Chapter 2
Importance of General Practice and Primary Healthcare
Introduction
2.1
Speaking at the AMA National Conference on 29 May 2015, Associate
Professor Owler spoke of general practice as the cornerstone of primary
healthcare. Associate Professor Owler told Health Minister the Hon Sussan Ley
MP and the Opposition health spokesperson Ms Catherine King MP that investment
in general practice was vital for healthcare in Australia:
“We need investment in general practice. With investment, GPs
will continue their work in providing world class, patient-centred care.”
He [A/Professor Brian Owler] appealed directly to Health
Minister Sussan Ley and Labor’s health spokesperson Catherine King to address
the task of rebuilding general practice.
“So Minister Ley and shadow minister King, I say to both of
you, if you want to improve care and drive lasting change in the health of all
Australians, don’t waste your money on fragmenting care in other settings.
Invest in general practice – general practice will deliver
for you.”[1]
2.2
The RACGP President, Dr Frank R Jones, made a similar statement in
response to the health measures in the 2015-16 Budget:
GPs see more than 80% of Australia’s population every year
and are the most cost-efficient pillar of the healthcare system so it makes
sense to invest in general practice. Investment in primary healthcare will
produce long term health savings and better outcomes for patients.[2]
2.3
From a rural perspective, Ms Jenny Johnson, Chief Executive Officer of
the RDAA, told the committee that GPs are often at the heart of a rural
community. Any policy which negatively affects GPs will have a magnified impact
on the local community:
Detrimental impacts on rural practices will also flow onto
other healthcare services in rural communities. I think this is an issue that
is largely ignored. Rural doctors traditionally provide a range of primary and
secondary care services and some tertiary care services. For example, a rural
doctor who is working in his or her general practice will also most likely be
providing visiting medical officer services to the local hospital. They will
probably be providing mental health services and counselling, they will be
teaching medical students and they will be providing after-hours and emergency
services. They may be providing more advanced procedural services... if a rural
practice is forced to close or it loses a doctor because of economic circumstances,
then that will flow onto the local hospital, which will have less doctors to
fill its after-hours rosters and to provide emergency and secondary care. This
in turn will compromise the ability of communities to access after-hours
services. It will lead to a downgrading of services in the hospital and then we
get into that awful downward spiral.[3]
2.4
The sentiments expressed by the AMA, RACGP, and RDAA are similar to
those the committee has heard throughout its inquiry. Throughout more than 30
hearings, witnesses have emphasised the central importance and effectiveness of
general practice and the importance of access to primary healthcare for
providing:
-
better health outcomes;
-
cost-effective healthcare; and
-
more responsive healthcare than acute care.
2.5
The committee has heard consistent arguments for a primary healthcare
model which recognises that GPs at the centre of an integrated healthcare
system, working for the patient's best interests with allied health
practitioners, specialists and acute care. This chapter records the evidence
presented to the committee regarding the need for general practice to be at the
centre of primary healthcare.
2.6
Further, as part of its report, both in this chapter and Chapter 3, the
committee notes the evidence it has received regarding the risks to general
practice and primary healthcare from the government's numerous policy changes
(fromĀ 2014-15 Budget to the current Budget). Witnesses and submitters have
told the committee clearly that without an emphasis on primary care in
healthcare policy they fear for the:
-
viability of general practice;
-
increased inefficiencies in the health sector; and
-
loss of opportunity to improve health policy outcomes.
Effectiveness of general practice in healthcare
2.7
The Bettering the Evaluation and Care of Health (BEACH) study is
a long running study of general practice conducted by the Family Medicine
Research Centre, at the University of Sydney. It is unique internationally for
its examination of general practice including patient encounters and
treatments. Findings from the 2013-14 BEACH study included that:
General practice and primary care represent the interface
between complex (and expensive) health care services and the wider community.
