At Catallaxy, Judith Sloan reposts the text of an op/ed critical of the government’s health and hospital reform agenda. She concludes by decrying the results of the plan’s implementation, claiming all that has been achieved apart from “much higher funding from the federal government” is:
a motley collection of cute sounding schemes, such as the GP super-clinics and Medicare locals, with little purpose.
Over the last year, I’ve been working on a couple of research and consultancy projects in health workforce innovation and health systems research. So, among other things, I’ve learnt a bit about GP Super Clinics and Medicare locals.
Both are responses to a couple of inter-related issues: the difficulties of co-ordinating the provision of care (including through markets) and workforce distribution.
We’re often told that there are massive shortages of health professionals. But since the increase in medical places, we have more graduate doctors than health departments know what to do with. The actual problems go to how and where health professionals work.
GP Super Clinics are designed to take pressure off emergency departments, and particularly to do so in places where access to private doctors is restricted by cost and supply. Unsurprisingly, GPs tend to go to where the most money can be made, because of incentives driven by fee for service cost reimbursement models. That’s usually in the inner city and wealthier suburbs. Just as importantly, GPs aren’t necessarily the most efficient providers of all aspects of primary care, and Super Clinics are based around models of care which bring together nurses and allied health workers, and use the full set of their competencies and skills to the utmost.
Such “new models of care” also respond to the fact that changes in population health mean that patients are increasingly suffering from “co-morbidities”: that is to say, a range of often inter-related conditions for which “bits of the body” specialists can’t treat the whole patient. Think older people living with diabetes. Medicare Locals are intended to co-ordinate care for patients so they’re able to access what they need in one spot, rather than being bounced from clinic to hospital to specialist to GP. They’re also intended to deliver care better and more cheaply in the community, rather than in acute care public hospitals.
Anyone interested in the Medicare Local program should read the excellent coverage at Melissa Sweet’s Croakey blog.
My biggest criticism of the implementation of these initiatives would be that the original vision has been diminished by separating primary care from acute hospital care governance, contrary to the Kevin Rudd plan. That’s going to make it harder to achieve the co-ordination of care, and potentially re-opens the whole can of worms about blame and cost shifting. But to say that these are just “cute sounding schemes” is manifestly wrong.
Part of the problem here, aside from the perennial issue of vested interests and turf wars that plagues health policy, is that the government itself hasn’t departed from the one note narrative of “more nurses and more doctors”. That’s a pity too.
NB: These comments represent my personal opinion, and not that of my employer or of funding bodies which have supported research in which I’ve been involved.
My biggest criticism of the implementation of these initiatives would be that the original vision has been diminished by separating primary care from acute hospital care governance.
For what it’s worth, I think you’re bang on the money here. It’s a shame to see something that had so much potential get watered down progressively like it has. My (limited) understanding from the data I’ve seen suggests that these models would address a real need /gap in the current healthcare landscape, and potentially do it in a way that gets better outcomes for the public, healthcare professionals and govts. Especially as the field of e-health continues to grow and mature.
I’m now a little skeptical how many of those benefits will materialise. I don’t believe it’s going to be a disaster, but it’s a shame some of the potential will not be realised.
I think it’s best seen as incremental reform, patrickg. Some of the biggest issues, imho, actually revolve around the Medicare schedule model of reimbursing practitioners for services – it acts as a big disincentive for GPs working in aged care, discourages longer consultations (and that’s at issue as well with recent changes to the reimbursement of consultations about depression and mental health issues), etc. That’s one of the elephants in the room – funding per patient visit is now probably recognisable as having distorting effects on both healthcare outcomes and the distribution and mode of work of practitioners. But this is barely on the agenda – yet.
Probably the biggest shift needed is in attitudes among the whole gamut of health workers – hence the caveat in the post. But there are some hopeful signs.
You are totally right that e-health has the potential to do great things. Again, many of its possible transformative effects aren’t really captured in the current discourse.
