Overseas trained health professionals comprise a significant proportion of the Australian health workforce. According to the Australian Institute of Health and Welfare, approximately 25% of medical practitioners and 15% of nurses who are currently practising in Australia having completed their training overseas.131
Despite Australia holding the stated aim of health workforce self-sufficiency since 2004,132 it is generally accepted that Australia’s reliance on international health professionals will need to continue in the short to medium term to meet the forecast demand for health services.133 This is supported by the modelling of Health Workforce 2025.134
Further information regarding the make-up of the international health professional workforce in Australia is included in Appendix vi.
The government engages a range of strategies to recruit, retain and support overseas trained health professionals – most particularly, overseas trained doctors (OTDs) – and to achieve workforce distribution aims, primarily in rural and remote areas.
In November 2010, the House of Representatives Standing Committee on Health and Ageing (the HoR Standing Committee) commenced an inquiry into registration processes and support for OTDs, in response to concerns about the transparency and complexity of the arrangements an OTD must go through to be eligible to practise in Australia. In March 2012, the HoR Standing Committee released its report Lost in the Labyrinth: Inquiry into the registration processes and support for overseas trained doctors. The inquiry focused on issues affecting OTDs practising within general practice settings and as specialists within DWS or state-based Areas of Need (AoN) for their specialty.135 A short summary of the key findings of the inquiry is included in Appendix vii.
This section presents an outline of the current initiatives supporting the recruitment of overseas health professionals. It then examines some of the issues relating specifically to OTDs that were identified in the Lost in the Labyrinth report.
Activities supporting the recruitment of international health professionals
Currently, both DoHA and Health Workforce Australia (HWA) administer initiatives to recruit and support international health professionals.
HWA administers the International Health Professionals Program (IHPP), which was funded as part of the Commonwealth’s commitment to the National Health and Hospital Reform Partnership Agreement in 2009-10. The IHPP (known under the Partnership Agreement as the International Recruitment Program) aims to improve and coordinate nationally consistent international recruitment of health professionals, inclusive of national policy, and improve awareness and marketing, retention and recruitment, and pathways to practice.
These objectives relate to facilitating a supply of health professionals in areas of workforce shortage/need, over the short to medium term.
HWA has streamed the IHPP into four elements:
- National Policy – aims to identify potential opportunities to improve the efficiency and effectiveness of international health professional migration and identify more effective and efficient approaches to their attraction and deployment.
- Retention and Deployment – aims to improve deployment, retention and the contribution of nurses and allied health professionals to primary health care services and Aboriginal and Torres Strait Islander health services in rural and remote Australia.
- Attraction and Marketing – aims to increase the capacity of the health workforce by streamlining and coordinating international health professional attraction and marketing through a collaborative approach with jurisdictions. HWA is pursuing this element through the establishment of Health Careers Australia as a ‘one stop shop’ for international recruitment into Australia.
- Pathways to Practice – aims to increase the capacity of the workforce by streamlining and creating a more efficient pathway into practice for international health professionals.
In implementing the retention and deployment component of the IHPP, HWA have developed the Rural Health Professionals Program (RHPP), which provides recruitment, orientation, and retention support services to nurses and allied health professionals into rural and remote Australia and Aboriginal and Torres Strait Islander health services. HWA is coordinating the program with Rural Workforce Agencies (RWAs) in each state and territory delivering the program.
The RHPP was announced, with funding of $16.18 million, on 4 October 2012 by Minister Butler, then acting Minister for Health.136 Since January 2012, 229 nursing and allied health professionals have commenced work in rural and remote Australia under the RHPP. Over 380 placements are anticipated by 30 June 2013. It is important to note that the RHPP provides placement services for domestic as well as international candidates.
In delivering the pathways to practice element, HWA has contracted with six agencies. The program responds to a number of recommendations made by the Standing Committee to address the complexity of registration processes for international medical graduates. The projects commenced in July 2012 and include:
- Establishment of a National Clinical Examination Centre (Melbourne) to increase availability and ensure timely access to assessments for OTDs – assessments that inform decisions about registration to practise in Australia.
