Manajemen | Fakultas Ekonomi Universitas Maritim Raja Ali Haji 2003 1 (7)
THE STATE, IMMIGRATION POLICY AND
LABOUR MARKET PRACTICES: THE CASE
OF OVERSEAS-TRAINED DOCTORS
DIMITRIA GROUTSIS*
T
he state has played a critical role in defining the form and character of the labour
market through its regulation of immigration. This paper considers the implications
of the waves of migrant labour as driven by the state, with a special focus on overseasqualified professionals.1 Emerging from this discussion is an assessment of the immigration and settlement policies which have established, reinforced and also reflected the
dominant cultural milieu in the broader Australian society and the labour market.
Following this is an exploration of the implications of the policy rhetoric on the labour
market entry of overseas-qualified professionals, with a focus on overseas-trained doctors
as a case in point. The paper seeks to answer the following question: How, if at all, have
labour market practices—including accreditation and labour market entry—relating to
overseas-qualified professionals been influenced by the shift in the official rhetoric dominating migrant settlement and labour market integration as driven by the changing nature
of migration? To explore this question, this paper is divided into two sections. Part one
examines the state-driven socio-cultural policy trends throughout the post World War II
period and how and why these shifts in policy have directly shaped the labour market
experience of skilled migrant labour. Following the examination of the dominant sociocultural paradigm, part two explores the effect of the major state-driven policy shifts on
overseas-qualified professionals—with a specific focus on overseas-trained doctors. The
conclusion drawn is that the medical profession strictly directs the registration and labour
market access of overseas-trained doctors based on factors that contravene the broader
state policy, raising calls for a more active approach to monitoring professional practice
by the state and related institutional bodies.
PART
ONE: THE STATE AS CULTURAL ENGINEER—IMMIGRATION
POLICY, THE LABOUR MARKET, AND OVERSEAS-QUALIFIED
PROFESSIONALS
The state has played a central role in shaping the structure of the Australian labour
market since the beginning of Australia’s white settler history. As Bell and Head
(1994: 7) note:
In Australia the problems of infrastructure provision (roads, railways, ports, urban
services, communications) in a vast and sparsely settled continent saw colonial
Dr Dimitria Groutsis, Associate Lecturer, Work and Organisational Studies, Faculty of Economics
and Business, University of Sydney H69, Sydney, NSW 2006. Email: d.groutsis@econ.usyd.edu.au
Thanks to Stuart Rosewarne and the anonymous referees of the Journal of Industrial Relations for
helpful comments on earlier drafts of this paper.
THE JOURNAL OF INDUSTRIAL RELATIONS, VOL. 45, NO. 1, MARCH 2003, 67–86
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governments, not private enterprise, play a leading role in underpinning the process
of economic development, (and thus labour market expansion).
The legacy of such intervention continues. To service the demands of an
expanding labour market, the state has drawn on immigrant labour in times of
labour shortage (Martin 1984: 115, Crock 2000: 2, Hugo 2000: 11). In addition
to coordinating supply-side needs and underpinning, and in some cases generating demand, the state also develops policies and practices, which have an impact
on economic policy and the labour market agenda. Thus, since Federation, there
has been a ‘symbiotic relationship between immigration and labour market
regulation . . .’ (Crock 2000: 2).
The role of the state in forging this relationship has not been straightforward
but has been shaped by the confluence of a range of factors including the
various tiers of government, the political hue of the government of the day
and the state/national tussle (Gardner 1989). The state then functions ‘like
a constellation of competing interests’ (Witz 1992: 208), where often
contradictory agendas shape the decision-making processes and consequent
outcomes. For instance, although the Commonwealth has assumed responsibility
for key migration, settlement and labour market issues on both a state and
Federal level since World War II, the state’s bargaining strength has posed a
great challenge to the Commonwealth agenda (Gardner 1989: 207, Iredale
1998).
Post-war immigration and the consequent integration of immigrant workers
into the Australian labour market is one area that brings to light the fragmented
nature of the state and Federal powers, and the ensuing political, economic and
legal tussle (Streeck: 1992). This is clearly summarised in the following point
made by the National Office for Overseas Skills Recognition (1994: 3–4):
while the Commonwealth has responsibility for the migration program, it has
limited powers when it comes to the recognition of overseas qualifications in
Australia which is largely the responsibility of the States and individual professions.
This assymetry in policy explains why Commonwealth initiatives have been primarily
directed at the establishment of a solid framework and the provision of support
and encouragement to other stakeholders to make tangible progress in the area
of overseas skills recognition.
The accreditation process and consequent labour force integration of overseastrained professionals is a policy issue that has historically generated competition
and little cooperation between state and Federal jurisdictions. Not only does the
lack of cooperation between states create difficulties in skills transferability for
skilled immigrants, but the real issue is lost in the confusion that ensues between
the states and the Commonwealth.
Pressure then is applied from the varying layers within the state, and particularly from the variety of interest groups which occupy different power bases and
compete for funding and labour market positions. The state intervenes to set
the labour market boundaries, fostering access for some groups while creating
barriers for others.
OVERSEAS-TRAINED DOCTORS
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Gardner (1989: vii) captures how interests are served in the Australian political
economy in which power is a significant differentiating feature between the
groups:
Interests or groups are “served, or not served” according to the changing balance
between these (social, political and economic) forces. The dominant structural
interests are those which benefit from the particular combination of forces, even
without actively defending their own interests.
The medical profession is one group that has exploited its professional power to
systematically serve its own interests and thus operate above and beyond state
boundaries and demand and supply conditions.
From the shifting waves of immigration, settlement policies have emerged that
have been shaped by many influences and from which a stronger power position
has been created for some and a weaker position for others. The paper begins
with a survey of the state’s immigration and settlement policies throughout the
post World War II period through to the present day. This discussion leads
us to an assessment of the consequences of the shifts in policy on the labour
force participation of overseas-qualified professionals—and more specifically
overseas-trained doctors—in the Australia labour market.
Skilled migration and settlement policies in the post-World War II period
During and after World War II, Australia’s political economy underwent a major
structural overhaul with direct implications for the migration policy and related
public programs including the structure of post-war employment (Moore 1994:
5–7). In 1945 under the first Minister for Immigration, Arthur Calwell, the state
entered a new phase of immigration under the slogan ‘Populate or Perish!’. A
population shortage posed problems for the Australian nation in the late 1940s,
affecting both the national growth and labour market (Australian Information
Services Publication 1973: 7, Collins 1991, Jayasuriya et al. 1988, Brooks and
Williams 1995, Refshauge 1982: 264). For these reasons, mass migration from
non-British countries was undertaken. This was despite a Government commitment to the White Australia Policy, espousing to keep the immigration fabric
intact by maintaining British immigration (Collins 1984). Unions were most
suspicious of the government’s immigration policy, fearing a threat to their
employment, wages and conditions. These ‘fears’ were allayed as immigrants and
refugees filled areas that were weakly staffed by Australian labour, illustrating
that overseas settler arrivals had a role to play in the Australian labour market
that no-one else was willing to fill (Markus 1984).
The state’s rhetoric highlighted that the expanded growth required in the
immediate post-war reconstruction phase would absorb the newly arrived labour
(Withers 1991). This period was characterised by significant demand for lowskilled and semi-skilled labour (Moore 1994: 9). Consequently, given that the
recognition of skills was not part of the settlement process, there were no mechanisms in place to accredit the skills of the 70 000 displaced persons who were
resettled in Australia.
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In fact, the Comm onwealth imposed a two-year contract period (in areas of
need) for skilled settler arrivals entering the area in which they were trained (Kunz
1975 & 1988). The UK was used as a reference point for skills accreditation and
there were no mechanisms for recognising skills acquired outside of the UK, and
especially in non-English speaking countries. Immigrants from non-English
speaking countries were deemed to be ‘unskilled’ labourers irrespective of
their previous professional life (Appleyard 1964, Martin 1965, Kunz 1975, Kunz
1988). For individuals seeking to gain assessment and accreditation, they had to
approach the relevant professional body. The process of assessing overseasqualified immigrants remained the responsibility of each professional group. In
terms of the state’s role at this time, it involved little more than the processing
of new arrivals and the organisation of migrant labour in the massive infrastructure
projects. Thus, the state played a minor role in the assessment and accreditation
process.
Settlement policies shifted to assimilation throughout the 1950s and into the
early 1960s. This was superseded by the policy of integration throughout the
1960s and 1970s. As a consequence of the expanding labour market, coupled with
the more relaxed settlement policy, from 1963, overseas-trained professionals
from Non-English speaking countries (NESCs) were encouraged to migrate to
service a more specialised workforce.
The integration policy placed the onus of integration on the immigrant who
had to ‘assimilate’ and foster the reproduction of the dominant ethnic culture.
This policy reinforced the cultural imperialism evident throughout Australia’s
white settler history, propagated by the idea that it was up to ‘them’ to be like
‘us’ (Jayasuriya et al. 1988: 171, Withers 1991).
Most importantly for overseas-qualified professionals, the assimilation policy
was linked to a significant institutional development—the establishment of the
Committee on Overseas Professional Qualifications (COPQ).
The idea of a central committee to investigate and develop registration
practices was tabled in 1968, and realised in 1969 with the formation of the
COPQ. The Hon. Minister for Immigration, Snedden, commented about this
development:
The Committee will not decide individual cases of professional men and women.
It will direct and supervise the collection of information using methods it deems
appropriate, through existing departments and authorities, through professional
panels or otherwise in its own judgement. It will work closely with existing registration authorities (Moore 1994: 24).
The Committee saw the state taking a central role in providing information to
overseas-qualified professionals and opening dialogue between it, and professional
bodies responsible for the assessment and registration of overseas-qualified professionals. Until this time, the registration of overseas-qualified professionals
remained unmonitored by an external body.