The biggest problem is the Gordian knot of funding versus delivery. Either make the Federal Government completely responsible for both funding and delivery or make the States completely responsible.
I don’t think that is the biggest problem. There’s no doubt that there’s value in a national approach to health policy – illness doesn’t stop at state borders. The problems faced in rural health in remote areas have similarities, for instance. What we need is a *rational* funding model, preserving the chance for both innovation and local input.
The Rudd plan was far from perfect, but it was a closer approximation to being sensible than what we have now.
GP Clinics are also valuable when primary care is restricted by GPs wanting to have a life, including weekends. If your child gets sick on a long weekend, it doesn’t matter whether you live in the inner city, you can’t see a GP because they don’t do housecalls. My doctor’s answering machine tells you to go to Balmain Hospital, where there used to be a GP clinic. But without such clinics your only recourse is to go to Emergency at some hospital, even if you only want to be reassured that it’s a virus, or a headache, and not pneumonia or meningitis.
Emma, yep. Sometimes there is an alternative – private clinics which provide healthcare on a 7 day a week (and sometimes 24 hour) basis, but at a sharp cost premium, which drive people to emergency departments. Super Clinics provide equitable access, and don’t clog the EDs. You’re also quite right to say that EDs are designed around a triage model and have as their main purpose funelling people into acute care beds, and just aren’t meant to provide primary care.
I feel part of the problem is the – for want of a better term – health care discourse in Australia which, thanks to talkback radio and indifferent media, is based almost entirely around hospitals and hospital beds.
It’s a great disservice to the healthcare sector – not only does it put ever-increasing pressure on EDs and hospitals in general (both in terms of raw demand, but also in areas hospitals can’t/shouldn’t really manage), but also in ignoring that the majority of healthcare issues for the majority of Australians take place outside a hospital environment.
As pointed out above, hospitals then become the default super clinic, the default nursing home, the default palliative care, mental health facility, etc etc etc. Roles they neither want, nor are especially well equipped to deal with.
One thing I really liked about the Rudd reforms was how they targetted the entirety of the health sector. I feel that they recognised for a lot of Australians, hospital is only one part of their health journey, and there are many scenarios where it needn’t/shouldn’t be, with resulting better outcomes for all involved.
It’s not a popular line to take in the media, with their stultifying obsession on “hospital beds”, but the subtleties of the discussion seem to have been lost in the popular press. A shortage of hospital beds can’t be addressed in the hospital, if they are filled with people who should be in aged care, etc.
I couldn’t agree more, patrickg.
For me one of the ironies was being down in Melbourne last year during the state election and talking to Victorian health bureaucrats who know perfectly well that the “more doctors and more nurses” narrative is a huge part of what’s causing issues and seeing Brumby on tv promising… “more doctors and more nurses”.
Again, it’s a pity that the message that hospitals are only part of the picture wasn’t communicated better. It was certainly there in the Rudd reforms, but, alas…
It’s yet another instance of how poorly served we are by the intertwining of political and media discourse.
I live in the outer suburbs and I had to use a ‘GP connect’ clinic on the Anzac/Easter long weekend…rusty nail in zee foot. Funneling non-urgent cases away from the ER is great for hospitals and the GP connect system is great for patients. You can ring and make an appointment, which is great for families and would probably reduce the stress of dealing with a sick child. I think I was in the building for 3 minutes, which is great because I’m slightly phobic about doctors/hospitals/clinics. They could call it the Mr Happy Clinic for Accident Prone F*wits for all I care, I think it is a great innovation.
oops, too many ‘greats’ in that post^^. sorry.
Great!
I agree that the GP clinics are really useful. With a sick toddler, one really doesn’t want to see an overtired, panicky intern who’s going to order a lumbar puncture because she’s never seen a healthy kid with a minor illness before and she’s not sure. You want to see an experienced GP who’s seen hundreds of them and is prepared to make a call based on that experience. If you can see that GP without waiting 8 hours in a waiting room with said sick toddler, so much the better. Meanwhile the panicky intern gets to deal with the serious injuries and emergencies she is meant to be dealing with.
