Health Context
Australia’s response to COVID-19 has been rapid, and largely successful. Our success owes a lot to our dedicated doctors and nurses, but equally, the Australian community.
There were already warning signs before COVID-19 that without reform, our health system was under strain and in danger of producing an inferior outcome for patients. A rapidly aging population1 has put our health system under unprecedented demand. People aged 65 and over represent 16 per cent of the population but account for 50 per cent of total admitted bed days2. Chronic disease and injury dominate the Australian health landscape, contributing nearly two-thirds of the overall burden of disease3. Obesity data suggest that 67 per cent of Australian adults and 25 per cent of children are obese or overweight. For Aboriginal and Torres Strait Islander peoples, these figures are even higher, at 74 per cent of adults and 38 per cent of children4. Chronic respiratory disease affects seven million Australians, impacting 33 per cent of Aboriginal and Torres Strait Islander peoples and 30 per cent of non-Indigenous people5. This complexity burden is increasing6, which has implications for the workforce and necessitates protection of appropriate training opportunities for medical practitioners.
Mental health represents an increasingly large proportion of the health system; 8.7 million (45 per cent) of Australian adults will experience a mental disorder in their lifetime7. Data suggest the rate of having a common mental disorder is 4.2 times higher for Aboriginal and Torres Strait Islander peoples than for the general population8. Many health professionals, including GPs, psychiatrists, and emergency physicians, are witnessing significant growth in the number of patients seeking treatment and support for their mental health. Due to decades of under-resourcing and under-staffing, public mental healthcare services were struggling to deliver accessible and high-quality care before the pandemic crisis.
Australians are waiting longer for public hospital elective surgery, with the median wait time before COVID-19 (2018-19) of 41 days, eight days longer than in 2008-09. It is our worst performance on this measure since 2001-029. Likewise, our public hospital emergency system access block continues to worsen, increasing emergency department overcrowding which is associated with increased mortality, morbidity and length of hospital stay10. The number of available hospital beds per 1,000 residents aged 65 years or older – an important measure of public hospital capacity – has also been in persistent decline for decades11.
Australia’s private health system is also facing challenges. Pre-COVID, from June 2015 to June 2020, private health insurance membership fell for 20 successive quarters. Like the broader population, the age of the insured population is increasing; while Australians aged 75 and older have increased their insurance membership by 3 per cent, 25-34 year olds have dropped a full 6 per cent, between 2015 and 2018. This creates a cycle of increasing insurance premiums as insurers seek to deal with the increased cost of care per policy holder. It creates a health system out of balance for everyone, with a dwindling funding pool12.
Australia has a maldistributed medical workforce. We have a chronic shortfall of doctors in rural and remote Australia, while more broadly some medical specialties have an oversupply, and some have an undersupply. We are training doctors at one of the highest rates in the world, but we have not identified the correct mechanisms or levers to direct the workforce where it is needed, particularly in rural and regional areas where the pressure on the public system is exacerbated by low rates of private health insurance and private practice.
General Practice is one specialty where training has been undersubscribed for three consecutive years. Australia’s GPs are a central component of our health system but the extent of successive funding reductions in General Practice and loss of focus on this critical, unique function they fulfill, has diminished the coordination of care and endangered outcomes for patients. Primary healthcare professionals control or influence approximately 80 per cent of healthcare costs, with 83 per cent of patients seeing a General Practitioner (GP) each year. Yet spending on General Practice accounts for only 8 per cent of total government health spending.13
In 2017-18, 7 per cent of all hospitalisations were due to 22 preventable conditions that could be managed by General Practice. This accounted for almost 3 million bed days14. The increased prevalence of chronic health conditions has greatly increased the demand for and cost of treatments15. But with sufficiently funded longer consult item numbers GPs could have the time and resources to spend with patients with complex conditions, which would deliver major improvements for the health system.
