Primary Health Care Reform in Australia - Report to Support Australia’s First National Primary Health Care Strategy

Element 1: Accessible, clinically and culturally appropriate, timely and affordable

Objective: All Australians have access to required primary health care services, which are clinically and culturally appropriate to their needs and circumstances, and are delivered in a timely and affordable manner.

Key Points

At the core of an effective and high performing health care system is good access to clinically appropriate services. Essentially this means being able to see the right health professional, at the right time, in the right place, and in a manner that is affordable and culturally appropriate.

While many Australians experience good access to primary health care services, there are a range of areas and populations facing significant access gaps. Of particular concern is that those individuals with high health needs or facing significant disadvantage most often experience difficulties in accessing necessary services.

These access gaps can be categorised to four broad groups, noting that some individuals experience a combination of issues across these categories:
  • Location and workforce availability: Where workforce availability restricts access to health services in a local area or where specialised service delivery arrangements are needed to support highly dispersed populations.
  • Service delivery: Where individuals requiring a range of services are prevented from accessing them as a result of poor integration across the health system and inflexible service delivery arrangements.
  • Affordability: Where individuals are unable and/or unwilling to access primary health care services due to their capacity to pay privately or meet out-of-pocket costs for subsidised services.
  • Specialised needs: Where individuals with specialised health needs and/or among disadvantaged and/or marginalised populations face physical or cultural barriers in accessing appropriate services.

Where are we now?

The population nationally averages 5.1 MBS subsidised GP visits per year47 and experience a high level of access to GPs with 80% of Australians visiting their GP at least once a year.48 However, primary health care is more than the provision of services by a GP through Medicare, and also includes specialists, nurses, pharmacists and other allied health workers, providing publicly and privately funded services.

Despite this level of access there is a proportion of the population who are unable to access primary health care services when and where they are needed.

Primary health care is also generally the entry and exit point to and from hospital care, in that patients who require hospital care for acute treatment are usually cared for in a primary health care setting before entering hospital and immediately after being discharged. This aspect of primary care can exacerbate the existing access issues, while also demanding a more organised response from the primary health care system.

Location and Workforce Availability

Workforce distribution is one of the major determinants affecting access, with estimates that 74% of Australia is currently considered to be experiencing health workforce shortage (affecting 59% of the population).49
  • While only 68% of the Australian population live in major cities, this is where the majority of Australian health professionals are located, including specialists (85%), dentists (81%), GPs (77%), allied health workers (77%) and pharmacists (76%).50
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Figure 5: Primary health care workforce by remoteness per 100,000 people, 2006


Figure 5: Primary health care workforce by remoteness per 100,000 people, 2006

Source: AIHW, Health and community services labour force, 2006

  • This workforce shortage in rural and remote areas is further compounded by the logistical challenges of servicing highly dispersed populations over wide and diverse geographical areas.
  • Workforce availability is also an issue in many outer metropolitan areas. For example, in examining the equity of access to general practice by remoteness the Family Medicine Research Centre at the University of Sydney estimated that for 2005-06, outer metropolitan areas were undersupplied by 1,303 GPs.51
  • The availability of specialists is also an issue for areas facing health workforce shortage. Increasingly specialists are playing a role in the delivery of primary health care services – particularly in managing transition arrangements between different care settings. They are also providing more services out-of-hospital which may have once been provided through the acute sector, which now need to be integrated and coordinated under a primary health care setting. At the same time, access to specialist services in rural and remote regions has been enhanced through the More Specialist Outreach Assistance Program visiting specialist arrangements.

The 2008 Report on the Audit of Health Workforce in Rural and Regional Australia52 and a review of rural programs examined the issues for rural and remote Australia and responded with a major package of initiatives in the 2009-10 Budget, which will improve the recruitment and retention of rural and remote doctors.53

Workforce availability is also a key factor in the provision of after-hours services by GPs. This can be particularly acute in rural areas where complementary health services may not be available.
  • Despite more than 80%54 of general practices having arrangements to provide after-hours care, many Australians report problems in accessing general practice services after hours. The Commonwealth Fund55 reported that 64% of adult Australians found it difficult or very difficult to access care on weeknights, weekends or holidays without going to a hospital emergency department.