Overall, though, I think we need to keep in mind just how GOOD our health system is, and how equitable, and I say that as someone who would have died and/or been bankrupted by health costs several times over had I been unlucky enough to have been born American.
It’s worth noting there too, Emma, that a lot of the “horror stories” come from inappropriate reliance on hospitals because the ball has been dropped in ensuring access to primary care. Again, another reason why the Super Clinics and Medicare Locals are a *good idea*.
It’s interesting to compare the response here to these innovations with the uproar in the UK over “polyclinics,” which are essentially the same thing. Australia has been innovating in this direction a lot longer than the UK, too – our 24 hour health centres were a huge improvement on the traditional single-handed GP model, and were introduced years and years ago. But in the UK any move away from the single-handed GP surgery is seen as a catastrophe by all sides of politics, even though that’s exactly what the system needs. And we were lucky to start with – compared to Australian GPs, UK GPs do virtually nothing except refer patients to hospital, creating a hugely clogged system.
I actually think in comparison to the UK, Australian debate on healthcare is more mature in all dimensions.
What sort of debate, though, sg? I think there’s a pretty sensible and mature policy debate, but the political debate is atrocious. And the media’s approach even worse.
I would love to see a show similar to the SBS program about boat persons, only focused on healthcare. I am sick and tired of hearing the media mouth the ‘our healthcare is worse than third world’. Really! Try living in the ‘richest country’ on earth, or go to any developing nation. No waiting list for that hip replacement, no doctor that you can afford or in some cases even find.
Anyone know why the don’t run 24/7 GP clinics adjacent to all emergency departments?
After hours in my regional area it’s all horror stories because a reliance on hospitals is all that’s available. Call an ambulance and enter the world of uncertainty and long waits. EG two weeks ago a little toddler climbed on some shelves in the local store, they collapsed on her and among other things dislocated her pelvis. It was 18 hours before that child was properly treated after a runaround of 3 hospitals and a cancelled flight. The paramedics were great but the frustration shared by all involved truly horrendous.
$$ Chris. 24/7 GP clinics are expensive to run and would need a steady stream of paying patients to make them worthwhile, plus available doctors. Out here we can’t even get a Dr for the hospital some days.
@Chris and Mindy – I think the underlying issue again here is the way doctors are remunerated.
@Zorronsky – Having worked on a rural and regional health research project, I’m in a position to state that I think the unfortunate truth is that there is no feasible way, under the current circumstances, to ensure an adequate supply of doctors outside cities. There are a range of reasons why international doctors aren’t the magic bullet, and there is just no way to design incentives for a sufficient number of medical graduates to work rurally with the current structures of funding in place – if not enough want to. Hence, there needs to be attention paid to what other health professionals can do, and e-health needs to be supported to realise its full possibilities.
The GP as one stop primary health care provider model is creaking. There’s increasing awareness of that, but the debate needs to be reframed further to get the solutions working. There’s no lack of viable ones out there, but the way the debate is distorted by both a focus on simple numbers in particular professions and vested professional interests is a huge barrier.
@17 – because they are two seperate systems.
GPs are Federally funded and licenced.
Emergency Departments are State funded and run.
There is little or no crossover in co-ordinating GP locations and availability and Emergency Departments.
When my kids are sick after hours the first thing I do is ring Health Direct and get advice from them. If they advise or I am still concerned then I duck down the Princess Margaret Children’s Hospital and check out the waiting room. If it is empty-ish I’ll wait but otherwise I then head off to the nearest afterhours GP.
I am fortunate in that I live close to PMH and can afford to go to the AH GPs that don’t bulk bill.
Another major issue is that Medicare payments have not kept up with inflation for GPs. Maybe if it had then there would be more GPs available.
