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Optimal health requires a two-pronged approach: prevention and treatment. On the one hand we can seek to reduce the likelihood of a disease or disorder occurring, or at least slow down its advancement. On the other hand we need to treat people as effectively as possible when they do become ill.
Ideally, prevention or treatment programs and services should not only be effective, they should also be affordable to society and accessible, so that they reach the people who need them most. This chapter looks at the range of ways we prevent and treat ill health.
On a global scale, prevention activities can include, for example, better hygiene in the home, safer home and workplace environments, minimisation of harmful pollutants, good sanitation, and better food and water supply. In Australia, most of these measures are well developed. The current focus of prevention, as outlined in a feature article in this chapter, is on chronic diseases through modifying human behaviours that affect health, such as tobacco smoking, unhealthy diet, lack of physical activity, and harmful use of alcohol. There is also a snapshot on cancer screening programs as a major area of prevention activity in Australia.
On the treatment side, primary health care in Australia provides for most needs most of the time, and aims to provide universally available health care for patients, while ensuring accessibility for all people, from all backgrounds, in all situations. It includes a range of providers, from general practitioners and dentists, to pharmacists and allied health workers, to nurses and Aboriginal health workers. Primary health care is featured in this chapter.
Sometimes, primary health care is not enough, and the emergency, surgical, medical and other treatment services provided by public and private hospitals are needed. Information on public and private hospital services and activities are covered in this chapter, with extra attention to emergency department activity, and the role of private hospitals.
Information is also provided on safety and quality in hospitals, elective surgery waiting times, ambulance services, medications, and specialised services such as drug and alcohol treatment services and mental health services.
A fundamental aim of any health system is to prevent disease and reduce ill health, so that people remain as healthy as possible for as long as possible. In Australia, prevention as part of advocacy and action in public health has long been a core focus of health authorities (Gruszin et al. 2012).
One hundred years ago, the biggest health challenges were the prevention of infectious diseases, the improvement of maternal and child health and the creation of safer home, work and physical environments. Sanitation, communicable disease surveillance, immunisation, quarantine, workplace health and safety, safe birthing practices, promotion of breastfeeding and ensuring a better food and water supply were key prevention strategies then, and they remain so today.
More recently, changes affecting climate, water, air and other aspects of the physical environment present new risks to population health which will require new prevention strategies (McMichael et al. 2008).
The ongoing need for prevention has also been brought into sharp focus by the increase in chronic diseases, with the large associated health, social and economic burdens (see Chapter 4 'Chronic disease—Australia's biggest health challenge'). This 'overtaking' of the burden of disease by chronic disease has been driven by the decline in infectious disease mortality in combination with unfavourable trends in some health risk factors, as well as by the ageing of the population.
Many of the 14 million annual premature deaths worldwide which result from cardiovascular disease, cancer, chronic respiratory disease, diabetes and other chronic diseases could be prevented by eliminating or reducing common risk factors—mainly tobacco smoking, unhealthy diet, physical inactivity and the harmful use of alcohol (WHO 2013). In turn, these health behaviours and risk factors are affected by the social determinants of health—the conditions into which people are born, grow, live, work and age (see Chapter 1 'Health and illness'). Reduction of these modifiable risk factors and tackling unfavourable social determinants where practicable can reduce illness and the risk of premature death, with the potential for large health gains in the population. Preventing or delaying chronic disease is one of the most important priorities for the Australian health care system today.
Chronic disease is a global concern, with prevention of chronic diseases considered to be a key approach that will ensure that future generations are not at risk of premature death from these diseases (Beaglehole et al. 2011). In 1977, the World Health Organization (WHO) highlighted the importance of promoting health so that all persons had an economically productive level of health. The 1986 Ottawa Charter for Health Promotion added momentum with a goal of 'Health for all' by the year 2000 and beyond through better health promotion.
The World Health Assembly's current vision for prevention is 'a world free of the avoidable burden of noncommunicable diseases', through multisectoral collaboration and cooperation, so that populations achieve the highest attainable standards of health and productivity at every age (WHO 2013). Two important objectives of WHO's action plan include reducing modifiable disease risk factors and underlying social determinants through creating equitable health-promoting environments, and strengthening and orienting health systems through people-centred primary health care.
The World Health Organization defines prevention as 'approaches and activities aimed at reducing the likelihood that a disease or disorder will affect an individual, interrupting or slowing the progress of the disorder or reducing disability' (WHO 2004).
Within this broad definition there are some more specific characterisations:
An important part of disease prevention is health promotion. This describes activities which help individuals and communities to increase control over the determinants of their health. Health education and social marketing can be used to promote health, as can policy and structural changes such as taxation, legislation and regulation.