As a central body responsible for overseeing the accreditation process for
overseas-trained professionals, COPQ offered little in terms of much needed
reforms to the outdated system of qualifications accreditation. The autonomy
OVERSEAS-TRAINED DOCTORS
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of the professional bodies in the accreditation process thus remained undisturbed.
That is, for all the efforts of the government to set up a more centralised process
of assessment and accreditation for overseas-qualified professionals, the process
remained tightly in the hands of individual professions. A further complication
for overseas-qualified professionals was that the process differed from state to
state, making skills transferability a difficult process.
Overall, the major criticism of COPQ was that the structural changes failed
to bind migration and labour market settlement. Given the assimilationist foundations of this institutional shift it is no surprise that the reform agenda was in
the main weak.
The Whitlam Government discarded the assimilationist policy soon after
election in 1972 and in its place introduced multiculturalism (Jakubowicz
1981). According to Jupp (1996: 6):
Multiculturalism ended the belief that all other cultures were inferior to and incompatible with the “mainstream” culture of white British Australia . . . It was accepted
that physical appearance or non-European origin were not a suitable basis on which
to exclude people from the Australian community.
Underpinned by the multicultural agenda the Fry Committee of Inquiry was held
in 1982 to investigate the recognition of overseas qualifications. Thus, the plight
of professional migrants became a public issue. This Inquiry also attempted to
bridge the gap between migration, settlement and labour market integration with
an effort to differentiate between migrant categories, acknowledging that not all
migrants are unskilled. That is, on migrating, the individuals concerned want to
resume labour force participation in a similar position to that in which they were
prior to migration.
In all, 86 recommendations were made by the Committee to reform the accreditation of overseas-qualified professionals. Regarding the responsibilities of COPQ,
it was recommended that the tasks of the body be expanded. Although COPQ
continued to be under-resourced, by 1988 it was orchestrating the assessment of
a number of professions; the majority of which were in the health occupations.
At this time, pressure for reforms to the settlement program increased with the
number and diversity of migrant groups.2
Discussion within the public arena continued with the National Agenda
for Multicultural Australia, launched in 1989 (Office for Multicultural affairs
(OMA) 1989). This signalled the start of some meaningful institutional
developments. The Agenda comprised three dimensions: cultural identity;
social justice; and economic efficiency. In essence, the agenda highlighted
the ‘need to maintain, develop and utilise effectively the skills and talents
of all Australians, where these skills and abilities are employed without
barriers of discrimination or prejudice’ (OMA 1989). This approach was
deemed central to ‘managing and valuing’ diversity. At the core of this
policy shift was the marriage of two polarised agendas: social equity and
micro-economic reform. Thus, not only was the issue of foreign-trained
professionals brought to the forefront, but the economic ‘usefulness’ of these
skills was emphasised.
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The National Agenda for a Multicultural Australia was part of the prioritised
reforms to the recognition process for overseas-qualified professionals. At its
launch, several changes to the structure of qualifications accreditation were
announced, including:
• The establishment of the National Office of Overseas Skills Recognition
(NOOSR), which incidentally, was directly linked to the micro-economic
reform package (NOOSR 1994: 3).
• Further developments in, and funding of, measures to improve access to
education and training by migrants with unrecognised qualifications.
• The encouragement of the adoption of national skills standards and other
measures so as to reduce the fragmentation evident in the current system of
overseas qualifications recognition.
All the recommendations made in the National Agenda were introduced with
varying degrees of success. One of the most significant reforms to the assessment
and accreditation process to emerge from the recommendations was the
establishment of NOOSR which subsumed the role of COPQ.
Four key points were identified in the establishment of NOOSR which
encapsulate the agenda for reforms to the accreditation process:
• Set a simpler and more flexible accreditation structure from an administrative
perspective.
• Ensure that the process is based on non-discriminatory assessments, incorporating national competency procedures.
• Develop fair and open procedures which are subject to a uniform appeal
process.
• Improve remedial and bridging courses including English language training
which is, as mentioned earlier, cited as a primary factor in delays to gaining
labour market access in a position representative of skills (NOOSR 1989)
Overall then, NOOSR aimed to take the responsibilities of assessment and
accreditation from the professional bodies and employers.
Until the establishment of NOOSR, the accreditation process had been
hampered by the multivariate accreditation models enforced by the emphasis
on state licensing bodies. Structurally, NOOSR intended to improve the system
by developing closer links with state and territory agencies and educational institutions involved in the accreditation of the overseas-qualified professionals. It
was expected that the coordination between the various bodies would establish
more accurate and accessible flows of information, and thus an adherence to ‘best
practice’ models.
In terms of NOOSR’s policy direction, by the early 1990s, NOOSR had shifted
the focus from paper qualifications to competency-based assessment, arguing that
the previous mechanisms for accreditation were ineffective in assessing and thus
recognising occupational competence and skill.
NOOSR’s reform agenda was also aligned to the broad changes transforming
the Australian labour market, incorporating training, industry progression and
labour market deregulation (NOOSR 1992: 8). Clear contradictions emerged with
this prescribed process of labour force integration for overseas-qualified professionals.
OVERSEAS-TRAINED DOCTORS
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The possibility of reform was undermined given the politico-economic shift
to micro-economic reform and labour market deregulation. Why? The shift
pushed the reform process to the professional bodies and the employers, leaving
it up to them to either ‘embrace’ or reject the defined changes. Consequently,
professional bodies have been slow to embrace the changes proposed by the
state to facilitate a fairer and more efficient process of accreditation for overseasqualified professionals. According to Moore (1994: 33):
the creation of NOOSR and the development of competency based skills assessment
by no means ended discrimination in the workforce against non-English speaking
background migrants . . . Many Australian employers want local experience and most
insidious of all is the tendency of employers to recruit and promote “people like us”
by using non-work related selection criteria.
In spite of the touted reforms, the state agenda failed to deliver for a number of
reasons. The state succumbed to pressure from professional organisations eager
to remain in control of the assessment and accreditation procedures of potential
labour force participants. Given that the state lacked the will to assume a greater
level of institutional responsibility, the labour market customs and practices
remained impenetrable. More broadly, the state socio-cultural agenda remained
weak. Although based on sound principles of equality, multiculturalism lacked
conceptual clarity and as a consequence it has failed to identify and address
the essence of exclusionary tactics in the labour market on the grounds of
‘difference’ (Kalantzis 1989). As Jakubowicz (1984: 42) points out:
Multiculturalism gives the ethnic communities the task to retain and cultivate, with
government help, their different cultures, but does not concern itself with
struggles against discriminatory policies as they affect individuals or classes of
people.
This policy has done little to scrutinise the institutions within which power differentials are borne and where the dominant culture was, and continues to be
validated (Jayasuriya et al. 1988, Collins 1984). Fundamentally, these weaknesses
are based on the policy’s failure to address the very parameters of inequality, a
point effectively displayed by an examination of the settlement processes and
labour force participation of overseas-qualified professionals. The problem stems
from the fact that the migration and settlement of labour force participants
is not considered as a whole but separately. That is, one migrates and then
settles—which involves participating in the labour market. The process moves
along a continuum and as a result, so should the policy approach. One should
be an extension of the other, yet the policy rhetoric has failed to reflect this, as
has the practice.
As a result, in spite of the ensuing policy interest coupled with the shifting
demographic constitution of immigration from the 1970s into 2000, the clear
discrepancy between different migrant cohorts entering the Australian labour
market has remained (National Advisory Committee on Skills Recognition
(NACSR) 1991: 63, Ruddock 2000, DIMA 2000). This labour market
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condition has been consolidated and reinforced primarily because professional
bodies—especially elite professions—have held on to a position of self-evaluation
and self-regulation working above and beyond state-developed changes in
policy and the available labour supply. The consequence is that labour demand
has largely remained blind to the ethnic diversity of the labour supply with skilled
immigrants from non-English speaking countries pushed to alternative areas of
the labour market.
This consideration brings to bear the state’s complex and often contradictory
role. On the one hand, the state must satisfy the equitable labour market integration of overseas-trained professionals. Settlement and labour market policies
and procedures are in place to set a ‘level playing field’ for all individuals seeking access to the labour market. These are policies motivated by state action and
monitored by players within the state. Alternatively, the state must adhere to a
cost-effective method of labour recruitment as facilitated by the micro-economic
reforms. This is coupled with pressure from a variety of interest groups—
primarily professional licensing bodies, for the state to interfere as little as
possible in the accreditation process.
Policy-making in Australia is complex, defined by the interdependence of
public and private sectors, parliaments, ministers, government departments and
statutory authorities, consultants and interest groups (Gardner 1995). The process
of qualifications accreditation provides evidence of this complexity. Although the
policy rhetoric has highlighted a shift toward accommodating for the greater
skills of new settler arrivals, and to minimising the wastage of skills, the labour
market practices fall short of this ideal (NOOSR 1994:3).
PART
TWO:
THE
CASE OF OVERSEAS-TRAINED DOCTORS
Drawing on overseas-trained doctors as a case in point demonstrates why and
how the changes in the broader process have been undermined by the continued
regulation of the medical labour market by the medical fraternity. In fact, the
medical fraternity has drawn on state support in order to restrict particular groups
of overseas-trained doctors from entering the labour market.3
Although the medical fraternity has justified the approach to assessment
and registration in terms of upholding a standard of medical practice, contention
emerges over the agenda that runs parallel to the test of standards. Throughout
the post-war period through to 2000 the accreditation process has been
employed as a tool to directly restrict supply in order to protect the workforce
position of locally trained medical practitioners.