There are lots of basic health services currently provided by GPs that could be provided just as well by experienced nurses. Looking in kids’ ears and throats, vaccinations, basic tests, listening to chests etc. Just as optometrists can send you off to a real eye doctor if they see a problem, so nurses could send you off to the city to a doctor if you are sicker than they can treat. It is the AMA and GPs who resist this, in a classic restraint of trade manoeuvre. If I were in a country town, I think I’d rather see a good nurse practitioner who lives in town and knows my family, than some blow in locum doctor who flies out on the next plane, and is being paid some huge amount for a week’s work.
“Another major issue is that Medicare payments have not kept up with inflation for GPs. Maybe if it had then there would be more GPs available.”
By my calculations, a lone GP with a full appointment book is grossing somewhere above $200 per hour, even if they don’t charge more than the Medicare rebate. That means their practice would pull in over $350K per year, based on a 40 hour week and 4 weeks closed for holidays. If they are greedier than that, maybe they shouldn’t be in a caring profession?
@23 – Emma – then they have to pay the running costs of their business unless they are a paid employee – none get the full amount straight into their pocket.
That’s right, and that’s why there are few single practitioner GPs left.
@21 –
… which is one of the reasons that it’s really a bad thing that Medicare Locals aren’t integrated with Local Hospital Networks, as the Rudd plan envisaged. It’s defeating the aim of co-ordinating and leveraging all healthcare resources in particular localities to optimum patient care, and leaving the separation between primary care and hospitals intact, for a lot of purposes. In theory, there will be some mode of engagement between hospital and non-hospital governance, but it’s far from ideal.
OBR, I’m aware of that. As a sole trader myself for a long time, I would have loved to make that much, and would have easily paid running expenses, insurance and a receptionist out of it. There is no reason that doctors should be paid the huge amounts they are (especially specialists), except that their very successful union, sorry ‘professional association’, the AMA, has managed to swing it.
Emma – every time I lay on the table waiting for the gas to put me out I am more than happy that the smartest people are getting paid a shed load to make sure they are unlikely to stuff what ever operation I am having up.
Emma, specialists are paid on quite a different basis to GPs. There is no doubt that restrictive practices have had an impact on restricting labour supply and thus increasing remuneration. In that context, it’ll be interesting to see what the medium term implications of the increased supply of medical graduates now entering the workforce is. Having said that, they’re unique in being the only profession where every graduate is guarenteed state employment (at least in Qld and NSW, not sure on other states) which is a very big “distortion of the market”…
There probably is some force to the argument that remuneration should reflect very long years of pre-vocational and postgraduate training (it can take around 12 years to produce a specialist). That aside, the basic issues go to the complexity and distributional effects of medical remuneration – the combination of ‘the right of private practice’ and pressures on state budgets, which flow through to other health professionals is an issue, as is the fee for service model of the Medicare schedule. Similarly, there’s a nursing shortage in aged care, not because “there are not enough nurses” but because of much poorer wages in the (largely private) aged care sector.
All this is a minefield politically and industrially.
So it’s not as simple as “greedy doctors versus the rest” by a long shot. What needs doing is at least a path to examining the irrationality of medical remuneration.
It’s also not necessarily the case that nurse practitioners are cheaper to employ than GPs. For a start, there’s the fact that nurse practitioners are highly skilled workers with Masters degrees and a lot of CPD and competencies developed in the workplace, and able to command up to 100k a year. Secondly, a combination of limited scope of practice and a different approach to consultations often means the cost per hour is higher…
The idea of “efficient price”, which is also getting a bit watered down, is one way to start to quantify some of these things. But, also, far from ideal. What is really needed, and I don’t think this is yet in prospect, is an overall review of the remuneration of health professionals – taking into account wage justice as well!
Emma – Given their overheads I wonder if most GPs end up with net even half of what you calculate though? My sister-in-law is a GP and I rather doubt she’s making anything like that (though she not a partner in the clinic).
