Report on the 2010 review of the Medicare provider number legislation

Chapter Five - Section 3GA workforce programs

Page last updated: 15 November 2012

This chapter outlines how effectively individual workforce programs are operating and makes recommendations to address operational issues.

Many program stakeholders identified operational issues that should be addressed as a matter of course rather than waiting for the next legislative review or for DoHA to initiate a formal review of program guidelines.

5.1 Overall findings across all workforce programs

Workforce programs are not generally funded measures, rather these programs are mechanisms to allow doctors access to Medicare benefits if they provide services to those communities in most need. Doctors can face restrictions on time allowed to practice and are expected to obtain vocational qualifications while working under a s3GA program, but in general the Government has not invested in support to assist these doctors in education.

5.1.1 Section 3GA workforce programs assist in placing doctors in placements where it is difficult to attract doctors

Rural Australia and outer metropolitan areas still struggle to recruit and retain doctors both in hospitals and general practice and governments are putting significant resources into solving the problem. The Australian Government has recently established Health Workforce Australia (HWA) to meet the future challenges of providing a health workforce that responds to the needs of the Australian Community.

Section 3GA is one mechanism by which doctors working towards vocational qualifications can work in DWS, including in rural Australia. There are at least 2,000 doctors 23  a year providing medical services in areas where it is difficult to attract doctors—an estimated 1,900 doctors provide general practice services under the RLRP (managed by RHWA), the AGPT program (Rural Pathway), the RVTS and ACRRM training programs.

Section 3GA also supports the recruitment of doctors into after-hours services, which is an area where it is difficult to attract doctors in urban Australia. The majority of doctors working for MDSs are on the AMDS program.

5.1.2 The guidelines and quality processes for section 3GA programs have been strengthened

The 2005 Review recommended ways to strengthen the quality systems for and services delivered under the s3GA workforce programs. This recommendation was somewhat overtaken by the introduction of two new systems in Australia: the national assessment process for OTDs (July 2008) and the national registration system (January 2010). As a result, doctors on most workforce programs are now required to be working toward qualifications and adequate supervision must be provided.

All of the program guidelines in the 2005 Biennial Review that were identified as being in need of revision were updated in response to the review’s recommendations. The relevant professional and industry stakeholders appear not to have been involved in the review process of revising the guidelines, despite the review recommending their involvement.

The 2010 review found anecdotal and inconsistent evidence about the impact of changes to guidelines and the health reforms on the quality of doctors’ services. More evidence is needed and the Government could do some specific and targeted research in this area.

On one hand, program managers reported positive improvements in quality of services in the RLRP, the AMDS program and the QCRD program. But, general practice stakeholders say there are still problems with the competency and standards of care provided by some doctors on these programs.

In particular, general practice stakeholders are concerned about the appropriateness of junior doctors being placed in sole rural placements under the QCRD program. This view was supported by expert witnesses and the Queensland Coroner, who reported into the death of a patient under the care of a junior doctor providing relief in 2006. 24  Queensland Health have indicated that all of the Coroner’s recommendations have been implemented and that Queensland Health is currently developing a senior relief pool, which is expected to reduce the risks for junior doctors and also has policies in place to ensure junior doctors have access to direct supervision.

5.1.3 Program guidelines require doctors to be working towards vocational recognition, but support for education is underfunded and inconsistent

This review considered whether the s3GA workforce programs are meeting the intent of the s19AA legislation, that is, all medical practitioners should have or be working towards vocational training to ensure that medical services are delivered to a high standard.

Although workforce programs have greater focus on mentoring and providing support to achieve vocational qualifications than they did five years ago, stakeholders still say that insufficient resources have been invested and that some doctors may face difficulties in accessing education and support. 25  Doctors on workforce programs also face barriers to meeting the four year time-frame for achieving VR such as being unable to take study leave due to work commitments.

How much mentoring and support is provided varies across programs and jurisdictions (see Table 5.1 and Chapter 6). Compared with training programs, funding for education and support is limited for doctors on workforce programs. Currently support for doctors on the RLRP to access education and training for Fellowship is limited to a one off payment of $7,000 under the Additional Assistance Scheme. Training organisations estimate that the real cost of general practice vocational training is between $20,000 and $30,000. Although welcome, the Additional Assistance Scheme allocation is underfunded - there are not enough funded places and the level of funding is too low. The Government doubled funding to the Scheme in 2010-11 to address the waiting list. In November 2010, there were 105 doctors on the wait list for Additional Assistance Scheme funding. The length of time doctors wait to receive Additional Assistance Scheme funding differs across States and Territories.