Those who have traditionally been included in the medical workforce—
Australian and New Zealand trained doctors and until very recently British male
and more recently female doctors—have wanted to retain their monopoly
over the market supply.4 The basis for this monopoly was created early on in the
establishment of the Australian medical workforce, a position supported by
the state (Johnson 1977 & 1982). As Kunz writes (1988: 38):
The unusually high status and esteem accorded to doctors, reinforced by the absence
of effective competition and the discouragement of specialisation, and a subdued and
OVERSEAS-TRAINED DOCTORS
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uncritical public, in turn created a medical profession which at best prided itself
on its self-reliance, on its ability to cope single-handed with all types of medical
problems, and on its capacity to assume leadership in sundry affairs.
The control of competition within the medical market continues to the present
day. By safeguarding the financial position of its members, it has been able to
influence the cost of medical care, and the provision of medical services. As
Gardner (1989: 9) points out:
While health services are characterised by both public and private ownership of goods
and services, it is the medical profession which makes the greatest impact on the
kinds of services that will be provided, and therefore, on the economic consequences
of those services. (See also Hetzel 1980, Marmor and Thomas 1971; Palmer 1978;
and Scotton, 1967;1974).
This structure thus results in restricted competition for buyers of the services
provided. Consequently, demand is left unmet and in this context groups
traditionally ostracised from the medical labour force face continuing obstacles
as indicated by the restriction of particular groups of overseas-trained doctors
into the Australian labour market.
The ‘flooding’ of the medical market with overseas-trained professionals has,
and continues to be, considered a great threat to local practising doctors fostered
by the more intensive competition for buyers of services provided. In the early
1990s the Federal Government pointed out that:
The situation in Australia is now such that it can no longer afford to permit
relatively unrestricted entry of overseas medical practitioners (Innominate 1991).
It has been suggested that unrestricted labour market access for overseas-trained
doctors will have a negative impact on the Australian economy as the cost of training local graduates may be lost, compounded by the cost of supporting locally
trained doctors left unemployed (Donalds 1991, Norman 1996). Increasing the
number of doctors is also said to result in over-servicing, consequently blowing
out Medicare outlays (Donalds 1991, Birrell 1997b).
There are a number of separate but related issues in the scenario presented
thus far. One is the examination of professional standards, which involves the
overseas-trained doctor passing through an accreditation process to gain registration. This process should by definition only be used to measure the standard
of training, skills, and practice—as advocated by NOOSR.
The second issue is the supply of available labour (groups successfully passing
through the accreditation process) in response to demand in the medical labour
market. This process should involve employers, the state, the patient/consumer
and the overseas-trained doctors (demand and supply). Throughout the history
of accrediting overseas-trained doctors the medical fraternity has, with the
support of government (ironically), conflated the accreditation process (the
assessment of standards) and labour supply and demand (labour force issue).
Consequently, the accreditation process has and continues to be used as a tool
for controlling supply rather than simply assessing the quality and standards of
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the qualifications (Birrell 1997a & 1997b), thus undermining the broader policy
rhetoric and the designated role of bodies such as NOOSR.
Like all health areas, the demand for medical services and thus the medical
labour market is subject to expansion and contraction. Over the last 50 years for
instance, there have been incremental increases in the medical workforce.
During the 1960s, the demand for labour was greater than the available
supply. Reports at the time projected that the medical profession could continue
to expand with little threat of an oversupply, or encroachments on the salary
and conditions of registered medical practitioners (Scotton 1974). Given the
current restrictions placed on the supply of general medical practitioners, it is
ironic that it was general medicine that was forecast as requiring increasing
candidates in the future. This was especially so due to the expanding role of
the medical practitioner into areas, such as research institutes, universities,
non-resident medical posts and business. Also, particular specialties were
further developed —booming from the 1960s to the 1990s—such as surgery and
obstetrics (Department of Health, Housing and Community Services (DHHCS)
1992: 114). By the 1970s active steps were taken to cap supply especially in the
metropolitan areas (Doherty Report 1988, Jensen 1991, DHHCS 1992).
The ‘supposed’ rising doctor to patient ratio has been used as evidence of
the overcrowding of the medical market, where overwhelmingly overseas-trained
doctors have been targeted as responsible for exacerbating and compounding the
oversupply of medical practitioners. Thus, although the vocational orientation
of medical practitioners has broadened, the supply of new graduates has been
considered more than adequate to fulfil demand (Iredale 1990, Birrell 1995,
Harding 2000). Until recently, what has been missing from the debate regarding
the alleged oversupply of medical practitioners is that the bulk of the financial
capital and human capital resources are deployed in the metropolitan areas, while
the rural areas have continued to be under resourced. The growing supply
has thus concealed the uneven distribution of medical labour and the fact that
significant areas of demand are left unmet and a pool of labour is left underutilised.
To overcome the alleged oversupply situation several measures were implemented in the 1990s directly targeting overseas-trained doctors (DHHCS
1992: 25).5 Barriers imposed involved the reduction of overseas-trained doctors
entering Australia, the reduction of overseas-trained doctors passing the AMC
exam and entering the medical workforce6 and restrictions on overseas-trained
doctors billing on Medicare. These strategies clearly highlight the inextricable
links between migration, accreditation and the labour market as directed by the
medical fraternity, which has successfully operated outside of the broader
policy and institutional platform informing the accreditation and labour
market entry of overseas qualified professionals. The following evaluation of
the multifaceted nature of barriers imposed by the medical fraternity illustrates
the state’s failed attempts at establishing a ‘level playing field’ for all potential
labour force participants. Instead restrictions have been imposed on particular
groups based on labour demand and supply concerns driven by the medical
fraternity.
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The first barrier was raised at the point of migration. Principal applicants—
arriving as permanent residents—who trained as medical practitioners were
penalised in the points system. In 1992, the government imposed a ten-point
penalty on doctors applying for permanent residence under the independent and
concessional categories. This was then increased to a penalty of 25 points in 1995.7
Ironically, although overseas-trained doctors entering as permanent residents
have been ‘officially’ penalised, those arriving under temporary visas have continued to flood in. Throughout the period of the clamp-down on supply
the Federal Government ignored the arrival of overseas-trained doctors under
temporary visas. This group made a significant contribution to the annual
supply of doctors. From 1986 to 1991 overseas-trained doctors arriving on
temporary visas increased by 100 per cent. For those who arrived on temporary
visas several conditions applied. They were restricted to a stay of no more than
two years and were prohibited from working in private practice. Further, they
were restricted from participating in the AMC, or from applying for permanent
residency based on occupational status. The majority of these arrivals were
recruited to fulfil short-term positions in public hospitals, in locum services, rural
areas and in research (DHHCS 1992: 63). These doctors then were able to
practise without going through the AMC examination process, a significant point
given that once applying for permanent residency the overseas-trained doctor
was instantly forced to go through the multi-level AMC examination process to
test standards. This indicates a gross discrepancy in the assessment and accreditation process (Horsburgh 1997, Tattam 1999, Marsh and Downey 1999). As a
consequence of much vocal opposition from groups representing overseas-trained
doctors seeking permanent positions and attempting to get through the AMC
process, active measures were employed to limit the infiltration of overseas-trained
doctors on temporary visas. This condition has since changed as a result of the
Table 1
Year
1990–91
1991–92
1992–93
1993–94
1994–95
1995–96
1996–97
1997–98
1998–99
1999–2000
AMC MCQ and clinical examination results
No. newly
presenting
MCQ
No.
sitting
No.
passed
No. newly
presenting
Clinical
No.
sitting
No.
completed
538
523
344
332
350
Nil
758
300
301
450
915
921
812
619
688
Nil
1382
779
669
769
455
298
297
343
391
Nil
612
234
372
304
279
344
194
193
207
Nil
341
265
250
242
391
587
434
418
404
Nil
556
427
459
434
194
246
193
211
222
Nil
266
151
220
219
Data: AMC Annual Report (2000), Canberra, Australia.
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urgent demand for doctors in “areas of need”. Once again demand is being
satisfied by temporary resident doctors (Birrell 1997b).
The second and more effective point of restriction was imposed on overseastrained doctors entering the AMC examination process. This is illustrated in
Table 1, which shows a severe dip in those presenting for the examination and
passing through the process in the 1992–93 period followed by a sharp increase
in the 1996–97 period and steady figures from 1997–2000.8
In resolutions reached by the AMC, the Working Party (1990) made a motion
to support:
the imposition of a quota on the number of overseas trained doctors sitting the AMC
examination and a restriction on the number of overseas trained doctors allowed to
enter general practice to a maximum of 10 per cent of the number of Australian
graduates entering general practice. (See also DHHCS 1992: 26, Doherty Report
1988)
As a result, from 1992 through to 1995 a maximum of 200 overseas-trained
doctors were permitted access to the final phase of the examination—the
clinical component.9
The decision to do so was reached at the Health Minister’s Conference in that
year, following pressure from the Federal and State Ministers, Deans of the
Medical Faculties, the AMA and the Royal Colleges. In correspondence to the
President of the Overseas Trained Doctors Association (December 1992), the
Chair of the Health Minister’s Advisory Council pointed out that:
After examining the Australian medical workforce in considerable depth, Australian
Health Ministers agreed in April 1992 that there was an oversupply of doctors in
Australia, resulting in considerable negative implications for the costs of health care
delivery. Ministers acknowledged, however that the surplus was concentrated mainly
in urban general practice and in some rural areas.
Once the quota was implemented, the AMC MCQ exam was no longer based
on a pass/fail structure in order to progress to the next stage of the examination
(clinical stage). Rather, passing was determined by merit order of performance.
As stipulated in the AMC Information Sheet (1995):
(a) A candidate must be within the group of the top 200 eligible candidates at the
MCQ examination.
(b)The minimum performance requirement is a minimum score of 50 per cent
or better and not less than 40 per cent in any of the five component subjects
examined at the MCQ examination.
