There have been repeated government promises to establish a nationally consistent assessment system for overseas trained doctors (OTDs). No such assessment has been put in place. As a result, each year, thousands of OTDs are being appointed to practice medicine in Australia without a preliminary systematic test of their medical knowledge and clinical skills calibrated to Australian standards. This article explores why the medical authorities, including the Australian Medical Council and the state Medical Registration Boards allow this situation to continue. It also examines some of the consequences for medical service provision in Australia.
Readers of People and Place will be aware of our previous reports on this issue. (1) These reports have documented Australia's growing dependence on overseas trained doctors (OTDs) and our concern about deficiencies in the assessment of these doctors prior to their practice of medicine here.
The reason for returning to the issue is that there is still no resolution to it. This is despite successive official promises to rectify the situation and increasingly frantic calls for these promises to be implemented. The latest official promise is that of the Council of Australia Governments (COAG) which stated that the federal and state governments will establish a national process for the assessment of OTDs by December 2006. (2) The most recent call for action comes from a report of the Joint Standing Committee on Migration of the Commonwealth Parliament, which recommended in September 2007 that:
in the light of the serious concerns raised during the inquiry about skills assessment processes for overseas trained doctors (OTDs) the Department of Health and Ageing, together with the Department of Immigration and Citizenship, will work to ensure initiatives announced by the Council of Australian Governments to establish a national process for the skills assessment of OTDs are implemented as a matter of urgency. (3) There is no compulsory assessment of OTDs on a nationally consistent basis because Australia's dependence on OTDs is increasing in the face of a chronic shortage and maldistribution of doctors trained in Australia. In these circumstances the state and federal health authorities are reluctant to require a compulsory assessment for fear that it would jeopardise future flows of such OTDS. The chronic shortage is evident among specialists, particularly surgeons in regional locations, among hospital medical officers and among general practitioners. The Australian government has recently increased the level of domestic medical training, but it will be a decade before this increase helps solve the present shortage problem. Even then there is no guarantee that the additional doctors will go into the specialties and regions that have the worst workforce shortages.
We first ask whether there are any other solutions to this shortage besides increased recruitment of OTDs. The answer is that there may be but, as suggested shortly, they are not politically acceptable and/or feasible. This still leaves the question, if Australia must depend on OTDs, why does the supply imperative trump concerns about medical standards, especially in the aftermath of the 'Dr Death' affair in Queensland? There are two organisations in Australia whose task it is to protect medical standards--the Australian Medical Council and the various state Medical Registration Boards. There is nothing in their charters that allows them to compromise standards in the interest of supply.
GOVERNMENT MEASURES TO MAKE BETTER USE OF DOCTORS TRAINED IN AUSTRALIA
Doctors trained in Australia receive a massive subsidy from the taxpayer to finance their education, and once they begin employment most of their (substantial) income comes from the taxpayer via the Medicare system. Few medical service consumers would question this arrangement. Nonetheless, just as teachers in the government's employment are deployed where they are needed, there is a case for ensuring that doctors too, serve where they are most needed.
The Australian Commonwealth could ration provider numbers to this end, thus stopping excessive numbers of doctors from servicing general or specialist practices in the metropolitan areas. The evidence of maldistribution of general practitioner (GP) services is palpable. Typically, non-metropolitan divisions of general practice show at least 50 per cent higher numbers of people to full-time work equivalent (FWE) GPs than is the case for metropolitan divisions. For example, there were 763 people per FWE GP in the Eastern Sydney division compared with 1647 in the NSW coastal division of Hastings Macleay and 2157 in the North West Slopes division in northern NSW. (4)
The Commonwealth has not been prepared to ration provider numbers, perhaps because of fears that such measures would be challenged on constitutional grounds. Alternatively, the Commonwealth could reward regional providers with substantially higher service fees than those available for metropolitan services. It has not been prepared to do this either, perhaps because of the cost. These measures would also be fought by organised medicine in Australia. There are a range of Commonwealth and state programs that provide financial incentives for doctors to locate in regional areas, but these appear to be having little impact in prompting domestic doctors to move from metropolitan areas.
One strategy being implemented is to tie the allocation of new medical school places to students willing to accept a bond requiring them to serve in a district of workforce shortage when they have completed their medical degree and vocational training. There are currently hundreds of medical students on such bonds. Whether this arrangement will work remains to be seen. This is because those affected, and those who accept medical scholarships tied to subsequent rural service, who prefer to remain in a metropolitan area are likely to have the resources to buy themselves out of the bond once they are employed.
RELIANCE ON OTDs
In practice, the Commonwealth and state governments have prioritised the recruitment of OTDs as the prime solution to medical shortages outside metropolitan areas. Employers with vacancies defined as in 'areas of need', where the relevant state health departments believes no resident doctor can be attracted on the financial terms offered, can sponsor these doctors to Australia on four-year (renewable) temporary visas--usually the 457 visa--without any formal assessment of their medical...