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1 Australia s Health Workforce Series Doctors in focus 2012

2 Enquiries concerning this report and its reproduction should be directed to: Health Workforce Australia This work is copyright. It may be reproduced in whole or part for study or training purposes only, provided that the acknowledgment below is included. Any reproduction for purposes other than those indicated above, or otherwise not in accordance with the provisions of the Copyright Act 1968 or any other legal obligation, requires the written permission of Health Workforce Australia (HWA). Health Workforce Australia GPO Box 2098, Adelaide SA 5001 T F E [email protected] Citation: Health Workforce Australia 2012, Australia s Heath Workforce Series - Doctors in focus, Health Workforce Australia: Adelaide

3 Australia s Health Workforce Series Doctors in focus 2012

4 The health of our people is critical to our national economy, our national security and, arguably, our national identity. Our own health and the health of our families are key determinants of our wellbeing National Health and Hospitals Reform Commisson

5 Contents Introduction... 1 How many doctors?... 3 Type of practitioner Type of specialist Gender profile Age profile Hours worked Where are doctors located? State and territory distribution Regional distribution How many doctors is Australia training? Students and graduates Interns Vocational medical training and fellows How many doctors are from overseas? Visas granted Countries of origin Assessment pathways In closing... 37

6 Introduction There are significant challenges facing Australia s health workforce now and into the future, including an ageing population, expected increased demand for health services and increasing expectations for service delivery, changing burden of disease and broader labour market issues. Such challenges are well documented in a number of publications including the Productivity Commission s 2005 report Australia s Health Workforce and The Treasury s Intergenerational Report. Health Workforce Australia (HWA) is an initiative of the Council of Australian Governments and was established to address the challenges of providing a skilled, flexible and innovative health workforce that responds to the needs of the Australian community. To be able to plan for these Doctors play a vital role in maintaining our health and wellbeing. For most people, their first contact with the health system is through a general practitioner. future challenges, it is imperative to understand the existing workforce, its size and characteristics and origins. To this end, HWA designed the Australia s Health Workforce series, to focus on describing particular professions, settings and issues of interest to provide the context for understanding future health workforce challenges. This is the first issue in the Australia s Heath Workforce series and in this issue doctors in Australia are in focus. Information is brought together from various sources to provide a picture of Australia s existing doctor workforce. In 2009 the National Health and Hospitals Reform Commission noted The health of our people is critical to our national economy, our national security and, arguably, our national identity. Our own health and the health of our families are key determinants 1 Health Workforce Australia

7 of our wellbeing. 1 Doctors play a vital role in maintaining our health and wellbeing. For most people, their first contact with the health system is through a general practitioner (GP). People can choose their own GP and GPs often act as gatekeepers to the rest of the health system, by making patient referrals to specialist services. With an increasingly important focus on reducing demand for health care through early intervention, GPs also have an important role to play in advising on wellness and prevention strategies. However GPs form only one component of the medical workforce in Australia s health system. Other specialist medical practitioners exist within numerous settings including public and private hospitals and community based settings; with doctors often working together and in concert with other health workforce participants such as nurses, carers and allied health professionals to provide care for patients with complex conditions. Playing such a critical role in Australia s health system and in maintaining people s health, it is important to examine and understand the changing face of Australia s doctors. Data sources used The main data sources used in this report are: The Australian Institute of Health and Welfare (AIHW) Medical Labour Force Survey. This survey collects information about the demographics and employment of individuals registered in the medical profession. The medical labour force survey was conducted annually up to 2009, with the questionnaire administered by the state and territory registration boards, in conjunction with the registration renewal process. Response to the AIHW survey was voluntary and the variability of response rates is a limitation of the data. In 2009, the response rate for the medical survey was 53%. The response rate declined in later years, with AIHW suggesting estimates for Victoria, Queensland, Western Australia, Tasmania and the Northern Territory be interpreted with caution due to low response rates. As such, this article focuses at a national level. From 2010, the labour force survey is administered through the new national registration body, the Australian Health Practitioner Regulation Agency (AHPRA), on behalf of HWA, as part of the National Registration and Accreditation Scheme. This scheme commenced on 1 July 2010 and means for the first time in Australia the ten health professions covered by the scheme are regulated by nationally consistent legislation. The new scheme provides the opportunity for enhanced information on our health labour forces. Information on the various steps in the medical education pathway was sourced from data published in the Medical Training Review Panel Fourteenth Report (MTRP). In particular, data on undergraduate medical students and medical graduates is from the Medical Deans of Australia and New Zealand s Student Statistics Collection, which is conducted annually. Information on prevocational medical training is obtained from state and territory health departments; information on vocational medical training is from the specialist medical colleges and General Practice Education and Training. Department of Immigration and Citizenship (DIAC) administrative data includes applications granted to medical professionals for visa types: temporary business long stay (subclass 457); occupational trainee (subclass 442); medical practitioner temporary (subclass 422); general skilled migration and employer sponsored migration outcomes. (1) A Healthier Future For All Australians Final Report of the National Health and Hospitals Reform Commission June Australia s Heath Workforce Series - Doctors in focus 2

8 How many doctors? In 2009 there were 82,895 doctors registered in Australia (excluding multi-state registrations), with the majority (90%) in the medical labour force (either working, looking for work or on leave). Of those in the medical labour force, almost all were working (72,739 or 98%) at the time of the survey. Most (93%) were working as clinicians, that is, doctors who spend most time working on the diagnosis, care and treatment of patients. Non-clinicians, or those doctors that reported they spent most of their time not involved in clinical practice, made up less than 10% of working doctors. Nonclinicians include administrators, teachers or educators, researchers, public health physicians and occupational health physicians. Over the last decade, the number of registered doctors has increased by almost half (44%), rising from 57,553 registrations in The number of working doctors increased by a similar amount (45%) over the same timeframe, rising from 50,223. While overall numbers of registered and working doctors increased substantially from 1999 to 2009, their distribution across the workforce is similar. 3 Health Workforce Australia

9 Figure 1: Registered medical practitioners by labour force status, 2009 All medical practitioner registrations in states and territories in ,261 Registered medical practitioners 82,895 (91.8%) Multi-state registrations 7,366 (8.2%) In medical labour force in Australia 74,260 (89.6%) Not in medical labour force in Australia 8,636 (10.4%) Employed elsewhere and not looking for work in medicine 840 (9.7%) Not employed, not looking for work 2,654 (30.7%) Retired from work 2,111 (24.4%) Australian-registered medical practitioners working overseas 3,030 (35.1%) Currently employed in medicine 72,739 (98%) On extended leave 1,154 (1.6%) Looking for work in medicine 366 (0.5%) Clinicians 67,613 (93.0%) Non-clinicians 5,127 (7.0%) Employed elsewhere 62 (17.0%) Not employed 304 (83.1%) Primary care practitioners 25,707 (38.0%) Hospital non-specialists 7,677 (11.4%) Specialists 24,290 (35.9%) Specialists-in-training 9,154 (13.5%) Other clinicians 785 (1.2%) Source: AIHW Medical Labour Force Survey 2009 For example, in 2009: 90% of registered doctors were in the medical labour force (88% in 1999) 98% of those in the medical labour force were employed (99% in 1999) Most working doctors (93%) were employed as clinicians (92% in 1999). As it is working doctors who provide services to the community, the remainder of this article focuses on those working or employed doctors, rather than all registered doctors. While overall numbers of registered and working doctors increased substantially from 1999 to 2009, their distribution across the workforce is similar. Australia s Heath Workforce Series - Doctors in focus 4