Although subject to an annual review, little changed in the quota throughout
the period of imposition. A major turning point occurred when overseas-trained
doctors took legal action to lift the quota. On October 6 1995, the AMC
announced changes to the examinations for overseas-trained doctors. The
announcement came following the complaint brought before the Human Rights
and Equal Opportunity Commission (HREOC) by Dr Siddiqui against the AMC
and the Commonwealth Department of Human Services and Health. In the case
of Dr Siddiqui, the decision passed down by HREOC found for the complainant
OVERSEAS-TRAINED DOCTORS
79
on the basis that the quota system and the nature of the examination process contravene basic human rights as set out in the Race Discrimination legislation s(9)
s9(A) and 25ZB. The nature of the examination was found to be inappropriate
for an overseas-trained doctor who in most cases had been a practising professional
for some years. With regard to the quota, the extreme injustice created was
emphasised in the Reasons for the Decision (1995: 33):
Every human being, as we have seen, has the right to equality before the law
including the right to work consistently with his/her qualifications and experience.
We find that the imposition of the quota . . . has impaired the enjoyment of that right
on an equal footing with graduates of accredited medical schools by persons of a
national origin other than Australian and New Zealand.
In its decision, HREOC found that the AMC and the Commonwealth
Department of Human Services and Health (DHSH) were practising indirect
discrimination in applying a quota system to the assessment of overseas-trained
doctors. As a result of the determination, the AMC decided to lift the quota. The
AMC also stopped offering the examination at overseas posts and prohibited entry
on temporary visas, so as to reserve the positions for Australian doctors who were
trained overseas. A successful counter-challenge by the DHSH was resolved in
1996 before the full bench of the Federal Court. This turn in events raised the
potential for the reintroduction of a more restrictive quota, coupled with the
continuation of discriminatory practices (SMH 4 September 1995), a reality which
did not transpire given the shift in demand and supply conditions.
The final barrier was imposed on overseas-trained doctors once in the labour
market. For those who successfully pass through the AMC MCQ/clinical examination process, they are restricted to bill on Medicare for a period of ten years.
This restriction was introduced in 1997.
In the late 1990s and into 2000, the medical labour market has been hit by a
severe shortage in some regional and rural areas, particular hospitals and locum
services (Australian Medical Workforce Advisory Committee 2000). Thus,
demand-driven forces are generating a pull for doctors and as a consequence a
re-evaluation of the assessment and accreditation procedures—although subject
to conditions (Downey and Johnston 1996, Harding 2000). For those willing to
take up posts in ‘areas of need’ they may do so subject to a screening process
that does not involve the multi-tiered and lengthy process of accreditation
through the AMC. Once passing through this process these candidates are granted
‘conditional’ registration, limiting their work to an assigned area of practice for
a fixed period.10 As noted in a media release by the National Rural Health Alliance
(27 April 1999):
Overseas-Trained Doctors with GP qualifications recognised by the Royal Australian
College of General Practitioners (RACGP) and the Australian College of Rural and
Remote Medicine (ACRRM) will be provided with immediate medical registration
for a minimum of five years, provided they agree to practise in a designated rural or
remote area of need. As an alternative to the Australian Medical Council (AMC) examinations, they will be subject to a selection process involving the RACGP, ACRRM
and the State Registration Board. After a minimum of five years it is expected that
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they will have the option of a full Provider Number to work through Medicare in
any part of Australia, although it is to be hoped that many of them will want to remain
in country areas.
The recent turn in events driven by an urgent demand in particular areas, illustrates how the accreditation process is used as a tool to directly regulate available stocks of labour. This is noted by the explicit links between the accreditation
process and the medical labour market where the use of conditional registration
for overseas-trained doctors—operates outside the AMC examination process.
The ‘conditional’ nature of access to the medical labour market raises a
number of questions regarding the assessment and accreditation process. Why
are overseas-trained doctors allowed to work in these ‘areas of need’ without
having to go through the lengthy AMC process of accreditation? Furthermore,
why aren’t these groups integrated into the Australian labour market without
restriction once completing a term in an ‘area of need’? Presently should the
overseas-trained doctor on temporary registration wish to move to a metropolitan
area, they must then go through the AMC examination process. These inconsistencies in the accreditation process will only be redressed once the accreditation process is used solely for the purpose of assessing standards rather than as
a tool for controlling labour demand and supply. It is this very contention that
raises the calls for the implementation of a stricter monitoring process by an
external body such as NOOSR.
CONCLUSION
Monopoly conditions have made it possible for the medical profession to restrict
services in spite of demand, thus directly controlling the supply of the labour
force and above and beyond state driven policy changes. Although the policy
Table 2 Labour market participation by ethnic cohort for general medicine: Total
persons 1986–91
Region
New Zealand
UK and Ireland
Eastern Europe
USSR & Baltic States
Middle East
North Africa
South East Asia
North East Asia
Southern Asia
North America
Southern & East Africa
Unemployed
Participation by ethnic cohort
0
2.2
43.8
32.1
45.1
53.5
23.2
12.6
27.3
5.9
2.1
85
88.1
56.3
45.9
72.5
72.3
69.3
73.8
65.6
69.9
87.4
Source: Unpublished Census Data (1986–1991).
OVERSEAS-TRAINED DOCTORS
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rhetoric has highlighted a shift toward accommodating for the greater skills
of new settler arrivals, and minimising the wastage of skills, the labour market
practices fall short of this ideal.
The Commonwealth, state and territory governments have over the years
placed the responsibility of assessing the standard of overseas-trained persons with
the professional licensing bodies. As a result, although both state and national
bodies have increasingly been directly involved in developing structures for
accreditation, little change has been achieved, as the bases of power have remained
institutionalised in the structures of the professional bodies. Consequently, the
lack of effective dialogue and negotiation between the many players involved
in the accreditation process continues to hamper a successful resolution to
the conditions experienced by overseas-qualified professionals in the Australian
labour market.
The process of qualifications accreditation for overseas trained professionals
highlights the difficulties the state encounters in fulfilling its objectives. Supplyside needs in an era of tight demand take priority, while the policies and practices pertaining to overseas trained professionals remain nothing more than an
ideology. The experience of overseas trained doctors from NESCs features the
disparity between this groups’ reality and the state-driven policy rhetoric.
NOTES
1. This paper focuses on the experience of legal immigrants. The issues relating to illegal immigrants go beyond the subject terrain covered here.
2. The Galbally Report (1978) was commissioned by the Federal Liberal Government to consider migrant settlement, with particular focus on access services. Among the recommendations
was the need for ethno-specific welfare workers and the creation of Migrant Resource Centres.
3. The Commonwealth, state and territory governments place the responsibility of assessing
the standard of medical knowledge of overseas trained persons with the AMC. The process is
monitored by sessional reviews. On a national level, the Commonwealth funds the AMC and
it has a representative on the Council, while also sitting on committees which look at various
issues. Despite this, the Commonwealth has limited direct powers in the recognition of overseas qualifications in the medical profession. Entry to the medical profession in particular, is
regulated by state and territory legislation. Within New South Wales for instance, the recognition and accreditation of overseas qualifications for health professions is embodied within
the various legislative enactments governing the different professions such as the NSW Medical
Practice Act and the NSW Nurses Act. In relation to doctors, in addition to the prima facie
eligibility for the registration of Australian and New Zealand graduates (regardless of ethnicity
and other background characteristics), examinations are also conducted by the Australian
Medical Council and are open to all overseas trained doctors who meet minimum residency
requirements.
4. Unpublished data for 1986–91 (Australian Bureau of Statistics 1991) reveals labour market
differences for overseas-trained doctors cut along ethnic lines (Table 2). This trend has undoubtedly continued, especially given the imposition of greater barriers to the medical labour
market introduced throughout the 1990s.
5. Federal Government initiatives to slow down general practitioner (GP) numbers also included
a variety of other groups in the medical labour market, although overseas-trained doctors have
been hardest hit by the imposed barriers to labour market participation. The strategy to
slowdown GP numbers has included:
a) A cap on the number of entrants into the Royal College of General Practitioners’ (RACGP)
Post-graduate Training programme for GPs to 400 annually, since 1995;
b) A cap on access to Medicare provider numbers to those who successfully progress through
the RACGP training programme, since 1996;
c) A cap on medical school enrolments in Australia, since the 1980s; and
d) restrictions on New Zealand-trained doctors to bill on Medicare, since 1997.
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6. The AMC shifted from a position that sought to redress inequities within the accreditation
process by changing the structure and content of the examination—which was foreshadowed
in the 1989 AMC Review—to one that created greater barriers for overseas-trained doctors
attempting to gain registration.
7. In spite of this, data throughout the period of the penalty suggests that the penalty has failed
to block overseas-trained doctors entering as permanent residents. The penalty captured those
arriving under the skilled category but failed to capture those entering as spouses sponsored
by Australian residents (Australian Institute of Health and Welfare 1999).
8. Of note are less direct barriers in the process of accreditation including the Occupational English
Test (OET) which has been shown to slow progress through the accreditation process
(see Hawthorne and Toth 1996). Also, the dismantling of the Independent Office for overseas
trained doctors and with it the bridging courses offered to doctors progressing through the
accreditation process has compounded the difficulties faced by overseas-trained doctors in
progressing into the labour market (Razaghi 2000). These issues are, however, beyond the
scope of this paper.
9. The quota of 200 did not include specialist medical practitioners who deal directly with the
Specialist Colleges.
10. Unpublished data indicates that 30 per cent of doctors from NESCs have been allowed to access
the medical labour market in so-called Areas of Need and three per cent are pending approval.
