Australia doesn’t have a health system. We have a maze of poorly connected health services which barely manage to work together to provide health care of extremely variable quality depending on many competing variables such as income, geography, ethnicity, culture, and type of illness. In addition, politicians generally do not link health outcomes to other crucial factors in our lives, the social determinants of health, the conditions in which people are born, grow, live, work and age. 

This pandemic brings these issues into sharp focus.

Consider the divisions in health service funding. The Federal Government funds doctors and some allied health; funds private hospitals through the Private Health Insurance (PHI) rebate, the Pharmaceutical Benefits Scheme, and Medicare rebates for doctors’ services; and funds Primary Health Networks (PHNs). The State and Territory Governments fund most non-doctor delivered community health care. Both levels of government share the funding of public hospitals. Individuals fund 17% of the total.

These separate funding roles lead to endless blaming battles as each player attempts to shift responsibility to the other. ‘Not my problem’ is the catchcry as patients suffer as a result of the inadequately funded and poorly co-ordinated care. The hospital/primary care divide continues to the detriment of patients as the federally funded GPs and the state run hospitals fail to work together. ‘Not my problem’ they both say, or, at best they work in such an inefficient way the patient is no better off. A classic example of this inefficiency is My Health Record used by only a few percent of doctors.

When a pandemic hits ‘Not my problem’ is not an answer. When it was clear that a global response was needed, our public health teams very quickly became more co-ordinated in rolling out the advice and the public health response. But the response also depended on individual front-line workers: GPs, nurses, practice staff, community health workers, and hospital staff, to work together to put the response in place.

Despite PHNs being charged with integrating care, GPs were often making their first contact with their local PHN to get Personal Protective Equipment (PPE). Some publicly subsidised private hospitals continued to use vital PPEs for elective surgery whilst others were threatening to close for financial reasons despite the real possibility their beds, staff, and equipment might be needed if infection numbers rocketed. Instead they won a $1.3 billion pay-check from taxpayers before it was clear they would even be needed.

Imagine if instead of using public taxpayer funds to increase the capacity of private hospitals over the last 20 years, we had instead put that money into public hospitals.  Sixty percent of elective surgery in now done privately. If most of that was being done in an enlarged public system, we would have a huge increase in bed and ICU capacity easily accessible without any need to pay more money to the private hospital industry.

Now is the time to consider an independent single funder for health care tasked with funding and integrating prevention, emergency services, primary health care including dental care, and hospital services.

Such an organisation must have a remit to fund services which can be demonstrated are effective and which are integrated with other services. As discussed previously on this blog, implementing this reform is a long-term project. It could start with controlling all new funding and gathering the data required to establish services based on need across the country and across the health service spectrum.

In addition we must address the social determinants of health, the importance of which has been so well exposed by this pandemic. People need an income to survive. They need shelter, protection from violence, social support and ongoing education. Too often the political focus has been an indiscriminate obsession with jobs. Now we see a realisation that jobs are only a part of the answer. If there are no jobs, an income is still required. If the job is unstable and insecure, or too demanding, support is required. If there is a job but children need looking after, childcare needs to be accessible.

Hence, we see Job Seeker, Job Keeper, free childcare, and a boost to welfare recipients. How much easier would it have been if we had had a basic income guarantee (BIG) about which I have written previously? No Centrelink queues (with or without physical distancing). No hours on the phone trying to contact Centrelink. No days or weeks waiting for the phone call from Centrelink. No demeaning experience of trying to interact with an organisation with such a focus on stopping rorting (whilst politicians receive slaps on the wrist for their financial rorts). Even with a BIG, huge changes would still have been required. It would however, have been much simpler, faster and less traumatic for all involved.

Whilst these various financial supports come from the conservative side with support from across the political spectrum, the pandemic has brought to the fore a realisation that a strong economy depends on having a healthy community. Moving to a post pandemic world, one hopes it is more widely appreciated that the healthier the population, the stronger the economy will be.

It is reassuring that politicians have sought out and accepted scientific advice on how to address the current health crisis. A key lesson to be taken from this response is the importance of evidence and science and the need for greater acceptance of the science of climate change which has the capacity to wreak even more havoc to both our health and our economy over time than this pandemic.

Hopefully, we will not be going back to a world where welfare recipients are demonised, job seekers are punished, and vulnerable people with a poor education, a mental illness, a drug addiction, or any number of other life challenging conditions/situations are regarded as lazy useless sub-humans.

It is time to move to a progressive, kinder, caring society which sees every person as valuable, which maximises everyone’s very variable capacity to contribute to society, and which enables rather than hinders the integration of our most vulnerable brothers and sisters.

Jobs need to be secure, not just any job. Income needs to be adequate, not held low in an unsubstantiated belief that that gets people working again in a productive way. Income and wealth disparities need to be reduced. We need to recognise the stark correlation between health and social problems and income (see slide: Health and social problems worse in more unequal countries).

As we manage our way through this crisis, it is time to think about an integrated, comprehensive, equitable health system. It would be good for the economy. Further, it is time to look at restructuring our society to recognise and address those factors outside the health system which affect health and therefore affect our economy and our individual well-being.