10 How does Australia compare internationally? Chile (b) Turkey (b) Korea Mexico Poland Japan Canada (b) United States Slovenia New Zealand United Kingdom Finland Luxembourg Netherlands (b) Ireland (b) Belguim Australia Hungary France (b) Estonia Israel Denmark Spain Czech Republic Iceland Germany Sweden Portugal (c) Switzerland Norway Austria Greece (b) International comparisons are useful and allow for examination of performance against the experiences of other countries. The OECD produces a range of key indicators for international comparison one of which is the number of physicians per 1,000 population. Australia s ratio of physicians (3 per 1,000) is similar to many other developed countries. Figure 2: Physicians (a), density per 1,000 population - headcount, OECD countries, 2008 (a) Practicing physicians, those providing care directly to patients. (b) Professionally active physicians, which includes practising physicians plus other physicians working in the health sector as managers, educators, researchers, etc. (c) All physicians who are licensed to practice. Source: OECD Health Data Number 5 Health Workforce Australia

11 Type of practitioner While the ratio of clinicians to nonclinicians remained similar from 1999 to 2009, the composition of the clinician workforce is changing. The clinical workforce is made up of: Primary care practitioners while primary care practitioners are mostly GPs, the definition is broader and encompasses those practitioners who: were employed at the time of the survey; spent most of their time the week prior to the survey as a clinician; and reported their main area of clinical practice as primary or general care. Specialists doctors with a qualification awarded by or deemed equivalent to that awarded by, a specialist college in Australia to treat certain conditions. Specialists-in-training doctors who have been accepted by a specialist college into a supervised training position. A key focus of government reform has been to strengthen primary health care. In relation to GPs, this has seen significant increases in GP training places. Table 1: Employed clinical doctors by type, 1999 and 2009 Hospital non-specialists doctors mainly employed in a salaried position in a hospital who do not have a recognised specialist qualification and who are not in training to gain a recognised specialist qualification. This includes interns, resident medical officers, career medical officers and other salaried hospital practitioners. Other clinicians doctors who do not report as belonging to any of the categories above. This category was first identified separately in 2006, and in 2009, doctors classified as other clinicians comprised approximately 1% of working doctors. In the following analysis, this group is not identified separately due to the size of the category, however they are included in totals where applicable. While doctor numbers increased across all clinician types, primary care practitioners, Change 1999 to 2009 Average annual growth 1999 to 2009 Primary care practitioner Specialist Specialist-in-training Hospital non-specialist 20,616 16,459 4,455 4,469 no. no. % % 25,707 24,290 9,154 7, Total 45,999 67,613 (a) (a) Includes other clinicians. Source: AIHW Medical Labour Force Survey 1999 and 2009 National Clinical Supervision Support Framework 6

12 although having the highest numbers of doctors overall, experienced the smallest percentage growth over the period 1999 to Specialistsin-training experienced the greatest percentage increase, more than doubling in number over the period 1999 to 2009 (Table 1). Consistent with primary care practitioners experiencing the lowest percentage growth from 1999 to 2009, this group has also fallen as a proportion of all working doctors. In 1999 primary care practitioners accounted for 41% of all working doctors, falling to just over a third (35%) in This was countered by increases in specialists-in-training (increasing four percentage points to 13% of all working doctors) and hospital non-specialists (increasing to 11% from 9%) (Figure 3). Joyce and McNeil 2 suggested reasons for medical graduates being less inclined to enter general practice may include: the perception that general practice is less prestigious than other specialties; reports of low morale, high workload, heavy administrative burden and poor job satisfaction negatively influencing career choices; tightening of training requirements in late 90s including compulsory rural placements, making it less attractive compared with other specialties. In recent years however, a key focus of government reform has been to strengthen primary health care. In relation to GPs, this has seen significant increases in prevocational and vocational GP training places the number of prevocational training places will increase from approximately 400 to 975 in 2014 and the number of vocational training places will increase from 600 to 1,200 by These increases may impact on the proportion of doctors becoming GPs. General practitioner numbers - Medicare Medicare is another source of medical practitioner data, holding substantial data on the general practitioner workforce. Medicare data and AIHW Medical Labour Force Survey data are collected differently Medicare is an administrative collection while AIHW is a voluntary self-reported survey. Differences in methodologies and definitions account for different results in the two collections. GP headcount is a count of all GPs who provided at least one Medicare Service during the reference period and had at least one claim for Medicare Service processed during the same reference period. This data shows slowly increasing GP numbers, with an average annual growth of approximately 1% from to Another measure used to examine the GP workforce is full-time workload equivalent (FWE). FWE provides a standardised measure to estimate workforce activity of GPs, adjusting for the partial contribution of parttime doctors. FWE is a measure of service provision and has experienced a slightly higher rate of average annual growth over the period to (2%) compared with GP headcount numbers. Table 2: General Practice Workforce Statistics, and Headcount Full-time workload equivalent (a) ,147 16,433 Change 1999 to 2009 Average annual growth 1999 to 2009 no. no. % % 26,613 19, (a) Full-time workload is calculated by dividing each doctor s Medicare billing by the average billing of full-time doctors for the reference period. Source: Medicare, Internal DoHA, October 2010, viewed on Department of Health and Ageing website 30 August (2) Joyce CM and McNeil JJ 2006 Fewer medical graduates are choosing general practice: a comparison of four cohorts, Medical Journal Australia, Volume 185 Number 2; Health Workforce Australia

13 Figure 3: Type of clinician as a proportion of all employed doctors, 1999 to 2009 Proportion of employed doctors (%) Source: AIHW Medical Labour Force Survey 1999 to 2009 Primary care practitioner Specialist Hospital non-specialist Specialist-in-training Australia s Heath Workforce Series - Doctors in focus 8

14 Type of specialist The AIHW medical labour force survey asks specialists to report their main field of specialty, with information published for 54 specialty fields in Despite the large number of specialty fields, most doctors are concentrated amongst a small number, with the top 10 specialty fields accounting for 62% of all specialists in This was similar to 1999, where the top 10 specialties accounted for 64% of all specialists. It should be noted that GPs are not included in this analysis, as they are considered separately as primary care practioners in the AIHW medical labour force survey. The specialty fields with the highest numbers have remained almost the same from 1999 to While the order was slightly different between the two years, the only change in specialty fields was the inclusion of emergency medicine in the top 10 in 2009 (whereas general medicine was included in 1999). Emergency medicine experienced significant increases in both numbers and percentage from 1999 to 2009 increasing by almost 200% (674 specialists) over the period. This largely reflects the fact that emergency medicine is a relatively recently established medical specialty it was first recognised as a principal specialty in Emergency medicine had the second highest percentage increase over the period 1999 to 2009 (behind occupational medicine, which has small specialist numbers, reaching 65 in 2009) and the third highest absolute increase (behind anaesthesia and psychiatry). Most doctors are concentrated amongst a small number of areas, with the top 10 specialty fields accounting for 62% of all specialists in Health Workforce Australia

