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Australia’s Health Workforce Series Doctors in focus 2012

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Citation: Health Workforce Australia 2012, Australia’s Heath Workforce Series - Doctors in focus, Health Workforce Australia: Adelaide

Australia’s Health Workforce Series Doctors in focus 2012

“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

Introduction . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 1

How many doctors? . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 3

Type of practitioner . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 6

Type of specialist . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 9

Gender profile . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 11

Age profile . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 13

Hours worked. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 15

Where are doctors located? . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 17

State and territory distribution. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 18

Regional distribution . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 19

How many doctors is Australia training?. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 22

Students and graduates. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 24

Interns . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 27

Vocational medical training and fellows . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 29

How many doctors are from overseas?. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 31

Visas granted . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 35

Countries of origin . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 36

Assessment pathways . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 37

In closing . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 37

Contents

Health Workforce Australia 1

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

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

“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.”

Australia’s Heath Workforce Series - Doctors in focus 2

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.

Data sources used

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.

(1) A Healthier Future For All Australians – Final Report of the National Health and Hospitals Reform Commission – June 2009.


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. Non-

clinicians 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 1999. 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.

How many doctors?


Registered medical practitioners82,895 (91.8%)

Multi-state registrations7,366 (8.2%)

Primary care practitioners25,707 (38.0%)

Hospital non-specialists7,677 (11.4%)

Specialists24,290 (35.9%)

Specialists-in-training9,154 (13.5%)

Other clinicians785 (1.2%)

Clinicians67,613 (93.0%)

Non-clinicians5,127 (7.0%)

Employed elsewhere62 (17.0%)

Not employed304 (83.1%)

Currently employed in medicine72,739 (98%)

On extended leave1,154 (1.6%)

Looking for work in medicine366 (0.5%)

In medical labour force in Australia74,260 (89.6%)

Not in medical labour force in Australia8,636 (10.4%)

Employed elsewhere andnot looking for work

in medicine840 (9.7%)

Not employed,not looking for work

2,654 (30.7%)

Retired from work2,111 (24.4%)

Australian-registeredmedical practitioners

working overseas3,030 (35.1%)

All medical practitioner registrationsin states and territories in 2009

90,261

Figure 1: Registered medical practitioners by labour force status, 2009

Source: AIHW Medical Labour Force Survey 2009

“While overall numbers of registered and working

doctors increased substantially from 1999 to 2009, their distribution across the workforce is similar.“

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.


How does Australia compare internationally?

Chile (b)Turkey (b)

KoreaMexicoPolandJapan

Canada (b)United States

SloveniaNew Zealand

United KingdomFinland

LuxembourgNetherlands (b)

Ireland (b)Belguim

AustraliaHungary

France (b)Estonia

IsraelDenmark

SpainCzech Republic

IcelandGermanySweden

Portugal (c)Switzerland

NorwayAustria

Greece (b)

0 1 2 3 4 5 6

Number

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 2011

While the ratio of clinicians to non-clinicians 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.

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,

National Clinical Supervision Support Framework 6

Type of practitioner

Table 1: Employed clinical doctors by type, 1999 and 2009

1999

2009Change

1999 to 2009Average annual growth

1999 to 2009

no. no. % %

Primary care practitioner Specialist Specialist-in-training Hospital non-specialist

20,616 16,459 4,455 4,469

25,707 24,290 9,154 7,677

24.7 47.6

105.5 71.8

2.2 4.0 7.5 5.6

Total 45,999 67,613(a) 47.0 3.9

(a) Includes other clinicians. Source: AIHW Medical Labour Force Survey 1999 and 2009

“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.”


although having the highest numbers of doctors overall, experienced the smallest percentage growth over the period 1999 to 2009. Specialists-in-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 2009. 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 McNeil2 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 2014. These increases may impact on the proportion of doctors becoming GPs.

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 1999-00 to 2009-10.

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 part-time doctors. FWE is a measure of service provision and has experienced a slightly higher rate of average annual growth over the period 1999-00 to 2009-10 (2%) compared with GP headcount numbers.