There are several suitable pathways to Fellowship for OTDs without vocational recognition, but stakeholders concur that the needs of this group are typically higher than other non VR doctors. Stakeholders suggest that additional funding and case management needs to be provided to OTDs to ensure they are enrolled in the most appropriate support program for their situation.

A pilot program to help non VR OTDs ran successfully between 2006 and 2008, and may be a good model for supporting non VR OTDs to Fellowship. The program provided an integrated medical education program to support OTDs to achieve FRACGP. The program incorporated assessment, learning resources, educational activities and support. The RACGP reported a high success rate in passing the qualifying examination and positive integration into the Australian health workforce. The program had non recurrent funding and has not been re-offered.

Table 5.1: How workforce programs support doctors to do vocational training

ProgramTraining requirementsExtent training needs supportedExtent doctors on placement achieve FellowshipComments
Approved Medical Deputising ProgramGuidelines say doctors must work towards Fellowship.Varies across services.No information provided.
Approved Private Emergency Department ProgramAdvanced medical training.Fully supportedNo information provided.
Queensland Country Relieving Doctors ProgramOnsite induction and Clinical Rural Skills Enhancement Program prior to placement.

Not required to be involved in vocational training.
Doctors must complete specified training to support relief placement.Not applicable.
Rural Locum Relief ProgramGuidelines say doctors must achieve Fellowship within four years (FACRRM/ FRACGP).Additional Assistance of $7,000 per person available.No information available.Requirement introduced two years ago.
Special Approved Placement ProgramMust be actively working toward vocational recognition/seeking placement on vocational training program.No support for training.No information available.Provider numbers are time limited.
Temporary Resident Other Medical Practitioner ProgramEncouraged to work towards vocational training.Provided with a list of appropriate contacts.No information available.

5.1.4 Setting supervision requirements is the responsibility of the Australian Medical Board, but there is uncertainty about doctor’s ability to access supervision and the sector’s capacity to provide adequate supervision

Industry stakeholders believe that under the new national registration system, the Australian Medical Board rightly has the responsibility of assessing doctors’ right to practice and terms of this practice including supervision. As a consequence, they feel it is inappropriate for workforce programs to impose additional supervision requirements as part of their guidelines.

The amount of supervision a doctor requires is linked to the type of registration conferred on them by the Australian Medical Board. Doctor’s designated supervisors are responsible for implementing supervision. For positions in DWS, most OTDs are eligible for limited registration with requirements to comply with supervision and professional development plans. Their supervisors also submit regular reports on the doctor’s safety and competence to the Australian Medical Board. If an OTD intends to work as a doctor in Australia for the longer term, they must also provide evidence to confirm satisfactory progress towards meeting the qualifications required for general registration or specialist registration.

Stakeholders agree that the level of supervision provided for doctors on the RLRP and the QCRD program has not always been adequate in the last five years, because of a lack of capacity within the system. For example, the available supervisors are stretched or identified supervisors not being onsite or readily contactable. 26  The consequences are instances where unqualified doctors are working largely unsupervised, or doctors working towards Fellowship can find it harder to meet expected competencies because they do not have access to adequate supervision or a mentor.

The review stakeholders acknowledge that the supervision needs of doctors depends on their experience and skills. Although direct onsite supervision for doctors who require a high level of supervision is ideal, the reality is that it can be difficult to provide onsite supervision for doctors in rural and remote practices. Professional bodies such as ACRRM are using supervision by distance models and the AMC has approved a number of pilot projects in remote supervision, which offer some way forward to addressing concerns about capacity to provide the required supervision. These projects will be evaluated in 2011.

Industry stakeholders indicate that having a mentor is an important way of providing additional clinical support for doctors requiring higher levels of supervision.

Table 5.2: How supervision and mentoring is provided for doctors placed on workforce programs

Workforce ProgramRequirements for supervision as specified in guidelinesMentoringEffectiveness of mentoring and supervision requirements
Approved Medical Deputising programSupervision arrangement as required by Australian Medical Board as part of registration.

Also required by program guidelines but what and how much is provided depends on MDSs
Supervisors provide mentoring.Anecdotal evidence only.
Approved Private Emergency Department programSupervision arrangement as required by Australian Medical Board as part of registration.