15 Table 3: Specialists (a), Top 10 main specialties of practice, 1999 and 2009 Main specialty Specialists Proportion no. % Anaesthesia Psychiatry Diagnostic radiology Obstetrics & gynaecology General surgery Paediatric medicine Orthopaedic surgery Ophthalmology General medicine Cardiology Other specialties 2,060 1,988 1,109 1,089 1, , Total 16, Main specialty Specialists Proportion no. % Anaesthesia Psychiatry Obstetrics & gynaecology Diagnostic radiology Paediatric medicine General surgery Orthopaedic surgery Emergency medicine Ophthalmology Cardiology Other specialties 3,424 2,682 1,514 1,470 1,184 1,116 1,089 1, , Total 24, (a) Practitioners who spent most of their time as clinicians only. Source: AIHW Medical Labour Force Survey 1999 and 2009 New fellows To become a specialist, a doctor must complete a recognised medical specialty training program through a provider accredited by the Australian Medical Council. A person must succeed through a competitive selection process to become part of a specialty program, with most programs requiring trainees to successfully complete both clinical and practical exams, and exit exams, in order to qualify for fellowship of the college. The time required to complete specialist training varies according to specialty, and can range from three to seven years full-time. Successful trainees are referred to as new fellows, with each accredited college collecting information on the number of new fellows. Although considered primary care practitioners in the AIHW medical labour force survey, general practice admitted the highest number of new fellows in This was followed by adult medicine (which includes a range of specialties such as cardiology, gastroenterology and hepatology, geriatric medicine and medical oncology). Table 4: New fellows by specialty, 2009 Medical specialty No. Addiction medicine 6 Adult medicine (a) 397 Anaesthesia 197 Anaesthesia - Pain medicine 9 Dermatology 11 Emergency medicine 82 General practice RACGP 928 ACRRM 40 Total General practice 968 Intensive care 63 Medical administration 9 Obstetrics and Gynaecology 56 Occupational & environmental medicine 11 Ophthalmology 11 Paediatrics 116 Palliative medicine 8 Pathology 64 Psychiatry 125 Public health medicine 12 Radiation oncology 18 Radiodiagnosis 44 Rehabilitation medicine 13 Sexual health medicine 1 Surgery (a) 174 Total 2,395 (a) Includes all new fellows admitted by both the Australian and New Zealand branches and overseas trained specialists. Source: Medical colleges, cited in Medical Training Review Panel Fourteenth Report. Australia s Heath Workforce Series - Doctors in focus 10

16 Gender profile Increased female workforce participation is documented across a number of professions and this is also reflected in the medical workforce. In 1996 the Australian Medical Workforce Advisory Committee published Female Participation in the Australian Medical Workforce, which stated that The female medical workforce is growing at a much faster rate than the male medical workforce and it is projected that women will comprise 30% of the medical workforce by 2000 and 42% of the medical workforce by This observation is still relevant while males formed the greatest proportion of working doctors in 2009 (64% or 46,750) compared with females 50 (36% or 25,989), the number of females is still increasing at a greater rate than males. From 1999 to 2009 the number of female doctors rose by more than three-quarters (11,471) while the number of male doctors rose 31% (11,045). This can be expected to continue as across 2000 to 2010 more than half of all medical students were female. 3 This increase in participation is reflected in females forming a greater proportion of working doctors. In 1999 females comprised 29% of all working doctors, rising to more than one-third (36%) of all working doctors in Similar patterns were repeated across clinician types, with females accounting for 39% of the Figure 4: Female clinicians as a proportion of all employed doctors, 1999 to 2009 Proportion of employed doctors (%) Primary care practitioners Specialists Hospital non-specialists Specialists-in-training Source: AIHW Medical Labour Force Survey 1999 to 2009 (3) Medical Training Review Panel Fourteenth Report 11 Health Workforce Australia

17 The number of female doctors is increasing at a greater rate than the number of male doctors. primary care practitioner workforce (which includes GPs) in 2009 (rising 6 percentage points from 1999) and 47% of hospital nonspecialists (rising 9 percentage points from 1999) (Figure 4). Females are least represented amongst specialists (excluding GPs), accounting for one-quarter of all specialists in Reasons for this may include the length and structure Specialty Females Persons % Females Anaesthesia Psychiatry Obstetric & gynaecology Paediatric medicine Diagnostic radiology ,424 2,682 1,514 1,184 1, of specialist training, family considerations and work considerations in terms of hours worked and time on call. 4 However, consistent with trends across other clinician types, the proportion of female specialists has been increasing (rising 7 percentage points from 1999). This can be expected to continue with the increasing proportion of females in the training pipeline the proportion of female specialists-in-training rose from 36% in 1999 to 44% in Females are more highly represented amongst specialties that provide greater flexibility 4, with the greatest numbers working in anaesthesia, psychiatry and obstetrics and gynaecology. Female specialists demonstrate low participation in surgery, with three of the five specialties with the least number of females being surgery specific (Table 5). Higher proportions of females are in advanced training positions/trainees in obstetrics and gynaecology, general practice, paediatrics, rehabilitation medicine and public health medicine across 2006 to Over the same period, surgery has maintained consistently lower proportions of female advanced trainees, ranging from 18% in 2006 to 23% in Table 5: Specialties with highest and lowest (a) number of female clinicians, 2009 Specialty Females Persons % Females Cardiothoracic surgery Pain medicine Other surgery Paediatric surgery Occupational medicine (a) Clinical immunology, clinical pharmacology, cytopathology, immunology, medical administration and other were not categorised by gender due to confidentiality, therefore the lowest listed in this table excludes those specialties. Source: AIHW Medical Labour Force Survey (4) AMWAC. Influences on Participation in the Australian Medical Workforce (5) Medical Colleges and GPET, cited in Medical Training Review Panel Fourteenth Report Australia s Heath Workforce Series - Doctors in focus 12

18 Age profile A considerable literature exists about Australia s ageing population. Effects of this demographic change will include a smaller pool of working age people from which we can draw our health workforce and a larger pool of older Australians who will consume more health care services. The age profile of the medical workforce is therefore important for planners in anticipating the impact on supply of workforce attrition due to retirement. Information on average age is presented, which indicates the most common age within the workforce group; and information on the percentage of doctors aged 55 years and over, which can be a useful indicator of those potentially retiring or reducing working hours within the next 10 years. The average age of doctors was similar in 1999 and 2009, at 46.0 and 45.6 respectively, with males having a higher average than females in both years (Table 6). Table 6: Employed doctors, age profile by gender, 1999 and 2009 Male Female 1999 no Average age 2009 no Proportion aged 55 & over 1999 % % Persons Source: AIHW Medical Labour Force Survey 1999 and Health Workforce Australia

19 Average age differs by practitioner type primary care practitioners and specialists are older, both with average ages of Hospital non-specialists, which is primarily comprised of resident medical officers and interns (with an average age of 33.5) and specialists-in-training (average age 33.1) are younger. Both males and females have average ages in the year cohort (Table 6), however their age profiles are different. Almost one-third (31%) of working male doctors were aged 55 years or over in 2009 with 44% aged less than 45 years. Females have a younger age profile 13% of female working doctors were aged 55 years or over in 2009 while more than half (62%) were aged less than 45 years. In 1999 this pattern of older male working doctors (with 30% aged 55 years and over) and younger female working doctors (67% aged less than 45 years) was also evident (Figure 5). This is a reflection of the larger numbers of young females entering the medical workforce. A considerable literature exists about Australia s ageing population. Effects of this demographic change will include a smaller pool of working age people from which we can draw our health workforce and a larger pool of older Australians who will consume larger numbers of health care services. Figure 5: Employed doctors by age cohort and gender, 1999 and Proportion of employed doctors (%) > Males 1999 Females 2009 Males 2009 Females Source: AIHW Medical Labour Force Survey 1999 and 2009 Australia s Heath Workforce Series - Doctors in focus 14

