Primary care services are usually our first point of contact with the health system. Each year, about A$50 billion – nearly a third of all health expenditure – is spent on more than 400 million primary care services delivered by more than 90,000 providers. This includes GPs, pharmacists, dentists, podiatrists and maternal and child health nurses.
Although by world standards Australia has an extensive set of primary care services, the Grattan Institute’s new report, Mapping Primary Care, finds too many poorer Australians still can’t afford to go to a GP when they need to, or a dentist when they should.
Beyond the cost issues, Australia’s primary care system is fragmented and poorly coordinated, and is ripe for reform.
High out-of-pocket costs
About 4% of Australians delay seeing a GP because of cost. About 7% delay or do not fill their prescriptions.
About one-third of patients pay for GP services at least once a year, with an average out-of-pocket cost of around A$34. If a GP prescribes medication, non-concessional patients pay up to A$39.50. Together with the GP consultation, this quickly adds up to A$75 or more for those who are not bulk billed.
Out-of-pocket costs are higher again for allied health and specialist medical practitioners. On average, allied health practitioners charge A$40 to the patient and specialists A$75. About 8% of people delay seeing a specialist because of cost.
Cost is an even bigger problem for dental services. Around 18% of Australians delay seeing a dentist because of this. More than half of six-year-olds and one-third of adults have tooth decay.
Not surprisingly, out-of-pocket costs are a bigger problem for people on low incomes. One-quarter of those on the lowest incomes delay or do not see a dentist because of cost.
People who need to see a GP, allied health practitioner, dentist or specialist medical practitioner are less likely to do so if they live in a rural location, due to workforce shortages.
There are half as many GPs, 25% as many allied health services and 20% as many specialist medical services per person in remote rural areas as in major cities.
Compounding the problem, state government-funded primary care and specialist community services (including alcohol and drug, mental health and public dental services) often have capped budgets. When the budget runs out, people have to wait for services. People who need public dental services, for example, often wait a year or more.
About 20% of Australians have ongoing complex care needs and need services from GPs, specialists, pharmacists, nurses, allied health and home support.
GPs are often seen as the gatekeepers and coordinators of care, particularly for people with greater needs, such as a combination of chronic diseases like diabetes, arthritis, depression, cancer and heart disease.
People with late-stage diabetes, for example, often have heart disease, kidney disease and poor circulation in their hands and feet. They may need a combination of ongoing medication, dialysis, wound management and support at home.
Coordination should help people with complex needs navigate the healthcare system to get the right care at the right time. But only 60% of this group see GPs as their main care coordinator. Nearly one-third of people who saw three or more health professionals say they have no care coordinator.
Lack of coordination can lead to difficulties in communication and frustrating experiences for patients. If treatment for people with advanced diabetes is not well managed, for instance, they are more likely to have kidney failure, a heart attack or lose a foot or a leg through amputation.
Poor coordination often reduces the quality of care patients get and leads to treatment, including hospitalisation, that could be avoided.
Much of primary care is delivered by small, privately owned professional practices working independently of one another. They operate next to a range of relatively small non-government and state-run agencies providing primary care and specialist community services.
The Commonwealth government is meant to be responsible for managing primary care, but the states continue to have responsibility for a range of primary care and specialist community services.
The result is that responsibility for policy, planning, funding, data collection, organisation and management is fragmented, ineffective and inefficient.
Access and the integration and coordination of services for patients suffer as a result. In rural areas, poor policy and planning means patients have to travel long distances to see allied health professionals like physiotherapists or psychologists, or to see specialist medical practitioners like psychiatrists and dermatologists.
It’s time for the Commonwealth and state governments to negotiate a comprehensive national primary care policy framework to address the funding and organisational shortfalls.
We need a plan to provide better long-term care for the increasing number of older Australians who live with complex and chronic conditions, and to help keep populations healthy in the first place.