Mindy @ 19 – Doctors are expensive but they have them in emergency departments anyway – surely it is more efficient to employ a specialist GP (and I understand most GPs are specialists these days) to handle the cases they can rather than have emergency room doctors do it. A lot of the overheads for a 24/7 GP clinic such as security etc have to be there for the emergency room anyway, Perhaps it is just a funding issue with the federal government not wanting to pay for it so overall the community ends up paying more.
Emma, I think you would find your insurance as a sole trader of almost any description would be dwarfed by the medical malpractice insurance that GPS – let alone surgical specialists – have to pay for. I’m not saying that doctors are hard done by, and I agree that the AMA and colleges have a lot to do with it, however there are very real and very rising costs for practising medicine in Australia. There’s a reason why so many surgeries are being bought out by large conglomerates, and doctors brought on as employees rather than partners.
Moreover, 350k per year sounds like great money, but to get there requires substantial higher education and study. Additionally, student doctors working in hospitals and as registrars during night shifts etc – whilst not going poor – are not paid anywhere near what specialists and GPs are.
The prospect of studying for nearly ten years, accruing hundreds of thousands of dollars in student debt, and working graveyards for average pay in hospitals that are in reality predominantly geriatric and chronic disease care, whilst still on an academic treadmill of masters degrees etc is not very appealing for a lot of people – especially the kind of people smart enough and industrious enough to qualify for medicine degrees, especially women who – if they want a career – will have to hold off an having kids until they are in their early to mid-thirties at the least.
Doctoring is very much a long game in terms of personal benefits, and knowing you’re one or two malpractice suits away from bankruptcy wouldn’t be very comforting…
I dunno, I think – much like with politicians – a lot of people look at doctors lifestyles with envy, but they neglect to look at what it takes to get there, and stay there. Sure, there are a few exceptions, but for the majority it’s damned hard work for a very long time before you get the timeshare yacht etc. My friends in finance have, in the main, started doing much better for themselves much faster than my friends in medicine.
@30 – Chris, most doctors in emergency departments are junior doctors who are comparatively cheap to employ (and are really only supposed to be there to deal with emergency medicine per se) compared to experienced GPs who are quite expensive to employ.
Mark, I think actually the political debate in the UK over the NHS is pretty terrible, worse than we have in Australia. We’re fortunate here that medicare is just one part of a complex system, whereas in the UK they just have one big fat monolith which everyone is simultaneously complaining about and valorizing. The GPs have too much control and there is no serious free market flexibility built in, but any move towards “choice” or market structures is greeted with howls of “US style medicine” and fears that grandma will never be able to see a doctor again. It really is terrible.
Regarding getting doctors to work in the country, I think in Japan they introduced a system of having two medical schools that are very tough to get into but completely free (this is unusual in Japan). But graduates are required to spend 5 years in a rural practice chosen by the government. I heard this story a few years ago and may be confusing it with Sudan (oops). But it seems like a possible model for getting doctors into the country.
I saw a similar version of this problem at hte university I worked at last year, which is in the country and just cannot keep good staff (who prefer Kyoto or Tokyo). I think to get around this problem you need a general policy of rural development, which makes country towns more attractive to young doctors, or makes them good places for older doctors to want to move to. This means rural development, and probably some kind of “picking winners” industrial policy to encourage that sort of thing, as well as disproportionate levels of investment in non-health lifestyle stuff (parks, pools, etc.) i.e. increased urban subsidization of rural areas. This is not popular with a neo-liberal worldview.
But, incidentally, I think figuring out rural health policy is a key part of fixing Aboriginal health. They’re very closely linked.
Regarding GP salaries, compare the ratio of Gp to specialist salaries in the UK (favours GPs!) with Oz (favours specialists). My (outdated) knowledge of this issue was that average GP wages in Oz are quite low as a proportion of e.g. the average wage compared to other countries. In the UK they’re out of control. I don’t think it would be bad for the health system to increase GP salaries, there’s much more complex issues than that to attend to.