- Expanding access to medical training and supervision for OTDs that supports attainment of general medical or vocational registration. This will be delivered by General Practice Education and Training Limited (GPET) through the Overseas Trained Doctors National Education and Training (OTDNET) program – a new program established under IHHP.
- Expansion of existing workplace based assessment (WBA) programs in Western Australia and Hunter New England; and development of new WBA programs in Hobart, Tasmania, and rural Western Australia, and in rural general practice through the Australian College of Rural and Remote Medicine (ACRRM). The WBA programs provide orientation, inter professional teamwork, acclimatisation to Australian medical practice, and a mix of formative and summative assessments of candidates.
- Simplifying the red tape processes associated with processing applications for OTDs, progressed through working with the Australian Health Practitioner Regulation Agency (AHPRA) and other regulatory authorities to establish a single documentation bank for the administration of international health professional registration and accreditation.
In addition to these activities managed by HWA, the Commonwealth’s efforts in international medical recruitment are delivered through the International Recruitment Strategy (IRS), funded by DoHA. The IRS was established as a part of the 2004 Strengthening Medicare initiative to increase the supply of appropriately qualified OTDs to DWS areas throughout Australia. It provides a financial incentive for the recruitment and placement of OTDs into designated DWS locations. In addition to the recruitment of OTDs, the IRS also includes the following support components:
- The Five Year OTD Scheme provides assistance and incentives to attract OTDs to regional, rural and remote locations that have experienced difficulties in recruiting and retaining OTDs. The Five Year OTD Scheme provides a reduction in the ten year moratorium on provider number restrictions under s. 19AB of the Health Insurance Act 1973 (the Act) (discussed in further detail below).
- The Rural Locum Relief Program (RLRP) aims to ensure that Australian regional, and remote communities, especially the more isolated regions, have experienced and skilled medical practitioners in hard to fill locations. The RLRP is an approved program under s. 3GA of the Act and enables Australian-trained and OTDs to undertake rural locum work while working towards postgraduate qualifications. Doctors can be on the program for a maximum of four years without obtaining fellowship.
- The Additional Assistance Scheme (AAS) seeks to provide support to permanent resident OTDs and Australian-trained doctors to enable them to access education and upskilling opportunities to facilitate their work towards gaining fellowship of the Royal Australian College of General Practitioners (RACGP) or ACRRM. The AAS is available to participants of the Five Year OTD Scheme and the RLRP.
Rural Health Workforce Australia (RHWA) administers the IRS, and subcontracts RWAs in each state or territory to deliver the program.
Although the IRS has underachieved on the Government’s recruitment targets (recruiting 82 doctors in 2011-12 against a target of 108137), it has had some success in placing doctors in rural areas, a number of which are now long-term placements. Of the 282 doctors recruited under IRS since October 2008, 94% were recruited to rural and remote locations, and of these, 95% stayed in their placement for longer than 12 months. RHWA argues that the case management approach used by RWAs has been successful in increasing retention of doctors in the longer term.
The recruitment targets set for RWAs have been criticised as unrealistic, given the intensive nature of the work required for each recruit. RHWA is currently compiling evidence to better quantify the resource investment required over a number of years to secure the successful recruitment of an OTD. RHWA also argues that because the placement of an OTD may occur after up to two years of involvement by RWAs, a funds release provided only on completion of recruitment activities leaves RWAs financially exposed during the period between recruitment activity and payment. This would create particular difficulties for the organisation if the IRS were to be substantially cut back or ceased. Such issues will need to be addressed in any amended future contractual arrangements for the IRS.
In terms of recruitment, placement and retention efforts, HWA’s RHPP is most strongly focused on nursing and allied health placement and retention, whereas the RHWA’s efforts under the IRS are targeted towards the placement of OTDs in primary care. Both programs aim to place international health professionals in locations where there are workforce shortages, such as rural and regional Australia. (It should also be noted that private recruitment agents, state and territory governments, and individual institutions also undertake recruitment action of various kinds, sometimes in competition with one another.)
