education, including for remote Aboriginal and Torres Strait Islander communities;
(ii)The provision and uptake of vocational education; and
(iii)Attainment of higher education qualifications?
(b)What initiatives could encourage increased school attendance in Northern Australia?
(c)How might governments encourage university students from Northern Australia to remain in Northern Australia?
(d)How might governments encourage international students to enrol in higher education and vocational courses in Northern Australia?
(e)Which of the above solutions do you consider have merit?
(f)What historical and existing government initiatives have been most effective in improving educational outcomes and service delivery in Northern Australia?