Table 2: General Practice Workforce Statistics, 1999-00 and 2009-10

1999-00 2009-10

Change 1999 to

2009

Average annual

growth 1999 to

2009

no. no. % %

Headcount Full-time workload equivalent (a)

23,14716,433

26,61319,729

15.020.1

1.41.8

(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 2011

General practitioner numbers - Medicare

(2) Joyce CM and McNeil JJ 2006 ‘Fewer medical graduates are choosing general practice: a comparison of four cohorts, 1980-1995’ Medical Journal Australia, Volume 185 Number 2; 102-104.


45

40

35

30

25

20

15

10

5

01999 2000 2001 2002 2003 2004 2005 2006 2007 2008 2009

Prop

orti

on o

f em

plo

yed

doc

tors

(%)

Primary care practitionerSpecialist

Hospital non-specialistSpecialist-in-training

Figure 3: Type of clinician as a proportion of all employed doctors, 1999 to 2009

Source: AIHW Medical Labour Force Survey 1999 to 2009


The AIHW medical labour force survey asks specialists to report their main field of specialty, with information published for

54 specialty fields in 2009. 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 2009. 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 2009. 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 1993. 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 2009.”

Type of specialist


Table 3: Specialists(a), Top 10 main specialties of practice, 1999 and 2009

Main specialty Specialists Proportionno. %

AnaesthesiaPsychiatryDiagnostic radiologyObstetrics & gynaecologyGeneral surgeryPaediatric medicineOrthopaedic surgeryOphthalmologyGeneral medicineCardiologyOther specialties

2,0601,9881,1091,0891,037

760739669534522

5,952

12.512.16.76.66.34.64.54.13.23.2

36.2Total 16,459 100.0

Main specialty Specialists Proportionno. %

AnaesthesiaPsychiatryObstetrics & gynaecologyDiagnostic radiologyPaediatric medicineGeneral surgeryOrthopaedic surgeryEmergency medicineOphthalmologyCardiologyOther specialties

3,4242,6821,5141,4701,1841,1161,0891,018

839752

9,202

14.111.0

6.26.14.94.64.54.23.53.1

37.9Total 24,290 100.0

Medical specialty No.Addiction medicine Adult medicine(a) Anaesthesia Anaesthesia - Pain medicine Dermatology Emergency medicine General practice RACGP ACRRM Total General practice Intensive care Medical administration Obstetrics and Gynaecology Occupational & environmental medicine Ophthalmology Paediatrics Palliative medicine Pathology Psychiatry Public health medicine Radiation oncology Radiodiagnosis Rehabilitation medicine Sexual health medicine Surgery(a)

6 397 197

9 11 82

928 40

968 63

9 56 11 11

116 8

64 125 12 18 44 13

1 174

Total 2,395

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 2009. This was followed by adult medicine (which includes a range of specialties such as cardiology, gastroenterology and hepatology, geriatric medicine and medical oncology).(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.

New fellowsTable 4: New fellows by specialty, 2009

(a) Practitioners who spent most of their time as clinicians only. Source: AIHW Medical Labour Force Survey 1999 and 2009


50

45

40

35

30

25

20

15

10

5

01999 2000 2001 2002 2003 2004 2005 2006 2007 2008 2009

Prop

orti

on o

f em

plo

yed

doc

tors

(%)

Primary care practitionersSpecialists

Hospital non-specialistsSpecialists-in-training

Source: AIHW Medical Labour Force Survey 1999 to 2009

Figure 4: Female clinicians as a proportion of all employed doctors, 1999 to 2009

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 2025.’ This observation is still relevant – while males formed the greatest proportion of working doctors in 2009 (64% or 46,750) compared with females

(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 2009. Similar patterns were repeated across clinician types, with females accounting for 39% of the

Gender profile

(3) Medical Training Review Panel Fourteenth Report


Specialty Females Persons % Females

Anaesthesia Psychiatry Obstetric & gynaecology Paediatric medicine Diagnostic radiology

908 872 540 483 349

3,424 2,682 1,514 1,184 1,470

26.5 32.5 35.7 40.8 23.7

Specialty Females Persons % Females

Cardiothoracic surgery Pain medicine Other surgery Paediatric surgery Occupational medicine

5 6 7 8 8

132 74 91 64 65

3.8 8.1 7.7

12.5 12.3

Table 5: Specialties with highest and lowest(a) number of female clinicians, 2009

(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 2009.