The availability of established infrastructure may also act as an additional incentive to attract health providers to under-serviced areas. As such, governments are investing in the development of primary health care infrastructure. For example:
  • The National Rural and Remote Health Infrastructure Program (NRRHIP) provides opportunities for partnerships and multi-disciplinary approaches in delivering health care in rural and remote communities through access to funding for infrastructure.56
  • The positive response57 towards the Australian Government GP Super Clinics Program indicates that there is significant interest to improve the capacity of the primary health care sector through investment in capital infrastructure.
  • State and territory governments also provide capital infrastructure support through a range of initiatives improving access to primary health care, for example the South Australian GP Plus,58 NSW Health One, 59 and Queensland North Lakes60 initiatives.

A range of other workforce issues are discussed under Elements 8/9.

Nursing in the primary health care sector

As illustrated below in Figure 6, nurses have become increasingly involved in the delivery of primary health care services:
  • The Australian General Practice Network (AGPN) reported in 2007 that 58% of general practices employed one or more practice nurses.61
  • Nursing is one of the major features of community primary health care service delivery models.62
  • Nurses have the potential to improve workforce capacity, with claims that practices employing a nurse can see over 800 more patients per year.62
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Figure 6: Number of practice nurses and number of Medicare practice nurse claims





Source: PHCRIS and Medicare

The 2009-10 Federal Budget extended access to the MBS and PBS for nurse practitioners.64 While only a relatively small proportion of the total nursing workforce, this initiative represents a significant step forward in recognising the skills and expertise that nursing brings to the provision of primary health care services.

Allied health in the primary health care sector

Allied health professionals are also important to the provision of primary health care. However accessing these services is an issue for many patients.
  • Historically, the majority of allied health services (including psychologists, physiotherapists and dieticians) have been funded through state and territory government community health and outpatient clinics or through private arrangements (including private health insurance).
  • Over recent years, the Commonwealth has invested in supporting allied health through a number of targeted programs. For example, the Better Access initiative provides a range of Medicare services for eligible people with a diagnosed mental disorder (including services provided by GPs, psychiatrists, psychologists, social workers and occupational therapists). Since 2006, this program has been accessed by over 1.4 million patients,65 although it is estimated around 60% of those in the community with mental health issues are not accessing the services they need.66
  • The MBS also provides some direct funding to patients receiving allied health services. However in order to access these services an individual must have a chronic and complex condition, and be a patient of a GP who has prepared an Enhanced Primary Care (EPC) Management Plan.67 Unfortunately, not all GPs provide these types of services to all patients for whom there would be a benefit. For example, while 89% of GPs provide at least one care plan service a year, only 34% of GPs provide more than one care plan a week.68 MBS care planning arrangements are further discussed under Element 4.
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Service Delivery

For many individuals, the health system is complex and fragmented. For example, a patient may be required to access Medicare, a state-funded service and utilise their private health insurance for the treatment and management of one health condition. For many individuals, access to primary health services largely relies on factors including their health condition, geographical location, level of private insurance cover and ability to pay privately.

In many ways, this variety of funding mechanisms and associated lack of integration, coordination and collaboration has put the service delivery model ahead of the needs of the individual, in that it is the patient that often has to adapt to the way services are delivered, rather than service delivery models responding to the needs and circumstances of patients.

This is also true for health care providers – who are increasingly expected to navigate multiple health service purchasers implementing and modifying large numbers of new programs (with associated reporting and eligibility requirements) to provide the most effective and evidence-based services to a growing number of patients.

In addition to these issues of fragmentation and integration, the traditional organisation of health care, based on a clear divide between general practice medical care and more specialised care provided on referral by consultant physicians and specialists, is increasingly out of step with the needs of both patients and health professionals.