Prescription co-payments are imposed by the Federal Government for subsidised drugs. Australians pay $1.6 billion a year in co-payments. Why do we continue to have financial barriers to accessing these drugs?

Co-payments are $7.30 or $30 per prescription for Pensioners and Health Care Card Holders or the remainder respectively. Scotland, Wales, and Northern Ireland abolished prescription co-payments in 2011. New Zealand has just abolished co-payments in July 2023.

Purpose of Co-payments

Co-payments in general are designed to reduce inappropriate use and to generate income. Some also believe that without co-payments the consumer will not value the product appropriately. In terms of medical care that sad view of human nature would appear to contradict my reality of many gifts and thanks from my bulk billed patients. Humans value good service. They value prescriptions which help.

Determining appropriate use of prescription drugs is the task of the prescriber, not the patient. Arguments for co-payments to reduce inappropriate use are nonsense.

Co-payments are taxes, levied on those unfortunate enough to need prescription drugs. People do not choose illnesses. One must ask if the purpose of co-payments is therefore also to punish the sick?

Health and Social Impacts of Co-payments

Prescription drugs are approved for listing on the PBS because they have been shown to save lives and/or reduce severity of illnesses. However, multiple studies show a reduction in use of medication with introduction or increase in co-payments. Repeated surveys over decades have reported that patients delay or do not fill prescriptions because of costs. Half a million people delayed or did not fill a prescription in 2021 according the Australian Bureau of Statistics Patient Experience Survey. The largest effects are in those living in areas of low socio-economic status, the elderly, those with long term health conditions, and females. There are widespread reports from doctors that their patients are reducing the dose or taking the drug every second day to save money.

It is well established that mortality and morbidity correlate with income, socio-economic status, and postcode. Access to health care probably accounts for 20% of the differences in life expectancy in first world countries. Socio-economic status accounts for most of the rest. Cost barriers are either met by decreased usage of life saving drugs or forcing the most vulnerable to pay co-payments and forgo spending on other basics in their lives which contribute to improved socio-economic status.

Studies of the direct effect of prescription co-payments on health show for example, improved compliance with taking heart medication if drugs are free, increased adverse events after the introduction of co-payments, and most recently a study in New Zealand showed decreased hospitalisation rates across a variety of medical conditions following the removal of co-payments for a selected group.

Economic Impact of Co-payments

An inflation adjusted figure from the Australian Institute of Health and Welfare 2012 data indicates that the day cost of a public hospital admission in 2013 is $1300. The Grattan Institute estimates there are 750,000 potentially preventable hospital admissions adding up to three million unnecessary days in hospital per year . Most of these are due to inadequate primary health care which includes financial barriers to access as well as adverse socio-economic factors. The government would only have to see a reduction of 185,0000 admissions across Australia to have easily saved the estimated $1.2 billion cost of abolishing all co-payments. Whilst the causes of these preventable admissions are multiple, medication compliance is likely to be a significant part of the problem. Improving compliance by abolishing co-payments will save money and reduce the net cost. It might even be budget neutral.

Thus, we have both an ethical and an economic argument for abolishing co-payments.

Current Policy Initiatives

The current Federal Government has done well with respect to reducing cost barriers to accessing prescription drugs. It implemented a reduction in the general co-payment from $42 to $30 in January.

It has since taken on one of the most powerful lobby groups in Australia, the Pharmacy Guild by extending prescription lengths from the usual month to two months. This halves the cost to patients for many drugs.

It has supported the concept of increased prescribing by pharmacists for some specific limited conditions, thus saving patients the challenge of finding and paying for an appointment to get a prescription. These changes combined will lead to a decrease in revenue from patients from $1.6 billion to about $1.2 billion.

It has maintained safety nets so that over a year there is a limit to how much one pays per prescription. But just because a safety net kicks in after a patient had spent $262 or $1563 (different depending on Health Care Card) on drugs for the year, this might not happen until May or October. It doesn’t help the budget in March or January.

What Now?

More should be done. The Federal Government updated its National Medicines Policy in February this year. The stated aims of the policy include that

All Australians have fair, timely, reliable, and affordable access to high-quality medicines and medicines services.

It’s time to align actual policy with the above. Co-payments continue to be a financial barrier to accessing lifesaving medication. Co-payments kill, lead to more hospitalisations, and waste money. It’s time to axe killer co-payments.

UK Health Minister Aneurin Bevan introduced the National Health Service (NHS) pointing out that “Illness is neither an indulgence for which people have to pay, nor an offence for which they should be penalised, but a misfortune the cost of which should be shared by the community.”

Advancing age brings with it infirmity and a much higher likelihood of ill health. People do not choose to become old and infirm.  

Whilst conservatives despise the sentiments expressed by Bevan, particularly the concept of sharing by the community, liberals do agree, but with very variable degrees of commitment.

Aged Care is a major concern. Recent discussion following the Royal Commission has been about what services should be provided, how to regulate quality, how to get appropriate workforce, and how to fund what is needed.

The main funding recommendations from the recently released Aged Care Taskforce report are means tested co-payments and a safety net to supplement ongoing government funding.

