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SkilledOccupationsListSOLJanuary2018review:SubmissiontotheAustralianWorkandProductivityAgencyCategory:GeneralMedicalPractitioner-category2531-including‘GeneralistMedicalPractitioners’,SubmittedbyMikeMoynihan,(FACRRMrtd)0427331370.moynidoc@gmail.com.Thissubmissionupdatesthosemadein2013-2015andincludesimportantnewinformationandupdatedstatistics. Please enter your details below:* First name: Michael Surname: Moynihan Phone number: 0427 331 370 Email address: moynidoc@gmail.com Your submission is on behalf of:* Individual, in association with The Australian Population and Research Institute (TAPRI) Please select the industry your submission is in relation to. If required, you may select multiple industries. Health Care and Social Assistance: Please identify which occupations your submission relates to: * Medical working clinicians especially General practitioners 253111 MLTSSL MBA. All other medical specialties.

As submitted in previous years by this author the SOL was introduced as a method of leavening Australian workforce. It is being used as a major source of medical workforce supply. Overseas doctors comprised 34% of total workforce by 2015 (AIHW) and 40% of GPs at 30.6.16 (DoH). These percentages have been increasing quite rapidly. They are added to greatly increased domestic medical graduate output (MRTP). There are strong indications that the working clinician workforce is deeply in oversupply.

Supplier induced demand is an intrinsic part of medical clinician working patterns. It increases and tends to maximise in oversupply. This is an inherent part of steadily increasing health expenditure as % of GDP.

It is again recommended that Overseas recruitment be immediately and severely curtailed

and alternative arrangements be made for genuinely challenged locations. This would especially involve implementation of a national rural generalist workforce to supply rural hospitals. There should also be much more forthright development of primary care teams based on General practices to ensure on-the-day attention to acute illness, and uniform care of chronic conditions. This means a carefully graded transition towards clearly stated goals, better funding of ancillary staff and ongoing infrastructure support. Despite the admirable goals of the “Medical Home” it cannot be properly implemented while there is unrestricted expansion of General Practitioner workforce. Provision of a gender balanced domestic GP workforce will also not occur until some restraint on the uncontrolled expansion of the specialties. 1. Are there additional labour market factors, for which there are national datasets available (ideally aligned to 6-digit ANZSCO occupation level), that are relevant to future refinements to the Department’s analysis and methodology? What is the frequency of data release? [Max 1,500 characters] Annual DoH GP Statistics usually in December, last published January 17. MBS statistics August 2017. AIHW Medical Workforce last 2016 for 2015. Medical Training Review Panel (MTRP) annual reports last October 2016 for 2014-15 for DWS and other statistics. 2015 selected DoH statistical analysis purchased from DoH and available from this author, AHPRA quarterly medical registrant analysis, ABS 3218.0 and population clock, OECD biennial Health at a glance Nov 2015 table 5.2 and allied database for Australian excess medical workforce expansion. From these can be extracted numbers of immigrant GP and specialist doctors currently in DWS, examination passes, on-flow into capital cities, servicing patterns, effect on medical services per capita, calculation of workforce excess, evidence of over-servicing, effects of age and gender balance, etc. Trend is important in evaluating the need for immigrant workforce supplementation. Unfortunately the MTRP 20th report has not appeared in time for this submission. AIHW have also not issued figures for medical workforce in 2017 so that for a number of parameters we are looking at 1014 and 2015 figures.

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DoH GP statistics up to 30.6.16 were nearly 2 months late in January this year. Medicare statistics up to 30.6.17 appeared on time. Total working clinicians have been increasing at an accelerating rate since 1995. Australia was singled out by OECD (Health at a Glance November 2015) for the rate of increase of its Medical workforce.

GP workforce has been growing over the last 6 years at rates of 4-6% against population growth of 1.4-1.6% (Table 1.2). Table 1.3 gives GP to population rates of up to 200 per 100,000. In 2006 only 4 EEC countries had rates over 100 (Masseria et al LSE). The UK is coping (uncomfortably) with rates around 80. In 2000 Australia was 112. This author found oversupply to commence (from reducing services per GP) at around 123

per 100,000 in 2009. Table 1.3 canvasses growth in supply for annual increases of 3, 4, and 5%, which takes supply to nearly 200/100,000.