This is largely due to the fact that many patients now receive a mix of services provided out-of-hospital – including GPs (for ongoing primary health care), allied health, specialists or consultant physicians (as required for more specialised treatment). For example, a patient diagnosed with diabetes in general practice will (as their condition progresses) benefit from investigation and management of aspects of their condition from a variety of health professionals, including nursing professionals, diabetes educators, endocrinologists, podiatrists, urologists, dieticians, nephrologists, pharmacists, neurologists, and/or cardiologists. All of these services are being provided as part of primary health care, along with the patient's ongoing care as provided by their GP. However, the patient may not have the means to access all of these services, and in obtaining these services the providers themselves may be unaware of the full range of services the patient is accessing (risking duplication of effort).

Under current arrangements, matters such as access, location of services and availability of information about the patient's needs have historically tended to reflect the separation of different medical and health professions rather than the provision of integrated care. There is increasing recognition of the need for better integration of the services provided across the full spectrum of primary health care, including effective shared care arrangements between general practice, allied health and specialists.

The different service delivery and funding models between sectors, providers, and governments can act as a barrier to patients accessing services. Through greater integration and coordination of investment in primary health care, patients will have access to more efficient and effective services, and governments will achieve higher cost benefit outcomes. For example:
  • increased collaborative efforts between health purchasers, such as the co-located GP clinics program69 and the delivery of Medicare services to Aboriginal and Torres Strait Islander patients through the state-funded community health sector;70
  • ensuring that funding and service delivery models retain flexibility to take account and make best use of technological advances, such as the potential for telephone, email and internet technologies to play a role in providing access to primary health care services for some patients; and
  • integrating and coordinating the use of information tools, such as ensuring the use of Individual Electronic Health Records is consistent across care settings, jurisdictions and health professionals. Issues associated with eHealth are discussed in detail at Element 6.
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Affordability of services

Australians generally have good access to affordable health services – particularly those provided through general practice, community care and the hospital sector. However there are disparities across the country for different services and locations in accessibility of affordable primary health care services.
  • Nationally (in 2007-08), 79.2% of MBS-funded GP and practice nurse services were provided with no cost to the patient (or ‘bulk billed’).71 However, this is not the experience of every patient as there is significant regional disparity in accessing bulk billed primary care services. For example, regionally aggregated GP bulk billing rates vary from under 50% to almost 100%.71
  • In 2007-08, there were 23.2 million GP and practice nurse services charged above the schedule fee, incurring $480 million in out-of-pocket costs, an average of $20.11 per non-bulk billed service.73
  • 2007-08 bulk billing rate for MBS allied health services was 47.2% nationally, incurring $49 million in out-of-pocket costs, an average of $37.04 per non-bulk billed service they access.74 Individuals accessing non-MBS allied health services experience out-of-pocket costs (including services accessed through private health insurance) or face waiting lists in accessing services through the hospital sector.
  • 2007-08 bulk billing rates for specialist services provided out-of-hospital was 32.1% nationally, with out-of-pocket gaps averaging $44.91.75
  • Some of these out-of-pocket expenses are partially offset by the Medicare Safety Net,76 the Extended Medicare Safety Net77 and the net medical expenses tax offset.78
  • The ABS 2003–04 Household Expenditure Survey found that on average, for all households,79 $2,381 was spent annually on medical care and health expenses, which equated to 5.1% of total household expenditure. Spending was further broken down to health insurance ($918), health practitioner fees (GPs, specialists, dentists, etc, $746), pharmaceutical products ($599) and other spending ($118).80

These issues have a relatively high impact on the decisions of individuals in accessing health services. For example, the Commonwealth Fund survey 200781 found that in Australia 26% of adults said that in the last year they either had not filled a prescription or skipped doses, had a medical problem but did not visit the doctor or skipped a test, treatment or follow-up due to cost. This rose to 36% in the 2008 survey of adults with chronic conditions.

