Policy responses to increasing workforce supply: IMGs, policy failure and continued reliance
 
Dr Ayman Shenouda
 
 
Over the coming weeks I’d like to start a discussion to support planning around a future Australian medical training model. The first starts here with IMGs and our continued reliance on them and what’s next in the context of national self-sufficiency planning.
 

 
A rural workforce reality: IMGs remain a key part of the rural medical workforce despite increasing graduate supply.
 
Whether described as policy failure or policy still in motion, it is clear we are yet to harness our increased domestic supply as intended. Our planned approach for less reliance on IMGs towards self-sufficiency has clearly not met its objective.
 
We’ve seen an increase in domestic supply of 2.7 per cent per year and above population growth. The raw numbers show an overall increase of 5.3 per cent per year, from 59,359 in 2005 to just under 94,000 in 2017.[i] But, despite these results, we just haven’t effectively utilised gains from increased supply to improve distribution.
 
It is a lack of a coordinated national planning approach which has seen a strong policy response in increasing local medical workforce supply fail at both the prevocational and vocational training points. This has made workforce supplementation through migration less of a temporary fix and more of a permanent policy fixture.
 
Visa reform
 
Despite slow gains in workforce planning we’re starting to see some key shifts coinciding with changes to the visa system and a broader commitment towards a national workforce strategy.
 
Policy announced earlier this year through the Commonwealth’s Visas for GPs initiative sees a reduction in IMG intake over the next four years. This remains a short-term measure. The wider medical workforce maldistribution problem in rural Australia needs a stronger national medical workforce plan and approach as discussed in newsGP when the policy was announced.
 
This strategy brings rural workforce planning into alignment with the broader skilled migration policy changes with the introduction of the Temporary Skill Shortage visa (subclass 482) replacing the former 457 visa. In facilitating targeted use of overseas workers to address temporary skill shortages – it provides stronger policy controls to direct these doctors to where they are needed the most.
 
Getting this policy lever to work for us and towards national workforce planning objectives is an important step in the right direction. This should always have been the aim and is more policy realignment than reform but represents an important first step.
 
Policy implications
 
Workforce distribution through migration can lead to unintended policy consequences in the absence of a national medical workforce plan.
 
Workforce supplementation through migration is a divisive issue: many will say the most obvious solution is forced distribution of our domestic supply. But we know forced policies just don’t work. We already have one, in the form of the 10-year moratorium, and this has seen most IMGs return to urban settings once they’ve satisfied the regulatory requirements.
 
Broader than policy, and putting cultural isolation issues aside, there are still plenty of negatives for the IMG. Often described as a two-tiered system, we place limits on their professional development and career opportunities while placing them in an unsupported and clinically complex environment.
 
Our failure to nurture rural retention just makes it so much harder for those wanting to stay. This makes this forced distribution scheme just flawed policy working against retention aims. It has led to a constant stream of IMGs leaving rural areas once they obtain their unrestricted licenses.
 
So, despite considerable policy efforts, the issue we started with nearly two decades ago remains. We still don’t have enough doctors in the areas where we need them the most. In fact, forced measures like these have just make rural practice less viable and appealing.
 
More broadly though, it is a lack of coordinated national medical workforce planning has led us here. The recent COAG Health Ministers commitment towards a national medical workforce planning strategy will enable a much stronger needs-based approach providing a way forward towards self-sufficiency.
 
Self-sufficiency planning
 
Important to self-sufficiency planning, a recent review on the reliance of our IMG workforce highlights our obligation to consider global maldistribution and not just our own in workforce planning.[ii] 
 
The review led by O’Sullivan et al. 2019 states that our ability to minimise our reliance on IMGs is important for equitable global workforce distribution. It highlights a key role in workforce planning, specifically in developing national workforce data capacity to help inform sustainable medical health workforce planning.
 
For Australia, in achieving the right balance of locally trained doctors, this review states policy to reduce our reliance on IMGs has to be mindful of the flow on effects to developing countries. This is an important point that often gets lost in the urgency to fill local positions. And, while I think more recent shifts to our visa controls brings us closer to meeting our moral obligations here, we still need to fully utilise the significant data and associate studies to support a national plan.
 
In working through this aim, this review skilfully demonstrates how the available data, in this case from the MABEL study findings can be used to consolidate the best available national evidence to inform self-sufficiency planning. 
 
New stratified analyses of MABEL data have been captured to identify IMG work location patterns. Results show the proportion of IMGs among rural GPs and other specialists increases for each cohort of doctors entering medicine since 1970 peaking for entrants in 2005-2009. In our efforts to build a locally trained workforce for rural Australia, the review also confirms recent domestic graduates are less likely to work either as GPs or in rural communities.
 
This study helps to identify the key drivers to successfully growing a local rural medical workforce - what we’ve done well and where we now need to focus our efforts. These are the broader reforms with many initiatives already in train.
 