Given that funding under both HWA’s RHPP and the Department’s IRS is directed to RWAs to undertake international recruitment of health professionals, it appears logical to streamline these arrangements through a single fund-holder. This would allow for greater flexibility in funding priorities, along with the potential for simplified contracting and reporting arrangements.
Issues relating to the use of overseas trained doctors in addressing workforce maldistribution
The use of OTDs to address medical workforce shortages and the maldistribution of the medical workforce raises many issues that have been explored in considerable detail within the Lost in the Labyrinth report. While the issues identified in that report are all pertinent and contribute to the difficulties encountered by OTDs seeking to join the Australian medical workforce and the various organisations seeking to employ them to serve the Australian public, they do not all fall within the remit of DoHA and hence of this review. The issues discussed in this report are those that relate to the Health portfolio, and which have been identified by stakeholders within the course of the review. These centre on providing appropriate support for OTDs and the operation of the Medicare Provider Number restrictions under the Act.
The impact of the operation of the DWS classification system, which is discussed below, is particularly significant for the placement of OTDs.
Ensuring appropriate support for OTDs
Stakeholders consulted as part of this review expressed the view that support for this workforce is key to the successful provision of medical services in DWS and AoNs.
A clear theme emerged about the need to increase awareness of OTDs as individuals from diverse backgrounds with different specialist interests and skill levels, and who require differing levels of support upon making the commitment to relocate to Australia. The term OTD encompasses several very different cohorts of medical practitioners.
Information about Medicare provider number restrictions
The DoctorConnect website contains information about operation of the Medicare provider number restrictions under sections 19AA and 19AB of the Act which is important for potential OTDs to be aware of, particularly if they are seeking employment in private practice. Whilst this information is technically accurate it is not always presented in a way that is easily understood. Stakeholders are concerned that many medical practitioners (particularly OTDs) significantly misunderstand the position on eligibility for Medicare rebates.
Queries received by DoHA reinforce stakeholder views that OTDs are receiving mixed messages about the Medicare provider number restrictions. This seems to occur when advice is sourced both from the Department or the MBA, and from private recruitment agents who may have an incorrect understanding of the legislation.
Interplay between assessment systems
With increasing numbers of internationally trained medical practitioners and FGAMs and the status of medicine as an area of national skills shortage, there is a resultant need for constant review of permanent and temporary visa status issues in order to maintain the balance between supply and demand. If OTDs are to be recruited, the process should be as efficient and effective as possible. At present, the interplay between the immigration, registration and assessment systems presents a barrier to OTDs potentially wanting to practise in Australia.
Several submissions to the HoR Standing Committee Inquiry noted the protracted recruitment period for OTDs and the potential for OTDs to find alternative employment before registration and visa issues have been finalised. It is reported that such delays can, in part, be due to the time taken by the Australian Medical Council and the specialist medical colleges to verify qualifications and experience.
Barriers to timely consideration of applications include the need to present duplicate information to several organisations. For example, the MBA and its accreditation body, the Australian Medical Council, require the same documentation to be presented to each as part of the registration process. This documentation is also required by prospective employers and the Department of Immigration and Citizenship.
Similarly, many specialist colleges lack a combined Area of Need and specialist comparability assessment. This leads to duplication of effort by both the college and the applicant. It can also result in inconsistent information being provided to the applicant about the requirements for further training prior to complete recognition of their expertise and subsequent full medical registration.
As described above, initiatives such as HWA’s International Health Professionals Program are seeking to minimise the need to provide duplicate information to several organisations.
Access to Medicare rebates
Access to Medicare rebates for OTDs and their families was raised by stakeholders both in the House of Representatives Inquiry and the consultation process for this review. While able to provide Medicare-rebateable services, those holding 457 visas (temporary residents) are not eligible for Medicare rebates for services they access as patients.