(4) AMWAC. Influences on Participation in the Australian Medical Workforce 1998. (5) Medical Colleges and GPET, cited in Medical Training Review Panel Fourteenth Report.

“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 non-specialists (rising 9 percentage points from 1999) (Figure 4).

Females are least represented amongst specialists (excluding GPs), accounting for one-quarter of all specialists in 2009. Reasons for this may include the length and structure

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 2009.

Females are more highly represented amongst specialties that provide greater flexibility4, 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 2010. Over the same period, surgery has maintained consistently lower proportions of female advanced trainees, ranging from 18% in 2006 to 23% in 2010.5


Average age Proportion aged 55 & over1999 no.

2009 no.

1999 %

2009 %

Male Female

48.0 41.1

47.8 41.5

30.4 11.1

31.2 13.4

Persons 46.0 45.6 24.9 24.8Source: AIHW Medical Labour Force Survey 1999 and 2009

Table 6: Employed doctors, age profile by gender, 1999 and 2009

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).

Age profile


40

35

30

25

20

15

10

5

0>35 35-44 45-54 55-64 65-74 75+

Prop

orti

on o

f em

plo

yed

doc

tors

(%)

1999 Males1999 Females

2009 Males2009 Females

Figure 5: Employed doctors by age cohort and gender, 1999 and 2009

Average age differs by practitioner type – primary care practitioners and specialists are older, both with average ages of 49.3. 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 40-50 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.”

Source: AIHW Medical Labour Force Survey 1999 and 2009


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 1999. 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 42.2. However female doctors have

experienced little change in their average weekly working hours over time, working an average of 38.4 hours in 1999. Male doctors’ average weekly working hours fell approximately four hours between 1999 and 2009, from 48.4 to 44.9.

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).

Hours worked


1-19 20-34 35-49

50

45

50-64

40

35

30

25

20

15

10

5

065-79 80+

Prop

ortio

n of

em

ploy

ed m

ale

doct

ors

(%)

Total hours worked per week1999 2009

Figure 7: Employed male doctors by total weekly hours worked, 1999 and 2009


Prop

ortio

n of

em

ploy

ed fe

mal

e do

ctor

s (%

)

Total hours worked per week1999 2009

1-19 20-34 35-49

45

50-64

40

35

30

25

20

15

10

5

065-79 80+

Figure 8: Employed female doctors by total weekly hours worked, 1999 and 2009


<35 35-44 45-54 55-64 65+ Total

Age group (years)

0

-1

-2

-3

-4

-5

-6

Figure 6: Male primary care practitioners(a), change in average weekly hours worked between 1999 and 2009

(a) Practitioners who spent most of their time as clinicians only. Source: AIHW Medical Labour Force Survey 1999 and 2009.

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 com-pared 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).


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 333.”


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 2009. 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.

State and Territory distribution

NSW(a) Vicb) Qld(a,b) SA WA(b,c) Tas(a,b) NT(b) ACT AustraliaNumber of working doctors

1999 2009

18,165 21,992

12,200 18,118

8,238 14,807

4,368 5,749

4,505 7,557

1,212 1,844

501 1,002

1,035 1,670

50,223 72,739

Number per 100,000 population1999 2009

283 309

260 333

235 335

292 354

244 337

257 366

260 443

331 474

265 331

Proportion female (%)1999 2009

28.8 35.0

27.7 36.2

29.6 35.0

28.9 34.2

29.8 36.7

26.4 35.6

35.9 47.8

35.1 39.9

28.9 35.7

Average age (years)1999 2009

46.2 46.7

48.1 45.2

44.1 45.2

44.8 46.0

n.a. 43.4

45.2 49.5

43.2 42.2

46.5 44.3

46.0(d) 45.6

Average total weekly hours worked1999 2009

45.5 42.3

46.0 42.7

44.9 42.5

45.0 41.1

45.6 41.9

45.1 39.6

54.9 42.7

47.0 42.9

45.6 42.2

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 2009.