20 Hours worked Doctors average weekly working hours are falling. In 2009 doctors were working an average of 42.2 hours per week, compared with 45.6 hours per week in The fall in average weekly working hours is attributed to two main causes the increasing participation of females in the workforce (highlighted earlier in this report) who historically work fewer hours than males, and the decreasing average working hours of males. Female doctors average weekly working hours in 2009 were 37.5 less than the overall average of However female doctors have experienced little change in their average weekly working hours over time, working an average of 38.4 hours in Male doctors average weekly working hours fell approximately four hours between 1999 and 2009, from 48.4 to This fall in male average hours has occurred across all age groups. Looking at male primary care practitioners, falls in average weekly working hours between 1999 and 2009 ranged from 2.4 hours for those aged 65 years and over to six hours for those aged 35 to 44 (Figure 6). 15 Health Workforce Australia

21 Figure 6: Male primary care practitioners (a), change in average weekly hours worked between 1999 and Figure 7: Employed male doctors by total weekly hours worked, 1999 and 2009 Proportion of employed male doctors (%) < Total Total hours worked per week Source: AIHW Medical Labour Force Survey 1999 and Age group (years) (a) Practitioners who spent most of their time as clinicians only. Source: AIHW Medical Labour Force Survey 1999 and The fall in average weekly hours worked is also reflected in male doctors patterns of total weekly hours worked. In 1999, most male doctors worked between 50 and 64 hours per week (14,712 or 43%). By 2009, the proportion of male doctors working between 50 and 64 hours per week fell 13 percentage points compared with 1999 to be 30%, with most (20,668 or 45%) working between 35 and 49 hours per week. For females, the highest proportion worked between 35 and 49 hours in both 1999 (35%) and 2009 (40%) (Figures 7 and 8). Figure 8: Employed female doctors by total weekly hours worked, 1999 and 2009 Proportion of employed female doctors (%) Total hours worked per week Source: AIHW Medical Labour Force Survey 1999 and Australia s Heath Workforce Series - Doctors in focus 16

22 Where are doctors located? In 2009 the Australian Capital Territory had the highest number of working doctors per 100,000 population (474), followed by the Northern Territory (443) and Tasmania (366). New South Wales had the lowest number of doctors per 100,000 population with 309, followed by Victoria with Health Workforce Australia

23 State and Territory distribution The number of working doctors across states and territories generally reflects population size, with the more highly populated states of New South Wales (30%), Victoria (25%) and Queensland (20%) accounting for the majority of working doctors in This was similar in 1999 when these three states accounted for over three-quarters (77%) of all working doctors. However on a working doctor per 100,000 population basis, the smaller states and territories have higher numbers of working doctors. In 2009 the Australian Capital Territory had the highest number of working doctors per 100,000 population (474), followed by the Northern Territory (443) and Tasmania (366). New South Wales had the lowest number of doctors per 100,000 population with 309, followed by Victoria with 333. In terms of other characteristics of working doctors, most state and territory experiences are similar to the national experience, where between 1999 and 2009: the proportion of female working doctors increased across all states and territories average age remained similar across most states and territories, except in Tasmania, where the average age of working doctors increased from 45 in 1999 to 49 in 2009; and in Victoria, where average age fell from 48 to 45 over the same period average hours worked fell across all states and territories. Table 7: Selected characteristics of working doctors, states and territories, 1999 and NSW (a) Vic b) Qld (a,b) SA WA (b,c) Tas (a,b) NT (b) ACT Australia 18,165 21, ,200 18, ,238 14, Number of working doctors 4,368 5,749 4,505 7,557 1,212 1,844 Number per 100,000 population Proportion female (%) Average age (years) n.a Average total weekly hours worked , ,035 1, ,223 72,739 n.a. not available (a) The number of medical practitioners in New South Wales, Queensland and Tasmania are underestimates as the benchmark figures did not include all registered medical practitioners. (b) Data for Victoria, Queensland, Western Australia, Tasmania and the Northern Territory may be affected by large falls in response rates between 2008 and 2009 and low response rates for particular age groups in Queensland. (c) The number of medical practitioners in Western Australia, for 2009, are based on general and conditional registrants. The benchmark data includes a significant number of registered medical practitioners that are no longer active in the workforce. This inflates the perception of the medical labour force in WA. In 1999, the number of practitioners are based on general registrants only. (d) Age was not collected in WA in 1999, therefore the Australian average age excludes WA. Source: AIHW Medical Labour Force Survey 1999 and (d) Australia s Heath Workforce Series - Doctors in focus 18

24 Regional distribution Geographic distribution of the health workforce is a significant issue, and has been recognised for a number of years. The National Health Workforce Strategic Framework 6 provided a set of principles guiding Australia s future health workforce policy and planning, in which an underlying principle was to achieve a health workforce that was distributed to provide equitable health care and outcomes for all Australians, regardless of location. Specific policies and programs exist to encourage doctors to work in rural and remote settings, including: the Bonded Medical Places scheme; the Medical Rural Bonded Scholarship scheme; the General Practice Rural Incentives Program; the five year Overseas Trained Doctor Scheme; and Medicare provider number restrictions for overseas trained doctors through Section 19AB of the Health Insurance Act However a range of factors exist that influence where doctors practise, including family, social and professional ties, lifestyle preferences and market forces; 7 and despite the programs in place, there continues to be variation in the availability of doctors in different regions of Australia. One measure of workforce availability is the ratio between the number of doctors and an area s population (noting that there is no internationally or nationally agreed ideal workforce to population ratio). In 2009, Major cities had the highest rate of doctors per 100,000 population (372). This rate was substantially higher than other remoteness areas, with Outer regional areas having the lowest rate at 188 per 100,000 population (Figure 9). However, across all remoteness areas, the ratio of employed doctors per 100,000 population has increased between 2001 and 2009: in Major cities, the ratio rose from 315 doctors per 100,000 to 372; in Inner regional areas, it rose from 173 to 212 doctors per 100,000; in Outer regional areas, it rose from 141 to 188 doctors per 100,000; and in Remote/Very remote areas, the ratio rose from 127 doctors per 100,000 to (6) Australian Health Ministers Conference (2004), National Health Workforce Strategic Framework, Sydney (7) Australian Medical Workforce Advisory Committee (1998) Sustainable Specialist Services: A Compendium of Requirements. AMWAC Report , Sydney (8) AIHW Medical Labour Force Survey 2001 and Care should be taken when interpreting 2009 figures for Remote/Very remote areas due to the relatively small number of employed medical practitioners who stated that their main job was located in this region. 19 Health Workforce Australia