Although services per GP have generally been falling, services per capita have been rising at about 0.1 per annum, although there are considerable disparities between the States (Table 1.4). This illustrates great capacity for increase in Medicare costs,

even though rebates continue to be held back to the limit of tolerance.

The pattern of billing suggested that rising supply stimulates supplier-induced demand and that oversupply maintains it, probably to a maximum extent (Table 1.5). Between the years presented there is a smooth progression of parameters. The tendency towards over-servicing has been enhanced through the growth of corporate chains and workforce entry through DWS outside the AGPT, only within which ethical management is a constant teaching theme. It is however demonstrable in all groups

1.1GPandestimatedHospitalWorkforcesFinYr Working

CliniciansMedicareGPs

EstHospWorkforce

%Hosp

1995 45342 23371 21971 482000 46619 21819 24800 532005 56094 23032 33002 592010 708571 27045 43812 622015 88068 34606 53462 61Sources:2014and2016DoHGPStats.AIHWMedicalWorkforcereports.Notes.1Meanof2009and2011.SecondaryworkforcecalculatedasinTable1a.

1.2GPsaccessingPrimaryCarerebatesFinancialYear Total %increase2015-16 34,606 4.02014-15 33,276 4.52013-14 31835 5.72012-13 30,118 6.02011-12 28,410 5.02010-12 27,045 4.1

1.32025GPworkforcegrowthprojectedagainstpopulationgrowthof1.4%Growth@ GPs Pop.M GP/100,000Present 34,606 24.4 141.85%Growth 53,685 27 198.84%Growth 51,225 27 189.73%Growth 46,506 27 172.3Sources:ABSpopulationclock.January2017DoHGPstatistics.1.4ServicesPerCapitabyState.2004–2015

F.Yr. NSW VIC Q SA WA Tas NT ACT Tot.2004-5 5.1 4.7 4.6 4.8 4.1 4.8 2.8 3.4 4.72009-10 5.5 5.2 5.1 5.4 4.2 4.8 2.7 3.9 5.22014-15 6.1 5.9 5.6 5.8 4.6 5.2 3.6 4.3 5.72015-16 6.2 6.1 5.8 5.9 4.7 5.3 4.1 4.4 5.8Sources:DoHGPstatisticsandABS3218.0populations

1.5GPsupplyparameters1988-2015FinancialyearsF.Yr GP/1000,000 Servs/GP ServsPC BB%Servs1988 120 4120 4.9 651992 125 4377 5.5 741996 127 4540 5.8 811998 792000 114 4434 5.01 782003 111 4211 4.67 682004 112 4205 4.70 732008 116 4383 5.08 792012 130 4166 5.43 822015 142 4100 5.81 85Source:DoH2014-16GPstatistics.AnnualMedicareStatistics.Note:10%ofGPrelatedservicesexcludedfrom2000onsothatpreandpost2000figuresarenotentirelycomparable.

1.6BulkBillingratesbyRAF.Yr 2006 2011 2015RA1 80 83 86RA2 72 78 83RA3 74 79 84RA4 79 79 84RA5 83 82 89All 78 82 85Source:2016MBSStats.

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and gender. It was less apparent in ATDs in the 2000s. Bulk billing facilitates over-servicing and rates are not an indication of quality of care. It was felt in the time of AMWAC that over-servicing was probably present when bulk-billing rates exceeded 65%. Rates have grown in all regions, particularly in ASGS RA 2, where competition has probably been greatest and where corporate chain growth has been proportionately highest. Because over-servicing is also facilitated by the ordering of excess tests, a further indication of over-servicing is obtained from MBS statistics for all Medicare services, of which GP related services form perhaps 60% of all expenditure. Services have doubled since the inception of Medicare and cost by over 700% (Table 1.7). A focus on care of the elderly is of course necessary but with knowledge of over-servicing patterns the huge increases seen over the age of 65 have to be questioned in the light of major expansion of ancillary medical services. Just how far is the expenditure on MBS extended primary care items improving quality of care and facilitating team management in real terms? It also has to be noted that with a ‘tsunani’ of specialists on the way, there will continue to be huge encroachment into General Practice with concomitant expansion of currently unlimited subsidy. Government is being lobbied to allow physicians to take over chronic disease management because of the massive increase in numbers trained. Specialists are just as prone to supplier-induced demand as GPs and this is undoubtedly inflating hospital costs, especially because of all the ancillary activity their own activity engenders. 2. The Department is also seeking submissions on suitable datasets that are disaggregated by region. Please provide details if you are aware of such a dataset, including whether it is aligned to ANZSCO occupations and how often the dataset is updated. [Max 1,500 characters]