As a condition of their visa, temporary resident OTDs are responsible for all health costs for themselves and their families. They are required by law to maintain adequate insurance for these health costs for the length of their visa.138
It has been suggested that access to Medicare rebates for temporary resident OTDs working in regional and remote areas (ASGC-RA 3–5) may encourage more OTDs to move as a family unit to live and work in rural and remote areas, thereby building the sustainability of medical services in these communities. While this proposal has clear attractions, it is important to tease out the legal and flow-on implications of such a step, particularly for the broader 457 visa scheme. It may be preferable to consider some package of family support measures for OTDs tailored to individual needs.
Professional support and peer mentoring
As noted above, RHWA is currently funded by the Department, through the International Recruitment Strategy, to support the OTDs they recruit as they navigate the immigration and professional registration pathways.
The Department also provides funding to the medical specialist colleges through the Specialist Training Program for a range of support activities to develop system-wide education and infrastructure projects to enhance training opportunities for eligible trainees. This includes educational support for OTDs such as the development of online learning models, training workshops and assistance with navigating college fellowship training requirements. Further activity in this area in partnership with the specialist colleges is recommended and should involve continuing engagement with the Committee of Presidents of Medical Colleges.
Another important component of a comprehensive professional support model is access to peer mentoring. Peer mentors are able to provide impartial, confidential advice on issues OTDs may face while providing medical services, for example, appropriate Medicare item use, culturally appropriate communication in a rural or remote setting, identifying gaps in the OTDs knowledge or skills, etc. This is particularly pertinent for overseas trained specialists working in rural and remote areas who have limited access to their peers, other than their supervisor.
Peer mentoring programs that target OTDs working in more isolated areas may facilitate access to professional advice and support as they progress to general and specialist registration and alleviate any sense of professional isolation. In the longer term, this will improve the quality of the OTD workforce.
Access to training
OTDs who hold limited registration have four years in which to achieve or make significant progress towards achieving general or specialist registration. OTDs can apply for permanent residency once they have achieved general or specialist medical registration. Therefore, there is a significant incentive for temporary resident visa holders to achieve general or specialist registration if they wish to stay in Australia beyond the four years allowed by their visa and the medical registration regime.
OTDs in inner or outer metropolitan areas (ASGC-RA 1–2) are readily able to access bridging courses for the Australian Medical Council’s (AMC) examinations and other professional education courses. However, access to appropriate training becomes more difficult with increased distance from major cities. Greater support from the specialist medical colleges for OTDs working in rural and remote areas may render these locations more attractive to OTDs.
Unfortunately, at present a catch-22 situation exists where an OTD may be unable to gain permanent residency because he or she has not met the requirements for general or specialist registration. This may be because the individual is a temporary resident and therefore unable to access appropriate training. There are several medical training programs which carry this limitation, and there are others that aim to meet the professional and education needs of OTDs, for example the recently commenced OTDNET program funded through GPET.
Since 2009, as part of the Council of Australian Governments (COAG) agreement to establish nationally consistent assessment processes for OTDs, the AMC and a number of other organisations have been funded to undertake pilot programs of workplace based assessment (WBA) specifically aimed at OTDs who have limited registration and are required to achieve general registration within the time limit specified by the MBA. The express intention is to provide an alternative route to registration to the AMC’s clinical examination, which is currently oversubscribed. (The AMC is at full capacity at 1,600 clinical examination places per year with intense demands being placed on the time of existing examiners. Advice is that the AMC is unable to increase places to meet current demand.) A number of submissions to the HoR Standing Committee Inquiry supported a comprehensive rollout of WBAs as a way of OTDs meeting the requirements for general registration.
Recent increases in the number of health students have placed additional pressure on the availability of clinical training placements across all health professions, including medicine. Stakeholders have highlighted the continuing difficulties for OTDs in obtaining the requisite level of supervision as a barrier to meeting the MBA requirements for general registration, both in metropolitan and rural areas. The COAG Health Workforce Reform package and HWA’s Clinical Training Program are to an extent addressing this issue, which is now attaining some urgency.