Programs that promote and protect health, and prevent illness, are undertaken by many agencies (Figure 8.1). All 3 levels of government (federal, state and local), along with non-government organisations, academia, the private sector and community groups fund and carry out prevention activities.
Other government sectors besides health—such as education, urban planning, and sport and recreation—have an important role in promoting good health. Although individuals ultimately make the decisions that affect their own health, each of these groups and sectors assist people in making healthy choices and leading healthier lives (ANPHA 2013).
Who needs to act depends largely on which area of prevention is a focus: whether it is modifying health risk factors, or preventing the progression, complications and recurrence of disease. Health promotion through public awareness campaigns and community-based programs largely target risk factor prevention. Prevention through health counselling and the effective management of disease is often undertaken by primary health care providers such as general practitioners, along with specialists and allied health care professionals (RACGP 2012) (see Chapter 8 'Primary health care in Australia').
Decisions to invest in prevention are guided by a number of considerations, including whether the intervention increases community wellbeing, whether it is costly or offers value, and how its benefits can be distributed fairly (Carter et al. 2012).
Source: ANPHA 2013.
Prevention targets different groups of people, depending on their need:
As people have complex needs, and personal circumstance differ considerably, no single approach works for everyone.
Experience from key approaches suggests that prevention activities appear to work best with a combination of universal and targeted approaches, and with multiple strategies and interventions. Efforts to reduce smoking, for example, have relied on universal approaches incorporating: restrictions on how tobacco products can be promoted and sold; graphic health warnings on packages and in the media; increased tobacco excise; public education programs; support for smokers who are trying to quit; and selective prevention approaches that target at-risk populations such as pregnant women and Indigenous Australians.
Preventive action is undertaken in different settings, from the home to urban spaces, schools and workplaces, with each playing a role in creating healthy, sustainable communities. Effective action also requires an enabling infrastructure, involving research, information, monitoring and evaluation.
Sometimes prevention is a long-term prospect, since behavioural and structural change leading to lower rates of disease or premature death can take time. But long-term investments to address deeply rooted social factors, or issues beyond the control of individuals or specific sectors, are as important as strategies that focus on shorter-term clinical prevention and other direct services.
Australia has a long history of implementing health promotion campaigns. Some well-known educational and behavioural campaigns from the past include:
Notable policy and regulatory activities have included free milk for school children, fluoridated water, polio and other mass vaccinations, fitted seat belts in motor vehicles, addition of folic acid to bread-making flour for the healthy development of babies early in pregnancy, iodised salt to prevent thyroid gland problems and tobacco plain packaging.
There are numerous population-level interventions currently operating which seek to influence health and behaviour. Selected Australian Government campaigns are directed at eye health awareness, sexually transmitted infections, illicit drugs, tobacco, alcohol, cancer screening, mental health, obesity and healthy lifestyles, immunisation, pandemic influenza and HIV/AIDS.
The Indigenous Chronic Disease Package provides funding for preventive health activities including smoking cessation and healthy lifestyle programs for Aboriginal and Torres Strait Islander individuals, families and communities.
A selection of case studies illustrating good practice and promising work can be found in the Australian National Preventive Health Agency's State of Preventive Health 2013 report.
For the financial year 2011–12, $2.23 billion, or 1.7% of total health expenditure, went to public health activities, which include prevention, protection and promotion. This amount does not include spending in non-health sectors such as road safety, the environment, and schools. Immunisation, health promotion activities that encourage a healthy lifestyle and reduce health risk factors, and cancer screening programs, were the major areas of public health spending (AIHW 2011, 2013).
Between 2000–01 and 2010–11, government expenditure on public health activities grew at an average rate of 3.8% per year. Much of the growth resulted from implementing the human papillomavirus vaccination (HPV ) program in 2007–08.
While public health expenditure estimates are subject to data quality issues that affect international comparability, comparisons suggest Australia spends less on prevention and public health services than most other Organisation for Economic Co-operation and Development (OECD) countries, ranking in the lowest third in 2010–11. New Zealand led the way, with 7% of total health expenditure, followed by Canada at 5.9% (OECD 2013).
Well-planned prevention programs have made contributions to a better quality of life and increased life expectancy. In recent decades there have been major improvements in tobacco control, road trauma and drink-driving, skin cancers, immunisation, cardiovascular disease, childhood infection diseases, and sudden infant death syndrome (SIDS) and HIV/AIDS control (National Preventative Health Taskforce 2009).
Successful prevention reduces the personal, family and community consequences of disease, injury, and disability. It allows for the better use of health system resources, producing a healthier workforce, which in turn boosts economic performance and productivity.