These figures do not include those who have progressed through the AMC and have been
granted full registration but have chosen to go to work in an Area of Need (Source: NSW
Medical Board. Information pertains to all doctors assessed through the Area of Need
LABOUR MARKET PRACTICES: THE CASE
OF OVERSEAS-TRAINED DOCTORS
DIMITRIA GROUTSIS*
T
he state has played a critical role in defining the form and character of the labour
market through its regulation of immigration. This paper considers the implications
of the waves of migrant labour as driven by the state, with a special focus on overseasqualified professionals.1 Emerging from this discussion is an assessment of the immigration and settlement policies which have established, reinforced and also reflected the
dominant cultural milieu in the broader Australian society and the labour market.
Following this is an exploration of the implications of the policy rhetoric on the labour
market entry of overseas-qualified professionals, with a focus on overseas-trained doctors
as a case in point. The paper seeks to answer the following question: How, if at all, have
labour market practices—including accreditation and labour market entry—relating to
overseas-qualified professionals been influenced by the shift in the official rhetoric dominating migrant settlement and labour market integration as driven by the changing nature
of migration? To explore this question, this paper is divided into two sections. Part one
examines the state-driven socio-cultural policy trends throughout the post World War II
period and how and why these shifts in policy have directly shaped the labour market
experience of skilled migrant labour. Following the examination of the dominant sociocultural paradigm, part two explores the effect of the major state-driven policy shifts on
overseas-qualified professionals—with a specific focus on overseas-trained doctors. The
conclusion drawn is that the medical profession strictly directs the registration and labour
market access of overseas-trained doctors based on factors that contravene the broader
state policy, raising calls for a more active approach to monitoring professional practice
by the state and related institutional bodies.
PART
ONE: THE STATE AS CULTURAL ENGINEER—IMMIGRATION
POLICY, THE LABOUR MARKET, AND OVERSEAS-QUALIFIED
PROFESSIONALS
The state has played a central role in shaping the structure of the Australian labour
market since the beginning of Australia’s white settler history. As Bell and Head
(1994: 7) note:
In Australia the problems of infrastructure provision (roads, railways, ports, urban
services, communications) in a vast and sparsely settled continent saw colonial
Dr Dimitria Groutsis, Associate Lecturer, Work and Organisational Studies, Faculty of Economics
and Business, University of Sydney H69, Sydney, NSW 2006. Email: d.groutsis@econ.usyd.edu.au
Thanks to Stuart Rosewarne and the anonymous referees of the Journal of Industrial Relations for
helpful comments on earlier drafts of this paper.
THE JOURNAL OF INDUSTRIAL RELATIONS, VOL. 45, NO. 1, MARCH 2003, 67–86
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governments, not private enterprise, play a leading role in underpinning the process
of economic development, (and thus labour market expansion).
The legacy of such intervention continues. To service the demands of an
expanding labour market, the state has drawn on immigrant labour in times of
labour shortage (Martin 1984: 115, Crock 2000: 2, Hugo 2000: 11). In addition
to coordinating supply-side needs and underpinning, and in some cases generating demand, the state also develops policies and practices, which have an impact
on economic policy and the labour market agenda. Thus, since Federation, there
has been a ‘symbiotic relationship between immigration and labour market
regulation . . .’ (Crock 2000: 2).
The role of the state in forging this relationship has not been straightforward
but has been shaped by the confluence of a range of factors including the
various tiers of government, the political hue of the government of the day
and the state/national tussle (Gardner 1989). The state then functions ‘like
a constellation of competing interests’ (Witz 1992: 208), where often
contradictory agendas shape the decision-making processes and consequent
outcomes. For instance, although the Commonwealth has assumed responsibility
for key migration, settlement and labour market issues on both a state and
Federal level since World War II, the state’s bargaining strength has posed a
great challenge to the Commonwealth agenda (Gardner 1989: 207, Iredale
1998).
Post-war immigration and the consequent integration of immigrant workers
into the Australian labour market is one area that brings to light the fragmented
nature of the state and Federal powers, and the ensuing political, economic and
legal tussle (Streeck: 1992). This is clearly summarised in the following point
made by the National Office for Overseas Skills Recognition (1994: 3–4):
while the Commonwealth has responsibility for the migration program, it has
limited powers when it comes to the recognition of overseas qualifications in
Australia which is largely the responsibility of the States and individual professions.
This assymetry in policy explains why Commonwealth initiatives have been primarily
directed at the establishment of a solid framework and the provision of support
and encouragement to other stakeholders to make tangible progress in the area
of overseas skills recognition.
The accreditation process and consequent labour force integration of overseastrained professionals is a policy issue that has historically generated competition
and little cooperation between state and Federal jurisdictions. Not only does the
lack of cooperation between states create difficulties in skills transferability for
skilled immigrants, but the real issue is lost in the confusion that ensues between
the states and the Commonwealth.
Pressure then is applied from the varying layers within the state, and particularly from the variety of interest groups which occupy different power bases and
compete for funding and labour market positions. The state intervenes to set
the labour market boundaries, fostering access for some groups while creating
barriers for others.
OVERSEAS-TRAINED DOCTORS
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Gardner (1989: vii) captures how interests are served in the Australian political
economy in which power is a significant differentiating feature between the
groups:
Interests or groups are “served, or not served” according to the changing balance
between these (social, political and economic) forces. The dominant structural
interests are those which benefit from the particular combination of forces, even
without actively defending their own interests.
The medical profession is one group that has exploited its professional power to
systematically serve its own interests and thus operate above and beyond state
boundaries and demand and supply conditions.
From the shifting waves of immigration, settlement policies have emerged that
have been shaped by many influences and from which a stronger power position
has been created for some and a weaker position for others. The paper begins
with a survey of the state’s immigration and settlement policies throughout the
post World War II period through to the present day. This discussion leads
us to an assessment of the consequences of the shifts in policy on the labour
force participation of overseas-qualified professionals—and more specifically
overseas-trained doctors—in the Australia labour market.
Skilled migration and settlement policies in the post-World War II period
During and after World War II, Australia’s political economy underwent a major
structural overhaul with direct implications for the migration policy and related
public programs including the structure of post-war employment (Moore 1994:
5–7). In 1945 under the first Minister for Immigration, Arthur Calwell, the state
entered a new phase of immigration under the slogan ‘Populate or Perish!’. A
population shortage posed problems for the Australian nation in the late 1940s,
affecting both the national growth and labour market (Australian Information
Services Publication 1973: 7, Collins 1991, Jayasuriya et al. 1988, Brooks and
Williams 1995, Refshauge 1982: 264). For these reasons, mass migration from
non-British countries was undertaken. This was despite a Government commitment to the White Australia Policy, espousing to keep the immigration fabric
intact by maintaining British immigration (Collins 1984). Unions were most
suspicious of the government’s immigration policy, fearing a threat to their
employment, wages and conditions. These ‘fears’ were allayed as immigrants and
refugees filled areas that were weakly staffed by Australian labour, illustrating
that overseas settler arrivals had a role to play in the Australian labour market
that no-one else was willing to fill (Markus 1984).
The state’s rhetoric highlighted that the expanded growth required in the
immediate post-war reconstruction phase would absorb the newly arrived labour
(Withers 1991). This period was characterised by significant demand for lowskilled and semi-skilled labour (Moore 1994: 9). Consequently, given that the
recognition of skills was not part of the settlement process, there were no mechanisms in place to accredit the skills of the 70 000 displaced persons who were
resettled in Australia.
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In fact, the Comm onwealth imposed a two-year contract period (in areas of
need) for skilled settler arrivals entering the area in which they were trained (Kunz
1975 & 1988). The UK was used as a reference point for skills accreditation and
there were no mechanisms for recognising skills acquired outside of the UK, and
especially in non-English speaking countries. Immigrants from non-English
speaking countries were deemed to be ‘unskilled’ labourers irrespective of
their previous professional life (Appleyard 1964, Martin 1965, Kunz 1975, Kunz
1988). For individuals seeking to gain assessment and accreditation, they had to
approach the relevant professional body. The process of assessing overseasqualified immigrants remained the responsibility of each professional group. In
terms of the state’s role at this time, it involved little more than the processing
of new arrivals and the organisation of migrant labour in the massive infrastructure
projects. Thus, the state played a minor role in the assessment and accreditation
process.
Settlement policies shifted to assimilation throughout the 1950s and into the
early 1960s. This was superseded by the policy of integration throughout the
1960s and 1970s. As a consequence of the expanding labour market, coupled with
the more relaxed settlement policy, from 1963, overseas-trained professionals
from Non-English speaking countries (NESCs) were encouraged to migrate to
service a more specialised workforce.
The integration policy placed the onus of integration on the immigrant who
had to ‘assimilate’ and foster the reproduction of the dominant ethnic culture.
This policy reinforced the cultural imperialism evident throughout Australia’s
white settler history, propagated by the idea that it was up to ‘them’ to be like
‘us’ (Jayasuriya et al. 1988: 171, Withers 1991).
Most importantly for overseas-qualified professionals, the assimilation policy
was linked to a significant institutional development—the establishment of the
Committee on Overseas Professional Qualifications (COPQ).
The idea of a central committee to investigate and develop registration
practices was tabled in 1968, and realised in 1969 with the formation of the
COPQ. The Hon. Minister for Immigration, Snedden, commented about this
development:
The Committee will not decide individual cases of professional men and women.
It will direct and supervise the collection of information using methods it deems
appropriate, through existing departments and authorities, through professional
panels or otherwise in its own judgement. It will work closely with existing registration authorities (Moore 1994: 24).
The Committee saw the state taking a central role in providing information to
overseas-qualified professionals and opening dialogue between it, and professional
bodies responsible for the assessment and registration of overseas-qualified professionals. Until this time, the registration of overseas-qualified professionals
remained unmonitored by an external body.
