State and territory first ministers are again pressing national cabinet to consider health care reform as its top priority at the first meeting for 2023. We have heard this song before.
The first so-called national cabinet after the election of the Albanese government considered health care reform, and asked first secretaries to carry out a review of health funding and health arrangements, recognising that “our hospital system at the moment has people who should be looked after by their local GP, but [the] GPs [are] just unavailable”.
As far as I can tell the review has never been released, but the communique from the 30 September national cabinet meeting stated that “National Cabinet considered advice from First Secretaries on improving care pathways for patients and addressing pressures on the health and hospital system. First Ministers agreed to further work, with policy options to be considered in the context of each jurisdiction’s budget processes.”
I wrote at the time that any experienced bureaucrat would have recognised this language as the kiss of death for any attempt at systemic reform.
But here we are three months later, and state and territory first ministers are trying to breath life into the corpse. From their perspective health care reform is very simple: the Commonwealth government needs to stop people who could be dealt with by a GP from turning up in an emergency department. If only that could be achieved, the pressure on public hospitals would be reduced, staff would not be burnt out, elective surgery waiting lists could be reduced, and all would be well with the world.
As I wrote in an earlier article on this blog, there is very little reliable evidence about how big a problem “unnecessary” GP-type attendances at emergency departments is, nor what causes it. There is some evidence that people attend a hospital because they (correctly) believe a general practice does not have the capacity to provide the diagnostic services needed for a one-stop shop for their particular health problem.
Beyond that, the evidence suggests that some people go to an emergency department rather than a hospital because hospital services are free and there are fewer and fewer bulk-billing GPs, and some people go to a hospital because they cannot find a timely appointment at a general practice – or, indeed, because they cannot find a general practice that will accept them as a new patient.
The AMA and the Royal Australian College of General Practitioners are arguing strongly that the cause of the problem is the low level of the MBS benefit means GPs can no longer afford to bulk-bill. Double the benefit level – at a cost of about $10 billion, 80 per cent of which will go to services that are still bulk-billed – and the problem will be solved. GPs will be able to resume bulk-billing, and those doctors that have left the profession will return.
While this solution may address the shortage of bulk-billed services, it will not do much to address the wider issue of a shortage of GPs to provide services. There is no evidence of a large pool of former GPs itching to return to practice if only the pay was higher.
A recent article on this blog by Professor Peter Brooks suggested that graduating doctors are not pursuing careers in general practice because of the poor financial rewards compared with other branches of medicine. If this is true, reducing the disparity in earnings by increasing GP benefits may eventually address the shortfall, once a new generation of students graduate from medical school and complete their post-graduate training over the next ten to twenty years. It will not address the immediate problem faced by states and territories – or the problem faced by more and more people of simply finding an appointment with a GP.
Before the May election Labor promised to allocate $750 million ($250 million annually from 2023-24) to “strengthening Medicare”, and after the election new Health Minister Mark Butler established a Strengthening Medicare Taskforce to report by the end of 2022 on how to spend it.
The minutes of the Taskforce include all the politically correct sentiments about increasing access to equitable and affordable primary care, encouraging multidisciplinary care, modernising primary care through data and digital reform, and supporting organisational and cultural change in the primary care sector. While we will need to wait for the final report to find out what concrete steps the Taskforce recommended, a budget of $250 million (about $35,000 per practice, or under $10 per person) won’t buy much.
The states and territories should not be holding their breath waiting for any changes flowing from this process to solve the emergency department problem. If they are really concerned about the issue, they need to be part of the solution.
NSW and Victoria are establishing priority primary care centres to “help ease pressure on emergency departments, give people faster care for urgent but non-critical conditions [such as mild infections, fractures and burns] and free up critical resources for patients with more serious needs”. These centres are akin to the Urgent Care Clinics the Commonwealth government is promising to establish during 2023, and the Walk-in Centres operated for some years by the ACT government.
As long as these centres adopt models of care that make full use of the scope of practice of non-medical health professionals, and do not simply exacerbate the GP shortage, they will help to ease the demand on emergency departments. National cabinet could agree to fund them through the National Health Reform Agreement on a 50:50 cost-shared basis, encouraging other states to adopt the model.
There is consensus among health commentators that the provision of primary health care in Australia needs to be reformed. Doing it properly won’t be quick, it won’t be easy, and it won’t be cheap. State and territory first ministers are deluding themselves if they think a few discussions with the Prime Minister will do the trick.
You may also be interested to read John Menadue’s article on Medicare Reform.
• 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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