Total numbers of GPs have increased dramatically since the turn of the century and the relative increase in the regions has been greater than the cities because of the focus on DWS and the affirmative distribution of Australian GP Training (AGPT) places in rural. However between 17% and 35% of AGPT placed have been filled with OTDs, (because of domestic graduate absorption into the specialties), all of whom are in rural DWS, comprising

around 50% of the rural program, and who tend to move to the cities once training is complete. These factors mean that rural supply is very high (Table 2.2). A slight drop in remote occurred in 2015-16. Table 2.3 DoH gives OTDs by region. Entry is all through District of workforce shortage (DWS), including outer metropolitan. Of the 8361 increase in OTD GPs since 1995, 5033 (60%) have been in ASGS RA 1. This build up emphasizes the nature of DWS as a conduit to city practice. DWS calculations are based on DoH Full Service Equivalence (FSE), but as OTDs translocate to major cities they elevate FSE rates there, elevating the DWS ceiling in ASGS RA 2-5, allowing high rates of migration to continue under DWS rules.

Table 2.4 shows total numbers of GPs and Specialists in DWS. These include those who have obtained fellowship but have not finished serving the “moratorium period” of 5 to 10 years depending

of ASGS RA location, after which they usually translocate towards ethnic communities. The latest figures would be useful for trend and should be

1.7AllannualMedicareservicespercapitabyAge1985-2015.FYr. ‘85 ‘90 ‘95 ‘00 ‘05 ‘10 ‘15 30y%+ ‘160-4 7.1 8.1 9.5 8.3 8.2 9.0 8.8 14 8.75-9 4.3 4.7 5.3 4.5 4.4 5.0 5.8 35 5.710-14 3.7 4.1 4.6 4.2 4.1 4.9 5.6 51 5.515-19 4.9 5.7 6.7 6.4 6.2 7.2 8.2 67 8.220-24 6.8 7.0 8.8 8.1 7.7 8.2 9.9 46 9.825-34 7.4 7.9 9.8 9.5 9.6 10.5 11.9 61 11.935-44 6.9 7.7 9.6 9.8 10.2 12.0 13.3 93 13.345-54 8.5 9.2 11.6 12.1 12.6 14.6 15.6 84 15.755-64 10.2 12.0 15.5 16.3 17.5 20.2 20.9 105 20.965-74 12.5 13.6 19.3 22.7 25.9 29.2 30.2 142 30.775-84 16.1 17.9 22.0 22.4 29.5 38.5 41.8 166 42.085+ 16.8 19.6 24.1 24.9 26.5 31.0 39.7 136 41.4Total 7.6 8.5 10.8 11.1 12.1 14.3 15.8 +108% 15.9Cost$b 2.6 4.2 6.0 7.3 11.0 16.3 21.1 +712% 22.0Source:annualMBSStats.IncludesGPs,specialists,pathology,Imagingandsundryotherservices.

Table2.1TotalGPnumbersbyASGCRAFin.Yr AllAust. RA1 RA2 RA3 RA4 RA519851 17574 13264 2711 1306 221 7219901 21127 16022 3157 1584 271 9319951 23371 17572 3640 1742 305 11220002 21819 15684 3639 1876 364 25620052 23072 16819 4077 2045 413 30920102 27045 18373 5093 2486 536 55720152 34806 23596 6477 3197 647 689Source:DoH20141and20162GPstatistics

2.2DoctorsaccessingPrimaryCareRebatesper100,000Pop.byASCG@30thJune AllAust. RA1 RA2 RA3 RA4 RA52000 112 115 100 99 120 1382005 111 112 103 105 133 1782010 118 116 117 117 153 2292015 139 133 147 150 213 3462016 142 140 152 153 202 332Sources:2016DoHGPstatisticsandABS3218.0populations.Note.HobartRA2andDarwinRA3.