This is of particular concern when considering individuals from low-socioeconomic backgrounds. For example, the 2007-08 National Health Survey (NHS) reported that the most disadvantaged82 populations in Australia face a higher prevalence of health issues compared with less disadvantaged populations, as illustrated below.
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Table 5: Health conditions experienced by individuals from different socio-economic populations


Most disadvantaged %

Least disadvantaged %

Has arthritis

23.0

16.4

Has asthma

15.9

9.6

Has diabetes

7.0

3.3

Has heart, stroke and vascular diseases

9.3

4.5

Has mental and behavioural problems

18.9

13.1

Has profound or severe activity limitation

25.2

12.5

Has a sedentary lifestyle

46.7

24.4

Is overweight/obese

65.7

56.3

Source: Australian Bureau of Statistics, 4364.0 National Health Survey: Summary of Results, Australia, 2007-08 This poses particular challenges for the health sector in that the longer a health issue is undiagnosed or untreated, the higher the costs associated with eventual treatment. For example, while early interventions can reduce the risk of the onset of diabetes by up to 70%, the average health cost (direct plus indirect) for people with diabetes was $5,325 a year.[83 Furthermore, the cost for individuals with diabetes complications was 2.4 times higher than in people who were effectively managing their condition.81

Patients with specialised needs

Despite our overall strong health outcomes, there are disparities within the population which can be influenced by access to appropriate health services. This is particularly the case when individuals with the highest health needs also face poor access to primary health care services. These access barriers can generally be summarised under two main categories: physical and cultural barriers.

It is also important to note that one of the major roles fulfilled by primary health care is the provision of high quality family care, child-specific and ‘generic or routine’ health care services. It will be necessary to ensure good quality care to patients requiring these services while also providing additional emphasis on the provision of services to marginalised and disadvantaged populations, or disproportionately on disease-specific initiatives.

While this section focuses on a number of key areas and populations, it is recognised that these examples are not exhaustive. As such, it should be noted that discussion under this section is not intended to exclude any such group and that examples are merely illustrative.
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Physical Barriers

Patients in residential aged care
  • As noted earlier, Australia has an ageing population.
  • Some residents of aged care facilities may have difficulty in accessing primary health care services from a GP, with data reporting that almost 60% of Australian GPs do not actually provide any MBS services to these patients and that only 12% provide more than 100 services annually to such patients.85
  • Innovative solutions to improving access to primary health care services for these patients and avoiding hospitalisation are being developed across Australia. For example, preliminary research from Western Australia86 has identified that up to 32% of all transfers from residential aged care homes to a tertiary hospital emergency department are potentially avoidable if improved primary health care services were available. This has resulted in the provision of a WA Health-funded outreach nursing service which works closely with GPs servicing the area to provide acute care assessment and management with residents in their facility. Economic analysis indicates this service is providing significant cost savings to the hospital sector.

Patients dealing with disability
  • According to the 2003 ABS National Survey of Disability, Ageing and Carers, 3.9 million Australians, or 20% of the population, had a disability.87.
  • People with physical and intellectual disability often experience difficulty in accessing primary health care services.88 Data indicates that people with intellectual disability die prematurely and often have a number of unrecognised of poorly managed medical conditions as well as inadequate health promotion and disease prevention.89
  • Following de-institutionalisation, general practice has played a key role in the provision of health care to people with intellectual disability (which constitute about 2% of Australia’s population), but this care is often inadequate due to many contributing reasons.90

Cultural Barriers

Indigenous Australians
  • The health issues and access gaps associated with some Indigenous populations are well established, including that Aboriginal and Torres Strait Islander peoples have higher rates of chronic disease, more disability, and greater exposure to risk factors (such as smoking and alcohol misuse).91
  • All Australian governments have committed significant funding to improve Indigenous Australian health outcomes in response to the Closing the Gap Statement92 through the COAG National Healthcare Agreement – National Partnership Agreement on Closing the Gap in Indigenous Health Outcomes.93
  • Part of this commitment included a statement of intent to work together in achieving equity in health status and life expectancy between Aboriginal and Torres Strait Islander peoples and non-Indigenous Australians by the year 2030.94