These key policy enablers, important to recruitment and retention, will be the focus of my next blog in this series. They include the required focus on generalism in ensuring the right balance of skills in moving closer to the National Rural Generalist Pathway. In addition, the more recent work towards an Integrated Rural Training Pipeline to support high quality rural medical training and as a key component of reform to ensure growth in graduates flows through to gains for rural Australia.
 
A more supportive approach
 
Distribution policies which can allow for self-sufficiency remain our key objective but benefits from increasing domestic supply will take time. However, it is clear that IMGs continue to address critical shortages in rural and remote areas and we need to continue to support them.
 
The focus should include a mix of retention strategies and education supports toward Fellowship which encourage a permanent place in the community they’ve served. The recently announced More Doctors for Rural Australia Program (MDRAP) will provide targeted support for non-VR doctors providing GP services towards attaining Fellowship.
 
A further positive shift in the new RACGP Practice Experience Program (PEP) Specialist Stream, replacing the current Specialist Recognition Program (SRP) from September, will allow doctors to access the highest Medicare benefits while working towards Fellowship. The PEP Stream encompasses educational modules as well as a workplace-based assessment with a core aim is to support professional development providing feedback on individual progress towards Fellowship. newsGP
 
Importantly, the O’Sullivan led study[iii] also highlights the need for continued support. The authors conclude that IMGs are a key part of ongoing rural medical workforce planning and while we need to monitor our reliance, we also need to continue to support them.
 
The positive is that we are now starting to see recognised our continued reliance on IMGs and the fact that they remain a key part of rural medical workforce. Importantly, we are seeing a strengthening of the data-policy link in national medical workforce planning leading to greater support. My message has always been: If you don’t need them – don’t get them. But if you need them then you must support them. It’s clear we need them and they must be continued to be supported in policy.
 
[i] Scott A.(2019) Health Sector Report The future of the medical workforce. ANZ Melbourne Institute: Applied Economic & Social Research, The University of Melbourne.
[ii] O'Sullivan, Belinda, Russell, Deborah J., McGrail, Matthew R. and Scott, Anthony (2019) Reviewing reliance on overseas-trained doctors in rural Australia and planning for self-sufficiency: applying 10 years' MABEL evidence. Human Resources for Health, 17 1: 8. doi:10.1186/s12960-018-0339-z
[iii] Ibid.

​Dr Ayman Shenouda
 
There remains a deep undercurrent of racism in this country but it is not mainstream Australian opinion driving it.
 
The problem is that the public debate in and around migration is persistently led by a far-right minority.
 
And actively challenging such intolerance is vital otherwise I think these low debates will come at a high price for us all.
 
I really think all doctors must unite against racist attacks on IMGs. This is doing considerable damage and we need to challenge these views.
 
Where’s the evidence?
 
If you were looking for more evidence that the media is complicit in fueling racism it could be clearly seen on the front page of The Weekend Australian last weekend.
 
Beneath a headline that read ‘Foreign doctors blow out Medicare’ sprawled the most unbalanced, uninformed piece which firmly targets International Medical Graduates (IMGs) as exploiters of Medicare.
 
This article, whether deliberate or not, purely through a sole focus on IMGs infers that they alone are responsible for driving some very complex problems facing our health system.
 
Issues around over servicing and professional standards are not confined to IMGs and we have effective non-discriminatory processes in place through various codes, guidelines, and policies to address these.
 
Let’s unpack the bias
 
Starting with over-servicing and alleged Medicare fraud we’re told about “a rampant increase in IMG Medicare billing”.
 
The article, of course, fails to balance this with required comparators for Gross Billings for Australian Trained Doctors (ATDs).
 
There is also policy in place which addresses such issues – the Professional Services Review - and this is not confined to IMGs.
 
Some much-needed context around what might be driving such increases other than the inferred fraud would have helped balance it.
 
Issues such as long hours and caseload, acuity and complexity of patient need, and broader need for the specific population and working to align resources to need all factor strongly.
 
The predictable narrow migration narrative
 
The article then forewarns a policy shakeup which will see the number of IMGs or ‘imported GPs’ slashed in coming years and then states a budget return for policy justification.
 
This just adds to a growing trend which sees skilled migration used as political fodder.
 
Skills lists really are a decision for government and if we don’t need them then don’t get them.
 
I actually don’t disagree that we should place strict parameters around skilled migration policy to ensure we are targeting the skills most in need.
 
But if we do need them then we need to support them and that is the key issue here. More on that later!
 
Recent policy through the new Temporary Skill Shortage (TSS) visa now works through short and medium-term skill requirement.
 
This is a good policy reform which also works to limit the pathway to permanent residency. 
 
Where’s the detail behind the analysis?
 