1 Australian Bureau of Statistics. Australian Demographic Statistics June 2018, Publication 3101, Table 7.
2 Australian Institute of Health and Welfare (2020) Admitted Patient Care 2018-19. Retrieved 22/01/2021 from: https://www.aihw.gov.au/reports-data/myhospitals/sectors/admitted-patients
3 Australian Institute of Health and Welfare (2019). Australian Burden of Disease Study: Impact and causes of illness and death in Australia 2015 - Summary report. Australian Burden of Disease Study series no. 18. Cat. no. BOD 21. Canberra: AIHW. Retrieved 21/01/2021 from: https://www.aihw.gov.au/reports/burden-of-disease/burden-disease-study-illness-death-2015/summary
4 Australian Institute of Health and Welfare (2019). Overweight and obesity: An interactive insight. Cat. no: PHE 251. Retrieved 19/11/2020 from: https://www.aihw.gov.au/reports/overweight-obesity/overweight-and-obesity-an-interactive-insight/data
5 Australian Institute of Health and Welfare (2020). Aboriginal and Torres Strait Islander Health Performance Framework Report 2020. Tier 1 - Health Status and Outcomes: 1.04 Respiratory Disease. Retrieved 12/01/2021 from: https://www.indigenoushpf.gov.au/measures/1-04-respiratory-disease/data#DataVisualisation
6 Australian Institute of Health and Welfare (2019). Australian Burden of Disease Study: Impact and causes of illness and death in Australia 2015 - Summary report. Australian Burden of Disease Study series no. 18. Cat. no. BOD 21. Canberra: AIHW. Retrieved 21/01/2021 from: https://www.aihw.gov.au/reports/burden-of-disease/burden-disease-study-illness-death-2015/summary
7 Australian Institute of Health and Welfare (2020). Mental Health Services in Australia. Retrieved 22/01/2021 from: https://www.aihw.gov.au/reports/mental-health-services/mental-health-services-in-australia/report-contents/summary
8 Nasir, B.F. et al (2018). Common mental disorders among Indigenous people living in regional, remote and metropolitan Australia: a cross-sectional study. BMJ Open 8(6), e020196. Doi: 10.1136/bmjopen-2017-020196
9 Australian Medical Association (2020). Public Hospital Report Card 2020. Retrieved 26/05/2021 from: https://ama.com.au/articles/ama-public-hospital-report-card-2020
10Mortality: Javidan, A.P., Hansen, K., Higginson, I., Jones, P., Petrie, D., Bonning, J., …& Lang, E. (2020). White Paper from the Emergency Department Crowding and Access Block Task Force. International Federation for Emergency Medicine. Retrieved 10/05/2021 from: https://www.ifem.cc/resources/white-paper-from-the-ifem-emergency-department-crowding-and-access-block-task-force-june-2020/; Paton, A., Mitra, B. & Considine, J. (2018). Longer time to transfer from the emergency department after bed request is associated with worse outcomes. Emergency Medicine Australasia 31(2), 211-215. Doi: doi.org/10.1111/1742-6723.13120; Sprivulis, P., Da Silva, J., Jacobs, I.G., Frazer, A.R.L. & Jelinek, G.A. (2006). The association between hospital overcrowding and mortality among patients admitted via Western Australian emergency departments. Medical Journal of Australia 184(5), 208-212. Doi: 10.5694/j.1326-5377.2006.tb00203.x
Morbidity: Pines, J., Pollack, C., Diercks, D., Chang, A.M., Shofer, F.S. & Hollander, J.E. (2009). The Association Between Emergency Department Crowding and Adverse Cardiovascular Outcomes in Patients with Chest Pain. Academic Emergency Medicine 16(7), 617-625. Doi: 10.1111/j.1553-2712.2009.00456.x; Bernstein, S., Aronsky, D., Duseja, R., Epstein, S., Handel, D., Hwang, U. …& Society for Academic Emergency Medicine, Emergency Department Crowding Taskforce. (2009). The Effect of Emergency Department Crowding on Clinically Oriented Outcomes. Academic Emergency Medicine 16(1), 1-10. Doi: 10.1111/j.1553-2712.2008.00295.x; Mullins, P.M., Pines, J.M. (2014). National ED crowding and hospital quality: results from the 2013 Hospital Compare data. The American Journal of Emergency Medicine 32(6), 634-639. Doi: 10.1016/j.ajem.2014.02.008; Innes, G., Sivilotti, M., Ovens, H., McLelland, K., Dukelow, A., Kwok, E., …& Chochinov, A. (2019). Emergency overcrowding and access block: A smaller problem than we think. Canadian Journal of Emergency Medicine 21(2), 177-185. Doi: 10.1017/cem.2018.446
Length of inpatient stay: Richardson, D.B. (2002). The access-block effect: relationship between delay to reaching an inpatient bed and inpatient length of stay. Medical Journal of Australia 177(9), 492-495; Liew, D., Liew, D. & Kennedy, M.P. (2003). Emergency department length of stay independently predicts excess inpatient length of stay. Medical Journal of Australia 179(10), 524-526. Doi: 10.5694/j.1326-5377.2003.tb05676.x
11 Australian Medical Association (2020). Public Hospital Report Card 2020. Retrieved 26/05/2021 from: https://ama.com.au/articles/ama-public-hospital-report-card-2020
12 Australian Medical Association (2020). AMA Prescription for Private Health. Retrieved 22/01/2021 from https://ama.com.au/articles/ama-prescription-private-health
13 Percentage of patients seeing a GP each year from: Australian Bureau of Statistics (2020). Patient Experiences in Australia: Summary of Findings, 2019-20. Retrieved 02/06/2021 from: https://www.abs.gov.au/statistics/health/health-services/patient-experiences-australia-summary-findings/latest-release; Government spend on General Practice as a proportion of total government health spend is an AMA calculation. GP spend taken from: Report on Government Services 2021 (2021). Part E Section 10, Primary and community health. Retrieved 02/06/2021 from: https://www.pc.gov.au/research/ongoing/report-on-government-services/2021/health/primary-and-community-health. Total government spend taken from: Australian Institute of Health and Welfare (2020). Australia’s health 2020: Data insights. Retrieved 02/06/2021 from: https://www.aihw.gov.au/getmedia/be95235d-fd4d-4824-9ade-34b7491dd66f/aihw-aus-231.pdf.aspx?inline=true
14 Australian Institute of Health and Welfare (2019). Potentially preventable hospitalisations in Australia by age groups and small geographic areas, 2017-18. Cat. no: HPF 36. Canberra: AIHW. Retrieved 19/05/2021 from: https://www.aihw.gov.au/reports/primary-health-care/potentially-preventable-hospitalisations/contents/overview
15 Frandsen, B.R., Joynt, K.E., Rebitzer, J.B. & Jha, A.K. (2015). Care fragmentation, quality, and costs among chronically ill patients. Am J Manag Care 21(5), 355–362. PMID: 26167702.