Examples of co-payments and safety nets.

The public hospital system provides first class hospital care to all and if it’s an emergency the care will be timely. If not, unacceptable wait times prevail. Public hospital care becomes a safety net. Those with means bypass the wait times and use the government subsidised private hospital system. Those without suffer.

Primary health care through GPs or other health providers is in theory accessible to all, except for the geographical inequities which have the greatest negative impacts on low-income earners in rural and remote locations. But even in the cities inequities abound.  Co-payments make a mockery of affordable access to care. The recently introduced increased rebates for pensioners, health care card holders (HCCH), and children does not mean they will be bulk-billed. It also leaves people just above the cut-off for an HCCH facing an average $40 co-payment per GP visit.

Visits to specialist physicians and surgeons regularly incur a $100 co-payment which sends many patients away and onto the years long waiting list at a public hospital.

A rebate subsidised psychology visit regularly costs $100 co-payment, well outside the affordability of an unemployed patient on sickness benefits, and a challenge to a low wage earner.

The above relate to voluntary co-payments applied by providers. Then there are government-imposed co-payments with safety nets. Prescription drugs are subject to co-payments of $7.30 per prescription for Pensioners and HCCHs and $30 per prescription for others. Despite the existence of a Safety Net, an estimated half a million people delayed or did not fill a prescription in 2021 according the Australian Bureau of Statistics Patient Experience Survey.

No Australian Government in recent history has delivered equity through a co-payment system. Equity in health has been defined by Starfield as ‘the absence of systematic and potentially remediable differences in one or more aspects of health across populations or population groups defined socially, economically, demographically, or geographically.’ The definition could be easily applied to Aged Care and education.

Conservatives are not interested in equity. Successive Labor Governments however, have also shown a lack of commitment. Many Labor politicians would describe themselves as social liberals. Perhaps this lack relates to the reality that equity is not at the heart of any form of liberalism. It is an optional extra, talked about by social liberals as an aspiration, but falling second to the priorities of the individual.

Problems with co-payments, fee-for-service.

Co-payments limit access to items of care. The size of the co-payment is at the whim of the provider or the Government. A Labor Government, led by Julia Gillard from the left faction, introduced a GP co-payment for economic reasons, knowing such payments would be inequitable. The vagaries of economic and political factors determine how much and who will pay.

To determine a co-payment, one needs an item of care. There are some situations where itemised care with appropriate caveats can help to determine appropriate payments. Itemised care, especially in primary health care and Aged Care, leads to a siloed approach, which is completely at odds with the complex care needs in Aged Care and chronic disease. It limits teamwork, including teamwork which involves the consumer/patient interaction with the provider team.

Problems with safety nets

Look at a net. It has holes in it. It sags. It has edges. One could regard the Aged Pension as a safety net. Imagine being a 70-year-old widow whose only work throughout life was low paid, and whose rental cost is 50% of her pension. She has rental assistance, another safety net. She lives below the poverty line.

The Safety Net for prescription drugs helps. But a 20-year-old couch surfer, living with a mental illness, doesn’t register for the net. Even if he did, it doesn’t cut in until he’s spent a certain amount. How does he afford his drugs until then?

The vagaries of economics and politics determine the level and quality of safety nets.

Conclusion

Firstly, when the more powerful and articulate in a community are not subject to the inadequate service provisions of health, Aged Care, and education because they buy their way past such inadequacies, their advocacy for improvements in the system for all is weakened. The safety net sags lower.

Secondly, to adapt Aneurin Bevan’s 1948 quote regarding introducing the NHS: “No society can legitimately call itself civilized if an elderly and infirm person is denied Aged Care because of lack of means”

Thirdly, inequity is entrenched with every introduction of a user pays, means tested co-payment system with safety nets. If Labor does not want inequity, the alternative is funding through an adequate progressive revised tax system.

Continue reading “Putting the mouth back into Medicare – DRS”

Health policies are out and there is little difference between the two major parties. The policies definitely help patients afford to see GPs and get medication. More GPs and more nurses will be trained. The Labor Government has signed off a hospital funding agreement with the States. It has opened more urgent care clinics. It has increased wages for aged care workers. It has funded women’s health issues better. It is paying GP registrars better (but not as well as hospital registrars). It has promised extra funding for mental health but it’s not in the budget so when will it happen? However, all these all these changes are band-aids or catch-ups. Most should have been done long ago.

What’s Missing?

Reform

To date all that has happened is that funding has increased to cope better with demand. Almost nothing has been done to address new ways of funding. Forty years ago, when a patient went to a doctor, he/she was given treatment perhaps sent to a hospital or private specialist. Health care has changed and it’s as if many politicians haven’t realised.  The epidemic of chronic disease is not best managed the old way. Prevention is important but once disease occurs, patients need, physiotherapy, podiatry, psychology, education and a range of other care. None of these policies are about comprehensive care. None shake the flawed model of paying for an item of service (like a consultation) with its inevitable consequences of inadequate time for the service and unjustified, indeed often unconscionable co-payments of $80-300.