Supervision provided by supervisors.
Supervisors provide mentoring.
Queensland Country Relieving Doctors programSenior supervisor allocated.Clinical Rural Skills Enhancement program prior to placement.Anecdotal evidence that quality of supervision is inconsistent, sometimes no onsite supervision.

Supervisors employed by Queensland Health.

A new senior relief pool being established.
Rural Locum Relief ProgramSupervision arrangements, as required by Australian Medical Board as part of registration.Additional Assistance of $7,000 per person available.Anecdotal evidence that quality of supervision is inconsistent, sometimes no onsite supervision.
Special Approved Placement ProgramSupervision arrangement as required by Australian Medical Board as part of registration.None provided.No evidence provided about quality of supervision.
Temporary Resident Other Medical Practitioner programSupervision arrangement as required by Australian Medical Board as part of registration.None provided.No evidence provided about quality of supervision.

No program funding for supervision.
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5.2 Approved Medical Deputising Service Program

5.2.1 About the Approved Medical Deputising Service Program

The program was established to expand the pool of available doctors who provide after-hours services on behalf of general practices. The program has allowed GPs based in metropolitan areas to provide after-hours services that attract Medicare rebates. There are no MDSs in rural locations.

The program allows doctors subject to Medicare provider number restrictions to work in metropolitan areas, for after-hours work only. 27  Access to Medicare rebates is time and location specific and the doctor will need a Medicare provider number for the specific practice location. Doctors on this program work for Australian MDSs. These services must be accredited by the Australian General Practice Accreditation Pty Ltd or GPA Accreditation and cannot be co-located within in-hours clinics. Essentially, the program provides the majority of the workforce for MDSs and encourages doctors to work towards Fellowship of the RACGP or ACRRM. MDS stakeholders agree that it would be difficult to recruit sufficient doctors without the AMDS program.

Offering after-hours services using MDSs is a growing business with the number of locations with MDSs more than doubling since 2005. These services are now being offered in 48 locations compared with 21 locations in 2005. The number of doctors who have provided at least one service under the AMDS program has increased two-and-a-half times over the last five years; from 108 in 2005 to 271 in 2010. MDSs receive 600,000 calls per annum for after-hours services. 28  Industry stakeholders observed that there is potential for more junior doctors to have placements in the industry.

MDSs are one way general practices can meet their accreditation requirements and access the After-Hours Practice Incentive Program (PIP), which encourages general practices to improve the quality of care provided to patients 29 . To be eligible to receive after-hours practice incentive payments, general practices must ensure all patients have access to 24-hour care (seven days a week) including access to out-of-hours visits at home, in a residential or aged care facility, and in hospital, where necessary and appropriate. Where an MDS is used, the general practice must have a formal arrangement with the deputising service. The PIP payments are used to augment rebates as Medicare rebates do not cover the cost of after-hours services.

5.2.2 Quality processes

Quality processes for the AMDS program are set by guidelines that came into effect in 2008 and are currently being implemented. The Guidelines also adopt the NAMDS definition of an MDS. The guidelines have a greater focus on quality than previously, for example, doctors are expected to work towards a Fellowship and MDSs must demonstrate how they will provide mentoring for doctors on the program. NAMDS reports that the program has been a positive pathway for doctors to obtain their Fellowship.

The guidelines appear to have had a positive impact on service quality, although we have no systematic evidence about this issue. Stakeholders from the AMA and RACGP report that their members are generally positive about the work of MDSs, although one GP observed that there are good and bad services and another said that they had heard of instances of poor recording of patient’s notes. General practices can readily change services if they are unhappy with services. DoHA indicated that the relevant program area has had no formal complaints about service coverage or quality of MDSs. 30 

Quality processes for the AMDS program are set by guidelines that came into effect in 2008 and are currently being implemented. The Guidelines also adopt the NAMDS definition of an MDS. The guidelines have a greater focus on quality than previously, for example, doctors are expected to work towards a Fellowship and MDSs must demonstrate how they will provide mentoring for doctors on the program. NAMDS reports that the program has been a positive pathway for doctors to obtain their Fellowship.

The guidelines appear to have had a positive impact on service quality, although we have no systematic evidence about this issue. S

The size of the MDS has an impact on the amount of training, supervision and support provided to doctors. NAMDS says that it can be difficult for smaller MDSs to provide effective supervision and support.