25 Figure 9: Employed medical practitioners, number per 100,000 population by remoteness area, Australia Major cities Inner regional Outer regional Remote / Very (a) (b) remote Primary care practitioner Specialist Hospital non-specialist Specialist-in-training Remoteness Area Non-clinicians (a) Care should be taken when interpreting 2009 figures for Remote/Very remote areas due to the relatively small number of employed medical practitioners who stated that their main job was located in this region. (b) Includes Migratory. Source: AIHW Medical Labour Force Survey 2009; unpublished ABS estimated resident population data. The Remoteness Area Structure within the Australian Standard Geographical Classification (ABS Catalogue No ), produced by the Australian Bureau of Statistics, is used to present regional data for doctors. This structure is based on the Accessibility/Remoteness Index of Australia, where the remoteness index value of a point is based on the physical road distance to the nearest town or service in each of six population size classes based on the 2006 Census of Population and Housing. These classes are: Major cities Inner regional Outer regional Remote Very remote Data on Remote, Very remote and Migratory classes have been combined and reported as Remote/Very remote. Australia s Heath Workforce Series - Doctors in focus 20

26 Differences in the ratio of doctors per 100,000 population also exist across practitioner types. Primary care practitioners are the most evenly distributed, ranging from 99.3 primary care practitioners per 100,000 population in Outer regional areas to in Remote/Very remote areas. In comparison, specialists are most concentrated in Major cities (with specialists per 100,000 population). It should be recognised that ratios, while useful for broad comparisons, can mask detailed issues. For example, differences in service delivery models are not accounted for in ratios, and delivery in rural and remote settings can vary significantly to that in urban areas. For example, in a rural and remote area a doctor is more likely to deliver health services across acute, aged care and community settings and across traditionally separate professional disciplines, whereas in an urban setting, people often visit specialists within each setting and/or discipline. In recent years, there has been a call for a move away from specialisation and towards generalism for the rural health workforce. 9 General practice workforce statistics by Remoteness Area - Medicare Medicare statistics on general practitioners show that in terms of headcount, Very remote areas experienced the greatest percentage growth (both between points in time and average annual growth) over the period to Change from to Average annual growth to Remoteness area Headcount Headcount % % Major cities 16,768 18, Inner regional 3,836 5, Outer regional 1,881 2, Remote Very remote Full-time workload equivalent (a) In terms of full-time workload equivalent (a standardised measure estimating workforce activity of GPs adjusting for the partial contribution of part-time doctors), Inner regional areas experienced the greatest percentage growth, followed by Very remote areas. Table 8: General practice workforce statistics by Remoteness Area, and Full-time workload equivalent (a) % % Major cities 12,470 14, Inner regional 2,563 3, Outer regional 1,176 1, Remote Very remote (a) Full-time workload is calculated by dividing each doctor s Medicare billing by the average billing of full-time doctors for the reference period. Source: Medicare, Internal DoHA, October 2010, viewed on Department of Health and Ageing website 30 August (9) Pashen, D., Murray, R., Chater, B., Sheedy, V., White, C., Eriksson, L., De La Rue, S., Du Rietz, M. The Expanding Role of the Rural Generalist in Australia A Systematic Review. Australian College of Rural and Remote Medicine, Brisbane Health Workforce Australia

27 How many doctors is Australia training? To become a doctor in Australia, extensive education and training is required. Figure 10 depicts the Australian education pathway to become a doctor from tertiary education through to registration, to specialisation training and fellowship a process that can take up to 15 years full-time. It has been noted that a striking feature of medical workforce training has been the piecemeal, reactive nature of change over the past 20 years 10, with cyclical periods of contraction and expansion in medical education: In the 1970s, medical school intakes were expanded in response to perceived workforce shortages; In the 1980s, the view changed to a medical workforce in surplus, with reductions to medical school intakes recommended and implemented, and graduate numbers then reducing from the mid 1980s; The 1990s experienced little change from the 1980s, with medical school intakes remaining static; and The late 1990s saw a change in view, that the medical workforce was in undersupply. As a result medical school intakes expanded along with a number of new medical programs commencing from Given the length of time medical education takes, the impacts of the cyclical periods over the last 20 years are still being experienced and the long lead time means the more recent expansion phase will take some time to impact on medical workforce supply. (10) Harris M, Zwar N A, Walker C F, Knight S M 2011 Strategic approaches to the development of Australia s future primary care workforce Medical Journal Australia Supplement, Volume 194; S88-S91 (11) Joyce C M, Stoelwinder J U, McNeil J J, Piterman L 2007 Riding the wave: current and emerging trends in graduates from Australian university medical schools Medical Journal Australia, Volume 186; Australia s Heath Workforce Series - Doctors in focus 22

28 Figure 10: Medical education pathway in Australia YEAR st year medical students ,469 2nd and 3rd year medical students ,761 In final year of 4 year course 1,116 4th year medical students th year medical students 2010 In final year of 5 year course 651 In 4th year of a 5 year course 827 6th year medical students In 4th year of a 6 year course 869 In 5th year of a 6 year course 806 There are 18 universities with accredited medical schools in Australia. Course length ranges from 4 to 6 years. GRADUATION 2,380 students graduated from Australian medical schools in Commencing postgraduate year 1 doctors ,394 Medical graduates generally enter the medical workforce through public hospitals as interns. Satisfactory completion of the intern year is required before full medical registration. Full medical registration with the Medical Board of Australia 8 Commencing postgraduate year 2 doctors ,313 Vocational specialists training accredited by the Australian Medical Council Not all doctors choose to complete vocational training. Other options include research, non-vocational roles, or leaving the medical workforce Vocational medical training positions/trainees ,679 Limits exist on the number of vocational medical training positions and medical practitioners must pass a competitive process to be accepted. Vocational training duration ranges from 3 to 7 years full-time depending on specialty. Fellowship of a medical college New fellows ,395 Source: Medical Deans Australia and New Zealand Inc, State and Territory Government Health Departments; Medical Colleges and GPET, cited in Medical Training Review Panel Fourteenth Report 23 Health Workforce Australia

29 Students and graduates The Australian Government is responsible for higher education, including the allocation of Commonwealth supported places in medical programs. This includes a medical loading for clinical training that replaced funding perviously provided as teaching hospital grants. While higher education is moving to a demand-driven system where providers can enrol as many eligible students as they wish and receive corresponding government subsidies (as a result of the 2008 Review of Australian Higher Education), medical courses are a specific exclusion, allowing the government to regulate student and graduate numbers (other than full-fee paying students). As previously noted, medical school intakes have been expanding since 2000 and this is clearly reflected in the number of commencing medical students, which have more than doubled from 1,660 in 2000 to 3,469 in Medical school intakes have been expanding since 2000 and this is clearly reflected in the number of commencing medical students, which have more than doubled from 1,660 in 2000 to 3,469 in Figure 11: Commencing medical students, 2000 to ,000 3,500 3,000 2,500 2,000 1,500 1, Domestic International Source: Medical Deans Australia and New Zealand Inc, cited in Medical Training Review Panel Fourteenth Report. Australia s Heath Workforce Series - Doctors in focus 24