The mouth continues to be ignored even as the Minister Mark Butler admits it is part of the body and just signals a long-term intention to address dental care.

Taxes prop up the private hospital system both directly and through the private health insurance rebate ($9+ billion+/year). We are told we need the private hospitals. It’s true but only because we won’t fund public hospitals adequately.

Nothing much is suggested for mental health although being more able to afford to see a GP will help, and the recent promise of extra funding (when it happens) is welcome.

Whilst a usable My Health Record would be of huge importance to improving quality of care, Mark Butler is recently quoted in The Saturday Paper, saying,

“So, we still have a pretty antiquated My Health Record system that we’re in the process of modernising”

What Has Been Considered?

In 2022-3 Butler chaired the Strengthening Medicare Taskforce which even included conservative groups like the Australian Medical Association. It provided general recommendations including

Support general practice in management of complex chronic disease through blended funding models integrated with fee-for-service, with funding for longer consultations and incentives that better promote quality bundles of care for people who need it most.

Subsequently an Expert Advisory Panel chaired by First Assistant Secretary Mark Roddam performed a Review of General Practice Incentives. Recommendations included:

• Voluntary Patient Enrolment. This means patients commit to a general practice and should expect their needs will have some priority over unenrolled patients. This has been implemented.

• A Baseline Practice Payment, adjusted for patient needs, socio-economic status and location. This payment is intended to be the basis for a major change in the manner of funding general practice. It is a move away from the current model of paying fees for single services. This change in the funding mix is designed to facilitate the comprehensive, integrated primary health care which is now needed because the complexity of illnesses and the proliferation of multiple types of treatment requires such care.

• An Independent primary care pricing authority to set remuneration without the influence of the politics of the day or the election campaign.

To date, and presumably until next years’ May budget, nothing has or will happen with respect to the above genuine reform and the many other recommendations from the Panels.

What has not been considered but needs to be?

The Private Health Insurance rebate which costs taxpayers over $9 billion a year could be reduced rapidly and directed to public hospitals. Evidence suggests that PHI enrolment is relatively insensitive to price rises.

Access to non-GP specialists needs to be improved. The Commonwealth could fund hospitals to employ more specialists and could set up salaried specialists in community settings. Aboriginal Community Controlled Health Services, and Aged Care facilities are ideal (e.g. a session a week for a geriatrician). These specialists would then compete with private specialists many of whom charge unaffordable co-payments. Currently, these co-payments force patients to go to public hospitals where they often wait for years to be seen. This would change.

Getting the funding models right will be a challenge. That, however, is what reform is about.

Labor considered some kind of Australian Health Reform Commission in 2019. That needs to be reconsidered but with a much more ambitious brief. Such a commission needs to be independent of all governments, and lobbyists such as health care provider organisations, the Pharmacy Guild, and the pharmaceutical industry It’s first task would be an assessment of health care needs across the nation. It would then distribute funding to those organisations which provide care, including state governments, regional hospital networks, primary health care networks, and primary health care practices. The funding would come from both State and Commonwealth Governments and be pooled for distribution. This would put an end to the farcical and incredibly wasteful cost shifting and ‘blame game’.

The Commonwealth charges people for medications approved by the Pharmaceutical Benefits Scheme for subsidy. This approval is based on evidence that the drugs either improve quality of life or save lives and are cost-effective. These PBS copayments, although reduced, are a tax on illness, an impost on those in the community unlucky enough to be afflicted by illness. That is simply not fair. But worse than that it also stops patients taking prescribed medication, as numerous studies have shown. That means patients suffer more and/or die earlier because of government policy. Scotland, Wales, and more recently New Zealand have eliminated these unfair taxes. It’s time we did too.

Dental care needs to be funded like care for any other part of the body. This needs to be done within the new model of funding rather than simply putting dental into the flawed fee-for-service model.

We go to this election with some significant reform ideas about health care from Labor, but no commitment to implementation. There are no stated ideas for meaningful reform from the Coalition.  The stated policies between the two major parties are similar. The Greens and Teals are way ahead on all of this, so perhaps in this as in other areas, we should be hoping for a minority Labor government.

The Social Determinants of Health (SDOH) are the conditions in which we work, live, and play. We, as a society, choose these conditions and/or choose not to change them. They play at least as important a role in health outcomes as access to care.

Climate Change

Most now don’t disagree that climate change is happening, and humans are a major contributor. The harmful effects on health in the next 30 years are likely to be major. There will be changes in the distribution of various known infectious diseases as well as the potential for the evolution of newer diseases in the ecological disruption which is inevitable as we head to a hotter planet

.We already see the destructive effect of changing weather patterns at home and across the world. Australians are dying in these disasters and will continue to do. Unexpected heat is killing people across continents.

The worldwide disruptions to life in areas affected by rising sea levels, weather changes, and climate related ‘natural’ disasters will have implications for Australia as we see large population upheavals across the world and increasingly desperate battles for basic resources such as food and water, let alone a stable house in a stable community.

We are making very slow progress in the amount of greenhouse gases we emit in Australia. Most of the improvement we have seen towards achieving our Paris Agreement commitments have been achieved through a reduction in land clearing from a peak in 2005, which is the baseline for the Paris targets.