5.2.3 Issues

Our consultations uncovered several operational issues for the AMDS program, which are summarised below.

Impact of the removal of the After-Hours Practice Incentive Payment and health reforms on the viability of medical deputising services

There is a lot of uncertainty about what the role of MDSs will be when Medicare Locals become responsible for funding and coordinating after-hours care. In December 2010, the Government indicated that after-hours PIP will be maintained until 2013 when funding for after-hours care is expected to be transferred to Medicare Locals. Currently, after-hours PIP help fund the cost differential between the cost of providing an after-hours service and the available rebate.

Under the health reforms an after-hours call centre will also be established. However, based on the United Kingdom experience, it is unlikely to reduce the demand for after-hours services. General practice stakeholders believe that the reform process needs to take into account the economics and practicalities of providing after-hours services and if MDSs are not viable then patient’s access to after-hours services in urban areas may be comprised.

Stakeholders indicate it will be important for DoHA to monitor the impact of health reforms on the provision of after-hours services.

RACGP accreditation standards do not include a definition of a Medical Deputising Service

MDS stakeholders claim that a lack of definition for MDSs in RACGP standards is impacting on service coverage, because it allows for ambiguity in what a service offers. An MDS may be accredited yet offer less after-hours coverage (e.g. no home visits) than is expected under the AMDS program guidelines. By doing so, an MDS could benefit commercially because of the high costs of home visits compared to providing extended clinic hours. We have no independent evidence about the extent that this occurs. 31  MDSs must state as part of their agreements with general practices that they have the capacity to provide out-of-clinics visits and are expected to do so when required.

In-hours care for residents of aged care facilities

Two previous reviews raised the potential for MDSs to provide in-hours care for residents of aged care facilities. It may be time to reconsider this issue as doctors in metropolitan areas are increasingly unable to provide in-hours care to this group. NAMDS has submitted to the Government, a proposal for MDSs to be allowed to provide in-hours medical services to residents of aged care facilities.

RACGP member status and the After-Hours Other Medical Practitioners (AHOMP) Program

Associate membership of the RACGP gives doctors on the AMDS program access to broad RACGP information but doesn’t give them access to online education, nor does it entitle them to have the College record the points they accrue as a result of completing RACGP accredited Quality Improvement and Continuing Professional Development (QI&CPD) activities. Associate members can only record QI&CPD points if they register with the RACGP as a participant in the AHOMP program. This requires an additional application to Medicare (that is, in addition to their provider number application) plus a separate application and declaration to the RACGP. One MDS believes all AMDS doctors should be associate members of the RACGP and that this membership should entitle them to have their RACGP QI&CPD points recorded by the College.

Continuing professional development requirements

The requirement for doctors on the AMDS program to amass 300 continuing professional development points over three years is higher than expected of RACGP Fellows. Industry stakeholders claim that the current requirement is onerous given the profile of their workforce in comparison to that required by the RACGP for their Fellows.

Alignment of time requirements to obtain Fellowship between AHOMPs and AMDS program need reviewing

Many doctors on the AMDS program are also on the AHOMP program and the requirements for obtaining Fellowship are different—in five years for AHOMP and four years for the AMDS program. To be consistent, these requirements should be aligned.

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5.3 Approved Private Emergency Department Program

5.3.1 About the Approved Private Emergency Department Program

The program was established because of a shortage in specialist emergency medical staff. The program allows accredited private emergency departments who require access to the sessional pool of medical staff the ability to apply for access to provider numbers for registrars. 32  This is both a workforce and training program with quality processes and standards being the responsibility of the Australian College of Emergency Medicine. The number of providers of at least one service under this program has increased from 108 in 2004–2005, to 271 in 2009–2010.

The 2005 Biennial Review did not identify any issues with or make any recommendations about this program. In 2010, industry stakeholders report that private emergency departments support the program but would like changes to requirements about how provider numbers are allocated to trainees. The current policy is impacting on retention of registrars and causing gaps in service provision. Hospitals must apply for provider numbers every 12 months in line with the Deeds of Agreement that the hospital has in place with the doctor. It appears hospitals are unaware that they can negotiate a longer period with the Commonwealth to eliminate the need to apply for provider numbers every 12 months. This could be readily addressed in consultation with the Department.

