Introduction by Croakey: The Federal Government has announced a review of current policies and programs that aim to promote a more equitable distribution of the health workforce.
The Working Better for Medicare Review, to be led by nurse, advocate and remote health expert Professor Sabina Knight and former senior health bureaucrat and academic Mick Reid, is expected to consult extensively and report its findings by mid-2024.
Health and Aged Care Minister Mark Butler said the review would in particular examine the Monash Modified Model (which defines whether a location is metropolitan, rural, remote or very remote), the system of District of Workforce Shortage (which defines areas where people have poor access to specialist medical practitioners), and Distribution Priority Areas, (which identifies locations with a shortage of general practitioner services).
“These levers we currently have to spread doctors and health workers around the country are from a very different time, before the COVID pandemic and before the global health workforce crunch,” Butler told the Committee for Economic Development of Australia yesterday.
“The Working Better for Medicare Review will identify ways to improve health access for Australians, by building a more stable, motivated, and properly located workforce. The aim is to have an appropriately located workforce, particularly in areas that find it difficult to attract and keep doctors, so that all Australians can access the care they need, when they need it, regardless of where they choose to live.”
A related review – Unleashing the Potential of our Health Workforce – is due to release its first issues paper in coming months, ahead of reporting back to Minister Butler by the end of October next year.
Meanwhile, the latest health report card for OECD countries suggests that Australia needs to focus much more on strengthening primary care and prevention, writes health policy analyst Charles Maskell-Knight.
While the report identifies a number of important areas in need of improvement, overall he says that Australia deserves a “solid credit” based on the data in this report: “On a wide range of indicators Australia performs better than the OECD average, but is still in the middle group of countries.”
Below, Maskell-Knight identifies seven key takeaways from the report.
Croakey also notes the report’s finding that in Australia, Belgium and Korea, the income of self-employed specialists was at least double that of self-employed GPs (although the figure for GPs in Australia included trainees, thus increasing the disparity with specialists). In Germany, the difference between self-employed specialists and self-employed GPs was much smaller, at about 12 percent.
Charles Maskell-Knight writes:
The OECD released the 2023 edition of its Health at a Glance 2023 report on 7 November.
The first thing to note is that the report needs more than a quick glance – it is 234 pages long and crammed with statistics for 38 member countries.
As well as reporting on health system indicators covering health status, health risk factors, access to care, quality of care, and capacity and resources, this edition includes chapters on digital health, the pharmaceutical sector, and ageing and long-term care.
While the OECD website provides links to summaries of the findings by country, these do not include much by way of context.
As a service to Croakey readers, this article will provide a ten-minute summary of Australia’s performance on key indicators against other OCED countries. It won’t cover the three thematic chapters.
Most of the data in the report relates to 2021, although in some cases (notably health expenditure) preliminary data from 2022 has been used. This means that the impacts of the COVID-19 pandemic are reflected in the data, but the return to “normality” is not.
1. Health status
Life expectancy in Australia is 83.3 years, the fourth highest in the OECD, and three years above the average. While life expectancy during the pandemic decreased for many countries (including a reduction of 2.4 years for the US), Australia was one of nine countries with a small increase during 2019-21 (0.4 years).
Across the OECD, age-adjusted all-cause mortality in 2022 was 2.9 percent higher than the average for the five years before the pandemic – Australia was right on the average.
However, while the 0 to 44 year age group in Australia saw a reduction of 3.2 percent, the over-64 cohort had an increase of 3.3 percent. This presumably reflects in part ongoing high levels of COVID-19 infection and mortality in residential aged care during 2022.
Australia performs well on most other health status indicators, including preventable and treatable mortality.
An exception is the suicide rate, where Australia is on the cusp of the worst quartile with a 2019 rate of 13.5 per 100,000 population. While many other countries have seen the rate decline since 2000, the Australian rate has marginally increased.
Caution is needed when considering self-reported health status, as Australia is one of a handful of countries which uses a scale of “excellent, very good, good, fair, and poor” for people to assess their health, compared with most countries which use “very good, good, fair, poor, and very poor”.
The six countries (including Australia) with the lowest percentage of the population self-reporting poor or very poor health all use the second scale.
2. Risk factors for health
Australia has a mixed performance against these indicators.
While our success in reducing smoking is well-known, we are in the middle of the field for vaping (using data from 2019), and in the highest quintile for binge drinking (26 percent of adults consumed six drinks or more on one occasion in the last month). Australia has the second highest rate of opioid use (behind the US), and leads the OECD in cocaine use (four percent of 15-64 year-olds have used in the last year).
While we are second in the OECD in the proportion of adults undertaking 150 minutes of physical activity per week (71 percent), our measured proportion of obese adults is 30 percent, a little above the OECD average.
Global warming is another important health risk factor.
The report notes that “on average across the 38 OECD countries, the proportion of the population estimated to have been exposed to hot summer days increased from 22 percent on average from 2000-04, to 29 percent on average in 2017-21 – a 35 percent increase across the two periods”. The Australian proportion is the fourth-highest across the OECD, and increased from 70.1 percent to 75.9 percent.
3. Access: affordability, availability and use of services
The report includes data on almost three dozen indicators under this heading. In a number of cases, including the indicators of unmet needs for care, Australian data is missing. In other cases, data definition issues impinge on comparability. (For example, “in Germany, data [on in-person doctor consultations] include only … the first contact over a three-month period, even if the patient consults a doctor more often”.)
Australia is one of the three-quarters or so of OECD countries where a nominal 100 percent of the population have access to a core package of healthcare services provided through government or compulsory insurance.