However, we export fossil fuels whose carbon (our carbon) goes into the atmosphere, and we ignore that figure in our policies. Twice as much CO2 is emitted by burning these fossil fuels as we emit in Australia. We intend to increase those exports.

These are the policies of the current Government, and the Coalition plans even more local emissions as it goes for more domestic gas.

Disaster will be the legacy we leave our grandchildren.

Education

There are clear links between education and health outcomes. Often it is indirect e.g. through earning capacity, but often it is much more direct as poorly educated people struggle to negotiate the complexities of understanding illness, prevention, and access to the health system.

The widely heralded Gonski recommendations of the Rudd era are yet to be fully implemented. Labor is finally making some changes to the huge disparity in schooling opportunities at the primary and secondary level. Universities are no longer places dedicated to learning. Learning is seen as a means to an end i.e. more money for the universities, rather than the prime purpose Access has been made a little easier by Labor but the new model of education as business permeates the sector and is getting worse rather than better.  The best and smartest rise above it. Others are left with wasted years.

Social Services

The Australian Council of Social Services reported in 2016 that in the decade to 2014, 13.3% of Australians and 17.4% of children lived below the poverty line. Pre-Covid, in the year 2019-20, the figures were 13.4% and 16.6%. This was and is despite the various assistance packages in place.

Jobseeker used to be 90% of the pension in 1990. It is now 69%. JobSeeker has been increased by Labor but remains below the poverty line. For the Coalition the justification is that the unemployed will not look for work if they are living at the poverty line. There is evidence from studies on basic income guarantee that even when given incomes slightly above the poverty line, the majority chase either jobs or education to get a better job. Labor ignores the fact that poverty is directly correlated with health outcomes.

It is worth noting that the link between income and health outcomes is not simply related to access to care. Groundbreaking research by Marmot in the 1960s looked at Whitehall public servants. He found a direct and continuous link between health outcomes for a range of diseases and position in the public service.  The rich did well. The middle earners did reasonably. The lowest paid (not in poverty) did worse. Similar work since has confirmed the link. Position combined with income suggests that a sense of control over one’s life is crucial to health outcomes irrespective of access.

Housing and Rental Affordability

Housing is a health issue. Health is worse in the homeless. It is worse in the poorly housed. Poor quality and siting of housing exposes people to environmental health risks, including pollution, noise, flooding, fire, and infectious diseases. This is a major issue for those on low and even middle incomes. It is multifactorial and both major parties have suggested policies, and Labor is implementing some policies which may help. Not considered at all is the possibility of a National Housing Commission which would build houses. There is nothing new in such a suggestion. In 1965 the authoritarian president of Singapore, Lee Kuan Yew, set up a Housing Commission and over 5 years housed 30% of its population in its apartment and by 1989, 80% were housed in government units. The UK did similarly postwar. It’s a suggestion former ACTU secretary Bill Kelty made on this blog recently. Instead, we leave ourselves at the mercy of private profit driven developers.  It does not appear to have been considered by the major parties.

Taxation

‘For one very rich man, there must be at least five hundred poor, and the affluence of the rich supposes the indigence of the poor’.   The Wealth of Nations

So said Adam Smith, a darling of capitalism. Conservative and liberals who take time to think do know that luck is so important in determining wealth and therefor health outcomes. Hard work is often but not always necessary. But few are prepared to redress the wealth imbalance as is clearly evidenced by our tax system which does a very modest job of redistribution. The reality of income and wealth inequality in our capitalist economy continues.  Most know what should be done. Labor lost the 2019 election proposing modest changes and have run from those changes ever since.

Our gradually less entrenched two party parliament will continue to fail to adequately address these issues. We can only hope that neither party is in total control after the election.

Imagine a 70-year-old woman barking her shin on her coffee table. She’s on blood thinners so bleeding is profuse. She goes to her general practice where she is enrolled. She’s immediately seen by a nurse who cleans the wound, and a nurse practitioner checks to see if it needs sutures. It doesn’t and she’s off home with a good dressing. Two days later she is reviewed, and it is clearly infected although it isn’t causing her pain. The nurse practitioner checks her file and prescribes the appropriate antibiotic and she’s home again. She pays nothing but her taxes.

A 70-year-old cyclist falls off his bike almost outside a medical clinic. His elbow is very painful. He is seen almost immediately by a paramedic who organises an Xray nearby and within an hour can tell the full story to one of the GPs who agrees that a non-urgent review by an orthopaedic surgeon is needed along with rest and analgesia prescribed by the paramedic. It takes two minutes of the GP’s time.

What I’m going to talk about I’ve divided into 4 parts. Firstly, what the main changes delivered by Labor in its last term, secondly what has been committed to in the recent budget and election campaign, thirdly what is being considered, and lastly what is ignored or largely ignored.

In Labor’s first term it was noted that bulk billing rates to see GPs were heading south and many patients were struggling to find a bulk billing GP. So, for children, pensioners, and health care card holders an incentive was already offered if the patient was bulk billed. It was only about $7 but increased as one moved away from cities. Labor tripled that incentive in the hope that doctors would not stop bulk billing their most financially disadvantaged patients.