Another issue is that the eligibility criteria restricts temporary resident OTDs, and OTDs who are undergoing recognition of standing and credentialing, from qualifying for the program. Program stakeholders report that the application process is more difficult and less clear with answers about eligibility taking some time to get. The AMA report this is a limitation of the program and indicated that once recognised, this group should be able to access Medicare rebates.

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5.4 Queensland Country Relieving Doctors Program

5.4.1 About the Queensland Country Relieving Doctors Program

The QCRD program is managed by Queensland Health.

The QCRD program has operated for at least 35 years, with Queensland Resident Medical Officers (RMOs) providing leave relief for annual, conference or study leave to Queensland Health’s rural staff and sole or small practices in rural and remote areas. The periods of relief vary but can be as short as one week.

Not all RMO locums are required to be registered on the QCRD program. This is only necessary for RMOs relieving in a Medical Superintendent or Medical Officer with Right to Private Practice position. Positions with rights to private practice are specific to Queensland and do not exist in other jurisdictions. The positions are generally in small rural locations where the hospital doctor also fulfils a general practice role.

The program has more than doubled in size since the 2004–2005 financial year, when 161 providers made claims for at least one service under this program. In 2009–10, 366 providers claimed at least one service.

For Queensland Health, QCRD program is a crucial component to retaining medical practitioners in rural areas because it offers a way of providing leave. The QCRD program provides relief to approximately 70 rural medical practitioners throughout Queensland, covering 1,576 weeks of leave. Relief under this program accounts for 60 per cent of all relief provided to rural practitioners. Many solo medical practitioners would have limited opportunities for relief if they were reliant upon the recruitment of private locums (just two per cent of rural practitioners make private arrangements for relief).

5.4.2 Quality processes

Quality processes for the QCRD program have been strengthened as a result of the Queensland Health review of the program in 2005, and the 2005 Biennial Review of the Medicare Provider Number Legislation.

Even so, experienced medical practitioners agree that there are inherent safety risks for a program that means inexperienced, junior doctors (PGY2) are working in challenging settings—sometimes without access to direct supervision. A coroner’s report described a case in September 2006, where a PGY2 doctor working on locum without direct supervision case did not follow the National Heart Foundation Guidelines for the management of acute coronary syndrome. This patient died, and the case illustrates the safety risks of insufficient supervision of junior doctors placed in challenging posts. 33 

In response to the findings of the coroner, oversight of s3GA processes has been centralised to Rural and Remote Medical Services and there are processes in place to ensure that only people in properly supervised and recognised positions can provide services that attract Medicare benefits. Queensland Health now requires that RMOs attend the Clinical Rural Skills Enhancement Program before taking up locum positions. District Health Services must now develop a job description and also allocate a senior supervisor within a support model for each reliever before they take up the relieving position. Relievers must also take part in an orientation program at the District level with formal report back to Queensland Health 34  In addition, Queensland Health has developed descriptions of roles and responsibilities for all parties including the supervisor; fact sheets for all relievers, and requires relievers to complete a post placement evaluation. Queensland Health is also developing a Senior Relief pool; a new relief database which is currently at the user acceptance stage and instituting a review and relaunching of the website.

Queensland Health report that the changes to the way the program is managed have resulted in a more reliable recruitment process and that Medical Officers are better prepared and able to access adequate supervision and support. Districts are more aware of their responsibilities to supervise and support locums. The senior relief pool may go some way to addressing safety concerns particularly if this means PGY2 doctors are not placed in sole doctor settings and more experienced registrars cover remote areas.

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5.5 Rural Locum Relief Program

5.5.1 About the Rural Locum Relief Program

The RLRP is a workforce measure and not intended as a specific mechanism for education, nor is it a funded program. The program is a key mechanism for recruiting medical practitioners to rural Australia, and providing a means of attracting Medicare rebates. The RLRP is managed by RHWA. The objectives of the program are to

  • attract medical practitioners to general practice in rural and remote Australia
  • provide a means by which medical practitioners restricted by s19AA of the Act can access Medicare benefits for general practice services whilst on an approved placements in rural areas.

Across Australia, approximately 94 per cent of doctors on RLRP placements are OTDs with permanent Australian residency or citizenship. The remaining six per cent are Australian medical graduates. 35  Places are taken by OTDs who are permanent residents and who are working toward becoming a VR GP in Australia and Australian graduates, or registrars trying out general practice or completing minimum time requirements for practicing as part of their vocational training.

