Introduction by Croakey: An instructive, entertaining and overall quite depressing summary of the history of Australian health reform is presented by Dr Bill Coote this week in Medical Republic, with a focus on general practice.
It’s well worth a read, if you haven’t already. Coote has many strings to his long bow – a former rural generalist and practice owner, Australian Medical Association Secretary-General, director of the Professional Services Review, and policy advisor to federal health ministers.
Overall, his analysis, titled ‘From universal care to a two-speed system’, highlights the persistent inertia confronting health reform efforts, and how little real progress has been made over decades despite the “alphabet stew of acronyms”, including “GPPAC, GPCG, MBCC, EPC, ADGP, AGPAL, FMP, RACGPTP, GPET, RTPs (re-birthed as RTOs), the PIP (originally BPP), RCS, RAMUS, PDSA, NPS and BEACH”.
His analysis – described by one reader as “an unlovely trip down memory lane” – would have been even more depressing if it had delved into the history of public health and prevention. Let’s not forget ANPHA (the Australian National Preventive Health Agency) and other public health initiatives slashed over the years, including many Aboriginal and Torres Strait Islander health initiatives.
What this lack of progress means for peoples’ health and lives can be seen in some of the data presented below by health policy analyst Charles Maskell-Knight, who has been wading through data recently released by the Productivity Commission, and identifies many worrying trends.
“Taken as a whole, the report shows a health system under stress and struggling to deal with increased demand by extending waiting times,” Maskell-Knight reports.
His analysis underscores the importance of reform that is effective in tackling inequities – in access, outcomes and within systems. If the Albanese Government hasn’t got meaningful dental reform on its policy agenda, then it must have a bad case of another acronym, FJiE (Fingers Jammed in Ears).
Charles Maskell-Knight writes:
On 31 January the Productivity Commission released the health part of its 2024 Report on Government Services. It includes four sections: primary and community health (with 16 performance indicators), ambulance services (7 performance indicators); public hospitals (16 performance indicators), and services for mental health (19 performance indicators). The data behind the indicators is presented in 248 tables.
The 2024 Report is the 30th in the series, which began in 1995.
The introduction to the 1995 report states that it was intended to “present information relating to the effectiveness and efficiency of a number of government-funded (and largely government-provided) social services… [and] inform parliaments, governments, government service agencies, and the clients of these agencies – the wider community – about their overall performance, based primarily on results rather than inputs”.
The only health service included in 1995 was public hospitals, and the report presented a potpourri of data, often collected and reported inconsistently by jurisdictions, with lengthy footnotes explaining the inconsistencies. (The footnotes for a table presenting the capital value of public hospitals (in five jurisdictions) amounted to 500 words.)
In addition, each jurisdiction was allowed to contribute a page of comments on the results, which they usually used to explain why the results weren’t really comparable and weren’t as bad as they appeared.
The report has come a long way in the past three decades. In this article I will report on the most significant results across the 58 performance indicators now used.
A note on data
The Productivity Commission does not collect any data itself to construct the report, and all the data comes from separate established data collections. The sections below identify the data source for each indicator.
Primary and community health
The report uses ABS Patient Experience Survey data to state that in 2022-23, seven percent of respondents people who needed to see a GP delayed or avoided a visit due to cost, double the rate in 2021-22. This was most common in NSW (9.5 percent) Tasmania (8.7 per cent), and ACT (8.1 per cent).
The same data source shows that 7.6 percent of people delayed or did not fill a prescription due to cost in 2022-23, an increase from 5.6 percent the previous year.
The Government’s recent decisions to increase the incentive for GPs to bulkbill from 1 November last year, and to cut the general co-payment under the PBS from 1 January 2023, are intended to address these affordability concerns.
The ABS survey also showed that 45.6 percent of respondents waited more than a day for an urgent appointment with a GP in 2022-23, up over six percentage points on the previous year, and almost 20 percentage points on 2013-14. In Queensland and South Australia, the proportion waiting more than a day is over half.