Table 7: Selected characteristics of working doctors, states and territories, 1999 and 2009


Geographic distribution of the health workforce is a significant issue, and has been recognised for a number of

years. The National Health Workforce Strategic Framework6 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 1973.

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 216.8

Regional distribution

(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 1998.7, Sydney (8) AIHW Medical Labour Force Survey 2001 and 2009. 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.


Remoteness AreaThe Remoteness Area Structure within the Australian Standard Geographical Classification (ABS Catalogue No. 1216.0), 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.

400

350

300

250

200

150

100

50

0Major cities Inner regional Outer regional Remote / Very

remote (a) (b)Australia

Primary care practitioner

Specialist

Non-cliniciansHospital non-specialist

Specialist-in-training(a) Care should be taken when interpreting 2009 figures for Remote/Very remote areas due to the relatively small number of employed medical practition-ers 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.

Figure 9: Employed medical practitioners, number per 100,000 population by remoteness area, 2009


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 125.8 in Remote/Very remote areas. In comparison, specialists are most concentrated in Major cities (with 131.3 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

1999-00 2009-10

Change from 1999-00

to 2009-10

Average annual growth

1999-00 to 2009-10

Remoteness area Headcount Headcount % %Major cities 16,768 18,180 8.4 0.8Inner regional 3,836 5,135 33.9 3.0Outer regional 1,881 2,359 25.4 2.3Remote 420 525 25.0 2.3Very remote 242 414 71.1 5.5

Full-time workload

equivalent (a)

Full-time workload

equivalent (a) % %Major cities 12,470 14,248 14.3 1.3Inner regional 2,563 3,667 43.1 3.6Outer regional 1,176 1,525 29.7 2.6Remote 166 208 25.3 2.3Very remote 58 81 39.7 3.4

(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 2011.

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 1999-00 to 2009-10.

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, 1999-00 and 2009-10

(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 2007.


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 2000.11

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.

How many doctors is Australia training?

(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; 309-312


1st year medical students 20103,469

2nd and 3rd year medical students 20106,761

6th year medical students 2010898

Commencing postgraduate year 1 doctors 20102,394

Commencing postgraduate year 2 doctors 20102,313

Vocational medical training positions/trainees 201014,679

New fellows 20092,395

GRADUATION2,380 students graduated from Australian medical schools in 2009

Full medical registration with the Medical Board of Australia

Vocational specialists training accredited by the Australian Medical Council

Fellowship of a medical college



In final year of4 year course

1,116

In 4th year ofa 5 year course

827


869

In final year of5 year course

651


806

There are 18 universities with accredited medical schools

in Australia.

Course length rangesfrom 4 to 6 years.

Medical graduates generally enter the medical workforce through public hospitals as

interns.

Satisfactory completion of the intern year is required before

full medical registration.

Not all doctors choose to complete vocational training.

Other options include research, non-vocational roles, or leaving

the medical workforce.

Limits exist on the numberof vocational medical training

positions and medicalpractitioners must pass a competitive process to be

accepted. Vocational training duration ranges from 3 to 7 years full-time depending on

specialty.

YEAR

1

2-3

4

5

6

7

8

9-15

Figure 10: Medical education pathway in Australia

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


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 2010.

“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 2010.”

Students and graduates

4,000

3,500

3,000

2,500

2,000

1,500

1,000

500

02000 2001 2002 2003 2004 2005 2006 2007 2008 2009 2010

InternationalDomestic

Figure 11: Commencing medical students, 2000 to 2010

Source: Medical Deans Australia and New Zealand Inc, cited in Medical Training Review Panel Fourteenth Report.