As a central body responsible for overseeing the accreditation process for
overseas-trained professionals, COPQ offered little in terms of much needed
reforms to the outdated system of qualifications accreditation. The autonomy
OVERSEAS-TRAINED DOCTORS
71
of the professional bodies in the accreditation process thus remained undisturbed.
That is, for all the efforts of the government to set up a more centralised process
of assessment and accreditation for overseas-qualified professionals, the process
remained tightly in the hands of individual professions. A further complication
for overseas-qualified professionals was that the process differed from state to
state, making skills transferability a difficult process.
Overall, the major criticism of COPQ was that the structural changes failed
to bind migration and labour market settlement. Given the assimilationist foundations of this institutional shift it is no surprise that the reform agenda was in
the main weak.
The Whitlam Government discarded the assimilationist policy soon after
election in 1972 and in its place introduced multiculturalism (Jakubowicz
1981). According to Jupp (1996: 6):
Multiculturalism ended the belief that all other cultures were inferior to and incompatible with the “mainstream” culture of white British Australia . . . It was accepted
that physical appearance or non-European origin were not a suitable basis on which
to exclude people from the Australian community.
Underpinned by the multicultural agenda the Fry Committee of Inquiry was held
in 1982 to investigate the recognition of overseas qualifications. Thus, the plight
of professional migrants became a public issue. This Inquiry also attempted to
bridge the gap between migration, settlement and labour market integration with
an effort to differentiate between migrant categories, acknowledging that not all
migrants are unskilled. That is, on migrating, the individuals concerned want to
resume labour force participation in a similar position to that in which they were
prior to migration.
In all, 86 recommendations were made by the Committee to reform the accreditation of overseas-qualified professionals. Regarding the responsibilities of COPQ,
it was recommended that the tasks of the body be expanded. Although COPQ
continued to be under-resourced, by 1988 it was orchestrating the assessment of
a number of professions; the majority of which were in the health occupations.
At this time, pressure for reforms to the settlement program increased with the
number and diversity of migrant groups.2
Discussion within the public arena continued with the National Agenda
for Multicultural Australia, launched in 1989 (Office for Multicultural affairs
(OMA) 1989). This signalled the start of some meaningful institutional
developments. The Agenda comprised three dimensions: cultural identity;
social justice; and economic efficiency. In essence, the agenda highlighted
the ‘need to maintain, develop and utilise effectively the skills and talents
of all Australians, where these skills and abilities are employed without
barriers of discrimination or prejudice’ (OMA 1989). This approach was
deemed central to ‘managing and valuing’ diversity. At the core of this
policy shift was the marriage of two polarised agendas: social equity and
micro-economic reform. Thus, not only was the issue of foreign-trained
professionals brought to the forefront, but the economic ‘usefulness’ of these
skills was emphasised.
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The National Agenda for a Multicultural Australia was part of the prioritised
reforms to the recognition process for overseas-qualified professionals. At its
launch, several changes to the structure of qualifications accreditation were
announced, including:
• The establishment of the National Office of Overseas Skills Recognition
(NOOSR), which incidentally, was directly linked to the micro-economic
reform package (NOOSR 1994: 3).
• Further developments in, and funding of, measures to improve access to
education and training by migrants with unrecognised qualifications.
• The encouragement of the adoption of national skills standards and other
measures so as to reduce the fragmentation evident in the current system of
overseas qualifications recognition.
All the recommendations made in the National Agenda were introduced with
varying degrees of success. One of the most significant reforms to the assessment
and accreditation process to emerge from the recommendations was the
establishment of NOOSR which subsumed the role of COPQ.
Four key points were identified in the establishment of NOOSR which
encapsulate the agenda for reforms to the accreditation process:
• Set a simpler and more flexible accreditation structure from an administrative
perspective.
• Ensure that the process is based on non-discriminatory assessments, incorporating national competency procedures.
• Develop fair and open procedures which are subject to a uniform appeal
process.
• Improve remedial and bridging courses including English language training
which is, as mentioned earlier, cited as a primary factor in delays to gaining
labour market access in a position representative of skills (NOOSR 1989)
Overall then, NOOSR aimed to take the responsibilities of assessment and
accreditation from the professional bodies and employers.
Until the establishment of NOOSR, the accreditation process had been
hampered by the multivariate accreditation models enforced by the emphasis
on state licensing bodies. Structurally, NOOSR intended to improve the system
by developing closer links with state and territory agencies and educational institutions involved in the accreditation of the overseas-qualified professionals. It
was expected that the coordination between the various bodies would establish
more accurate and accessible flows of information, and thus an adherence to ‘best
practice’ models.
In terms of NOOSR’s policy direction, by the early 1990s, NOOSR had shifted
the focus from paper qualifications to competency-based assessment, arguing that
the previous mechanisms for accreditation were ineffective in assessing and thus
recognising occupational competence and skill.
NOOSR’s reform agenda was also aligned to the broad changes transforming
the Australian labour market, incorporating training, industry progression and
labour market deregulation (NOOSR 1992: 8). Clear contradictions emerged with
this prescribed process of labour force integration for overseas-qualified professionals.
OVERSEAS-TRAINED DOCTORS
73
The possibility of reform was undermined given the politico-economic shift
to micro-economic reform and labour market deregulation. Why? The shift
pushed the reform process to the professional bodies and the employers, leaving
it up to them to either ‘embrace’ or reject the defined changes. Consequently,
professional bodies have been slow to embrace the changes proposed by the
state to facilitate a fairer and more efficient process of accreditation for overseasqualified professionals. According to Moore (1994: 33):
the creation of NOOSR and the development of competency based skills assessment
by no means ended discrimination in the workforce against non-English speaking
background migrants . . . Many Australian employers want local experience and most
insidious of all is the tendency of employers to recruit and promote “people like us”
by using non-work related selection criteria.
In spite of the touted reforms, the state agenda failed to deliver for a number of
reasons. The state succumbed to pressure from professional organisations eager
to remain in control of the assessment and accreditation procedures of potential
labour force participants. Given that the state lacked the will to assume a greater
level of institutional responsibility, the labour market customs and practices
remained impenetrable. More broadly, the state socio-cultural agenda remained
weak. Although based on sound principles of equality, multiculturalism lacked
conceptual clarity and as a consequence it has failed to identify and address
the essence of exclusionary tactics in the labour market on the grounds of
‘difference’ (Kalantzis 1989). As Jakubowicz (1984: 42) points out:
Multiculturalism gives the ethnic communities the task to retain and cultivate, with
government help, their different cultures, but does not concern itself with
struggles against discriminatory policies as they affect individuals or classes of
people.
This policy has done little to scrutinise the institutions within which power differentials are borne and where the dominant culture was, and continues to be
validated (Jayasuriya et al. 1988, Collins 1984). Fundamentally, these weaknesses
are based on the policy’s failure to address the very parameters of inequality, a
point effectively displayed by an examination of the settlement processes and
labour force participation of overseas-qualified professionals. The problem stems
from the fact that the migration and settlement of labour force participants
is not considered as a whole but separately. That is, one migrates and then
settles—which involves participating in the labour market. The process moves
along a continuum and as a result, so should the policy approach. One should
be an extension of the other, yet the policy rhetoric has failed to reflect this, as
has the practice.
As a result, in spite of the ensuing policy interest coupled with the shifting
demographic constitution of immigration from the 1970s into 2000, the clear
discrepancy between different migrant cohorts entering the Australian labour
market has remained (National Advisory Committee on Skills Recognition
(NACSR) 1991: 63, Ruddock 2000, DIMA 2000). This labour market
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condition has been consolidated and reinforced primarily because professional
bodies—especially elite professions—have held on to a position of self-evaluation
and self-regulation working above and beyond state-developed changes in
policy and the available labour supply. The consequence is that labour demand
has largely remained blind to the ethnic diversity of the labour supply with skilled
immigrants from non-English speaking countries pushed to alternative areas of
the labour market.
This consideration brings to bear the state’s complex and often contradictory
role. On the one hand, the state must satisfy the equitable labour market integration of overseas-trained professionals. Settlement and labour market policies
and procedures are in place to set a ‘level playing field’ for all individuals seeking access to the labour market. These are policies motivated by state action and
monitored by players within the state. Alternatively, the state must adhere to a
cost-effective method of labour recruitment as facilitated by the micro-economic
reforms. This is coupled with pressure from a variety of interest groups—
primarily professional licensing bodies, for the state to interfere as little as
possible in the accreditation process.
Policy-making in Australia is complex, defined by the interdependence of
public and private sectors, parliaments, ministers, government departments and
statutory authorities, consultants and interest groups (Gardner 1995). The process
of qualifications accreditation provides evidence of this complexity. Although the
policy rhetoric has highlighted a shift toward accommodating for the greater
skills of new settler arrivals, and to minimising the wastage of skills, the labour
market practices fall short of this ideal (NOOSR 1994:3).
PART
TWO:
THE
CASE OF OVERSEAS-TRAINED DOCTORS
Drawing on overseas-trained doctors as a case in point demonstrates why and
how the changes in the broader process have been undermined by the continued
regulation of the medical labour market by the medical fraternity. In fact, the
medical fraternity has drawn on state support in order to restrict particular groups
of overseas-trained doctors from entering the labour market.3
Although the medical fraternity has justified the approach to assessment
and registration in terms of upholding a standard of medical practice, contention
emerges over the agenda that runs parallel to the test of standards. Throughout
the post-war period through to 2000 the accreditation process has been
employed as a tool to directly restrict supply in order to protect the workforce
position of locally trained medical practitioners.