In addition, Labor introduced Urgent Care Clinics which they placed in areas of disadvantage across Australia. All consultations are bulk billed. They are usually open 8am to 10pm. These clinics were not and are not designed to give ongoing care. They are mainly for issues which arise quickly, and the patient can’t easily get access to their usual GP. The stated aim of these clinics was to provide urgent care including afterhours care and to reduce the burden on public hospital Emergency Departments. They appear to have been popular. The Government to date has not revealed any sound data on whether they have had any impact on public hospital Emergency Departments, or on the relative costs of care in these clinics compared to a standard GP clinic. In other words, it is very unclear whether they are value for money.  There may be cheaper ways of addressing the issue. GPs are divided on what they think. Clearly, those GPs who are happy to work in them feel positive. Some GPs think they are an attack on general practice.

Patient enrolment was introduced. This is a scheme whereby a patient enrols with a particular GP or practice. It is voluntary but is aimed, at least in the long run, to improve continuity of care.  There are small financial benefits for patients and practices.

Labor promised to reduce the price of prescription drugs. That promise came prior to the election and interestingly it was made to match an identical promise by Scott Morrison in that election campaign. The copayment was reduced from $42 to $30. The concession copayment was not reduced.  The next prescription drug change was to fund a 2-month supply of many of the more commonly used drugs. Most prescriptions have been for an amount that lasts for about a month if taking a standard dose. Making it a 2-month supply for the same price means it lasts longer, and the patient doesn’t need to get so many repeats. As many of you would know, many doctors require either an appointment or a special fee to give a new script.

Labor introduced some significant improvements in Aged Care. They specified minimum staffing levels and increased the pay of many of the staff. They started the process of working out how to better fund and supervise Aged Care facilities.

Home Care packages for the Aged have been evolving for decades. They are designed to enable people to continue living at home for as long as possible. There are 4 levels, gradually increasing how much care is provided. They are becoming increasingly needed as the population ages. Over the 2 years to March 2024 there was an increase from 215000 to 284,000 packages in operation. That’s a 30% increase. The trouble is that demand is outstripping supply by a long way. There are at least 70,000 on the waiting list and that number is increasing by about 30,000. In 2024 Labor funded an extra 24,000, i.e. it wasn’t keeping up with demand. Waiting times inevitably increased. The standard wait time is about 9 months, longer if it is a higher level.

So, that’s a summary of the main changes in health care in their first term back at the helm. What have they promised this year?

Firstly, that bulk billing incentive that was introduced for children, pensioners, and healthcare card holders will now be extended to all patients who are bulk billed and in addition a practise which bulk bills everyone will receive a 12.5% increase over all rebate items. This means that in a practise where the copayment is about $35 it works out that if they bulk bill everyone, they will break even so this is a clear encouragement to bulk bill everyone for those wanting to bulk bill, but feeling a small copayment has become necessary.

Secondly there are even more urgent care clinics funded.

Thirdly, there is a further incentive to enrol patients in that the bulk billing incentive will apply to longer consultations by telephone or telehealth.

The requirement to have a care plan to access allied health has been removed. It has been observed that many care plans are done without any regular follow up or review of the plan. To increase the reviewing of the care plan the payment for doing one has doubled.

All these changes are making access to GPs somewhat easier and more affordable. Some of the changes will increase the income of GPs.

Every five years since Medicare was introduced the state and federal governments work out an arrangement whereby the federal government funds partly funds public hospitals. Initially for the first decade or so this tended to be a 50/50 split. Under the Howard government the proportion of funding that came from the federal government decline to about 42%. Under the Gillard government there was an arrangement for that to be very gradually increased. This year this agreement was renegotiated but the Federal Government did not agree to a five-year plan. It appears it is awaiting the politics of funding of the NDIS. The Federal Government is passing back to the states some responsibilities that have belonged with the NDIS previously. That’s politics. However, the federal government has promised to fund public hospitals next year, 2026 more than they’re doing currently and they have also allowed for increased use of public hospitals. Previously if a public hospital increased its work throughput by 10% the Federal Government only contributed 6.5%. So, an increased demand was not being met by the federal government. That cap has been abolished. The Prime Minister has indicated a desire to increase the proportion of funding to 45% by 2030 but that’s a long way away.

Despite the figures I mentioned earlier about home care packages where demand is currently outstripping supply, there was no commitment to increasing home care packages in this year’s budget.

So, having inherited a health system structured to deal with healthcare 40 years ago labour has in its first term back applied some very large and welcome band aids but has not introduced any significant structural reforms to cope with the epidemic of chronic disease, and the emergence of increasing technological solutions to healthcare problems.

There are however plans the details of which has not been released. One of the early actions of health minister Butler in his first term was to convene a Strengthening Medicare task force. This task force comprised academics and most of the major players in publicly funded primary healthcare i.e. general practice, including the conservative Australian Medical Association. Its report recommended major changes in how primary healthcare should be funded and organised. Over the last two and a half years various subcommittees have met to take the recommendations further and turn them into policy.