It remains to be seen if Urgent Care Clinics will attract patients waiting for a GP, who might well be attending an Emergency Department because they cannot find a GP appointment.
The report presents data from the AIHW on so-called ‘Potentially avoidable presentations to emergency departments’ showing an overall decrease between 2021-22 and 2022-23 of 7.2 percent. (SA and NT bucked the trend, with small increases.)
The report notes that the definition of a potentially avoidable presentation is an interim measure. As I have written before, it is likely that many patients captured by the existing definition attend EDs because they are aware that their condition could not actually be managed in a general practice. Indeed, one study found that just a quarter of patients captured by the current definition were in fact referred to the ED by a GP.
Leaving the definitional issue to one side, the establishment of Urgent Care Centres represents the Government’s policy response to the problem.
Sustainability of the GP workforce is an emerging problem. The report cites departmental data showing that the proportion of full-time equivalent GPs aged over 60 has been steadily increasing (from 23.1 percent in 2015 to 26.6 percent in 2022). While the Government acknowledges there is an issue with GP supply, its response so far has been to commission a review of distribution mechanisms.
The report uses a combination of MBS and ABS data to calculate the rate of First Nations people receiving an Aboriginal and Torres Strait Islander-specific health check or assessment. After reaching a peak of 288 checks per 1,000 people in 2018-19, the rate declined to 235 in 2021-22. It has now climbed back to 270. A welcome improvement, but there is clearly a lot more to do.
The final primary and community health indicator worth mentioning is the median waiting time for a first visit to a public dental service.
While it is reported idiosyncratically by each jurisdiction, in only SA and WA is it less than a year, and in NSW it is 13 months. In every other state or territory it is over 18 months, and as long as 47 months in Tasmania.
The Government is due to respond to the Senate Select Committee report on dental services by the end of the month.
Ambulance services
The report presents Council of Ambulance Authorities data on ambulance response times, comparable across all jurisdictions except SA. The state-wide median response time in 2022-23 was between 10 and 15 minutes (excluding SA), but in every case was higher than 2013-14.
Public hospitals
The report presents data on emergency department waiting times drawn from the National non-admitted Patient Emergency Department Care Database.
This shows a gradual decline in the overall proportion of patients seen on time from 75 percent in 2013-14 to 71 percent in 2018-19. Following an uptick to 74 percent in 2019-20 (associated with a decline in the number of presentations), the proportion has now declined to 65 percent.
While NSW is still managing to attend to 74 percent of patients on time, the performance in WA, SA, Tasmania and ACT hovers around 50 percent.
The report also presents data from the AIHW National Elective Surgery Waiting Times Data Collection showing that the median elective surgery patient waited 49 days for surgery in 2022-23, up from 40 days the previous year, and 37 days in 2013-14.
The NSW experience is again an outlier, but this time in a bad way, with a median waiting time of 69 days, far higher than the second worst performer, Tasmania, at 53 days.
The report includes three indicators of adverse events in public hospitals – the rates of: Staphylococcus aureus bacteraemia infection; adverse events treated in hospitals; and falls resulting in patient harm in hospitals.
While the first two indicators are largely stable, the rate of harmful falls has increased nationally from 4.0 per 1000 separations in 2013-14 to 6.1 per 100 separations in 2021-22. The rate in NSW, WA, SA and Tasmania is now over 7 per 1000: an alarming prospect for anyone with an older family member admitted to hospital.
It also includes data on unplanned readmissions following seven common procedures. It is difficult to discern any clear trend by jurisdiction or over time, other than a 70 percent increase in the rate for tonsillectomy and adenoidectomy over the ten years to 2021-22 to 48 per 1000 separations.
Services for mental health
The report presents data on use of mental health services by patients classified by the SEIFA (socio-economic index for areas) of their postcode of residence.