Australian general practice can reasonably claim to represent world best
practice in terms of both cost and patient outcomes... There is ample evidence
that preventive and primary care services that are patient-focussed rather than
disease-focussed provide the most cost effective health outcomes for those
individuals and communities.[4]
2.8
Although primary healthcare is the most efficient part of the healthcare
system, there are already a number of reasons that Australians avoid going to
see their GP. According to the 2013-14 Patient Experience Survey
conducted by the Australian Bureau of Statistics, cost is a significant barrier
to accessing healthcare. At a national level, the 2013-14 Patient Experience
Survey showed that:
-
One in twenty (4.9 per cent) people who needed to see a GP
delayed or did not go because of the cost;
-
One in twelve (7.9 per cent) who needed to see a medical
specialist delayed or did not go because of the cost; and
-
Of the one in seven (14.3 per cent) people who had visited an
emergency department for their own health in the previous 12 months, one in
five (21.6 per cent) thought the care could have been provided by a GP.[5]
2.9
The RACGP noted that hospital admissions are a major driver of
Australian healthcare costs. Figure 1 below, taken from the RACGP submission,
shows the comparison between rising hospital costs and the relatively stable
costs for general practice. The RACGP submission argues that:
Primary healthcare services are the most cost-effective part
of the health sector. They can reduce healthcare costs through chronic disease
management and health service integration, decreasing emergency department
presentations and preventable hospital admissions. Better use of and access to
properly resourced general practices will reduce hospital expenditure and
stress on the system.[6]
2.10
The AHCRA noted that for the cost of primary healthcare, it is
exceptionally efficient:
The total cost of GP services is less than 7% of the total
health budget - a relatively small slice of the pie. International research
shows that countries with stronger and more easily accessible primary care
systems have better overall health status at lower costs.
And in terms of benefit-cost, investment in prevention and
early intervention are always the wise choices.[7]
Figure 1—Healthcare expenditure between 1997-98 and 2011-12[8]
2.11
Evidence received by the committee of the benefits of primary
healthcare, delivered through a model in which GPs are central, is explored
below in the following sections:
-
better health outcomes;
-
cost-effective healthcare; and
-
greater responsiveness than acute care.
Better health outcomes for health
consumers
2.12
In his submission, Professor Andrew Bonney, Roberta Williams Chair of
General Practice, University of Wollongong detailed a recent UK study which
examined the effect that general practice could have on delivering better
health outcomes for a community:
Twenty quality of care indicators were selected by the
researchers, each indicator having evidence of mortality reduction. This broad
range of activities included items such as influenza vaccination in patients
with diabetes, coronary heart disease, stroke or emphysema; treatment of
hypertension, diabetes and hypercholesterolaemia; use of beta-blockers in
patients with coronary disease and other evidence based use of medication in
chronic illnesses; and Pap smears.[9]
2.13
The results of the study demonstrated clearly the value of general
practice in delivering life-saving primary health interventions to health
consumers:
High performing practices were potentially saving over 300
lives per 100,000 of the population per year from these 20 activities alone
(there are many other mortality reducing activities not included in this
study). Given that the overall mortality rate for this population is
approximately 900 per 100,000 per year, the impact of high functioning general
practice on the health of a community is significant (Ashworth, Schofield et
al. 2013).[10]
2.14
Ms Ellen Kerrins, the Manager of Advocacy and Policy at the Health
Consumers Alliance of South Australia drew the committee's attention to a quote
from the Director‑General of the World Health Organisation which
succinctly summarises the benefits of primary healthcare:
Decades of experience tell us that primary health care
produces better outcomes, at lower costs, and with higher user satisfaction.
... ... ...
It can prevent much of the disease burden, and it can also
prevent people with minor complaints from flooding the emergency wards ...[11]
Cost-effective healthcare
2.15
In its submission, the Hunter General Practitioners Association (HGPA)
gave a series of examples which highlight the role GPs play in providing
cost-effective healthcare:
It is far more cost effective (and better for the
patient!) for a GP to both see a patient and administer a joint injection,
than for a GP to see a patient and then refer the patient to a specialist for
the same joint injection. So why has the MBS item number for GP joint
injections been removed?
It is far more cost effective (and better for the
patient!) for a GP to see and treat early a patient with a skin infection.
The alternative is for the same service to be done at the emergency department
for a much higher system cost; or for an extraordinarily higher system cost to
be imposed if the patient has to be admitted due to a late presentation.
It is far more cost effective (and better for the
patient!) for a GP to optimise the care of a patient with diabetes and high
blood pressure, than for the patient to have a stroke, be hospitalised, undergo
months of rehabilitation, and then spend the rest of their life in an aged care
facility.
So why try to deter people from presenting to their GP?
International research shows over and over again that primary
care is, when viewed from a “whole-of-system” perspective, the most
cost-effective way to deliver health care. (Starfield, 2010)[12]
2.16
The HGPA submission's examples demonstrate the main reasons why GPs are
at the forefront of cost-effective primary healthcare:
-
improved access to healthcare;
-
reduced cost to the overall healthcare system; and
-
superior preventative health outcomes.