Reductions in smoking rates are a prevention success story in Australia. Health promotion, regulation and increased taxation have each played a role in reducing smoking rates among both males and females; for males from around 70% in the 1950s to 18% today, and for females from around 30% to 14%. Death rates from smoking-related diseases have fallen, with a time lag, from the high levels of the 1970s and 1980s—lung cancer deaths have fallen by 40%, and chronic obstructive pulmonary disease deaths by 60%.
A second notable example is SIDS death rates, which fell by almost three-quarters, from an average of 196 deaths per 100,000 live births during 1980–1990 to 52 during 1997–2002. The fall was largely due to the SIDS Reduce the risk campaign on safe sleeping for babies (d'Espaignet et al. 2008).
An epidemiological and economic analysis of a number of public health programs by the then Australian Government Department of Health and Ageing (DoHA 2003) highlighted further prevention successes. Some specific examples were:
Decision makers in health have long been interested in strategies that can reduce morbidity and mortality at a reasonable cost to the public (Tengs et al. 1995). Health promotion and disease prevention activities can be expensive, especially those directed at large population groups rather than, for example, specific target populations or people with specific risk factor profiles. There is a need for a sound business case to assess the evidence for appropriate interventions and demonstrate value for money, as well as economic evaluations of these activities. This will better inform decision-making about which programs are more likely to be successful and where they may best be targeted when considering both effectiveness and cost.
Cost-effectiveness analysis is a method which is often used to compare programs and policies on the basis of their estimated cost and potential to improve health. It is also, however, an area where the costs of implementation and the value of attributed cost savings or benefits are highly contested and often difficult to demonstrate over time. This makes the case for investment more difficult for decision makers.
Sources: National Preventative Health Taskforce 2009, BITRE 2013.
One Australian study, for example, concluded that taxing nutritionally poor food and using generic drugs to target combined health risk factors were 2 actions that were cost-saving in obesity prevention, while having a high health impact (Vos et al. 2010). However, another study indicated that there was a lack of long-term evaluation to test the veracity of claims for cost-effectiveness, and that in the case of childhood obesity, further evidence on actions which could positively influence children's eating behaviours and levels of physical activity were needed to develop long-term community interventions (Crowle & Turner 2010).
Another example is an international project which examined the economics of chronic disease prevention. It used cost-effectiveness analysis to conclude that interventions aimed at tackling obesity by improving diet and increasing physical activity in areas such as health education and promotion, regulation and fiscal measures, and counselling in primary care, are all effective in improving health and longevity, and are more cost effective than treating chronic diseases once they emerge. The study also found that when multiple interventions were undertaken which targeted different age groups and determinants simultaneously, overall health gains increased, adding years of healthy life to people's health expectancy, without any loss in cost-effectiveness (Sassi 2010).
Based on current evidence, the World Health Organization has suggested a number of 'best buy' policy interventions as well as individual interventions that may assist in the prevention of chronic disease. WHO suggests that these 'best buys' be implemented in primary care settings in all countries to produce rapid results in terms of lives saved, diseases prevented and large costs avoided (WHO 2013). They include:
Monitoring and evaluation play a critical role in assessing the performance of disease prevention and health promotion programs, and provide the evidence that researchers, policy makers and service providers need on what works.
Successful monitoring and evaluation examines the long-term sustainability of outcomes for target populations. There is an increasing recognition of the importance of assessing activities which focus on the social determinants of health, especially among disadvantaged populations (Commission on Social Determinants of Health 2008).
Monitoring relies on available data to determine who is most affected by a health problem, and whether the situation changes following an intervention.
The Council of Australian Government indicators and benchmarks for smoking, alcohol and obesity are key monitoring tools for prevention-related health risk behaviours (COAG Reform Council 2013). The National Partnership Agreement on Preventive Health has developed a set of performance measures for states and territories.
Specific prevention activities require robust evaluation so that their success or failure can be measured and lessons can be learnt. Successful evaluation depends on determining which benefits to select, their cost and the value assigned to these benefits. Evaluation results and other information can guide future chronic disease prevention activities (Swinburn & Wood 2013). To maximise effects, an appropriately resourced capacity and method for evaluation should be developed as prevention proposals are planned, with baseline data, targets and anticipated outcomes documented before a campaign or program begins (AIHW 2009).
Government agencies have key roles in health data monitoring and the evaluation of health promotion. The 2011–13 Australian Health Survey, funded by the Australian Bureau of Statistics, the Australian Government Department of Health and the National Heart Foundation of Australia, provides valuable information. The AIHW and other reporting agencies can use results from this survey and other data sources to monitor diseases and risk factors, and evaluate preventive activities.