The program take-up varies across jurisdictions, with New South Wales having the highest number of placements, and South Australia the least (see Table 5.3).

Table 5.3 Placements on the RLRP as at November 2010 by jurisdiction

No. Drs

The program allows both short and long-term placements. The program is used to fill medical practitioner positions in rural areas. Medical practitioners can be on concurrent s3GA placements, for example, registrars on the AGPT program who want to work in another practice outside their training placement can apply through the RLRP at the same time.

According to the program guidelines, doctors can be on the RLRP for a maximum of four years without obtaining Fellowship. Typically doctors are placed on the RLRP for between one week (for example, if undertaking locum work) and four years. Medical practitioners who leave the program before the four years are up do not need to obtain Fellowship, and indeed it is not appropriate for doctors on short-term placements who intend to leave Australia.

The maximum time period was chosen to reflect the normal amount of time needed to train to be a GP. There is disagreement between stakeholders about whether this timeframe is appropriate. Some general practice stakeholders believe that this timeframe is too short and that the minimum length of time should be up to six years and others think that the time frame is too long.

The numbers of doctors who have provided at least one service under the program have fluctuated between 551 and 767 in the last five years. In November 2010, 608 individual medical practitioners were working in approved positions under the program.

Some stakeholders commented that the name ‘RLRP’ does not reflect the nature of the program and should be changed; given that most providers are not providing locum services but are working towards vocational recognition.

5.5.2 Quality processes

The 2005 Biennial Review raised issues about the consistency of assessment for the program. The new national assessment process has addressed concerns about inconsistency of approaches across jurisdictions regarding assessment. The RLRP program guidelines were reviewed by RHWA in 2008, and again in March 2010 36 .

The adequacy of supervision provided to doctors under this program has remained a concern over the last five years, as does the amount of support for individual doctors. Although the new national registration system introduced in 2010 will ensure that supervision requirements are consistent, doctors working under this program for over 12 months still face barriers in accessing education and training for vocational recognition.

Assessment: A standard national assessment process was introduced in 2008 37 . The medical practitioners’ qualifications and proficiency in English are now verified by the AMC. Doctors then choose a pathway: either through a competent authority; sitting the AMC exam; or through a specialist pathway. The next step is a clinical competence test (either pre-employment structured clinical interview (PESCI) or face to face clinical exam). After passing the exam, doctors then apply for national registration through AHPRA 38 . Receipt of medical registration allows the doctor to apply for a visa.

Once AHPRA has confirmed the identity of the person through a face to face interview the doctor can apply for a s19AB exemption (if required) and then a provider number through an approved placement program, in this case the RLRP.

Supervision: The amount of supervision required is linked to the type of registration conferred on the applicant by AHPRA as part of the registration process, with designated supervisors having the responsibility of implementing supervision.

In the last five years, stakeholders agree that the level of supervision available for doctors on the RLRP is not always adequate, because of a lack of capacity in the system and because the available supervisors are stretched. 39  The consequences are that there are cases where unqualified doctors are working largely unsupervised and doctors working towards Fellowship are finding it more difficult to meet the requirements because they lack access to advice from their supervisor.

Mentoring: The 2005 Biennial Review found that doctors on the RLRP receive insufficient mentoring. The program guidelines were changed, and now require that doctors on RLRP have a mentor. The RLRP is an unfunded program and this review has found that because there are insufficient resources to provide the same level of mentoring for all doctors, resources are prioritised to those in most need.

General practice stakeholders 40  believe that adequate mentoring should be a mandatory component of all authorised workforce programs under s3GA of the Act.

Training: The 2005 Biennial Review found that insufficient support for training was provided to doctors on the RLRP. It recommended implementing a staged program and that all doctors on the RLRP for an extended time should be assessed and participate in training to achieve Fellowship of a recognised specialist college.

Revision of the program guidelines now requires doctors on the program for an extended period of time to pursue Fellowship. These doctors are being provided with support and training to obtain Fellowship (either the FRACGP or FACRRM) by State and Territory rural workforce agencies, through the Additional Assistance Scheme. Established in 2003, the scheme provided $7,000 per person to 200 doctors in 2010–11. In November 2010, there were 105 doctors waiting to receive the funding with the waiting time to access the fund varying across jurisdictions.