Access to healthcare
2.17
As primary healthcare is one of the fundamental foundations of the
Australian healthcare system, access to general practice for consumers is essential.
A strong and properly resourced Medicare system, which provides universal
primary healthcare for all Australians, is fundamental to ensuring access to
general practice.
2.18
Dr Anne-marie Boxall, Senior Policy Adviser with the National Rural
Health Alliance argued that universality—a key aspect of Australia's Medicare
system—has been lost in the current healthcare funding debate:
We have been talking a lot about the impact on patients of
the potential changes, which is right, but the potential changes also have a
big impact on our health system if they are implemented. One of those is that
threat to universality. High bulk-billing rates have been pursued by both sides
of government for a long time, and there is a reason for that. It is because it
essentially functions as a safety net. Whilst some people may be able to afford
to pay more, and they do, through the taxation system, bulk-billing is seen as
a universal benefit. So if we are undermining a system and scaling back bulk‑billing
and making it a targeted system, we then need to be very sure that the safety
nets we have in place are effective, and that is something that we are not
entirely sure about at the moment, and we have evidence that people are falling
through the safety nets.[13]
2.19
Bulk-billing allows equity of access to healthcare, in particular for
vulnerable groups and those with chronic illness. Dr Graeme Alexander of the
Claremont Village Medical Centre, Tasmania, maintained that the practice of
bulk billing was a means to achieving better health outcomes:
We use bulk billing to get better health outcomes. We might
use it to pay part of the cost of an urgent visit eg. Acute Myocardial
Infarction, a child with a fractured arm presenting directly from school,
improve follow up, treating those with ongoing chronic illness and also helping
those who have troubles handling their finances e.g. mental health patients.[14]
2.20
Dr Con Costa, President of the Doctors' Reform Society, argued that
adding barriers to healthcare access, in the form of any price signal, would
reverse the gains made since the introduction of Medicare, particularly for
lower socio-economic areas in both cities and rural areas:
Let us be quite clear about what we will lose. We will lose
all those gains that we outlined before [Medicare's expansion of GP care to
outer urban areas, rural areas, for working people and lower socio-economic
areas]. There were very few doctors in the western suburbs. Working people
never had a family doctor, and the only women who had pap smears were the women
in the inner city. This would come back. People would leave the poorer country
towns, for example. There are no hospitals around the poorer country towns, and
so where they will go, I do not know. There will be a cost explosion for sure.
I am certain there will be a cost explosion, which will need to be covered by
the private health funds. And you will lose that control of costs where
Medicare bulk-billing is holding back on the whole system.[15]
2.21
Dr Stephen Duckett, Director Health Program, Grattan Institute, told the
committee that the debate about Medicare had originally been one regarding the
efficiency and equity of a universal scheme. He observed:
...I am old enough to remember what life was like before
Medibank [now known as Medicare] was introduced. Before Medibank was introduced
a number of programs were introduced to try to target and introduce special
programs for poor people. The reality was, even with special programs for poor
people, there were other people who could not afford health care because they
fell outside the restricted definitions and restricted mean tests. So the
debate about Medibank and Medicare was: is it more efficient and more equitable
to introduce a universal scheme so no-one falls through the cracks or should we
have schemes where it is possible for people to fall through the cracks? The
Australian people have made the decision time and time again that the right way
to do it, and in my view demonstrably the efficient way to do it, is a
universal scheme.[16]
Reduced cost to the healthcare
system
2.22
Regarding cost to the healthcare system, many submitters argued that the
better the primary healthcare system, the lower the costs for acute care and
the overall health system. For example, Professor Andrew Bonney, Wollongong
University, told the committee:
The first is that internationally we know, and there is no
doubt, that jurisdictions with strong primary care also have lower costs and
reduced rates of health expenditure increase. At worst, in comparisons among
countries in Europe, strong primary care is associated with lower levels of
health expenditure increase even if the baseline healthcare costs were higher
in the first place. So there is no conflict between seeking to contain costs
and improve health outcome, providing that it is recognised that serious policy
investment in primary care is the vehicle.[17]
2.23
When announcing the campaign against the government's attempt to
introduce a health price signal by co-payment, the RACGP observed that primary
healthcare delivers far more for far less than acute care:
The RACGP believes that the Australian health system is
complex and that there are many opportunities for improved efficiency without
targeting general practice.