Individuals from Culturally and Linguistically Diverse (CALD) backgrounds
  • Australia has one of the largest proportions of immigrant populations in the world.95
  • Although governments have produced a number of health resources in multiple languages, there is limited information in regard to the availability of translation services when a patient is visiting a doctor.
  • Under current Medicare arrangements,96 there is a provision for the medical practitioner and patient to use the services of a translator by accessing the Australian Government’s Translating and Interpreting Services (TIS) and the Doctors’ Priority Line:
    • The TIS only provides free services for non-English speaking people receiving Medicare rebateable services from a privately practising provider (or pharmacies dispensing PBS medications).
    • For ineligible individuals, the telephone translation costs range from $23.10 to $36.95 per 15 minutes which could act as a significant barrier for individuals, their families and carers seeking access to translated medical services.97
    • Furthermore, it might be reasonably assumed that the involvement of a translation service could add to the consultation time required and complexity associated with provision of a service. As such, a practitioner may choose not to provide such a service for the perceived risk of financial penalty and/or inappropriate claiming.
Other concerns for this population which are not necessarily resolved through the availability of translation services extend to safety and quality aspects, and the sensitivity, awareness and diversity of the primary health care workforce.
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What the submissions said

The limitations of our current system in dealing with the health care needs of special needs, marginalised and disadvantaged populations was a recurrent theme in submissions.

Patients with special needs require intense, time consuming care which is difficult to provide in a standard consultation under the present funding model.98Strategies put forward to address these issues included greater focus on cultural competencies in training and accreditation frameworks, enhanced use of interpreters and greater involvement of communities in health service development and greater resourcing for outreach and support services which could address the needs of specific high need population groups.

It is high time that all health professionals have specific training, education and professional development, within existing training structures, in cultural safety that fits within a broad framework of cultural respect. Such training must be mandated for all health professionals and service providers on the health, history and cultures of Aboriginal and Torres Strait Islander people. This demand is based not on geographical location of health professionals, service type or funding source, but on the need to recognise the significance of poor knowledge and the flow-on effects to Aboriginal and Torres Strait Islander service users.99Many submissions noted that funding inflexibilities were a key barrier to the provision of clinically and culturally appropriate primary health care services. A range of views were presented on preferred funding models which included moving from fee-for-service to population or service-based approaches, greater use of blended payments or salaried arrangements, ‘cashing-up/out’ the MBS, and adopting regional-based ‘funds pooling’ of health services. A consistent theme across many submissions was the need for financing models that allow for local flexibility to meet a specific community’s requirements and the need for inter-sectoral collaboration.

The funding model …. has a population based approach within local communities, provides targeted funding aligned to services offered, including preventative services, and is then weighted based on population. The model should allow for consultations with a range of health care practitioners in a variety of settings that best meets the local need. In doing so, the model must adequately sustain a primary health care team approach to delivering services and builds in incentives for targeting services to clients with chronic and complex needs and those from marginalised communities to reduce the disparity in wellness amongst the population.100The out-of-pocket costs associated with accessing private primary health care services were consistently identified in submissions as being a major inhibitor to access.

In regional, rural and remote areas, only 51% of doctors bulk bill, and doctors should be urged to bulk bill. This is the reason patients flock in great numbers to casualty/emergency centres, because they know that there will be no cost to them - charged under Medicare, when they cannot afford to pay doctors’ fees.101Submissions noted the disparity in access to certain services and therapies on the basis of geographical location.

There are strong regional variations in medicine use in Australia – and these must, in part, reflect problems that these patients face in ing health professionals in primary care. For example, in 2007 the AIHW reported: ‘Compared to those in major cities, people in rural and remote areas have higher death rates from cardiovascular disease, but are dispensed these medicines at half the rate in rural areas [and] about one-thirtieth the rate or less in remote areas’.102Many submissions commented on the accessibility of pharmaceutical services through the network of established community pharmacies.

With its network of over 5,000 pharmacies in urban, regional and rural communities throughout Australia and its highly trained workforce, community pharmacy is the most accessible of all health services, and is well placed to play a constructive and dynamic role in the provision of effective primary health care.A number of submissions commented on the funding arrangements for practice nurses and how these arrangements impact on practice nurses’ ability to operate at their full capacity. In particular a number of submissions commented on the task-oriented ‘for and on behalf of’ funding.

The general practice nurse role could be substantially developed and enhanced through greater investment and commitment to developing the general practice nurse practitioner role. This autonomous advanced practice role, particularly with independent access to MBS and PBS, would provide a significant support to the general practice and enable medical practitioners within general practice to concentrate on more clinically complex health care management. Furthermore, it provides a career trajectory for general practice nurses and enhances and strengthens the layers of health care service available in the PHC [primary health care] sector.104
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What is the way forward?