2.3OTDsaccessingprimarycarerebatesbyASGSRAEndF.Yr. AllAust. RA1 RA2 RA3 RA4 RA51995-61 5589 4193 740 515 96 452000-12 5335 3039 822 591 142 902005-62 6668 4347 1247 812 167 942010-112 9316 5919 1959 1092 201 1432015-162 13950 9226 2786 1516 256 122Sources:DoHGP12014and22016statistics

2.4OverseasderiveddoctorsinDWSYear GPs Specialists All09-10 4157 2418 657610-11 4809 2652 746111-12 5403 3052 845512-13 6330 3061 993113-14 7130 4329 1045914-15 8162 4333 12495Source.MTRPannualreports

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available this month if the MTRP 20th report is published. It is not clear whether these include overseas derived AGPT trainees in the rural program. AIHW has reported overseas derived clinicians since 2012 but irregularly before that. The available figures (Table 2.5) show a sharp accentuation from 21.7% of working clinicians in 2007 to 30.0% in 2015, with only slight growth from 1995 to 2007. New Zealand graduate GPs are now included by DoH with Australian as “Foreign graduates of approved Medical schools” (FGAMS). A further measure of numbers is the non-vocational category reported in DoH GP statistics (Table 2.6). These became nearly all OTD as a residuum of non-vocationally recognized Australian trained GPs phased out after the turn of the century. Comparing these with the MTRP figures suggests that in 2015-6, 3000 or so had GP Fellowship and were awaiting end of moratorium period. There are indications that the non-vocational workforce has a low rate of medical fellowship acquisition. This is meant to occur by the fourth year of immigration but anecdotally many are staying on for 7 or more years through various exemptions. Anecdotally also a number without fellowship are having to exit DWS practice but appear to be staying in Australia and working in metropolitan after-hours services. The recruitment program of doctors from overseas remains highly active (Table 2.6). There are 290 examination stations overseas for the AMC MCQ exam, which allows commencement of supervised practice. Clinical exam passes peaked in 2013 and MCQ passes in 2011. Clinical passes were lower in 2015 but remain substantial.

Another portal of entry is through the practice- eligible route. The numbers gaining entry by having their overseas fellowship approved have been reported by MRTP for 2012-14 and are quite substantial (Table 2.7). The RACGP describes them as “Fellow ad Eundum Gradum” (FAEG). These are probably for the most part from the UK. The poaching of doctors from less developed countries is damaging to those countries and has been widely criticized. It was renounced in the 2002 “Melbourne Manifesto” but ignored in the overseas recruitment exercise which developed its full extent soon after,

(despite contrary advice from the AMWAC). 3. Is there any other advice or evidence that the Department should consider in its review of the methodology? We are particularly looking for research, surveys or modelling that is Australian based, recent and aligned to ANZSCO occupations. [Max 3,000 characters] Structural problems with medical workforce supply are related to huge increase in graduate output, unrestricted expansion of hospital workforce, massive increase in numbers, preference of male graduates for specialist training, consequent lack of male GPs, lack of a proper rural generalist program, and self generating immigration levels through the DWS system.

2015 purchased data showed that there had been no increase in male Australian trained GPs from 1986 to 2014 (Table 3.1). Table 3.2 shows how the sex ratio of new medical fellowships is reversed between the GP and specialist sectors. The increased number of male GP fellowships is chiefly or almost entirely due to doctors from overseas. Table 3.3 shows that, except for graduate output, which has plateaued, and a slow down in medical fellowship acquisition, medical

workforce growth over 5 year periods since 2000 has been exponential. More detailed examination reveals that growth became accentuated after the global financial crisis, just when restraint should have been imposed. Medical workforce increases once in place maintain higher healthcare costs long term.

2.5TotalOverseasderivedworkingmedicalclinicians TWorkingClinicians NZ OtherOverseas2015 88040 2155 26413(30.0%)2007 62652 2196 13567(21.7%)1995 44111 1054 8560(19.4%)Source:AIHWreports(annualsince2012,irregularbefore).

2.6AustralianMedicalCouncilExamination 2005 2010 2015MCQ Sat 982 3807 2418 1sttime 672 2276 1077 Passes 523 1999 1447Clinical Sat 842 1596 1997 1sttime 567 1171 283 Passes 552 981 571Source:AMCannualreport.Note.290overseasexaminationstations.