One committee, chaired by a senior public servant, recommended that there should be a fundamental change in how general practices are funded. Currently 90% of the Medicare income is through fee for service, i.e. you have a consultation, and the practice gets paid through a Medicare rebate. The change suggested is that by 2030 this would reduce to 60% by giving block payments of some sort for various services provided. This would include all the allied health the practice provides. The idea behind this change is to directly fund care from professionals other than the doctor, a huge need when dealing with chronic disease. It would also allow individual practices to employ those professionals which they identify are most needed. This is such a major change that will take years for it to be implemented, particularly as the Government needs and wants to bring general practices with it rather than impose change upon them

There has been a significant ongoing investment in digital technology including trying to make My Health Record much more useful. It would be so much easier to provide better care to patients if communication between health professionals was easy. That is the aim of My Health Record, but the Minister is on record as saying it currently is not very good, and we know that. Once again this is part of a long-term major change to how things are done. One legislative step has been made in 2024 to force publicly funded providers to upload data to the record, in this case all pathology results. Radiology will probably be next in the firing line.

What is being ignored and should be addressed. The Minister has stated that dental health is too big an issue to address now. There is no appetite for setting up a National Health Commission independent of all the stakeholders including governments, tasked with determining need and distributing all funding according to need. This would kill off the regular excuses for inadequate funding, ‘that’s not our responsibility’. Patients are still having to pay copayments for prescription medicines, despite long standing evidence that that means some patients cannot afford them and are suffering and probably dying because of those payments. New Zealand recently abolished such payment. Wales and Scotland did that years ago.

Lastly, there is that huge issue of the social determinants of health, the conditions in which we work, live, and play. In a wealthy country like ours these factors are possibly even more important to health outcomes than affordable access to care. Thus, adequate home care packages address these very well. But, whilst ever we have JobSeeker payments below the poverty line we know we are not committing to a fair go. And whilst 13% of Australians live on incomes below the poverty line, we know that our taxation and welfare systems are grossly inadequate. Poverty kills.

The Government has plans for Medicare. It clearly sees that the changes are huge and therefore difficult, but it also sees now that it probably has two terms in which to pursue its agenda which I hope will lead to a better and fairer Medicare.

It is time to think more broadly about security than the narrow military concept about which there is endless debate. Security for individuals and communities does not depend on a nuclear powered and nuclear armed submarine. We are humans and human security is about many things including health, and it is health which our organisation, the Doctors Reform Society, has focused on for the last 50 years.

Specifically regarding health, there are two key principles we support.

Firstly, there is no cost access to timely, culturally appropriate health services (including dentistry and mental health) for everyone.

Secondly there is the requirement that individuals and communities have the capacity to make optimal use of that access. For that to happen, people need to feel a sense of control over their lives. For that to happen, the social determinants of health, the conditions in which we work, live, and play, must be optimized.

These two principles are intertwined. One without the other embeds insecurity. Indeed, a sense of control over one’s life and those around is perhaps another way of saying Human Security, at least for the individual.

People who are sick and cannot afford or cannot access appropriate health care feel insecure. Fixing that issue is not hard if there is political will. In Australia that does not currently exist. In the Whitlam era there were visionaries who believed in equitable access. There are few such people now in positions of political power. The rise of neoliberalism sees a country as a market and every government use of funds as a cost. Our society is firstly a community or should be. Market forces are useful in some sectors, but health care is not a market. If we see our society as a community, funding health care is an investment. Healthy individuals can contribute to the society. Failing to help unhealthy people (because of perceived cost) is the real drain on the community and the economy, with the most acute affects felt by families and individuals.

The funding model needs to be radically altered. Public hospitals provide excellent health care to anyone, so long as they can wait long enough. It is a political decision to make public patients wait while private ones jump the queue and seek private care, heavily funded by taxes. Getting access to health care in the community is completely different. It is a hodgepodge of up-front fees, caps, gaps and disease specific funding plans. Out of pocket costs are frequently unaffordable, and the distribution of doctors compared to need is appalling. A new way of funding would be to have salaried doctors everywhere. Doctors survive in public hospitals on salaries. Why not salaried health care providers across the country? That requires firstly a major consideration of the principles of Human Security, as well as political will in order to make such a big change.

But providing that access and affordability is just the first step in ensuring a feeling of security, a feeling of control over one’s life. Access is not enough. Countries which have much more equitable access to health care than we do (on equitable access we rate 9^th out of 10 OECD countries, just ahead of the USA), don’t necessarily have good health outcomes.

The reason: social determinants of health, the conditions in which we live, work, and play. This was beautifully illustrated in a study of English public servants in the 1980s. Despite a secure job in the same sector, and equitable access to health care through the NHS, mortality and morbidity from almost every cause followed a gradient. At the top, people felt in control, secure, and well able to make best use of the access and advice they were given, using the NHS. At the bottom, on a basic wage people felt insecure, not feeling able to make best use of what was available. And the middle-income earners were in the middle, in terms of health outcomes and sense of control. It is a gradient.