The Additional Assistance Scheme is administered by rural health workforce agencies in different ways according to the situation within their State or Territory. Some jurisdictions provide the funding directly to the doctor; others pool the funding to provide joint training. The program guidelines require doctors who receive Additional Assistance Scheme funding to develop Individual Learning Plans, although the guidelines are currently under review.

Stakeholders suggested ways that doctors on the RLRP could be supported to get training.

Increase places and individual funding for doctors through the Additional Assistance Scheme.

Increase investment and allow OTDs to be supported by registered training providers.

Consider other models; for example tailored training and support for individual doctors needs.

Given the complexity of programs available, it would be desirable for the providers to be case managed to choose the most appropriate education interventions for their situation.

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5.6 Special Approved Placements Program

5.6.1 About the Special Approved Placements Program

The program was established as a safety net program to ensure that doctors who are subject to the provisions of s19AA, but due to exceptional circumstances could not undertake a s3GA program or other vocational training, would not have their access to Medicare benefits disrupted.

The program guidelines 41  state that ‘exceptional circumstances’ that would be considered are:

  1. Where it can be demonstrated that there is substantial hardship because of particular family circumstances for the medical practitioner directly related to not being able to access Medicare benefits in a metropolitan area.
  2. Where serious illness to the medical practitioner or his or her immediate family can be demonstrated and where treatment for the illness is limited to particular locations.
  3. Other exceptional circumstances peculiar to the individual case.

While the Guidelines specify particular issues considered in making decisions regarding placing a doctor on this program, all applications are decided on individual merit.

The period of participation in the program may be up to five years in the first place and may be renewed at the discretion of the Minister on receipt of evidence demonstrating that the circumstances leading to the original approval remain current.

In 2009–2010, there were 61 doctors on the program; a fivefold increase since 2005–2006 42 .

Table 5.4: SAPP Placements granted over the past five financial years

Number of placements granted
Number of new placements
Number of extensions
Number of new doctors on SAPP
Total number of doctors on SAPP

5.6.2 Quality processes

There are a number of conditions placed on a SAPP placement including having adequate supervision, and that doctors be working towards vocational recognition or be seeking a placement on a vocational training program. SAPP doctors are responsible for arranging their own supervision and mentoring and are closely monitored by DoHA with regards to their progress towards Fellowship.

We have no evidence about whether doctors on SAPP are in need of additional support for education as is the case for doctors on other workforce programs.

5.7 Temporary Resident Other Medical Practitioner Program

5.7.1 About the Temporary Resident Other Medical Practitioner Program

This program provides access to the Medicare benefits arrangements (at the lower A2 rate) for eligible pre-1996 non VR medical practitioners (non specialists in general practice). As such it is not considered a workforce or training program. Although the program does not have workforce components, the provider numbers are linked to other workforce programs such as the AHOMP program.

The TROMP program was created to overcome an unintended consequence of amendments to the 1996 Medicare Provider Number Legislation, which would have seen a number of long-term temporary resident medical practitioners lose access to the Medicare benefits arrangements. This affected temporary resident non VR medical practitioners who had entered medical practice in Australia prior to 1 January 1997, and who were not vocationally recognised.

Registration on the program was initially quite steady, but in recent years only a handful of doctors are registering. As at 20 October 2010, there are 164 medical practitioners registered on the TROMP program. Seven medical practitioners have come off the program due to either gaining permanent residency or FRACGP. Of the other program participants, seven are New Zealand citizens; 118 are temporary residents from countries other than New Zealand and the doctor’s background unknown for 39 participants. 43 

5.7.2 Quality processes

Due to the intent of the program, it was not considered appropriate to enforce a pathway towards Fellowship for this cohort of doctors. Nevertheless, doctors on this program are encouraged to pursue vocational training and are given a list of appropriate contacts to do so. Under the new national registration system, participants will have to comply with the Australian Medical Board’s continuing professional development requirements in order to maintain medical registration.

The 2005 Biennial Review did not identify any issues with or make any recommendations about this program. In 2010, general practice stakeholders raised concerns about the amount of time (ten years) allowed for doctors on the TROMP program to achieve Fellowship.

DoHA is planning a review of the guidelines for TROMP and Other Medical Practitioner (OMP) programs with the objective of aligning assessment, competencies and requirements for obtaining Fellowships across all OMP Programs.