Unless it is an ER attached to a rural hospital. What we have some days is nurse practitioners who triage the patients then call a Dr and try to get the patient to a hospital in Goulburn or Canberra. Not good if you’ve had a stroke and the nearest care is an hour away.
@35 – Mindy, and that’s one of the possibilities that an intelligent combination of e-health consultations and delegated prescribing might mitigate.
@33 –
For sure, sg.
I think you’re spot on regarding the desirability of living in rural and remote areas. Various forms of what is in effect bonded labour (including making internationally qualified medical professionals work for years in the bush through immigration mechanisms) have been tried, and don’t work or have perverse outcomes. We’re also seeing – attitudinally – less of a disposition towards service as a large part of a profession, which is not surprising in a neo-liberalised individualised social realm.
It is the emptying out of life and services and variety in rural and regional areas that starts to have a downwards cascading effect that’s well documented. We need to think more seriously about what equity between country and city entails.
If you have good places to live and work and fairer structures of remuneration and the right set of incentives, the people will follow.
Mindy – sure but there are often huge queues in city hospital emergency rooms, filled with many people who probably would be fine with a GP. It might not make sense to have GPs staffed 24/7 at rural hospitals. Re: rural ER’s – a friend had to go to a country hospital once and had trouble finding *anyone*. Eventually found all the staff in one room watching television – I guess they don’t get many people coming through
Mark I would be intrigued to know if any of your work touched on this – or your opinion more broadly: I’m aware of some work regarding school teachers that basically intimated the most effective way to get rural teachers is to train more rural people to become teachers, i.e. people tended to return to their hometowns. Are you aware of any evidence that this might be the case for doctors?
As someone who fled my picturesque, and not-even-really-rural-in-a-meaningful-sense-anymore home town, I find it a fascinating argument! I suppose my sister still lives there, however, and going to the local IGA is like a high school reunion so I may have been an exception!
@39 – patrickg, there’s an experiment to test that hypothesis – which is the James Cook medical school, which is explicitly designed to attract regional students who will become regional doctors. But it’s only just producing its first bunch of graduates.
Surveys done of students probably don’t mean too much – most surveys of 2nd year med students find that their current career aspirations aren’t well correlated with their actual career destinations.
The other elephant in the room is that for a lot of medical specialties – not just the high profile excellently paid ones but things like paediatric medicine – you need a certain critical mass of colleagues, access to continuing professional development and education, facilities, etc, to make you want to work somewhere.
The same goes, and for the same reasons, for some specialised allied health roles (and nursing specialties). There are Queensland hospital districts with only one podiatrist or sonographer, for instance.
There may be several, Mark. There’s one in Gippsland too, offerring graduate medical places; but as far as I know it attracts very few Gippsland students.
Thanks, Ambi… James Cook is the only one I’m aware of that explicitly says its curriculum and ethos is designed to promote regional and rural practice. I imagine Gippsland wouldn’t have as big a catchment area of locals as Townsville too. Or the same distance from other med schools.
I think the Gippsland medical school would LIKE to enrol more Gippsland students….. but they’re seeking graduates, and many Gippsland school-leavers depart Gippsland when they first go to Uni. So those ones would need to be attracted back to the region.
… which I imagine is not likely to happen in great numbers. Probably for the same reasons or similar why it’s hard to get people to go and work there!
There’s also other factors like the skewed age profile of many rural and regional areas, and the overall poorer levels of education. So if you’re a 24 year old medical graduate who wants to have like-minded friends of a similar age, you’ve got the prospect of a very small pool of people in many rural and regional centres.
I read somewhere a while ago of the strong correlation between mega-agribusinesses buying up parcel after parcel of family farms in any given region and the subsequent stagnation of that region’s rural towns, but I can’t find the link.
