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.
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.
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.
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
Dr Ayman Shenouda