It is vital that Australia’s primary health care sector is able to effectively and efficiently provide an appropriate level of clinically relevant services including to the most disadvantaged in our communities.

At the same time, any reform of the primary health care system needs to acknowledge that the current system is working reasonably well for the majority of Australians and for many health care providers, but that it could work better for all Australians. In considering a way forward, there needs to be consideration and examination of where fundamental changes at a system level are required, and where the strengths of the existing primary health care system should be retained, amended and built upon.
  • This will identify the potential for the Australian primary health care system to:
  • make best use of the available workforce in providing clinically and culturally appropriate services across public and private sectors;
  • better support primary health care professions in delivering effective and efficient services through innovative and flexible service delivery models;
  • improve the level of integration across the primary health care sector to improve the patient’s experience of the primary health care system; and
  • address service gaps including the care needs of marginalised and disadvantaged populations.

Summary – Key Future Directions

A National Primary Health Care Strategy will provide a framework to guide future priorities for changes to support greater access to clinically and culturally appropriate, timely and affordable primary health care services.

In this context, strengthening and better integrating the mainstream primary health care system is a key starting-point for reducing current gaps in service delivery and improving outcomes for disadvantaged population groups.

At the same time, specialised or targeted programs linked to individual patient needs will remain an important component of service delivery.

Consideration of future changes is likely to involve a re-examination of the balance between existing universal fee-for-service arrangements and alternative approaches to service delivery and funding for both the mainstream system and specific targeted programs.

Importantly, these changes need to be informed by the specific policy objectives and priorities involved.
  • Compared to current arrangements, changes are needed to:
  • improve access and reduce disparities in access to services for disadvantaged populations and in under-serviced areas;
  • develop and implement effective and integrated models of care in delivery of primary health care services;
  • support and encourage greater flexibility in service provision including through opportunities afforded by technology;
  • develop infrastructure to support and expand comprehensive primary and ambulatory health care to facilitate effective primary health care; and
  • ensure service changes are monitored and evaluated.
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47Medicare Australia, MBS Statistical data for 2007-08, available from: http://www.medicareaustralia.gov.au/provider/medicare/mbs.jsp (accessed June 2009).

48 Catholic Health Australia and Newspoll Market Research, 2007. Medical treatment study, Catholic Health Australia, Canberra.

49 Australian Government Department of Health and Ageing, 2008. Report on the Audit of Health Workforce in Rural and Regional Australia, Commonwealth of Australia, Canberra.

50 Australian Institute of Health and Welfare, 2009. Health and community services labour force 2006, AIHW Cat. no. HWL 43, available from: http://www.aihw.gov.au/publications/index.cfm/title/10677 (accessed June 2009).

51 Family Medicine Research Centre, 2009. To what extent is equity of access now established in those areas defined under Government policies as ‘Outer metropolitan areas of need’?, produced for the Australian Government Department of Health and Ageing.

52 Australian Government Department of Health and Ageing, 2008. Report on the Audit of Health Workforce in Rural and Regional Australia, Commonwealth of Australia, Canberra.

53 Australian Government, 2009. Portfolio Budget Statements 2009-10, Budget related paper, Health and Ageing Portfolio, No 1.10, Commonwealth of Australia, Canberra, p. 215.

54 Medicare Australia statistics available from: https://www.medicareaustralia.gov.au/statistics/div_gen_prac.shtml (accessed June 2009).

55 The Commonwealth Fund, 2007. International Health Policy Survey in Seven Countries, The Commonwealth Fund, New York.

56 Australian Government Department of Health and Ageing, 2009. National Rural and Remote Health Infrastructure Program, available from http://www.health.gov.au/internet/main/publishing.nsf/Content/nrrhip-lp (accessed June 2009).

57 As evidenced by consultation attendance available from http://www.health.gov.au/internet/main/publishing.nsf/Content/pacd-gpsuperclinics-consultation (accessed June 2009).

58 South Australian Department of Health, 2009. Available from: http://www.health.sa.gov.au/Default.aspx?tabid=265 (accessed June 2009).