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 2009.

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.

4,000

3,500

3,000

2,500

2,000

1,500

1,000

500

0

1999

2000

2001

2002

2003

2004

2005

2006

2007

2008

2009

2010

2011

2012

2013

2014

2015

InternationalDomestic(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

Figure 12: Medical graduates, 1999 to 2015(a)

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 female12, 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


Distribution of medical studentsMedical 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).

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 2008.

Victoria has both the highest number (724) and highest proportion (22%) of international medical students, while ACT has the lowest (17 and 5% respectively).

2,606724

3,870700

2,957530

471104

1,461157

1,243219

33817

Figure 13: Medical students by state/territory, 2010

Source: Medical Deans Australia and New Zealand Inc, cited in Medical Training Review Panel Fourteenth Report.

Domestic

International


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 Commonwealth-funded medical graduates, as a result of a commitment by the Council of Australian Governments (COAG) in 2006. 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.

Interns

“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.”


With the increasing number of medical students and graduates, there are concerns about the pressure this is generating for the medical training pipeline14,15 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 Commonwealth-funded 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

Training pipeline pressures

2,600

2,400

2,200

2,000

1,800

1,600

1,400

1,200

1,0002004 2005 2006 2007 2008 2009 2010

Figure 14: Postgraduate year 1: commencing trainees, 2004 to 2010

Source: State and territory government health departments, cited in Medical Training Review Panel Fourteenth Report.

(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; 309-312(15) Crotty B J. More students and less patients: the squeeze on medical teaching resources (editorial). Medical Journal Australia, Volume 183: 444-445(16) Australian Medical Association – Position Statement on Prevocational Medical Education and Training 2011


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

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 2010.

Female doctors accounted for almost half (48%) of all advanced vocational trainees in 2010.

Distribution across the specialties varied greatly – less than a quarter of female doctors were in advanced vocational training in surgery (23%)

16,000

14,000

12,000

10,000

8,000

6,000

4,000

2,000

02006 2007 2008 2009 2010

Advanced Total

Vocational medical training and fellows

Figure 15: Vocational training positions/trainees, 2006 to 2010

Source: Medical colleges and GPET, cited in Medical Training Review Panel Fourteenth Report.

(17) http://www.health.gov.au/internet/main/publishing.nsf/Content/health-publicat.htm


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.

Medical specialty Basic trainees Advanced trainees

Total college trainees

Addiction medicine .. 11 11Adult medicine(a)(b) 1,904 1,406 3,310Anaesthesia 504 612 (c)1,116Anaesthesia - Pain medicine .. 51 51Dermatology 42 45 87Emergency medicine (d)803 881 1,684General practice - GPET .. 2,572 2,572 - ACRRM(e) 50 70 120Intensive care 167 332 499Medical administration(f) .. 105 105Obstetrics and Gynaecology 295 123 418Occupational and Environmental medicine(b) .. 87 87Ophthalmology(g) 55 49 104Paediatrics(a)(b) 560 583 1,143Palliative medicine(h) .. 58 58Pathology .. 301 301Pathology and RACP (jointly) .. 131 131Psychiatry 677 (i)350 1,027Public health medicine(b) .. 60 60Radiation oncology .. 110 110Radiodiagnosis .. 333 333Rehabilitation medicine(b) .. 143 143Sexual health medicine .. 19 19Surgery(j) .. 1,000 (k)1,190Total 5,057 9,432 14,679

Table 9: Vocational trainees by medical specialty, 2010

(a) Includes trainees based outside Australia.(b) All figures reflect only those trainees registered as of the end of July 2010.(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.


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 100”.19 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

better enabled. In its 2003-04 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 2006. Results between 2006 and 2009 were similar:

“In 2009, approximately one-quarter of working

doctors in Australia obtained their first medical qualification

overseas.”