According to Bettering the Evaluation and Care of Health
(BEACH) data, the average cost of a patient visit to the GP is $47 as opposed
to the emergency department, which can cost as much as $599.
GPs in Australia see approximately 85% of the population
annually with referrals to secondary and tertiary care accounting for less than
5–10% of consults. However, in terms of comparative Government spending,
general practice and hospital spending represents 15.5% and 84.5% respectively.[18]
Improved health prevention and
management
2.24
The Victorian Health Promotion Foundation (VicHealth) stated in its
submission that Australia currently invests less in preventative health than
most other OECD countries 'with just 1.7 per cent of 2010–11 health spending
going towards prevention efforts, or less than 0.2 per cent of GDP.20.'[19]
Yet, as VicHealth's submission argues, the economic benefits of investing in
preventative health are substantial:
Conservative estimates in 2008 found that if the prevalence
of key risk factors were reduced to realistic targets, it would save $2.3
billion across the lifetime of the adult Australian population. In addition,
economic evaluation of the costs and benefits of specific health interventions
shows that some can be very cost-effective, and in some cases investment can
have cost savings.[20]
2.25
Professor Andrew Bonney, University of Wollongong, argued that primary
care provided by GPs is the most effective method for delivery of preventative
healthcare:
Primary care provides first access to medical care for the
whole of the population – young, old, male and female. In the course of that
care a relationship with a practice is formed and from this ongoing person‑focused
care opportunities arise for preventive activities such as checking blood
pressure or screening for diabetes or Pap smears. This is all part of a
comprehensive range of care provided at a practice. Where chronic disease has
developed, continuity and co-ordination of care improves chronic disease
management and secondary preventive activities. This includes reaching targets
for diabetes, blood pressure and cholesterol level control; as well as
appropriate immunisations. Unnecessary and avoidable hospitalisations are
prevented and patient satisfaction, trust and compliance are higher. The net
result over time is improved health outcomes at lower costs, demonstrated by
international research (Starfield, Shi et al. 2005).[21]
2.26
Dr Stephen Duckett, the Director of the Health Program at the Grattan
Institute, noted that there are national and international studies showing that
better access to primary health results in improved preventative health rates
and better health management. With general practice being recognised as the
most efficient level of the healthcare system, internationally the trend is
towards improving access and encouraging health consumers to visit general
practice:
Certainly we know that, if you have out-of-pocket costs,
people defer visits to doctors. We also know that, if you have out-of-pocket
costs and people defer a visit to a doctor, the patient cannot make a judgement
about what is necessary care and what is unnecessary care; so they end up
missing out on necessary care as well. And there have been a number of overseas
studies which have shown that. There has been a major study which has assessed
the impact of co-payments... Generally, the overseas policy direction is not to
have financial barriers in general practice. The whole international direction
of health policy is to try to strengthen general practice, to try to strengthen
primary care because this is the most efficient level of the health system. I
am not saying that general practice or primary care is perfectly organised in
Australia at the moment and, indeed, I do not believe it is. I think there need
to be changes, but the changes you need to make are not forcing the consumer to
drive all the change in primary care when they are people who just do not know
what is necessary care and what is not necessary care.[22]
2.27
Similarly, Associate Professor Owler, told the committee that in primary
healthcare 'the first step when someone has a problem is the key to prevention
and the key to chronic disease management. That is not where we want a price
signal.'[23]
2.28
The government's previous policy of $7 and $5 co-payments as a price
signal on GP visits drew much criticism for the potential negative effects on
preventative health and management of chronic conditions. Organisations such as
the Doctors' Reform Society of Australia argued that GPs must be the ones to
decide if medical care is needed. The submission advocates for minimum barriers
to a person's decision to seek medical advice:
We doctors want patients to see us with what they might think
could be trivial complaints because we know it can save lives. The indigestion
which is really a heart attack, the blood in the faeces which could be piles
but could be completely curable bowel cancer, the small ulcer in a diabetic
which if ignored leads to gangrene and amputation, the mild/moderateĀ
depression which could progress to suicide. Let doctors be the judges of how
trivial the problem is. That is why we are expensively and highly trained.