2.7ApprovedoverseasFellowship. All GP Other2012 676 348 3062013 710 373 3372014 557 256 301Source.MTRP17-19threports-NewCollegeFellows

3.1GPsbysexandlocusoftraining1986-14 Australia-trained Overseas-trainedFYr Male Female Male Female Excess

1986-7 10,659 3,390 3,243 934 1995-6 11,296 5,856 3,971 1.618 2003-4 10,531 6,200 4,256 2,339 5572009-10 10,258 7,214 5,748 3,443 5962013-14 10,649 8,756 7,739 5,267 731Source:2015CustomisedpurchaseofDoHstatistics.NBDoublecountingofexcessOTDsrectifiedbyDoHinlate2015appliedonlytoNon-VROTDinDWS.

3.2NewMedicalFellows GP Specialist M F M F2000 149 216 523 2382005 357 309 609 3762010 384 479 960 5782014 630 695 924 704Source:MRTPannualreports.

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Within the GP workforce there are major disparities in working pattern between the domestic and immigrant workforce and their gender constituents. This is best illustrated by major city figures which include the bulk of those with Fellowship (Table 3.4). It was necessary to purchase DoH analysis to

establish the degree of difference, which at the time meant before the over-count in Non-VR OTD GPs was established and corrected. OTD services per GP are therefore underestimated in

the table, because total billed services were not exaggerated. Further data was requested but was no longer obtainable. These figures enable some kind of calculation to be made against projected workforce inputs, which could be updated from current Departmental data. Sex and origin data have also been requested from AGPT but are not as yet available. 4. Workforce supply methodology. The drivers of medical clinician workforce growth appear to be 1. Government desire to make medical care readily available and politically non-controversial, 2. over-expansion of medical undergraduate training, 3. Diversion of revenue into hospital funding thereby with resultant expansion of the specialities. This is reflected in the huge expansion of vocational training (Table 3.3). It is difficult to know why for example General Practice, Paediatrics, Emergency Medicine and Psychiatry are still listed in SOL when their training numbers have been increased by more than 100%. The current method of assessing workforce adequacy is that of workforce equivalence, which was commenced at a time when working hours were decreasing quite dramatically in the 1990s. AIHW continues to calculate equivalence from hours worked self-reported at annual registration. No differentiation is made between overseas and domestic graduates. There is however a major difference between output in the GP sector, measured by annual rebated services per GP. Using DoH statistics revised since 2015, Table 4.1 shows the difference between domestic and overseas graduates, and male and female. It demonstrates a rise in output during the first years of rising supply as the main overseas influx from overseas developed from 2003. ATD output then gradually fell but OTDs by and large have sustained output despite increasing numbers against rise in population (Table 2.2), the bulk in major cities. Data analysis purchased in 2015 by the author using the 2014 data set gives a differential for the two graduate groups. Table 4.2 shows that female OTD have rates not far off male ATDs. This is better exemplified in Major Cities because of the predominance of vocational registrants, who service at much higher levels. For GP workforce this gives a much better idea of what to expect at current workforce inputs. This analysis needs repeating with the current data set. A request for further data using the 2015 dataset was declined. DoH has used several parameters for workforce equivalence and currently combines earning, days worked and patients seen to estimate “Full Service Equivalence”, (FSE). In the author’s view this is not a good measure of Medicare effectiveness because it is heavily influenced by over-servicing. Table 4.3 Shows that OTDs with vocational recognition are virtually all FSE. What this means is that if Government wants to ensure liberal availability at current or greater GP servicing levels for the long term, it will have to continue to recruit from overseas. To prevent future unthinkable levels of supply it would have to curtail domestic training. ATDs are better able to privately bill for co-payment. This improves income but also allows greater time to be spent in

3.3WiderMedicalworkforcesupplyparameters. 2000 2005 2010 2014DomesticGraduates1 1195 1320 2259 2968FGAMS2 2983 474 521AMCClinicalexampasses4 552 981 571VocationalTrainees1 7262 8710 14679 20069NewFellows1 1126 1656 2401 2993Totalworkingclinicians5 47232 56094 707576 88040TotalPrimaryCareGPs7 21899 23022 27044 34606Source:1MRTP11-19threports(BasicandAdvancedtrainees.2FGAMS:Foreigngraduateofapproved(AustralianandNZ)medicalschool1.32006.4AMCannualreports.5AIHWMedicalLabour/Workforceannualreports,summaries,bulletins(62010averageof2009and2011asno2010figures).7DoHGPStatistics.