59 NSW Department of Health, 2009, available from: http://www.health.nsw.gov.au/initiatives/healthonensw/index.asp (accessed June 2009).

60 QLD Government Department of Health, 2007. Construction starts on North Lakes health hub, media release, Department of Health, Queensland Government, Brisbane, available from: http://statements.cabinet.qld.gov.au/MMS/StatementDisplaySingle.aspx?id=54974 (accessed June 2009).

61 Australian General Practice Network, 2007. National Practice Nurse Workforce Survey Report 2007, available from: http://www.agpn.com.au/site/content.cfm?page_id=32207¤t_category_code=106&leca=16 (accessed June 2009).

62 Australian Nursing Federation, 2009. Snapshot of nursing roles in primary health care, available from: http://www.anf.org.au/anf_pdf/publications/Snap_Shot_Primary_Health.pdf (accessed June 2009).

63 Australian General Practice Network, 2007. Real Health Solutions key election priorities launched today, available from: http://www.agpn.com.au/client_images/120922.pdf (accessed June 2009).

64 Australian Government, 2009. Portfolio Budget Statements 2009-10, Budget related paper, Health and Ageing Portfolio, No 1.10, Commonwealth of Australia, Canberra, p. 190.

65 Australian Government Department of Health and Ageing, 2009. Medicare subsidised primary care mental health services - fact sheet, available from http://www.health.gov.au/internet/main/publishing.nsf/Content/mental-ba-fig-fact (accessed June 2009).

66 Russell L, 2008. Time to review Mental Health Services, The Australian newspaper, 25 October 2008.

67 Australian Government Department of Health and Ageing, 2008. Allied Health Services under Medicare – Fact sheet, available from: http://www.health.gov.au/internet/main/publishing.nsf/Content/health-medicare-health_pro-gp-pdf-allied-cnt.htm (accessed June 2009).

68 Australian Government Department of Health and Ageing, 2009. Unpublished data.

69 Australian Government Department of Health and Ageing, 2004. Launch of new after-hours clinics, available from http://www.health.gov.au/internet/ministers/publishing.nsf/Content/health-mediarel-yr2004-ta-abb130804.htm?OpenDocument&yr=2004&mth=8 (accessed June 2009).

70 Urbis Keys Young, 2006. Aboriginal and Torres Strait Islander Access to Major Health Programs Final Report, prepared for Medicare Australia and the Australian Government Department of Health and Ageing, Urbis Keys Young, Sydney, p. 24.

71 Australian Government Department of Health and Ageing statistics, 2009, available from: http://www.health.gov.au/medicarestats (accessed June 2009).

72 Medicare Australia statistics, available from: https://www.medicareaustralia.gov.au/statistics/mth_qtr_std_report.shtml (accessed June 2009).

73 Australian Government Department of Health and Ageing statistics, available from http://www.health.gov.au/medicarestats (accessed June 2009).

74 Australian Government Department of Health and Ageing, unpublished data.

75 Australian Government Department of Health and Ageing, unpublished data.

76 The Medicare Safety Net covers the difference between the Medicare fee and the Medicare benefit, which averages around $11 for a non-GP service. When a person or family accumulates $383.90 in gaps in a calendar year the Medicare benefit increases to 100%, removing that gap.

77 The Extended Medicare Safety Net was introduced in 2004 to meet out-of-pocket medical costs. Once an individual or family reaches a threshold of Medicare-related out-of-pocket costs in a calendar year Medicare reimburses 80% of the out-of-pocket costs for the remainder of the year. The current thresholds are $555.70 for Commonwealth concession card holders and families eligible for Family Tax Benefit Part A and $1,111.60 for the general population. In 2007, this safety net distributed $324 million in benefits to 422,000 families and individuals.

78 The net medical expenses tax offset allows taxpayers to claim a tax offset of 20% of net medical expenses over $1,500 for a broad range of health care services provided by doctors, dentists, opticians and chemists. The Australian Taxation Office reported 667,160 claims for the offset in 2006-07 (7.2% of all taxpayers), totalling $420.7 million in foregone tax revenue.