Issues relating to section 19AB of the Act
Historically, access to medical services has always diminished with distance from major centres, and some rural and remote areas will always find it particularly difficult to attract and retain suitably qualified medical practitioners. Interventions to address maldistribution include incentives to work in areas that are difficult to recruit to, and restriction on where some medical practitioners can work if they wish to access the Medicare benefits arrangements. Workforce distribution levers such as s. 19AB of the Health Insurance Act 1973 have been successful in directing OTDs into priority areas such as general practice, districts of workforce shortage, after-hours clinics, locum services and accredited Aboriginal Medical Services.
Workforce location is also influenced by registration requirements. OTDs are able to enter and work in Australia with limited professional registration if they agree to practise in an AoN. They can obtain a Medicare provider number if they work in a DWS. Together, these requirements mean that many newly arrived OTDs will have their first years of professional life in Australia in rural and remote areas often with minimal opportunity for professional support and ongoing training.
Ten year moratorium
The operation of the ten year moratorium requirement under s. 19AB (described in Box 6.1) continues to be criticised by a number of stakeholders most notably OTDs who are subject to provider number restrictions. The report of the HoR Standing Committee Inquiry recommended that the options for a ‘planned, scaled reduction in the length of the 10 year moratorium’139 be examined so that it aligns with the average length of the return of service obligations (RSO) applying to Australian participants of the Bonded Medical Places scheme.
There is some evidence to suggest that the ten year moratorium requirement has had a positive impact in achieving a more equitable distribution of the Australian medical workforce by increasing the number of medical practitioners practising within DWS areas. However, it is difficult to differentiate between the impact of this requirement and the impact of other medical workforce distribution initiatives such as the bonded schemes and the introduction of scaling140 in improving access to doctors in rural areas.
Any change to the operation of the ten year moratorium requirement would also need to be considered against the operation of s. 19AA of the Act. Currently, temporary resident medical practitioners are considered to satisfy the vocational recognition requirements of s. 19AA of the Act if they hold a valid exemption under s. 19AB(3) of the Act.
If the ten year moratorium requirement were to be reduced, this may have negative impacts on some OTDs who may not easily transition to permanent residency or hold general medical registration. Specifically, these medical practitioners may have difficulties in obtaining approved specialist program placements and obtaining a Medicare provider number.
The current operation of s. 19AB of the Act requires that OTDs and FGAMS who are subject to the ten year moratorium requirement hold a valid s. 19AB(3) exemption in order to access a Medicare provider number. Section 19AB of the Act states that applications for s. 19AB(3) exemption are processed within a statutory timeframe of 28 days by the Department and that a s. 19AB(3) exemption cannot be backdated under any circumstances.
The inability to backdate s. 19AB(3) exemptions has led to situations where OTDs and FGAMS have experienced problems for failing to renew a Medicare provider number, meaning that their patients are not eligible for Medicare rebates. These matters can be resolved through the discretionary ‘Act of Grace’ compensation process offered by the Department of Finance and Deregulation under s. 33 of the Financial Management and Accountabilities Act 1997, however this is often a long and protracted process.
As the majority of the OTDs and FGAMS are practising within DWS areas for their specialty, there is a perception that the Department is penalising these medical practitioners unduly for an oversight.
If the no-backdating provisions under the Act could be legally amended to provide some flexibility to account for simple oversights, OTDs and FGAMS who are practising within DWS areas would have a greater sense of support and a degree of assurance that their patients are able to access rebates for their services. The department should therefore investigate the ways in which this no-backdating provision may be amended.
Use of different geographical classification systems across programs
All stakeholders consulted during the course of this review demonstrated a clear understanding of the maldistribution of Australia’s medical workforce. Several of the Department’s programs seek to address this by providing incentives for medical practitioners to practise in communities within DWS or regional, rural or remote areas. As discussed in Chapter 4, DoHA utilises a number of different geographical classification systems across its programs. Combined with the use of DWS and the state-based AoN determinations for establishing an OTD’s eligibility for registration, the current arrangements add an unreasonable level of complexity for OTDs who are attempting to navigate an unfamiliar framework of legislation and regulatory requirements imposed by different levels of government and the medical profession.