Patients aren’t, whether rich or poor.[24]
2.29
Dr Emil Djakic, a GP from Ulverstone, Tasmania, told the committee that
his experience was that Australians understood the role GPs have in
preventative health. Dr Djakic felt that this attitude was reflected in part in
the increase in GP visits. He observed:
The last point I would like to make in my introduction is
clearly the role of GPs over this past 30 years has moved into a space that I
do not think people predicted, and that is significant involvement in
prevention. Some simple statistics I can look at in my municipality: in 1991
when I first appeared as a registrar in my patch, the population of Ulverstone
and Penguin, which were two separate municipalities, was about 19½ thousand. Those
populations are now about 22,000. In that period of time, my practice, when I
was training there, saw about 85 people or 85 contacts a day. The number of
practices in the area has not changed, but the doctor numbers have. Recently,
in this same population, my practices are now seeing 300 people a day.[25]
2.30
In concluding his opening remarks Dr Djakic echoed the sentiments of
other witnesses at previous hearings:
So I see us in a grave situation of disenfranchising the very
sector of the healthcare system that is the highest value... if we want to aspire
to the very best health for Australians, then we need to be investing in
primary care, not divesting in primary care.[26]
More responsive than acute care
2.31
The Australasian College of Emergency Medicine (ACEM) is well placed to
provide comment on the differences between primary and acute care. Dr Anthony
Cross, President of the ACEM, told the committee that the problem for acute
care was with treating patients whose conditions were preventable:
We work in emergency. But so much of what we see is
preventable. If it were not for alcohol, tobacco, speed—as in driving
fast—there would be work for three or four emergency physicians in Australia. I
am exaggerating. I am sorry. But we would be very pleased to see that. The
burden of preventable disease that we see is dramatic, all throughout the
health system. So of course, yes, anything to improve primary and preventative
care we would be supporting 100 per cent. This is where you get the bang for
your buck in health care.[27]
2.32
Acute care is aimed at treating emergencies, not chronic and ongoing
conditions, as Dr Simon Judkins, Victorian Councillor, ACEM, noted. Dr Judkins
told the committee that patients who chose the emergency department over the GP
due to increased cost would not be able to receive the ongoing care and
management they required:
...we do not need anything to encourage patients to come to us
to access care because we do not provide good GP type of care for patients. We
see them once and send them on their way. We are not there for continuity of
care. We are not there to treat chronic conditions. We are there for accidents
and emergencies.[28]
2.33
The ACEM argued that any policy which targets primary healthcare for
cost savings will be ineffective, 'as research has shown that the increase in
the rates of GP visits is in fact more cost-effective than if these services
were provided in other areas of the health care system'.[29]
Risks to general practice and primary healthcare
2.34
The evidence of the effectiveness of primary healthcare and general
practice is indisputable. However, this has not deterred the government from
targeting general practice as a source of budget savings. While the proposed
co-payments have now been dropped,[30]
the Minister for Health, the Hon Sussan Ley MP, has stated that the indexation
freeze will remain in place and that the government still believes that
Medicare spending is unsustainable.[31]
2.35
As a result of this government policy, the committee has heard growing
concerns from submitters and witnesses for the future of general practice. In
particular:
-
the viability of general practice;
-
increased inefficiencies in the health sector; and
-
the loss of opportunity to improve health policy.
Viability of General Practice
2.36
While the Prime Minister has insisted that the co-payment would not be
greater than five dollars,[32]
Dr Duckett told the committee that in reality the co-payment
could be as high as $40 per visit. Dr Duckett argued that the impact on general
practice of the government's proposed changes to Medicare is likely to amount
to a 10 per cent decrease in general practice income:
There are two changes that are taking place. There is a
rebate reduction that only applies to GPs' patients...who do not have a
concession card and are over 15. That is $5. That is the first change. The
second change is the freeze in rebates through to July 2018. That is a bigger
change in its cumulative effect. If you assume a two per cent increase or so
inflation per annum, it is a six or so per cent impact in reduction in revenues
to GPs, versus a four or so percentage impact from the $5. So it is a 10 per
cent impact we are talking about altogether.[33]
2.37
Dr Graeme Alexander, a GP from the Claremont Village Medical Centre near
Hobart warned that the government's policies threatened the ongoing viability
of general practice in Australia:
There will be a vastly inferior health system for the poor
and the disadvantaged whether they access clinics or get their health care
through the pharmacy. There is an interesting thing happening at the moment: as
general practice comes under attack—and I point out to you that one of the few
areas of general practice that will survive is the large corporate-run clinic,
and people should be asking the question why. The huge void that this will fill
as general practices' doors close—and that is what we are talking about; we are
talking about the viability of general practice, because general practices are
going to the wall as we sit here now and they are going to go to the wall with
this new health policy.[34]
2.38
Dr Richard Terry, Practice Principal of the Whitebridge Medical Centre
near Newcastle, outlined the impact of the government's proposed changes to
Medicare on solo practices:
I would just like to draw attention to the financial
vulnerability of solo practice. I have been in solo practice for a long, long
time, and for the last 10 to 15 years we have suffered a lack of indexation
medical rebates—10c a year on some rebates. Many of us in solo practice have
stayed in practice for the love of our patients, because our actual
remuneration, which is the money left in the pot at the end of the day, has
been going down as the cost has increased... Certainly if that Medicare level B
[short consultations policy] fiasco had gone through, you would have seen
practices dropping by their thousands, because you simply would have had to
close the door because you could not afford to keep it open. I think that the
co-payment and the lack of indexation again have the similar effect.[35]
2.39
The RACGP President, Dr Jones, talked about the difficulty of balancing
quality care, and managing a general practice in the face of the government’s
proposed changes:
Australian general practice patient services have been
unfairly targeted by the government to find savings within the health budget.