79 A household is defined as a group of related or unrelated people who usually live in the same dwelling and make common provision for food and other essentials of living; or a lone person who makes provision for his or her own food and other essentials of living without combining with any other person.

80 The ABS report’s explanatory notes makes it clear that it is not possible to draw conclusions on the proportion of income spent on different expenditure groups because the lowest quintile’s average is distorted by some households reporting low income by underreporting their incomes; having access to economic resources, such as wealth; income could be temporarily low reflecting business start up; and many low income households are single pensioner households which may use their assets to maintain a higher standard of living than implied by their incomes alone.

81 The Commonwealth Fund, 2007. International Health Policy Survey in Seven Countries, The Commonwealth Fund, New York; and The Commonwealth Fund, 2008. International Health Policy Survey in Eight Countries, The Commonwealth Fund, New York.

82 The disadvantaged categories reflect ABS population data relating to income, education, unemployment and skilled employment.

83 Tasmanian Department of Health and Human Services, 2009. Diabetes, available from: http://www.dhhs.tas.gov.au/health__and__wellbeing/understanding_health_conditions/related_topics/diabetes (accessed June 2009).

84 ibid.

85 Based on Medicare Australia data from July 2006 to June 2007.

86 The unpublished Western Australian study, A multifacet intervention to reduce demand for ED services of aged care facility residents through improved primary care services, was funded through a State Health Research Advisory Council grant.

87 Australian Institute of Health and Welfare, 2007. Australia’s Welfare 2007, AIHW Cat. no. AUS 93, available from: http://www.aihw.gov.au/publications/aus/aw07/aw07-c04.pdf (accessed June 2009).

88 Lennox N, Bain C, Rey-Conde T, Purdie D, Bush R & Pandeya N, 2007. Effects of a comprehensive health assessment programme for Australian adults with intellectual disability: a cluster randomized trial, International Journal of Epidemiology, vol. 36, no. 1, pp. 139-146.

89 ibid.

90 Millar L, Chorlton M & Lennox N, 2004. People with intellectual disability: Barriers to the provision of good primary care, Australian Family Physician, vol. 33, no. 8, pp. 657-658.

91 Australian Bureau of Statistics and Australian Institute of Health and Welfare, 2008. The Health and Welfare of Australia’s Aboriginal and Torres Strait Islander peoples, available from: www.aihw.gov.au/publications/index.cfm/title/10583 (accessed June 2009).

92 Close the Gap Coalition, 2007. Close the Gap campaign website, available from: http://www.closethegap.com.au/ (accessed June 2009).

93 Council of Australian Governments, 2009. National Partnership Agreement on Closing the Gap in Indigenous Health Outcomes, p. 13, available from: http://www.coag.gov.au/intergov_agreements/federal_financial_relations/docs/national_partnership/NP_closing_the_Gap_indigenous_health_outcomes.pdf (accessed June 2009).

94 Australian Human Rights Commission, 2008. Close the Gap - Part 2 Outcomes from the National Health Equality Summit, available from: http://www.hreoc.gov.au/social_justice/health/targets/closethegap/part2_1.html (accessed June 2009).

95 United Nations Department of Economics and Social Affairs, Population Division, 2006. Trends in Total Migrant Stock: the 2005 Revision, UN, New York, p. 3.

96 Australian Government Department of Health and Ageing, 2009. Medicare Benefits Schedule Book – Category 1, Commonwealth of Australia, Canberra, p. 59.

97 Australian Government Department of Immigration and Citizenship, 2008. TIS National Charge Structure, available from: http://www.immi.gov.au/living-in-australia/help-with-english/help_with_translating/service-charges.htm (accessed June 2009).

98 Submission from North East Victorian Division of General Practice (Sub #126)

99 Submission from Congress of Aboriginal and Torres Strait Islander Nurses (Sub #59)

100 Submission from Western Region Health Centre (Sub #125)

101 Submission from Country Women’s Association of NSW (Sub #41)

102 Submission from Pfizer Australia (Sub #131)

103 Submission from The Pharmacy Guild of Australia (Sub #178)

104Submission from Royal College of Nursing, Australia (Sub #127)


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