(19) http://www.aph.gov.au/senate/committee/clac_ctte/completed_inquiries/1996-99/insurance/report/index.htm


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 immi-gration and in July 2006, the Council of Australian Governments agreed to the introduction of a nation-al assessment process for overseas trained doctors. In October 2008, the agreed pathways were pre-sented 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 qualifi-cations 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 assess-ment) – this pathway is currently being implement-ed 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 work-place 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 optionsTemporary 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 workplace-based 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 Aus-tralia. 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 Oc-cupation List (compiled by Skills Australia). Medical practitioners have appeared on this list since 2004.

The immigration process for overseas trained doctors


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 2009-10 one-third (35% or 9,191) of GPs were overseas

trained (increasing to 41% or 8,044 on a full-time 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 1989-90 to 2009-10 has occurred since 2003-04 (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).

45

40

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30

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20

15

10

5

0

1989

-90

1990

-91

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-01

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-03

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-04

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-05

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-06

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-07

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-08

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-10

Full-time workload equivalentHeadcount

Figure 16: Proportion of overseas trained GPs in the Australian workforce, 1989-90 to 2009-10

Source: Medicare, Internal DoHA, October 2010, viewed on Department of Health and Ageing website 23 September 2011


100

90

80

70

60

50

40

30

20

10

0Major cities Inner regional Outer regional Remote / very

remoteOverseas trainedAustralian trained

Figure 17: Proportion of overseas trained GPs by FWE and Remoteness Area, 2009-10

Source: Medicare, Internal DoHA, October 2010, viewed on Department of Health and Ageing website 23 September 2011


457 - Temporary Business (Long stay) Visa

422 - Medical Practitioner - Temporary Visa442 - Occupational Trainee Visa

5,000

4,500

4,000

3,500

3,000

2,500

2,000

1,500

1,000

500

02004-05 2005-06 2006-07 2007-08 2008-09 2009-10

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 2007-08, falling since then to 3,190 in 2009-10. This was the

lowest number of temporary visas granted since 2004-05 (4,070). The pattern of temporary visas granted has changed over the same period. In 2004-05 most temporary visas were granted under subclass 422 (3,070) while in 2009-10 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 2004-05 to 250 in 2009-10.

Figure 18: Number(a) of temporary visas granted to doctors, by visa subclass, 2004-05 to 2009-10

(a) Numbers rounded to the nearest 10. Source: Department of Immigration and Citizenship administrative data

Visas granted


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 1997-98, most IMGs arriving under temporary resident visas were from the United Kingdom and Ireland, and by 2002-03 this had dropped to under 50% with IMGs now coming from a greater diversity

of countries.20 In 2009-10 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 2009-10.

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 2008-09 (450) to 2009-10 (1,070).

Citizenship country

Visa subclass

457

Visa subclass

442United Kingdom 714 43India 368 21Malaysia 292 25Ireland, Republic of 174 7Sri Lanka 124 22Pakistan 107 n.a.Canada 105 12Iran 72 n.a.South Africa 71 n.a.Singapore 63 17Other countries 583 105Total 2,673 252

Countries of origin

(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, 2009-10

n.a. not available Source: Department of Immigration and Citizenship administrative data.

Visa type 2005-06 2006-07 2007-08 2008-09 2009-10General skilled migration 182 222 290 446 1,070Employer sponsored 170 234 247 524 481

(a) Includes Skilled Australian Sponsored, Skilled Independent and State/Territory Sponsored visas. Source: Department of Immigration and Citizenship administrative data

Table 10: Number of general skilled migration(a) and employer sponsored visa grants, 2005-06 to 2009-10


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 2009.21

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 2014.

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.

In closing

(21) Australian Medical Council administrative data, cited in Medical Training Review Panel Fourteenth Report.

Assessment pathways

Health Workforce AustraliaGPO Box 2098, Adelaide SA 5001T +61 8 8409 4500 F +61 8 8212 3841E [email protected]

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1. Doctors in focus

AustraliaÕs Health Workforce Series Doctors in focus · most time working on the diagnosis, care...

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