The article alludes to some analysis that claims average billing of IMGs — across Medicare, the Pharmaceutical Benefits Scheme, and referrals — has tripled in three years.
 
Let’s be clear here defining total cost as MBS + PBS + referrals in no way reflects a GPs actual income.
 
We’re then told that removing IMGs would result in a forecast saving of $415.5 million. This, of course, assumes that most if not all the services provided by the IMG equated to over-servicing.
 
The article claims this is based on a policy assumption that other doctors would not cover the equivalent Medicare services or subsidised drugs and only half as many referrals.
 
This is a very big assumption and one that is impossible to verify against such diverse need.
 
Now to provide a much-needed defense for IMGs.
 
A reality check on the doctor shortage
 
Statistics might show there is no doctor shortage in Australia but there certainly remains a maldistribution issue.
 
Maldistribution persists in rural Australia and with increasing remoteness you can expect to see both workforce shortages and a higher burden of disease.
 
This is despite efforts to increase supply through policy measures which see increasing numbers of Australian Trained Doctors (ATDs) and broader workforce supplementation measures through skilled migration.
 
Some policy insights
 
Benefits from increasing domestic supply will of course take time and we’ve made great progress with more students training in rural areas through the Rural Clinical Schools.
 
What is not seen beneath the supply stats are the policy complexities in regard to addressing population need, ensuring the right workforce mix, health infrastructure deficits, and distance and geographic location.
 
There are still too many one doctor towns in rural Australia in need of an urgent injection of basic medical facilities.
 
Keeping services viable in these contexts is the story not told. And it is for all these reasons IMGs remain an integral part of our workforce.
 
Rural Generalist Training
 
Excessive specialisation means there are not enough generalists particularly in rural Australia.
 
We’ve been working hard to address this through the National Rural Generalist Framework.
 
This is key to ensuring a supportive pathway providing rural exposure in order to prepare trainees for work in a rural and remote setting.
 
There is significant policy work currently being undertaken in this area led by the National Rural Health Commissioner.
 
We need to facilitate some key shifts which turns a structure which currently sees most of the training being undertaken in the bigger tertiary hospital in the cities.
 
We need to turn that on its head to provide more training in regional locations to encourage more domestic graduates to take up and retain postings in rural and remote areas.
 
Currently, they are seconded for six months to a rural area but it’s just not going to be enough to give them the exposure they need to entice them to return.
 
They spend most of their time training in cities and naturally build a life around that. We need to provide more opportunity for them to work in rural areas and experience the rewards.
 
It is just about facilitating the training to connect these doctors to the communities that need them the most. It’s really quite simple and we’re now on the right path to make this happen.
 
IMGs and their contribution
 
IMGs are the lifeblood of rural towns. They are the backbone of our healthcare services in rural areas. You see without them many rural communities would be without a doctor.
 
It is estimated that IMGs comprise approximately 40% of the medical workforce in Australia and 46% of general practitioners in rural and remote locations.
 
IMGs saved this country from a disaster over the past 10-15 years and this type of reporting is just unhelpful.
 
Let’s not forget that they are often recruited to work in some of the most difficult environments, with little support.
 
IMG is also a broad definition
 
If we are going to persist with a debate that sets IMGs up against ATDs then lets first clarify the definition. I don’t think it is well understood just how broad this term is. And it’s a term that sticks.
 
IMG simply means that you have been trained overseas and while we’re on that point it also means that you’ve not cost the country a cent in your training.
 
Many IMGs have been through the system, working in rural areas for many years and achieved Fellowship. These doctors are serving their communities delivering a very high standard of care.
 
Legacy of forced distribution
 
The legacy of a forced distribution policy – the 10-year Moratorium – is that the gains for our rural communities are only short term, as doctors seek to return to more populated areas.
 
The policy may only provide intermittent gains, and ultimately fail to provide a stable workforce for the rural and remote areas in need.
 
For it to work, it is reliant on a longer-term commitment from IMGs – a key consideration which currently lacks policy focus.
 
For some practical policy solutions, here’s a link to a conference paper from the 14th National Rural Health Conference last year:  Keeping them there: shifting our focus toward IMG retention, beyond moratorium obligations
 
Shifting focus
 
Now one final word on the debate we ought to be having. The discussion we need to be having is keeping doctors where we need them.
 
For rural and remote communities, we need to shift the focus toward IMG retention, beyond moratorium obligations.
 
But we also need to focus most on a policy which prioritises and secures domestic graduates for regional, rural and remote Australia.
 
A strong investment in the National Rural Generalist Pathway will support this outcome. 
 
The reality is that we will also need to continue to rely on those IMGs currently working in regional, rural and remote Australia to help train our domestic workforce coming through.
 
IMGs are vital in securing the next generation of rural GPs and this is a really important point that just gets lost in these divisive debates.