3.4MajorCityannualServicesperGPbysexandplaceoftraining2003–2013byfinancialyear.

ATD OTDFYr. Male Female Male Female2003 5245 2798 6189 44412009 5605 3024 6881 52122013 5034 2709 6443 4886Source:Customisedpurchaseof2014MedicareStatistics.NoteaNon-VROTDnumbersover-countmeantOTDservicesperGPwereactuallyhigher.

4.1AnnualServicesperGPbycategory ATD OTD Male Female All2000-1 4120 5084 5182 3074 44842004-5 3937 4901 4955 2959 42052007-8 4396 5281 5187 3165 43962010-11 3778 5286 5100 3155 42042014-15 3406 5145 4839 3148 40912015-16 3357 5200 4830 3199 4100Source:2016DoHstatistics

4.2MajorCityServicesperGPbysexandplaceoftraining2003–2013byfinancialyear.

ATD OTDFYr. Male Female Male Female2003 5245 2798 6189 44412009 5605 3024 6881 52122013 5034 2709 6443 4886Source:Customisedpurchaseof2014MedicareStatistics.NoteaNon-VROTDnumbersover-count(T10.)meantOTDservicesperGPwereactuallyhigher.

4.3%ofFullServiceEquivalentforVocationallyrecognisedGPsinRA1byorigin2008-15FYear 2008 2012 2015ATD 66 64 66OTD 97 95 99All 74 73 74Source:DoH2015and2016GPstatistics.

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consultation. It gives the patient more control over content and has some preventive effect on unnecessary re-attendance. Obviously bulk-billing encourages over-servicing whenever the patient can be persuaded to re-attend. A ceiling for public demand has not been reached, if indeed it exists. Per capita attendances are rising year on year, as discussed above. Further analysis of attendance in proportion to employment and welfare dependence might be revealing. Assuming a growth in GP services per capita of 0.1% per annum would mean 6.7 by 2025, with 184.1m services for a population of 27m costing $9.132b at current rebate levels. This will mean of course steady reduction in GP incomes with commensurate loss of status for Australian graduates deciding on future careers. Private billing will become steadily more common and is already in major city CBDs. The viability of corporate chains may remain if they employ more doctors and maximize throughput, which appears to be occurring (Table 4.1).

Feminisation of the GP workforce will continue, which affects nominal output as measured by services per GP. Female domestic graduate numbers have declined

from levels around 56% to 51% in 2014 but the specialties will continue to absorb males at a greater rate than females unless the training system changes. New fellow specialists were still 57% male in 2014. The OTD GP workforce is slightly more predominantly male (Table 4.4) but this is outweighed by female ATD entry so that the percentage of female GPs has risen by about 3% every five years (Table 4.5). This would put the workforce at over 50% by 2025. It will rise faster as a % if immigration is curtailed.

Table 4.2 showed that services per female ATD fell back by 2013 to their 2003 level of around 2700. For Female OTDs they remained quite a lot higher at 4886. Using the 2016 corrected data we find that because of female OTD activity DOH Female FSE has steadily risen. This means that the female ATD FSE rate has fallen. The projections in Table 4.5 are therefore predicated on immigration remaining at

the same levels. If a return to dependence on Australian graduates occurs then, unless male Australian graduates appear in greater numbers, then much greater numbers of females will be required to sustain output. That is, if present levels of servicing are desired. Female Australian GPs are however more efficient, and less prone to over-servicing than other groups, so that there would be a drop in workforce requirements relative to this. HWA provided age differential for male and female GP workforces in 2009 (Table 4.7). This, as might have been expected, showed an older and a relatively younger female workforce outnumbering males in the 30-34 age group. The GP workforce age pyramid is quite different from the (much healthier) pyramid for working clinicians as a whole (Table 4.8). Table 4.9 shows how the GP age cohorts have been steadily changing since 1985. The huge influx of OTDs since 2010 has steadied up distribution so that the 35-44 group has enlarged. This means that an incipient retirement crisis, feared by HWA and the profession, which possibly somehow fueled the rise in immigration after 2010, is no longer on the cards. The

under 35 group is still far too small but should build up with the enlarged AGPT training numbers. AGPT data is required to calculate by how much. OTDs are a slightly older group and still comprise about 25% of entry to AGPT, because of diversion of Australian domestic graduates in to the specialties. There is also a considerable and anecdotally increasing number of doctors from overseas who have obtained permanent

residence by various means who are providing the balance of GP trainees in the AGPT. Analysis from the recent census would be of benefit. At present the 1600 intake into the training program was 4.6% of the total number of