GPs and practices are now faced with an ethical dilemma of providing ongoing
quality care balanced against practice business imperatives. Please remember
that most general practices in Australia operate as small businesses.[36]
2.40
The RACGP felt that the result of the Medicare reforms was that 'the
Government has shifted the onus of finding savings onto GPs'.[37]
Feedback from the members of the RACGP indicates that, facing the decision of
whether to pass on greater costs to patients or absorb the costs from their own
practice, 'most GPs will not be in a position to absorb these costs'.[38]
The RACGP noted that:
While these changes [$5 co-payment and extended indexation
freeze] will clearly have a negative impact on patient access and tertiary
healthcare expenditure, they will also threaten the sustainability and
viability of the business of general practice and the future of the profession.
Operating as small businesses, general practice owners will
now be forced to revaluate the viability of their business model and determine
if, under the proposed arrangements, the return on investment will be
sufficient to continue operating. It is likely that many practices will cut
practice staff, general practice registrars, medical students, and patient
services as required.[39]
2.41
According to the RACGP, the cut to funding for primary healthcare is
also negatively affecting the future of general practice:
Feedback received indicates that many young doctors view
general practice as an unattractive vocation and that the proposed government
changes are forcing many GPs who are currently practising to reconsider their
chosen speciality.[40]
2.42
Dr Ian Kamerman of the North-West Health practice in Tamworth provided a
clear example of the concerns voiced by others that the out-of-pocket costs to
patients was likely to be much higher than the $5 in the government's
announcement:
...it is a concern to me as a business owner and operator as
well as a GP that there is no funding now, essentially, to support the actual
practice of general practice. Certainly it is marginal at the moment, and, with
the changes to indexation, the gap between expenses and income is going to
increase from marginal to about $100,000 a year that I am going to need to make
up in costs and income in my practice. Either I am going to have to put staff
off or I am going to have to increase patient fees to do that over a period of
time. Currently, my non-concessional patients pay a $35 gap. That gap is going
to increase to about $60 or $65 if I am going to stay afloat as a business. It
is certainly much more than what has been talked about as the cost of a latte.
Either that or I am going to need to cut out bulk-billing altogether.[41]
Increased inefficiencies in the
health sector
2.43
Dr Duckett noted that there are national and international studies
showing that better access to primary healthcare results in improved
preventative health rates and better overall health management. With general
practice being recognised as the most efficient level of the healthcare system,
internationally the trend is towards improving access and encouraging health
consumers to visit general practice:
Certainly we know that, if you have out-of-pocket costs,
people defer visits to doctors. We also know that, if you have out-of-pocket
costs and people defer a visit to a doctor, the patient cannot make a judgement
about what is necessary care and what is unnecessary care; so they end up
missing out on necessary care as well. And there have been a number of overseas
studies which have shown that. There has been a major study which has assessed
the impact of co-payments... Generally, the overseas policy direction is not to
have financial barriers in general practice. The whole international direction
of health policy is to try to strengthen general practice, to try to strengthen
primary care because this is the most efficient level of the health system. I
am not saying that general practice or primary care is perfectly organised in
Australia at the moment and, indeed, I do not believe it is. I think there need
to be changes, but the changes you need to make are not forcing the consumer to
drive all the change in primary care when they are people who just do not know
what is necessary care and what is not necessary care.[42]
Loss of opportunity to improve
health policy outcomes
2.44
The committee heard from witnesses that the government's single-minded
focus on "budget repair" has led to the government developing
policies which will damage Australia’s primary healthcare system. As a result,
the national healthcare reform debate has been side tracked into protests
against the government's poor policy formulations and the opportunity has been
lost to engage meaningfully with stakeholders on positive health policy reform.