On most indicators Australia is near the middle of the field: total out-of-pocket health costs are on average 3.1 percent of final household consumption, a little below the OECD average of 3.3 percent, and the Australian rates of doctor consultations per capita are also broadly in line with OECD averages.
Notable divergences from the average include:
- Hospitalisation rates (excluding same day cases) are one of the highest in the OECD (177 per 1000 population, compared with an average 130). On the other hand, average length of stay at 5.3 days (again excluding same day cases, but also excluding private hospitals) is one of the lowest – and would be even lower if private hospitals were included.
- Australia was one of only five countries where the rate of emergency department attendance increased during the pandemic.
- Australia has 70 CT scanners per 100,000 population, the second highest in the OECD and two and a half times the OECD average. (This is a relic of the wave of CT scanners that began operation in the late 1980s and early 1990s, encouraged by unrestricted access to the MBS.)
- Only 16 percent of tonsillectomies in Australia are carried out on a same day basis, compared with an OECD average of 40 percent.
- 62 percent of cataract patients face a wait of more than three months between specialist assessment and treatment, compared with an OECD average of 42 percent. (The same metric for hip replacements and knee replacements is also above the OECD average.)
4. Quality and outcomes of care
Australia has a mixed performance against these measures, with above average vaccination rates and “people-centredness of ambulatory care”, and around average rates of cancer screening.
Other measures of primary care have worse results. Australian opioid and antibiotic prescribing rates are high, with defined daily doses per 1000 population per day of 21 and 17 respectively, against an OECD average of 13 for both classes of drugs.
The hospital admission rate of adults for asthma and COPD is the second highest in the OECD at an age-standardised 271 per 100,000 population, compared with an OECD average of 129. The admission rate for adult diabetes is also high (157, compared with the OECD average of 102).
The position with hospital care is mixed. The 30-day mortality rate (age-sex standardised per 100 admissions for people aged 45 years and over) following an admission for acute myocardial infarction of 3.3 is significantly better than the OECD average of 7.0, as is the equivalent rate for ischaemic stroke (4.8 compared with 7.9).
On the other hand, the combined rate of pulmonary embolism and deep vein thrombosis following hip or knee surgery is 1,192 per 100,000 separations, over two and a half times the OECD average of 467.
5. Health expenditure
At a high level, the report finds that health systems are under financial pressure.
The OECD average health expenditure as a share of GDP jumped from 8.8 percent pre-pandemic to 9.7 percent in 2021, before declining to 9.2 percent in 2022. Australia has followed this general pattern, with 2022 health expenditure as a share of GDP of 9.6 percent.
In most respects the pattern of health expenditure in Australia is similar to the bulk of OECD members.
Australia is one of only five countries where voluntary health insurance accounts for 10 percent or more of total health expenditure. (Across the OECD as a whole, government health expenditure during the pandemic grew by 25.8 percent in real terms, while voluntary health insurance spending grew by 0.7 percent.)
While Australian spending on primary healthcare as a percentage of total health spending is slightly higher than the OECD average (14.6 percent compared with 13.4 percent), only 0.1 percentage points was attributable to preventive care, compared with 1.4 percentage points across the OECD.
6. Health workforce
While health workforce shortages in Australia are an issue of public concern, the OECD report suggests that supply is not any worse than other countries, and in many cases is better.
Australia has 4.0 practising doctors per 1,000 population, slightly above the OECD average of 3.7.
However, this number has increased by almost 40 percent over the last decade, far faster than the OECD average. While the ageing of the medical workforce is often raised as an issue in Australia, only 25 percent of doctors are aged 55 years and over (in the bottom quartile of OECD countries), compared with an OECD average of 33 percent.
The number of practising nurses per 1000 population is 12.8, the fifth highest in the OECD and well above the average of 9.2. Nurses are graduating at a rate of 116 per 100,000 population, the highest in the OECD and well over two and a half times the average.
Compared with 2001, Australia is graduating three times as many nurses per capita every year.
Australia relies heavily on overseas trained doctors, who made up 32.2 percent of the workforce, compared with the OECD average of 18.9 percent. The proportion of overseas trained nurses is the fourth highest in the OECD, 18.1 percent compared with an average 8.7 percent.
7. Overall performance
Unlike some other bodies providing international comparisons (such as The Commonwealth Fund), the OECD does not provide an overall assessment of health system performance in the Health at a Glance report.
In my view, based on the data in this report, Australia deserves a solid credit. On a wide range of indicators Australia performs better than the OECD average, but is still in the middle group of countries.
If we are to improve our performance, we need to improve primary care, with a particular focus on prevention.
The report only includes indicators for preventable hospitalisations for three conditions: adult asthma and COPD, congestive heart failure, and diabetes. Australia’s performance against two of these indicators is terrible.
The country’s high hospitalisation rate for overnight stays (meaning our predilection to count renal dialysis or chemotherapy as same-day hospitalisations is not relevant) strongly suggests many Australians are ending up in hospital for conditions that would be managed in the community elsewhere in the OECD. A better primary care system is an important part of the solution to this problem.
Another important failing is Australia’s mental health “system”.
Despite National Strategies and Plans, despite appointments of Ministers for Mental Health and the creation of the National Mental Health Commission, despite numerous reviews and inquiries, and despite a proliferation of mental health lobby groups, the suicide rate has not changed over the last two decades. We need a new approach.
Charles Maskell-Knight PSM was a senior public servant in the Commonwealth Department of Health for over 25 years before retiring in 2021. He worked as a senior adviser to the Aged Care Royal Commission in 2019-20.
Infographics from the report
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