Providing that sense of control over one’s life, that security, requires addressing poverty, educational opportunities, secure housing, protection from violence, effects of climate change and many other social factors which impact different people’s lives. And when we talk about poverty, the evidence in richer countries is that it is relative poverty that counts. Thus, an entry level English public servant in the 1980s would not be seen as poor, but perceptions count when one is talking about security and control. The rich can do anything. The relatively poor base grade public servants cannot, they know it, they feel it, and they suffer, especially in a society with marked inequality.

In 1969 in his policy speech Gough Whitlam announced that “we propose a universal health scheme, based on the needs and means of families”. We would now say individuals rather than families. But he also said “We are all diminished as citizens when any of us are poor. Poverty is a national waste”.

Now our leaders of both major political parties are happy to leave the unemployed living below the poverty line, along with many others with poor paying jobs and rents which reduce their disposable incomes to poverty levels. Health goes out the door. Dental health never got in the door. Security is impossible.

We would like to see our policy makers taking responsibility for ensuring Human Security. To do that we need from them

1. the recognition that access to adequate health care is a basic human right.
2. a commitment to equity i.e. the opportunity for everyone to achieve their optimal capacity in life without impinging on others’ opportunities.

Only then might we see a move to recognition of Human Security rather than an obsession with geopolitical and military security.

First published: Tuesday, July 3, 2007

It’s tough losing a war of conquest. The historical record confirms that, in all times and places, defeated peoples whose land is seized do badly.

History gets written, and sometimes totally sanitised, by the victors. Despite this, Aboriginal health statistics–for instance a two-decade deficit in life expectancy–provide an objective and persistent reminder that something is very wrong.

I have many Aboriginal patients, and it’s been pleasing to hear good rhetoric on Aboriginal health from the newly-elected president of the Australian Medical Association. Admittedly, the good rhetoric isn’t surprising. Medical organisations tend to have good policies on anything–even if that occasionally seems close to nothing–that doesn’t conflict with the more self-centred concerns of their members.

It’s indisputable that, to solve Aboriginal health problems, more medical care is necessary. But, in itself, medical care is not sufficient.

Status is central to human communities. And, although contemporary societies might feature more upward and downward mobility than traditional ones, we still meander through life within boundaries largely determined before birth; and, all the time, we compare ourselves with others–both within and outside our community.

This is highly relevant to health. There’s compelling research evidence that it’s good for your health to feel in control of your life and to feel that you are respected. Many studies show that lower social status is associated with lower life expectancy, and that’s independent of risk factors like obesity and smoking. The greater the social disparity, the greater this effect.

Perhaps as a result, many people tend towards chronic insecurity. Not only are human pecking orders stressful, particularly if they’re grossly inegalitarian, but we live on a planet whose apex predator is a rapacious carnivore that’s easily moved to extreme violence. Who wouldn’t get nervous about that?

With this in mind, I have a question. Please treat it as a call to cognition, not a call to confrontation.

Would Aborigines feel better about themselves, and therefore have better health today, if their forebears had been more successful fighting Europeans?

Consider Aboriginal pride in Pemulwuy. He was a warrior of the Eora people, one-time owners of prime Sydney real estate–about 1800 square kilometres of it. Unfortunately, trespassers moved in and the neighbourhood got rough. Tit-for-tat slayings, or most likely an unequal struggle of several tits per tat, went on for years.

The bringers of civilisation to this dark land eventually killed him.
The stroppy native’s head was severed and dispatched to the motherland in spirits, presumably because the English lacked the skill to shrink it.

And, of course, over the next century or so, the invaders replicated similar victories over the locals right across the continent. Indigenous Australians–badly out-gunned and often out-numbered–lost the lot.

Tragically, many also lost the plot.

A human community’s pride and spirit rests on many things. Sadly, these include fighting effectively. It is hugely dispiriting to be easily defeated by invading forces.

Another source of pride is tool making, and this continent’s inhabitants paid dearly for their millennia of isolation. Woomeras and boomerangs remain brilliant innovations but the guns and metal of the invaders must surely have severely shaken the locals’ confidence in their abilities.

But, as previously noted, I’m not making a call to arms. That’s an ugly horse to back and, anyway, it bolted a couple of centuries ago.

Mahatma Gandhi, who admittedly had numbers on his side, demonstrated that there are more elegant ways to accrue power. The gains made by Aboriginal people–for instance recognition in the 1967 referendum and certain land rights–have not been through violence but through endurance and appeals to the rationality of powerful whites.

Unfortunately, rationality is not a strong point of our nation’s current leaders. The chances of significantly improving Aboriginal health are remote when many politicians are, in my opinion, too intellectually and morally bankrupt to even admit the blindingly obvious–no community willingly gives away its land and homes.

The pitifully inadequate funding of indigenous health programs needs to be fixed but this underfunding is just a symptom of the cause of poor Aboriginal health. A recent study in Arnhem Land pointed towards the underlying cause, when it demonstrated that Aboriginal communities that are connected with, and care for, their ancestral homelands have better health.

Indigenous Australians need to be accorded, and treated with, a respect that has been sadly lacking. Severely fractured human relationships can take years to repair but simply saying “sorry” is always a nice way to start.