2.45
Associate Professor Owler told the committee that the government had
focused on fiscal saving to the detriment of debate about beneficial health
policies:
I think the proposals that have been made...have all been
fiscal. They have all been about saving money. No-one would introduce those
measures if they were to look at the impacts through the prism of health. I
think one of the most disappointing things over the past 12 months is that we
have just had no health policy developed in this country. We need to get back
to talking about how we are going to make the health system better. I am
pleased that the new minister appears to be embarking on that process, but I
think it has been a disappointing 12 months from that perspective.[43]
2.46
Dr Linda Mann, a GP from Strathfield, Sydney revealed the loss of trust
between the government and general practice:
General practitioners, I think, are very insulted by the idea
that we are the part of medicine that has to show a price signal.[44]
2.47
Dr Charlotte Hespe, a GP from Glebe in Sydney with 20 years of
experience, articulated the frustration of GPs with non-evidence based,
fiscally driven policy making:
There seems to be a concern about the amount of money that
the government is spending on health, with the increasing population and the
increasing complexity of medicine that is before us; therefore, there is this
need to take control of the amount of expenditure that goes into health. If
that is truly what the government wants then this attack on primary health
care—which, can I say, has come from three directions in the budget: the
co-payment, the change with Medicare Locals and the change with the GP training
scheme—is completely ludicrous. When you look internationally, there is
astounding evidence that the way to make your health system efficient, to
increase its capacity, to improve health outcomes and to achieve the triple aim
of universal health—which is improving the patient journey, improving the
health of your population and decreasing cost—is to build up your primary
health care. The co-payment as an example of that is ridiculous. It is not
going to do that at all. What signal it puts out is ridiculous.[45]
2.48
Dr Duckett summed up the views of many who spoke to the committee with
his observations on the progress of the Minister's 'wider consultations'
process:
We had the unusual situation which I do not think I have seen
in health policy in this country of three health policies in less than a month,
which suggests that policy is being made on the run. As I said earlier, we do
need to look at primary care in general practice and we do need to think about
whether the current arrangements are right for the future.[46]
Committee observations
2.49
The evidence heard by the committee indicates that from the 2013
election to the recent 2015-16 Budget, the government's apparently single-minded
focus on making savings in healthcare has blinkered its approach to policy. The
government's fiscally drive approach has resulted in unjustified cost burdens
falling on the primary healthcare sector and in particular on general practice.
2.50
As this chapter has discussed, there is overwhelming evidence of the
importance of general practice and access to primary healthcare. The evidence
gathered by the committee has demonstrated that general practice provides:
-
better health outcomes for consumers;
-
cost-effective healthcare with an ability to focus on
preventative health; and
-
more responsive healthcare than acute care, particularly in
providing continuity of care and management of chronic conditions.
2.51
Despite this evidence, witnesses continually told the committee that
government policy has threatened the viability of general practice. In
particular, the committee notes with disapproval the government's renewed
commitment to non‑indexation until an agreed "value signal" is
reached with stakeholders in primary healthcare.
2.52
The committee observes with concern that instead of beginning a public
discussion about positive healthcare reform, the government has eroded the
trust and goodwill of the medical community. The government's targeting of
primary healthcare for budget savings has led to:
-
threats to the viability of general practice as GPs are forced to
pass on costs to patients from the continued indexation freeze;
-
poorer outcomes for patients as out-of-pocket expenses increase
or the indexation freeze prevents GPs from maintaining viable practices
(particularly in rural areas where attraction and retention of GPs is already
problematic);
-
increased inefficiencies in the health sector as patients who
cannot pay for primary health enter the public hospital system with preventable
conditions or mis-managed chronic conditions;
-
loss of opportunity to introduce positive healthcare programs and
policies; and
-
the loss of the trust and goodwill of the primary healthcare
sector.
2.53
The committee agrees with Dr Duckett's observation about a future
approach to healthcare policy:
Further, public policy should be based on both costs and
benefits. Purely focussing on outlays without considering the benefits from
those outlays can again focus policy attention in the wrong place.[47]
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