They don’t need so many workers, so the young men in particular either leave town or become part of a growing number of disaffected unemployed locals who don’t have enough disposable income to keep the local economy vitalised. With fewer young men in town, little prospect of being part of their own family farm, and with ambitions of their own, many of the young women also leave. The number of children born in the town goes down, so the school shrinks and has fewer teachers. More and more businesses in the main street close, meaning fewer and fewer local jobs. I think you can paint the rest of the picture for yourselves.
It’s extremely difficult to reinvigorate such a town that has shrunk to a pale shadow of its former thriving self over the last 20-30 years.
That’s for sure!
@Tigtog
It used to be that the single female teachers and nurses came to town to work and married a farmer and stayed. As you say with the agribusinesses coming in there are less farmers and flow on effects from that.
@Chris and Mark – whether e-health or an on site Dr it would be good to have coverage of the local hospital which unfortunately is not always the case. At least when I went for treatment on Sunday there was a bell to ring to summon them from the TV room!
Gosh!
Patrickg wrote: “One thing I really liked about the Rudd reforms was how they targetted the entirety of the health sector.”
Is that the case (genuinely asking)? Because I hadn’t heard that they were doing much for nursing homes, and my experience of looking at getting someone into one was a nightmare. It seems to me one of the priority areas for ‘reform’.
To get more doctors into rural areas surely you need to pay them what it takes. The mining companies up North don’t moan about a lack of truck drivers – they offer $200,000+ and they get truck drivers. Offer GPs $500,000 to work in a rural town and you’ll probably get offers.
I was reading the local AMA journal this arvo and one GP was saying that because the fees/rebates hadn’t been indexed he only bulk billed HHC holders, Indigenous etc and charged the rest – and had to charge them quite a lot because they were in effect subsiding his bulk-billed customers.
Russell, aged care was the subject of a separate productivity commission enquiry which has now reported. I don’t know if the government has responded yet, though.
I can’t help feeling that the phrases “aged care” and “productivity commission” should never be put in the same sentence!
I get the impression a lot of ALP thinking over the last 10 years has been about reforming the nursing care system to remove pressure on hospitals. I imagine they’ll incorporate that plan some way in their response to the PC report. But aged care is also a minefield, because it’s so easy to be accused of “kicking granny to the curb.”
My recollection, and it was about 6 months ago that I looked at it, was that the reaction was that the PC report wasn’t a particularly innovative or far reaching piece of work. The thrust of it was about aged care “bonds” – to finance people going into care. Other issues were given pretty short shrift.
It is interesting to consider that aged care is the only bit of Australian health and social care that it is overwhelmingly privately owned, and it’s the bit with the poorest wages, and the biggest issues in delivering a good standard of care.
Aged Care? – or do you mean Nursing Home/ Residential care?
Less than 20% of people utilize aged residential /nursing home care.
Aged Care is NOT Nursing Home care.
Most aged care in health care is conducted in public hospitals and under Medicare in GP / Podiatrist/ Physio etc clinics or under HACC or local government/ NGO run services – very little to almost nothing of this is privately owned.
Yes, I meant nursing home/residential care.
Can you point me to the figures for % of residential care private vs not for profit – I can’t find them ?
From memory around 75% of residential care people are on Centerlink pensions and 15% on Vet affairs persons.
Not off the top of my head, sorry – my recollection was that it was a citation in a social policy text to some data, but I don’t have it here at work.
There’s some 2005 data in this paper – 31% private for profit, 61% nonprofit, the rest government. That’s ownership of aged care residential places.
http://www.econ.mq.edu.au/research/2006/8_2006_Tannous_Luo.pdf
Thanks for that. I was concerned at the statement:
that aged care is the only bit of Australian health and social care that it is overwhelmingly privately owned,
It didn’t fit what I thought.
Aged Residential care only has to cater for less than 20% of the aged care needs and only 31% of Aged Residential Care is privately owned for profit.
Or did I misunderstand what you were getting at?