Those who have traditionally been included in the medical workforce—
Australian and New Zealand trained doctors and until very recently British male
and more recently female doctors—have wanted to retain their monopoly
over the market supply.4 The basis for this monopoly was created early on in the
establishment of the Australian medical workforce, a position supported by
the state (Johnson 1977 & 1982). As Kunz writes (1988: 38):
The unusually high status and esteem accorded to doctors, reinforced by the absence
of effective competition and the discouragement of specialisation, and a subdued and
OVERSEAS-TRAINED DOCTORS
75
uncritical public, in turn created a medical profession which at best prided itself
on its self-reliance, on its ability to cope single-handed with all types of medical
problems, and on its capacity to assume leadership in sundry affairs.
The control of competition within the medical market continues to the present
day. By safeguarding the financial position of its members, it has been able to
influence the cost of medical care, and the provision of medical services. As
Gardner (1989: 9) points out:
While health services are characterised by both public and private ownership of goods
and services, it is the medical profession which makes the greatest impact on the
kinds of services that will be provided, and therefore, on the economic consequences
of those services. (See also Hetzel 1980, Marmor and Thomas 1971; Palmer 1978;
and Scotton, 1967;1974).
This structure thus results in restricted competition for buyers of the services
provided. Consequently, demand is left unmet and in this context groups
traditionally ostracised from the medical labour force face continuing obstacles
as indicated by the restriction of particular groups of overseas-trained doctors
into the Australian labour market.
The ‘flooding’ of the medical market with overseas-trained professionals has,
and continues to be, considered a great threat to local practising doctors fostered
by the more intensive competition for buyers of services provided. In the early
1990s the Federal Government pointed out that:
The situation in Australia is now such that it can no longer afford to permit
relatively unrestricted entry of overseas medical practitioners (Innominate 1991).
It has been suggested that unrestricted labour market access for overseas-trained
doctors will have a negative impact on the Australian economy as the cost of training local graduates may be lost, compounded by the cost of supporting locally
trained doctors left unemployed (Donalds 1991, Norman 1996). Increasing the
number of doctors is also said to result in over-servicing, consequently blowing
out Medicare outlays (Donalds 1991, Birrell 1997b).
There are a number of separate but related issues in the scenario presented
thus far. One is the examination of professional standards, which involves the
overseas-trained doctor passing through an accreditation process to gain registration. This process should by definition only be used to measure the standard
of training, skills, and practice—as advocated by NOOSR.
The second issue is the supply of available labour (groups successfully passing
through the accreditation process) in response to demand in the medical labour
market. This process should involve employers, the state, the patient/consumer
and the overseas-trained doctors (demand and supply). Throughout the history
of accrediting overseas-trained doctors the medical fraternity has, with the
support of government (ironically), conflated the accreditation process (the
assessment of standards) and labour supply and demand (labour force issue).
Consequently, the accreditation process has and continues to be used as a tool
for controlling supply rather than simply assessing the quality and standards of
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the qualifications (Birrell 1997a & 1997b), thus undermining the broader policy
rhetoric and the designated role of bodies such as NOOSR.
Like all health areas, the demand for medical services and thus the medical
labour market is subject to expansion and contraction. Over the last 50 years for
instance, there have been incremental increases in the medical workforce.
During the 1960s, the demand for labour was greater than the available
supply. Reports at the time projected that the medical profession could continue
to expand with little threat of an oversupply, or encroachments on the salary
and conditions of registered medical practitioners (Scotton 1974). Given the
current restrictions placed on the supply of general medical practitioners, it is
ironic that it was general medicine that was forecast as requiring increasing
candidates in the future. This was especially so due to the expanding role of
the medical practitioner into areas, such as research institutes, universities,
non-resident medical posts and business. Also, particular specialties were
further developed —booming from the 1960s to the 1990s—such as surgery and
obstetrics (Department of Health, Housing and Community Services (DHHCS)
1992: 114). By the 1970s active steps were taken to cap supply especially in the
metropolitan areas (Doherty Report 1988, Jensen 1991, DHHCS 1992).
The ‘supposed’ rising doctor to patient ratio has been used as evidence of
the overcrowding of the medical market, where overwhelmingly overseas-trained
doctors have been targeted as responsible for exacerbating and compounding the
oversupply of medical practitioners. Thus, although the vocational orientation
of medical practitioners has broadened, the supply of new graduates has been
considered more than adequate to fulfil demand (Iredale 1990, Birrell 1995,
Harding 2000). Until recently, what has been missing from the debate regarding
the alleged oversupply of medical practitioners is that the bulk of the financial
capital and human capital resources are deployed in the metropolitan areas, while
the rural areas have continued to be under resourced. The growing supply
has thus concealed the uneven distribution of medical labour and the fact that
significant areas of demand are left unmet and a pool of labour is left underutilised.
To overcome the alleged oversupply situation several measures were implemented in the 1990s directly targeting overseas-trained doctors (DHHCS
1992: 25).5 Barriers imposed involved the reduction of overseas-trained doctors
entering Australia, the reduction of overseas-trained doctors passing the AMC
exam and entering the medical workforce6 and restrictions on overseas-trained
doctors billing on Medicare. These strategies clearly highlight the inextricable
links between migration, accreditation and the labour market as directed by the
medical fraternity, which has successfully operated outside of the broader
policy and institutional platform informing the accreditation and labour
market entry of overseas qualified professionals. The following evaluation of
the multifaceted nature of barriers imposed by the medical fraternity illustrates
the state’s failed attempts at establishing a ‘level playing field’ for all potential
labour force participants. Instead restrictions have been imposed on particular
groups based on labour demand and supply concerns driven by the medical
fraternity.
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OVERSEAS-TRAINED DOCTORS
The first barrier was raised at the point of migration. Principal applicants—
arriving as permanent residents—who trained as medical practitioners were
penalised in the points system. In 1992, the government imposed a ten-point
penalty on doctors applying for permanent residence under the independent and
concessional categories. This was then increased to a penalty of 25 points in 1995.7
Ironically, although overseas-trained doctors entering as permanent residents
have been ‘officially’ penalised, those arriving under temporary visas have continued to flood in. Throughout the period of the clamp-down on supply
the Federal Government ignored the arrival of overseas-trained doctors under
temporary visas. This group made a significant contribution to the annual
supply of doctors. From 1986 to 1991 overseas-trained doctors arriving on
temporary visas increased by 100 per cent. For those who arrived on temporary
visas several conditions applied. They were restricted to a stay of no more than
two years and were prohibited from working in private practice. Further, they
were restricted from participating in the AMC, or from applying for permanent
residency based on occupational status. The majority of these arrivals were
recruited to fulfil short-term positions in public hospitals, in locum services, rural
areas and in research (DHHCS 1992: 63). These doctors then were able to
practise without going through the AMC examination process, a significant point
given that once applying for permanent residency the overseas-trained doctor
was instantly forced to go through the multi-level AMC examination process to
test standards. This indicates a gross discrepancy in the assessment and accreditation process (Horsburgh 1997, Tattam 1999, Marsh and Downey 1999). As a
consequence of much vocal opposition from groups representing overseas-trained
doctors seeking permanent positions and attempting to get through the AMC
process, active measures were employed to limit the infiltration of overseas-trained
doctors on temporary visas. This condition has since changed as a result of the
Table 1
Year
1990–91
1991–92
1992–93
1993–94
1994–95
1995–96
1996–97
1997–98
1998–99
1999–2000
AMC MCQ and clinical examination results
No. newly
presenting
MCQ
No.
sitting
No.
passed
No. newly
presenting
Clinical
No.
sitting
No.
completed
538
523
344
332
350
Nil
758
300
301
450
915
921
812
619
688
Nil
1382
779
669
769
455
298
297
343
391
Nil
612
234
372
304
279
344
194
193
207
Nil
341
265
250
242
391
587
434
418
404
Nil
556
427
459
434
194
246
193
211
222
Nil
266
151
220
219
Data: AMC Annual Report (2000), Canberra, Australia.
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urgent demand for doctors in “areas of need”. Once again demand is being
satisfied by temporary resident doctors (Birrell 1997b).
The second and more effective point of restriction was imposed on overseastrained doctors entering the AMC examination process. This is illustrated in
Table 1, which shows a severe dip in those presenting for the examination and
passing through the process in the 1992–93 period followed by a sharp increase
in the 1996–97 period and steady figures from 1997–2000.8
In resolutions reached by the AMC, the Working Party (1990) made a motion
to support:
the imposition of a quota on the number of overseas trained doctors sitting the AMC
examination and a restriction on the number of overseas trained doctors allowed to
enter general practice to a maximum of 10 per cent of the number of Australian
graduates entering general practice. (See also DHHCS 1992: 26, Doherty Report
1988)
As a result, from 1992 through to 1995 a maximum of 200 overseas-trained
doctors were permitted access to the final phase of the examination—the
clinical component.9
The decision to do so was reached at the Health Minister’s Conference in that
year, following pressure from the Federal and State Ministers, Deans of the
Medical Faculties, the AMA and the Royal Colleges. In correspondence to the
President of the Overseas Trained Doctors Association (December 1992), the
Chair of the Health Minister’s Advisory Council pointed out that:
After examining the Australian medical workforce in considerable depth, Australian
Health Ministers agreed in April 1992 that there was an oversupply of doctors in
Australia, resulting in considerable negative implications for the costs of health care
delivery. Ministers acknowledged, however that the surplus was concentrated mainly
in urban general practice and in some rural areas.
Once the quota was implemented, the AMC MCQ exam was no longer based
on a pass/fail structure in order to progress to the next stage of the examination
(clinical stage). Rather, passing was determined by merit order of performance.
As stipulated in the AMC Information Sheet (1995):
(a) A candidate must be within the group of the top 200 eligible candidates at the
MCQ examination.
(b)The minimum performance requirement is a minimum score of 50 per cent
or better and not less than 40 per cent in any of the five component subjects
examined at the MCQ examination.