4.5FemaleworkforcegrowthprojectionFYr. 2005 2010 2015 ?2025%allGPs 38.0 41.2 44.7 50FSE%allFemale 48.3 51.0 54.1 60FSE%allGP 27.9 31.3 36.2 46%ServicesallGP 26.9 30.5 34.9 43%Totalrebate 27.6 30.5 35.6 44Source:DoHGPStatistics

4.4FemaleGPsas%Total 2005 2010 2013ATD 38.4 42.3 45.1OTD 35.1 38.2 40.5DoHGPStatistics.Purchased2015

4.6ServicesperFemaleGPFYr. 2000 2005 2010 2015TotalServicesm 23.8 26.3 35.2 29.5ServicesperGP 3074 3009 3154 3199FSE%allfemale 47.1 48.3 51.0 54.1Source:DoH2016GPstatistics

4.7FemalesandMalesas%ofworkforcebyage2009Agegroup 25-9 30-4 35-9 40-4 45-9 50-4 55-9 60-4 65-9 70-4 75-9 80+ AllFemale 2.2 5.9 6.0 6.9 6.7 5.7 3.2 1.7 0.7 0.3 0.2 0.1 39.6Male 2.2 5.1 6.2 7.5 9.1 9.6 8.4 5.7 3.2 1.7 1.2 0.6 60.4Source:HWAHealthWorkforce2025Vol3p106table13.8quoting2009AIHWfigures.

4.8GP&AllDoctorcohorts%workforce@30.6.16Age <35 35-44 45-54 55-64 65-74 75+

AllDoctors1 27 26 20 16 8 3GPs2 13 25 25 23 11 31AHPRARegistrantdata.22016DoHGPStatistics.

4.9GPAgecohortsas%ofworkforce1985to2015.Age/F.Yr 851 901 951 002 052 102 152

<35 35 31 24 15 10 10 1335-44 29 32 32 32 27 22 2545-54 15 17 22 31 33 30 2555-64 14 11 11 15 21 24 2365-74 6 7 8 7 7 9 11>75 1 2 2 3 3 2 3Source:12014and22016DoHGPStatistics.

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34,606 GPs. Allowing for long term attrition of 2.5% (40 year career) this allows annual expansion of 2.1% against population increase of 1.4-1.6%. Will attrition be greater? The necessity to provide for retirement out of Medicare income is a major incentive to work longer. Greater attrition will temporarily occur as older male Australian trained GPs retire. The exercise in table 4.7 needs repeating to see how age cohorts have changed and are currently represented. Comment. The District of Workforce Shortage arrangement should be ceased forthwith and special arrangements made to continue recruitment of GPs to Modified Monash Model towns class 4-7. This would put a brake on the current unsustainable increases in GP workforce. Different methods of recruitment of rural GPs and specialists need to be found, with implementation of a national rural generalist pathway on the lines of the well-established Queensland program. DWS Recruitment to Regional towns and fringe metropolitan is no longer required. Serious reconsideration to the matter of Geographical provider numbers is required as the predisposition for doctors to concentrate in the cities is unlikely to change (arguments against from the Constitution are probably spurious). Further analysis of workforce components is required to assess future workforce requirements in view of lower output by Australian trained GPs, especially as the workforce feminises but Australia needs to find (an appropriately sized and tasked) workforce from its own resources. In the long term this may require a substantial change in the model of primary health care provision, parallel to or on the lines of the ‘Medical Home’. And it is vital that a very long-term approach now be taken. Wider medical workforce planning is required to assess the appropriateness of medical graduate output and the high level of growth of the specialist workforce in the context of probably now slowing hospital workforce. The specialist workforce itself needs limiting in some manner as its growth is unconstrained. Workforce planning needs to be more openly conducted and advice within the NMTAN, which has published no reports, needs disclosure. NMTAN needs to have representation from the ACRRM to encourage an appropriate workforce to maintain long-term viability of the 520 or so rural hospitals nationwide. Note. The author would be pleased to provide further references on request. This submission reflects the guidelines for the submission and is not a comprehensive treatment of the subject.