30 Within this, both Australian (domestic) and international commencing students increased Australian students by 116% (from 1,361 to 2,940) and international students by 77% (from 299 to 529) over the same period. Across all years from 2000 to 2010, more than half of all commencing medical students were female 12, which indicates the increasing participation of females in the profession noted previously in this report is likely to continue. Increasing numbers of medical commencements has translated into increasing numbers of medical graduates. In 2009 there were 2,380 medical graduates, the highest number over the past ten years. Numbers of graduates are projected to increase by more than 50% again from 2009 to 2015 (to reach almost 3,800 in 2015). 13 Types of student places A domestic student undertaking medical studies may occupy a Commonwealth Supported university place, where through the Higher Education Contribution Scheme, the student is required to pay for only part of the cost of the degree. In 2005, a full-fee paying option was introduced for domestic students, however this ceased to be available to domestic medical students in Many universities also take international medical students all international medical students are full-fee paying students. Universities set the number of international full-fee paying medical students they take, without Commonwealth or other jurisdictional involvement. Figure 12: Medical graduates, 1999 to 2015 (a) 4,000 3,500 3,000 2,500 2,000 1,500 1, Domestic International (a) Medical graduate numbers for 2010 to 2015 are projections. Source: Medical Deans Australia and New Zealand Inc, cited in Medical Training Review Panel Fourteenth Report. (12,13) Medical Training Review Panel Fourteenth Report 25 Health Workforce Australia

31 Distribution of medical students Medical education is provided by universities that have accredited medical schools, of which there are currently 18 in Australia. Jurisdiction distribution of students is determined by the location and places available in these universities, with New South Wales having the highest number of medical students a reflection of the fact they have the highest number of medical schools (six). Figure 13: Medical students by state/territory, 2010 Three of the six universities in New South Wales that offer medical courses only recently began to do so, two in 2007 and one in Victoria has both the highest number (724) and highest proportion (22%) of international medical students, while ACT has the lowest (17 and 5% respectively) , , , , ,606 Domestic International Source: Medical Deans Australia and New Zealand Inc, cited in Medical Training Review Panel Fourteenth Report. Australia s Heath Workforce Series - Doctors in focus 26

32 Interns Before being able to fully register as a doctor, medical graduates need to successfully complete an internship (also referred to as PGY1) year, which is predominantly completed in hospital settings within state and territory health systems. A public hospital internship is guaranteed for all Commonwealthfunded medical graduates, as a result of a commitment by the Council of Australian Governments (COAG) in This was further reinforced in 2010 by the Australian Health Ministers Conference (AHMC), which agreed to ensure all Commonwealth-funded domestic medical students would have access to clinical placements during their training and also that all such graduates would be able to undertake a public hospital internship. In line with the growth in medical graduates, states and territories have made a significant investment in internships. From 2004 to 2010, the number of commencing interns has steadily increased, rising by more than half (56%) from 1,531 to 2,394. In line with the growth in medical graduates, states and territories have made a significant investment in internships. From 2004 to 2010, the number of commencing interns has steadily increased, rising by more than half (56%) from 1,531 to 2, Health Workforce Australia

33 Figure 14: Postgraduate year 1: commencing trainees, 2004 to ,600 2,400 2,200 2,000 1,800 1,600 1,400 1,200 1, Source: State and territory government health departments, cited in Medical Training Review Panel Fourteenth Report. Training pipeline pressures With the increasing number of medical students and graduates, there are concerns about the pressure this is generating for the medical training pipeline 14,15 and on the ability of all medical graduates to gain an internship. The Australian Medical Association noted recently a significant increase in numbers of medical students enrolled in Australian medical schools has created additional pressures on the system to provide clinical training for medical students and junior doctors. 16 While Commonwealthfunded students are guaranteed an internship through the COAG and AHMC commitments, historically, many jurisdictions have extended this to cover all graduates completing their studies at universities within their jurisdiction. Since policy changes in 2003 enabled international medical students to remain in Australia and complete their intern year to obtain general medical registration, this has also encompassed these graduates. A number of strategies have been proposed to increase the training pipeline capacity to manage the influx of students and graduates, including greater use of new technologies, such as simulated learning environments and expanding training into a greater range of settings beyond traditional public hospitals. 14 (14) Joyce C M, Stoelwinder J U, McNeil J J, Piterman L 2007 Riding the wave: current and emerging trends in graduates from Australian university medical schools Medical Journal Australia, Volume 186; (15) Crotty B J. More students and less patients: the squeeze on medical teaching resources (editorial). Medical Journal Australia, Volume 183: (16) Australian Medical Association Position Statement on Prevocational Medical Education and Training 2011 Australia s Heath Workforce Series - Doctors in focus 28

34 Vocational medical training and fellows Specialist, or vocational, medical training is undertaken by most medical graduates after their university education and intern year. Most specialist medical training is provided by the state and territory health systems, with some partly funded by the Australian Government (general practice placements and some specialist training placements in the private and community sector). Training is provided through specialist medical colleges, training programs are accredited by the Australian Medical Council and the length of training can range from three to seven years full-time. For doctors, it is not necessarily a consecutive progression from their intern year straight into a vocational training program not all enter specialist training at the earliest opportunity and it is a competitive process to gain a position. Further information about vocational medical training and medical Figure 15: Vocational training positions/trainees, 2006 to ,000 14,000 12,000 10,000 8,000 6,000 4,000 2,000 0 college training requirements can be found in the Medical Training Review Panel Report. 17 In 2010, there were almost 14,700 vocational training positions/trainees across 23 broad medical specialties. The highest number of trainees were in adult medicine (3,310) and general practice (2,692 for GPET and ACCRM combined). Some medical colleges require a period of basic training prior to doctors being able to commence the advanced training program. Just over one-third (34%) of all vocational training positions/trainees were in basic training in Female doctors accounted for almost half (48%) of all advanced vocational trainees in Distribution across the specialties varied greatly less than a quarter of female doctors were in advanced vocational training in surgery (23%) Advanced Source: Medical colleges and GPET, cited in Medical Training Review Panel Fourteenth Report. (17) Total 29 Health Workforce Australia

35 and occupational and environmental medicine (19%) while almost two-thirds were in obstetrics and gynaeocology, paediatrics (both at 65%) and general practice (64%). 18 Consistent with increases in medical students, graduates and interns, vocational trainee numbers have also been increasing. Over the five years from 2006 to 2010, the total number of trainees rose from 9,317 to 14,679 (up 5,362 or 58%) with advanced trainee numbers rising 45% (from 6,514 to 9,432). (Figure 15). Upon successful completion of a specialty training program, a doctor becomes a fellow of the relevant medical college. In 2009, almost 2,400 doctors qualified as new fellows. For the distribution of these new fellows across medical specialties, refer to Page 10. Table 9: Vocational trainees by medical specialty, 2010 Medical specialty Basic trainees Advanced Total college trainees trainees Addiction medicine Adult medicine (a)(b) 1,904 1,406 3,310 Anaesthesia (c) 1,116 Anaesthesia - Pain medicine Dermatology Emergency medicine (d) ,684 General practice - GPET.. 2,572 2,572 - ACRRM (e) Intensive care Medical administration (f) Obstetrics and Gynaecology Occupational and Environmental medicine (b) Ophthalmology (g) Paediatrics (a)(b) ,143 Palliative medicine (h) Pathology Pathology and RACP (jointly) Psychiatry 677 (i) 350 1,027 Public health medicine (b) Radiation oncology Radiodiagnosis Rehabilitation medicine (b) Sexual health medicine Surgery (j).. 1,000 (k) 1,190 Total 5,057 9,432 14,679 (a) Includes trainees based outside Australia. (b) All figures reflect only those trainees registered as of the end of July (c) A further 275 are undertaking pre-training. (d) Includes Basic and Provisional trainees. (e) These registrars are in the ACRRM Independent Pathway. ACRRM classifies the first 3 years of training as basic training and the fourth year of training as the advanced year. (f) Includes 15 New Zealand and overseas trainees. (g) In addition there are 29 trainees in national or international training posts in their final (5th year) of training and 5 trainees in their 6th year of training and yet to complete training requirements. (h) Only includes Palliative Medicine Chapter trainees, not college trainees. (i) Includes 161 Australian fellows undertaking subspecialty training. (j) RACS does not differentiate between basic and advanced surgical trainees, as the surgical program is an integrated program (SET). (k) Includes 1000 Australian, 177 New Zealand and 13 overseas trainees. Source: Medical colleges and GPET, cited in Medical Training Review Panel Fourteenth Report. (18) Medical Colleges and GPET, cited in Medical Training Review Panel Fourteenth Report. Australia s Heath Workforce Series - Doctors in focus 30