The complex issues relating to the continued concurrent use of multiple geographic classification systems for the purpose of workforce distribution programs and activities are discussed below.
|Recommendation number||Recommendation||Affected programs||Timeframe|
|Recommendation 6.1||the Department should continue to work with medical professional groups, including the specialist colleges, to identify opportunities to improve professional support for overseas trained doctors (OTDs) in rural and remote areas. Support should be targeted to help doctors to meet the requirements for general and specialist medical registration, and provide ongoing peer mentoring particularly for OTDs in rural and remote areas.||Nil||Short term – ongoing.|
|Recommendation 6.2||Funding for Rural Workforce Agencies (RWAs) to deliver the International Recruitment Strategy (IRS) and recruitment and retention activity under Health Workforce Australia’s (HWA’s) International Health Professionals Program (IHPP) should be consolidated through one fund-holder.
The most appropriate organisation to take on the fund-holder role should be negotiated with Rural Health Workforce Australia, HWA and the RWAs. If RWAs are to have a continuing role in this program, consideration should be given to enabling them to receive recruitment payments at the end of each funding period.
|IRS, HWA (IHPP)||Medium term|
|Recommendation 6.3||The Commonwealth should explore opportunities to provide additional information about Medicare provider number restrictions to ensure OTDs have full and accurate information before accepting job placements.||Nil||Short term|
|Recommendation 6.4||The Commonwealth should give detailed consideration to the legislative changes and practical implementation requirements that would be needed to enable OTDs and their families to access Medicare rebates for health services received as patients. If access to Medicare cannot feasibly be delivered other support mechanisms should be considered to ensure reasonable access to health care for providers supporting the community. Consideration of this issue may also need to be extended to other overseas trained health professionals.||MBS||Medium term – subject to costing analysis, consideration of implications for Medicare and other policy areas (e.g. Immigration) and available funding.|
|Recommendation 6.5||The Commonwealth should consider amending s. 19AB of the Health Insurance Act 1973 to allow for the backdating of s. 19AB(3) exemptions, under limited circumstances.||MBS||Longer term|
|Recommendation 6.6||The Commonwealth, through its role on the Standing Council on Health, should continue to encourage efforts to deliver a shared electronic repository for documents relating to the registration and employment of new OTDs, noting HWA’s current work with the Australian Health Practitioners Regulation Agency and the medical profession on this issue. The current requirements for multiple lodgement, inconsistent lodgement dates and formats are significant obstacles to effective workforce administration.||HWA||Longer term|
131 AIHW Medical Labour Force 2009; AIHW Nursing and Midwifery Labour Force, 2009. Comparable figures are not available for the allied health professions.
132 Council of Australian Governments, National Health Workforce Strategic Framework, 2004
133 See, for example, pages 16 – 20 of the House of Representatives Standing Committee on Health and Ageing report, Lost in the Labyrinth, 2012
134 HWA, HW2025 Vol 1 p. 24
135 The process for determining ‘districts of workforce shortage’ (DWS) and how these differ from state-based ‘Areas of Need’ determinations is discussed later in this chapter.
136 The Hon Mark Butler MP, “$17.69 Million to Boost Health Workforce in Regional and Remote Areas”, Media release, 4 October 2012
137 Department of Health and Ageing, Annual Report 2011-12, Commonwealth of Australia, p. 260
138 Costs for Overseas Visitors Health Cover in 2009 for a standard policy were approximately $5,400.
139 House of Representatives Standing Committee on Health Ageing, Lost in the Labyrinth: Report on the inquiry into registration processes and support for overseas trained doctors, Recommendation 27.
140 The scaling initiative was announced in the 2009-10 Federal Budget as part of the Rural Health Workforce Strategy. It applies to a range of government programs including rural incentive payments and programs with a return of service obligations such as the BMP Scheme, based on the principle of providing greater incentives for more remote areas. For OTDs and FGAMs it is a non-cash incentive that provides opportunities to reduce the ten year moratorium restriction period such as through the Five Year Overseas Trained Doctor Scheme.