State data on public mental health services shows a decline in service use from 2.2 percent of the population in the lowest SEIFA quintile to 1.2 percent in the highest. (Use of private hospitals for mental health services, likely to increase with SEIFA, is not reported.)
MBS data on service use showed the opposite gradient: 7.6 percent of the population in the lowest SEIFA quintile using services, rising to 14.4 percent in the highest. Almost 60 years ago Professor Lou Opit* found that use of private psychiatrists across Adelaide was positively associated with average income in the patient’s postcode. It appears nothing much has changed. Either wealth is a mental health risk factor, or access to private psychiatry is grossly inequitable.
The report presents data from the ABS Patient Experience Survey showing that 27.8 percent of respondents reported delaying or avoiding visiting a psychiatrist due to cost in 2022-23 – up from 18.4 percent in 2020-21.
There is some good news: State data shows that the rate of community follow-up within seven days for people discharged from an acute psychiatric inpatient unit was 75.2 percent in 2021-22, up from 60.0 percent in 2012-13.
But despite this improved follow-up, the rate of readmission within 28 days has remained fairly constant: 14.7 percent in 2021-22, up from 13.9 percent in 2012-13.
The report and accompanying tables also show that the age standardised suicide rates for the period 2018-22 of 12.4 per 100,000 population is the same as the average rate over the period 2012-22. Well over 3,000 people are taking their own life each year, despite the efforts of the health system.
Specific population groups
Many of the performance indicators reported by the Commission are also reported by SEIFA, remoteness, and First Nations status. In some instances (for example, MBS-funded psychiatric services) these results show exactly what one would expect: better resourced, non-Indigenous people living in metropolitan areas have better, more timely, and more affordable access to services with better outcomes.
But there are exceptions, and I will aim to report on some of these differences in a subsequent article.
Indicators of what, exactly?
The health section of the report includes a number of what the Commission regards as technical efficiency indicators, which “measure how well services use their resources (inputs) to produce outputs for the purpose of achieving desired outcomes. Government funding per unit of output delivered is a typical indicator of technical efficiency”.
The Commission goes on to observe that “some efficiency indicators included in the report are incomplete or proxy measures for technical efficiency. For example, as only the cost to government is reported on, some efficiency measures do not include the full cost of providing services and, are therefore, incomplete measures of technical efficiency”.
The health sections include a number of indicators defined as cost to government per some measure of output volume.
The cost to government per casemix-adjusted separation in the public hospital section does mean something – government funding makes up the whole cost, and the unit of output is standardised to remove any impact from changes in service mix. Even so, the measure is expressed in nominal not inflation adjusted dollars, reducing its utility.
However, the “cost to government of general practice per person” measure used in the primary and community health section doesn’t mean a great deal.
For a start, the cost to government in recent years has reflected a diminishing share of the total cost, as patient co-payments have increased. In addition, the denominator does not reflect changes in service mix or volume – particularly relevant given the changes in services due to COVID-19.
The indicator for 2023-24 and 2024-25 will show a substantial increase as the impact of the increased bulk-billing incentives flow through – but this won’t imply a reduction in efficiency.
What is the picture overall?
Taken as a whole, the report shows a health system under stress and struggling to deal with increased demand by extending waiting times.
Reduced affordability is also an issue, and while the Government’s recent measures will help address pharmaceutical costs and GP co-payments, they will not address the cost of community psychiatry or other specialist services.
* The Opit reference is not available online, but is cited in C.A. Maskell, Does Medicare Matter, 1988, ANU Graduate Program in Public Policy Discussion Paper No. 9.
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. He is a member of Croakey Health Media. Follow on X/Twitter at @CharlesAndrewMK.
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Have been waiting over four years for removal of implants put in 2010 that are textured and risk BIAL. The hospital has used a change in a list, I.e. waiting for an appointment with the plastics dept 2019 and then another waiting for surgery 2022 as a category 3.