36 How many doctors are from overseas? Views about the immigration of international medical graduates (IMGs) have altered over the past 20 years. The late 1990s saw disincentives for the migration of IMGs to Australia Section 19AB was introduced to the Health Insurance Act 1973 (the Act), preventing IMGs from billing Medicare until ten years elapsed from the time they gained registration (commonly referred to as the ten year moratorium ). At the time, it was announced as a move which the Minister estimated would cut the numbers of overseas trained doctors each year from about 600 to about This section of the Act still exists, and IMGs are required to gain an exemption in order to access Medicare benefits. Exemptions are generally only granted if the doctor works in a District of Workforce Shortage (defined by the Australian Government as where the GP to population ratio is less than the national average). In this way, IMGs are being used as a means to help address distributional issues for access to doctors, with these restrictions being effective in improving workforce shortages in areas of greatest need. In the 2000s, at the same time the number of education places began to increase for medical students, immigration for IMGs was In 2009, approximately one-quarter of working doctors in Australia obtained their first medical qualification overseas. (19) better enabled. In its annual report, the Department of Health and Ageing noted New arrangements have been established to improve the processes for attracting appropriately qualified overseas trained doctors to the Australian medical workforce. This included IMGs being able to gain a temporary visa for up to four years, compared with two previously; and in 2004 medical practitioners were included on the skilled occupation list for immigration purposes. This meant IMGs who met the requirements for registration no longer required a sponsor to migrate to Australia. This is still in effect, with doctors currently appearing on the immigration skilled occupation lists for general skilled migration (including general skilled migration nominated by a State/Territory government agency under a state migration plan) and the employer nomination scheme occupation list. Australia has a strong reliance on overseas trained doctors. In 2009, one-quarter (18,458) of working doctors in Australia obtained their first medical qualification overseas. The AIHW medical labour force survey first collected data on country of first medical qualification across all states and territories in Results between 2006 and 2009 were similar: 31 Health Workforce Australia

37 The immigration process for overseas trained doctors It is a complex process for doctors to immigrate to Australia. At a broad level, only four steps exist: 1. Skills recognition through an Australian Medical Council (AMC) assessment process (including English proficiency) 2. Apply to the Australian Health Practitioners Regulation Agency for registration 3. Arrange a pre-employment structured clinical interview (if required) 4. Apply to the Department of Immigration and Citizenship for a visa. However many requirements then sit behind each step, in particular in steps 1 and 4. Skills recognition through the AMC Up until the late 2000s, each state and territory had different approaches to medical practitioner immigration and in July 2006, the Council of Australian Governments agreed to the introduction of a national assessment process for overseas trained doctors. In October 2008, the agreed pathways were presented to the Australian Health Ministers Advisory Committee. There are four assessment pathways (all requiring demonstrated proficiency in English): Competent Authority Pathway is for IMGs applying for non-specialist positions or working in general practice area of need positions, who have completed their education through an approved overseas competent authority (as assessed by the AMC). Standard Pathway (AMC Examination) is for IMGs not eligible for the Competent Authority or Specialist Pathways, whose basic medical qualifications are not recognised by the Medical Board of Australia (MBA). IMGs are required to pass an AMC administered examination consisting of two sections, a multiple choice questionnaire and a clinical examination. Standard Pathway (Workplace based assessment) this pathway is currently being implemented and is for IMGs seeking general registration in Australia, who have obtained limited registration from the MBA to be employed in the approved clinical position for workplace based assessment. This pathway requires IMGs to undertake the AMC multiple choice questionnaire and a workplace based assessment in lieu of the AMC clinical examination. Only four accredited sites currently exist for this pathway. Specialist pathway is for doctors who have completed all required education and training and are recognised as a specialist in their country of training. Applicants are assessed on their comparability to Australian standards, with the assessment conducted by the relevant specialist college. An area of need specialist pathway also exists, which is a fast-track for processing applications for overseas trained specialists going to work in areas of need specialist positions. Visa options Temporary visas are the usual pathway for doctors to enter Australia. To be eligible for a temporary visa, a doctor must be employer sponsored (ie, have a job offer). Temporary visa options for doctors are: Temporary Business (Long Stay) visa (Subclass 457). This is the most common program for employers to sponsor overseas workers to work in Australia on a temporary basis. This visa allows an overseas worker to be employed for between one day and four years. Occupational trainee visa (Subclass 442). This allows doctors to complete supervised workplacebased training in Australia for up to 12 months. The doctor must be appointed to a designated training position to be eligible for this visa. Until 1 July 2010, doctors could also apply under the Medical Practitioner Temporary (Subclass) 422 visa. This visa was only open to medical practitioners, permitting them to work in Australia from three months up to four years. This visa option is no longer available, with applicants now encouraged to choose the 457 visa subclass. Permanent visa options exist for overseas trained doctors who hold full medical registration in Australia. Doctors holding full medical registration may apply for permanent residence under an employer sponsored visa (subclasses 856 and 857), labour agreements or an independent visa (general skilled migration). To be eligible for the general skilled migration program, the applicant must be applying for an occupation that appears on the Skilled Occupation List (compiled by Skills Australia). Medical practitioners have appeared on this list since Australia s Heath Workforce Series - Doctors in focus 32

38 Almost three-quarters (74% or 53,843) of working doctors obtained their first qualification in Australia in 2009, compared with 47,930 (or 77% of working doctors) in 2006; In both 2006 and 2009, 3% of working doctors obtained their first qualification in New Zealand (1,639 in 2006 and 2,112 in 2009); 6% of working doctors obtained their first qualification in the UK/Ireland in both 2006 and 2009; and 14% (8,812) of working doctors obtained their first qualification in other countries in 2006, compared with 16% (11,948) in 2009, a rise of 3,136 between the two periods. This was the second highest increase, behind those that first qualified in Australia. Medicare holds substantial data on the general practitioner workforce, including information on place of basic qualification. In one-third (35% or 9,191) of GPs were overseas trained (increasing to 41% or 8,044 on a fulltime workload equivalent basis). The proportion of overseas trained GPs in Australia has been increasing since the early 2000 s more than half of the growth in overseas trained GPs over the period to has occurred since (Figure 16).This aligns with the introduction of arrangements to better enable the immigration of IMGs in the 2000 s. The use of the Health Insurance Act 1973 to help address distributional issues through the ten year moratorium on Medicare provider number access has been effective in increasing the workforce in areas of need. This has encouraged IMGs to work in identified areas of need, with Medicare data showing a higher proportion of overseas trained GPs working in Outer regional (51%) and Remote areas (47%) (on a full-time workload equivalent basis). This compares with 39% of overseas trained GPs working in Major cities, and 44% in Inner regional areas (Figure 17). Figure 16: Proportion of overseas trained GPs in the Australian workforce, to Headcount Full-time workload equivalent Source: Medicare, Internal DoHA, October 2010, viewed on Department of Health and Ageing website 23 September Health Workforce Australia