Although subject to an annual review, little changed in the quota throughout
the period of imposition. A major turning point occurred when overseas-trained
doctors took legal action to lift the quota. On October 6 1995, the AMC
announced changes to the examinations for overseas-trained doctors. The
announcement came following the complaint brought before the Human Rights
and Equal Opportunity Commission (HREOC) by Dr Siddiqui against the AMC
and the Commonwealth Department of Human Services and Health. In the case
of Dr Siddiqui, the decision passed down by HREOC found for the complainant
OVERSEAS-TRAINED DOCTORS
79
on the basis that the quota system and the nature of the examination process contravene basic human rights as set out in the Race Discrimination legislation s(9)
s9(A) and 25ZB. The nature of the examination was found to be inappropriate
for an overseas-trained doctor who in most cases had been a practising professional
for some years. With regard to the quota, the extreme injustice created was
emphasised in the Reasons for the Decision (1995: 33):
Every human being, as we have seen, has the right to equality before the law
including the right to work consistently with his/her qualifications and experience.
We find that the imposition of the quota . . . has impaired the enjoyment of that right
on an equal footing with graduates of accredited medical schools by persons of a
national origin other than Australian and New Zealand.
In its decision, HREOC found that the AMC and the Commonwealth
Department of Human Services and Health (DHSH) were practising indirect
discrimination in applying a quota system to the assessment of overseas-trained
doctors. As a result of the determination, the AMC decided to lift the quota. The
AMC also stopped offering the examination at overseas posts and prohibited entry
on temporary visas, so as to reserve the positions for Australian doctors who were
trained overseas. A successful counter-challenge by the DHSH was resolved in
1996 before the full bench of the Federal Court. This turn in events raised the
potential for the reintroduction of a more restrictive quota, coupled with the
continuation of discriminatory practices (SMH 4 September 1995), a reality which
did not transpire given the shift in demand and supply conditions.
The final barrier was imposed on overseas-trained doctors once in the labour
market. For those who successfully pass through the AMC MCQ/clinical examination process, they are restricted to bill on Medicare for a period of ten years.
This restriction was introduced in 1997.
In the late 1990s and into 2000, the medical labour market has been hit by a
severe shortage in some regional and rural areas, particular hospitals and locum
services (Australian Medical Workforce Advisory Committee 2000). Thus,
demand-driven forces are generating a pull for doctors and as a consequence a
re-evaluation of the assessment and accreditation procedures—although subject
to conditions (Downey and Johnston 1996, Harding 2000). For those willing to
take up posts in ‘areas of need’ they may do so subject to a screening process
that does not involve the multi-tiered and lengthy process of accreditation
through the AMC. Once passing through this process these candidates are granted
‘conditional’ registration, limiting their work to an assigned area of practice for
a fixed period.10 As noted in a media release by the National Rural Health Alliance
(27 April 1999):
Overseas-Trained Doctors with GP qualifications recognised by the Royal Australian
College of General Practitioners (RACGP) and the Australian College of Rural and
Remote Medicine (ACRRM) will be provided with immediate medical registration
for a minimum of five years, provided they agree to practise in a designated rural or
remote area of need. As an alternative to the Australian Medical Council (AMC) examinations, they will be subject to a selection process involving the RACGP, ACRRM
and the State Registration Board. After a minimum of five years it is expected that
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they will have the option of a full Provider Number to work through Medicare in
any part of Australia, although it is to be hoped that many of them will want to remain
in country areas.
The recent turn in events driven by an urgent demand in particular areas, illustrates how the accreditation process is used as a tool to directly regulate available stocks of labour. This is noted by the explicit links between the accreditation
process and the medical labour market where the use of conditional registration
for overseas-trained doctors—operates outside the AMC examination process.
The ‘conditional’ nature of access to the medical labour market raises a
number of questions regarding the assessment and accreditation process. Why
are overseas-trained doctors allowed to work in these ‘areas of need’ without
having to go through the lengthy AMC process of accreditation? Furthermore,
why aren’t these groups integrated into the Australian labour market without
restriction once completing a term in an ‘area of need’? Presently should the
overseas-trained doctor on temporary registration wish to move to a metropolitan
area, they must then go through the AMC examination process. These inconsistencies in the accreditation process will only be redressed once the accreditation process is used solely for the purpose of assessing standards rather than as
a tool for controlling labour demand and supply. It is this very contention that
raises the calls for the implementation of a stricter monitoring process by an
external body such as NOOSR.
CONCLUSION
Monopoly conditions have made it possible for the medical profession to restrict
services in spite of demand, thus directly controlling the supply of the labour
force and above and beyond state driven policy changes. Although the policy
Table 2 Labour market participation by ethnic cohort for general medicine: Total
persons 1986–91
Region
New Zealand
UK and Ireland
Eastern Europe
USSR & Baltic States
Middle East
North Africa
South East Asia
North East Asia
Southern Asia
North America
Southern & East Africa
Unemployed
Participation by ethnic cohort
0
2.2
43.8
32.1
45.1
53.5
23.2
12.6
27.3
5.9
2.1
85
88.1
56.3
45.9
72.5
72.3
69.3
73.8
65.6
69.9
87.4
Source: Unpublished Census Data (1986–1991).
OVERSEAS-TRAINED DOCTORS
81
rhetoric has highlighted a shift toward accommodating for the greater skills
of new settler arrivals, and minimising the wastage of skills, the labour market
practices fall short of this ideal.
The Commonwealth, state and territory governments have over the years
placed the responsibility of assessing the standard of overseas-trained persons with
the professional licensing bodies. As a result, although both state and national
bodies have increasingly been directly involved in developing structures for
accreditation, little change has been achieved, as the bases of power have remained
institutionalised in the structures of the professional bodies. Consequently, the
lack of effective dialogue and negotiation between the many players involved
in the accreditation process continues to hamper a successful resolution to
the conditions experienced by overseas-qualified professionals in the Australian
labour market.
The process of qualifications accreditation for overseas trained professionals
highlights the difficulties the state encounters in fulfilling its objectives. Supplyside needs in an era of tight demand take priority, while the policies and practices pertaining to overseas trained professionals remain nothing more than an
ideology. The experience of overseas trained doctors from NESCs features the
disparity between this groups’ reality and the state-driven policy rhetoric.
NOTES
1. This paper focuses on the experience of legal immigrants. The issues relating to illegal immigrants go beyond the subject terrain covered here.
2. The Galbally Report (1978) was commissioned by the Federal Liberal Government to consider migrant settlement, with particular focus on access services. Among the recommendations
was the need for ethno-specific welfare workers and the creation of Migrant Resource Centres.
3. The Commonwealth, state and territory governments place the responsibility of assessing
the standard of medical knowledge of overseas trained persons with the AMC. The process is
monitored by sessional reviews. On a national level, the Commonwealth funds the AMC and
it has a representative on the Council, while also sitting on committees which look at various
issues. Despite this, the Commonwealth has limited direct powers in the recognition of overseas qualifications in the medical profession. Entry to the medical profession in particular, is
regulated by state and territory legislation. Within New South Wales for instance, the recognition and accreditation of overseas qualifications for health professions is embodied within
the various legislative enactments governing the different professions such as the NSW Medical
Practice Act and the NSW Nurses Act. In relation to doctors, in addition to the prima facie
eligibility for the registration of Australian and New Zealand graduates (regardless of ethnicity
and other background characteristics), examinations are also conducted by the Australian
Medical Council and are open to all overseas trained doctors who meet minimum residency
requirements.
4. Unpublished data for 1986–91 (Australian Bureau of Statistics 1991) reveals labour market
differences for overseas-trained doctors cut along ethnic lines (Table 2). This trend has undoubtedly continued, especially given the imposition of greater barriers to the medical labour
market introduced throughout the 1990s.
5. Federal Government initiatives to slow down general practitioner (GP) numbers also included
a variety of other groups in the medical labour market, although overseas-trained doctors have
been hardest hit by the imposed barriers to labour market participation. The strategy to
slowdown GP numbers has included:
a) A cap on the number of entrants into the Royal College of General Practitioners’ (RACGP)
Post-graduate Training programme for GPs to 400 annually, since 1995;
b) A cap on access to Medicare provider numbers to those who successfully progress through
the RACGP training programme, since 1996;
c) A cap on medical school enrolments in Australia, since the 1980s; and
d) restrictions on New Zealand-trained doctors to bill on Medicare, since 1997.
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6. The AMC shifted from a position that sought to redress inequities within the accreditation
process by changing the structure and content of the examination—which was foreshadowed
in the 1989 AMC Review—to one that created greater barriers for overseas-trained doctors
attempting to gain registration.
7. In spite of this, data throughout the period of the penalty suggests that the penalty has failed
to block overseas-trained doctors entering as permanent residents. The penalty captured those
arriving under the skilled category but failed to capture those entering as spouses sponsored
by Australian residents (Australian Institute of Health and Welfare 1999).
8. Of note are less direct barriers in the process of accreditation including the Occupational English
Test (OET) which has been shown to slow progress through the accreditation process
(see Hawthorne and Toth 1996). Also, the dismantling of the Independent Office for overseas
trained doctors and with it the bridging courses offered to doctors progressing through the
accreditation process has compounded the difficulties faced by overseas-trained doctors in
progressing into the labour market (Razaghi 2000). These issues are, however, beyond the
scope of this paper.
9. The quota of 200 did not include specialist medical practitioners who deal directly with the
Specialist Colleges.
10. Unpublished data indicates that 30 per cent of doctors from NESCs have been allowed to access
the medical labour market in so-called Areas of Need and three per cent are pending approval.
These figures do not include those who have progressed through the AMC and have been
granted full registration but have chosen to go to work in an Area of Need (Source: NSW
Medical Board. Information pertains to all doctors assessed through the Area of Need