5.8 2010 Recommendations for section 3GA workforce programs

Recommendation 11

DoHA to invest in support for doctors on workforce programs.

Recommendation 12

DoHA to fund a research project that assesses the extent that doctors on s3GA programs access the required level of supervision, and act on the findings of this research project. The research project could include an anonymous survey of doctors’ experiences of the quality of supervision.

Recommendation 13

Relevant program areas in DoHA (or relevant authority) to establish a mechanism that allows regular industry input into operational issues in order to identify and address any problems in delivering services under the programs, rather than wait for the five year review of the Medicare Provider Number Legislation.

Recommendation 14

DoHA to add the ACRRM Independent Pathway (a fully accredited independent general practice training pathway) to Schedule 5 of the Regulations to facilitate access to Medicare provider numbers for registrars on this pathway.

Recommendation 15

15.1:DoHA to add Fellowships of the RACGP, ACRRM, the Australasian College of Sports Physicians and the College of Intensive Care Medicine of Australia and New Zealand to Schedule 5 of the Regulations, which lists organisations and courses for s3GA of the Act.

15.2: DoHA to routinely update Schedule 5 of the Regulations as Fellowship courses are certified by the AMC.

Approved Medical Deputising Service Program
Recommendation 16

DoHA to actively monitor the impact of health reforms on the provision of after-hours care by AMDSs and revise the AMDS Program Guidelines as needed.

Queensland Country Relieving Doctors Program
Recommendation 17

17.1: Queensland Health to ensure that all junior doctors on a relief placement have access to direct supervision and endeavour to place more senior doctors in remote relief placements.

17.2: Queensland Health to monitor the achievement of this recommendation and report on its success at the next review of the Medicare Provider Number Legislation in 2015.

Rural Locum Relief Program
Recommendation 18

DoHA to fund rural health workforce agencies to provide support for doctors working under the RLRP.

11 Source: DoHA data, table 4.1
12 Coroner’s Report of Inquest into the death of Jillian Peta McKenzie, 3 October 2008,
13 Although outside the scope of the review; RVTS Ltd is also concerned that ‘there are many temporary resident doctors not subject to 19AA practicing in rural and remote areas with minimal or no education training and support’. This group of doctors are now eligible for training place on RVTS but it is likely that the RVTS has insufficient funded places to meet demand.
14 No evidence was provided to the reviewers about the numbers or proportion of doctors who do not get adequate supervision under workforce programs
15 National Association of Medical Deputing Services estimated that 75 per cent of doctors on the program are international medical graduates
16 Australian Medical Association submission, p10
17 Audit Report No.5 2010–11, Performance Audit Practice Incentives Program Department of Health and Ageing, Medicare Australia. From November 2012 after-hours payments will be made retrospectively
18 DoHA
19 A 2010 Australian National Audit Office audit of 34 practices with low after-hours MBS item billings that were receiving after-hours practice incentive payments of almost $500 000 in 2008–09, showed that only half of the practices provided callers with an after-hours number for a practice doctor. The audit did not identify if the practices identified had agreements with MDSs to provide the after-hours services.
20 APED Guidelines, undated
21 Coroner’s Report of Inquest into the death of Jillian Peta McKenzie, 3 October 2008, page 11
22 Coroner’s Report of Inquest into the death of Jillian Peta McKenzie, 3 October 2008, recommended these measures be taken, after the inquest found that the junior doctor who had treated Jillian McKenzie in September 2006 had no access to direct supervision
23 Source: HWA, 29 November 2010
24 2010 Guidelines in draft form
25 Australian Medical Board announced a review on 12 November 2010
26 The new national registration system introduced in 2010 is intended to ensure all medical practitioners have equivalent skills to Australian trained graduates.
27 No evidence was provided to the reviewers about the numbers or proportion of doctors who do not get adequate supervision under the RLRP
28 RACGP Submission, 2010
29 SAPP Guidelines dated December 2003
30 Note that these data are different than that shown in Table 4.1, covering slightly different time periods and using a different definition of participants. In Table 4.1, participants are defined as having made at least one claim and in Table 5.4, the count is of approved placements.
31 Under the Health Insurance Act, the Migration Act is used to define temporary and permanent residency, which means that New Zealand Citizens are considered to be temporary residents. From 1 April 2010, an amendment of the 19AB legislation means that NZ citizens with permanent residency are able to seek vocational reciprocal vocational recognition or be granted a vocational place