39 Figure 17: Proportion of overseas trained GPs by FWE and Remoteness Area, Major cities Inner regional Outer regional Remote / very remote Australian trained Overseas trained Source: Medicare, Internal DoHA, October 2010, viewed on Department of Health and Ageing website 23 September 2011 Australia s Heath Workforce Series - Doctors in focus 34

40 Visas granted As outlined on page 32, there are a range of visa options that doctors wishing to work in Australia can choose. Temporary visas are the usual pathway to permanent residence status for doctors not yet holding full medical registration in Australia. Temporary visas allow overseas trained doctors to commence supervised practice and formal assessment in Australia to meet requirements for full medical registration. In the last six years temporary visa approvals reached a peak of 4,930 in , falling since then to 3,190 in This was the lowest number of temporary visas granted since (4,070). The pattern of temporary visas granted has changed over the same period. In most temporary visas were granted under subclass 422 (3,070) while in most were granted under subclass 457 (2,670). This is a result of visa subclass 422 closing from 1 July 2010, with applicants encouraged to apply under subclass 457 leading up to the cutoff date. The number of occupational trainee visas (subclass 442) granted has reduced by almost three-quarters (73%), from 930 in to 250 in Figure 18: Number (a) of temporary visas granted to doctors, by visa subclass, to ,000 4,500 4,000 3,500 3,000 2,500 2,000 1,500 1, Occupational Trainee Visa Medical Practitioner - Temporary Visa Temporary Business (Long stay) Visa (a) Numbers rounded to the nearest 10. Source: Department of Immigration and Citizenship administrative data 35 Health Workforce Australia

41 Permanent visa options exist for overseas trained doctors who hold full medical registration in Australia. In addition to those who apply offshore, permanent visa grant figures are likely to include people who initially arrived in Australia on a temporary visa grant, who have subsequently achieved full medical registration and are then eligible for permanent migration. In contrast to temporary visa grants, the issue of general skilled visa grants has increased over the past five years, more than doubling from (450) to (1,070). Table 10: Number of general skilled migration (a) and employer sponsored visa grants, to Visa type General skilled migration ,070 Employer sponsored (a) Includes Skilled Australian Sponsored, Skilled Independent and State/Territory Sponsored visas. Source: Department of Immigration and Citizenship administrative data Countries of origin Over the past decade there have been increasing global concerns about the impact of international health professional recruitment on developing countries workforce supply. This has resulted in a number of international codes of practice being developed. Australia is currently a signatory to the The Pacific Code of Practice for the Recruitment of Health Workers (2007), has endorsed the principles of the Commonwealth Code of Practice for the International Recruitment of Health Workers (Commonwealth Secretariat, 2003) and is a signatory to the WHO Code of Practice on the International Recruitment of Health Personnel (2010). Additionally, the National Partnership Agreement on Hospital and Health Workforce Reform, which calls for consolidating jurisdictional international recruitment programs into one, specifically states that the program is to be conducted in accordance with the Commonwealth Code Of Practice For The International Recruitment Of Health Workers. These global concerns have coincided with a change in the trend of source countries for immigrating to Australia. In , most IMGs arriving under temporary resident visas were from the United Kingdom and Ireland, and by this had dropped to under 50% with IMGs now coming from a greater diversity of countries. 20 In six of the top ten citizenship countries temporary visa applicants were from, are considered emerging or developing countries (India, Malaysia, Sri Lanka, Pakistan, Iran and South Africa). 21 Citizens from these countries accounted for over one-third of visa subclass 457 visa grants in Citizenship country (20) Birrell, R J. Australian Policy on overseas-trained doctors. The Medical Journal of Australia. 2004; 181:635. (21) International Monetary Fund, World Economic Outlook Report April 2011 Table 11: Visa applications granted for medical practitioners by citizenship country, Visa subclass 457 Visa subclass 442 United Kingdom India Malaysia Ireland, Republic of Sri Lanka Pakistan 107 n.a. Canada Iran 72 n.a. South Africa 71 n.a. Singapore Other countries Total 2, n.a. not available Source: Department of Immigration and Citizenship administrative data. Australia s Heath Workforce Series - Doctors in focus 36

42 Assessment pathways Doctors migrating to Australia can enter under a number of pathways, which are administered by the Australian Medical Council (AMC). Various steps are involved in each pathway and in 2009: 1,626 applicants were assessed through the competent authority pathway, with 1,325 of these qualifying for advanced standing. This means they passed their pre-employment assessment of suitability and are able to undergo up to 12 months workplace based assessment to be eligible to receive the AMC certificate. In 2009, a further 853 international medical graduates received the AMC certificate, meaning they were then eligible to apply for general registration as a doctor in Australia. 2,460 international medical graduates passed the multiple choice questionnaire under the standard pathway (51% of attempts) and 748 (59% of attempts) passed the clinical exam. 332 overseas trained specialists had their applications approved under the specialist pathway. A further 469 were deemed as requiring further training or exams in In closing The number of doctors has increased over the last decade, although the characteristics of the workforce are changing. The number of females entering the medical workforce is increasing at a greater rate than males, average working hours are falling (particularly for male doctors) and the composition of specialties has been changing, with lower proportions of primary care practitioners. The primary supply mechanisms for Australia s medical workforce immigration and education have also experienced change over the same period. Immigration is fluctuating temporary visa grants have fallen in recent years while permanent visa grants have increased. The most dramatic change has occurred in education. Numbers of commencing students and graduates have increased substantially since 2006 and are projected to continue to do so. A number of specific initiatives have also been undertaken in recent years to assist in expanding training capacity, including: Measures in the National Partnership Agreement on Hospital and Health Workforce Reform (2008) to expand clinical training capacity for health professional students to support the growth in higher education places; The expansion of the pre-vocational general practice placements program, which is increasing from around 400 to 975 places a year; A commitment to increase the GP training program from 600 to 1,200 places a year by 2014; and An expansion in the specialist training program that provides funding for specialist training positions in expanded settings, from 360 training rotations a year to 900 by While these increases pose a number of challenges for the capacity of the health system and call for a co-ordinated and planned approach in management, they are a positive for the future of the national medical workforce. (21) Australian Medical Council administrative data, cited in Medical Training Review Panel Fourteenth Report. 37 Health Workforce Australia

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44 Publications in this series: 1. Doctors in focus Health Workforce Australia GPO Box 2098, Adelaide SA 5001 T F E [email protected] Printed on 100% post-consumer recycled paper