I think so…
Mark @ 32 – btw does it really end up cheaper overall to have people go through emergency rooms for GP services than go to a GP?
@62 – I suspect not, Chris, and I don’t know if it’s a question that’s been answered, but it’s a good one.
@62 chris – one of problems around this issue is that a lot of the players start from a preconceived position and then argue it without a lot of knowledge about the system, even the parts they operate, and without much regard to the facts.
EDs operate on state funding (there is federal funds but they are mixed at state level) and are part of state planning. GPs operate on direct Federal $ from Medicare and are not subject to state planning and co-ordination. (Federal service planning & co-ordination is basically non existent)
In general the Feds have not allowed GP clinics to operate in Hospitals with some exceptions.
Where there have been GP clinics located in hospitals EDs or nearby they have not generally been a success. Many have closed. People either do not attend them or the GPs clinic ends up referring back to the ED anyway.
The Feds are talking about the possibility of hospitals billing Medicare ( currently not possible always some exceptions), for “primary care type consultations” . Nobody knows what “primary care type consultations ” are in a hospital context.
Patient behavior says that many people prefer to go to hospitals for many treatments, certain demographics like 17 – 30 s who don’t have a GP, older immigrant groups etc, prefer to go to EDs. Despite a lot of effort not much has been shown to change that behaviour.
Parents will drive past two hospitals and 3 after hours GP clinics to take their children to the Children’s Hospital for a cough that has been worrying them for 3 days.
GP like consultations (and there is disagreement as to what % are GP like) in EDs do not hold up more serious cases except that they require triage. More serious cases always bump less serious – always. Most, not all, serious cases arrive by ambulance and thus have a beginning diagnosis and often beginning treatment already.
The problem, and there needs to be more debate and research as to what the actual problem is, is complex and not easily solved.
GP superclinics will not solve it what ever it is.
Fxh, while I’d agree that there are underlying problems that are not being foregrounded, I’m not so pessimistic about the potential of super clinics to provide some evidence about whether “new models of care” work in the generalised primary health care context. Indeed, in a sense, some of the ones under the auspices of universities are envisaged to be “natural experiments”.
I think it would be fascinating to understand *why* there’s so much of a behavioural disposition to seeing hospitals as a primary care option. I suspect it has some historical legacies in that in many instances prior to Medicare they were a free or low cost option. I also think issues to do with bulk billing (perceptions included) and a range of other factors which shape patient perceptions of care options are at play.
If you’re aware of any research on this, I’d be fascinated to see it.
One of my problems with the superclinics is is the lack of planning on a population level, no consultation at all withe the states or existing planners or providers, and the “whiteboard” method of implementation.
My other problem is that I’m in Victoria where they are solving problems according to Canberra understanding of other states.
We already have a statewide network of integrated community health services and planning and departmental support where GPs and other professionals work in local communities and with “private” GPs and other clinicians and hospitals. Superclinics are just cannibalizing staff, energy, time and capital funds.
The “why” of some, and its only some, people preferring hospitals has been the subject of numerous theories – hardly anyone – except a part of the College of Emergency Physicians ( and even they have their own agenda) – can accept it as a given and deal with it.
I don’t have those bits of research on hand but many natural experiments have been carried out and ignored because they are inconvenient.
One large example is the Nurse On Call phone lines – all evaluations are either just happy sheets or show that despite the significant costs and diversion of nursing skills from useful work they have not relieved EDs at all. The WA evaluation showed that a few years ago but still we have that sort of phone “help” being implemented.
Fhx, for what it’s worth, I couldn’t agree more about the problems caused by proceeding in the face of the evidence, or on the basis of yay! evaluations. A lot of the propositions on which people proceed are at best ambiguous and at worst flatly wrong.
There’s a whole myth busting research agenda here, and we made some recommendations to a federal government agency accordingly.
For a start, it would be nice to recognise that not everything labeled as ‘innovation’ is necessarily good.