The challenges presented by an ageing population and the prevalence of overweight and obesity, along with the chronic diseases they initiate, are fertile areas for the attention of prevention research, policy and action for the foreseeable future (see Chapter 4, 'Chronic disease—Australia's biggest health challenge', and Chapter 6 'Ageing and the health system: challenges, opportunities and adaptations'). Besides obesity, health promotion is expected to continue to target risk factors such as physical inactivity, poor nutrition, harmful alcohol use, and smoking, and will also seek to prevent injury, oral conditions, cancers and other chronic diseases.
Mental health research suggests that there is an increasing need to promote psychological wellbeing. Managing biological and reducing psychosocial risk factors will help to prevent debilitating depression and anxiety, reduce suicide risk, and head off harmful behaviours (Jorm & Reavley 2013; National Mental Health Strategy 2009).
Another issue is the potential role of preventive action in redressing health disadvantage across the social gradient. Low socioeconomic groups generally have a higher prevalence of risk factors and greater health needs, and can benefit from targeted prevention activities. Hard-to-reach population groups, whether through distance or other access barriers such as language or culture, present additional challenges which can benefit from community-level action.
Building strong partnerships with industry—food and beverage, fitness, health insurance and others— where government regulation and business interests interact, are important for effective health promotion and disease prevention.
As with other health interventions, preventive health strategies need evaluation of their appropriateness, cost and effectiveness, to help avoid future treatment costs associated with ill-health, and wasted expenditure on what may be poorly designed, ineffective prevention approaches.
The Australian National Preventive Health Agency's website is focused on this topic. On 13 May 2014, the Australian Government announced that the Agency's functions would be transferred to the Department of Health from July 2014.
Information on Australian Government disease prevention and health promotion campaigns is available at Australian Government Department of Health website.
AIHW (Australian Institute of Health and Welfare) 2009. Prevention of cardiovascular disease, diabetes and chronic kidney disease: targeting risk factors. Cat. no. PHE 118. Canberra: AIHW.
AIHW 2011. Public health expenditure in Australia 2008–09. Cat. no. HWE 52. Canberra: AIHW.
AIHW 2013. Health expenditure Australia 2011–12. Cat. no. HWE 59. Canberra: AIHW.
ANPHA (Australian National Preventive Health Agency) 2013. State of preventive health 2013. Canberra: ANPHA.
Beaglehole R, Bonita R, Horton R, Adams C, Alleyne G, Asaria P et al. 2011. Priority actions for the non-communicable disease crisis. Lancet 377:1438–47.
BITRE (Bureau of Infrastructure, Transport and Regional Economics) 2013. Road deaths Australia, 2012 statistical summary. Canberra: BITRE.
Carter SM, Cribb A & Allegrante JP 2012. How to think about health promotion ethics. Public Health Reviews 34:1–24.
COAG (Council of Australian Governments) Reform Council 2013. Healthcare 2011–12: comparing performance across Australia. Sydney: COAG Reform Council.
Commission on Social Determinants of Health 2008. Closing the gap in a generation: health equity through action on the social determinants of health: Commission on Social Determinants of Health final report. Geneva: WHO.
Crowle J & E Turner 2010. Childhood obesity: an economic perspective. Productivity Commission Staff Working Paper. Melbourne: Productivity Commission.
d'Espaignet E T, Bulsara M, Wolfenden L, Byard RW & Stanley F J 2008. Trends in sudden infant death syndrome in Australia from 1980 to 2002. Forensic Science Medicine and Pathology 4:83–90.
DoHA (Department of Health and Ageing) 2003. Returns on investment in public health: an epidemiological and economic analysis prepared for the Department of Health and Ageing. Canberra: DoHA.
Gruszin S, Hetzel D & Glover J 2012. Advocacy and action in public health: lessons from Australia over the 20th century. Canberra: ANPHA.
Jorm AF & Reavley NJ 2013. Preventing mental disorders: the time is right. Medical Journal of Australia 199:527.
McMichael AJ, Friel S, Nyong A & Corvalan C 2008. Global environmental change and health: impacts, inequalities, and the health sector. British Medical Journal 336:191–4.
National Mental Health Strategy 2009. National mental health policy 2008. Canberra: Commonwealth of Australia.
National Preventative Health Taskforce 2009. Australia: the healthiest country by 2020—National Preventative Health Strategy—the roadmap for action. Canberra: Commonwealth of Australia.
OECD (Organisation for Economic Co-operation and Development) 2013. OECD statistics. Paris: OECD. Viewed 4 December 2013.
RACGP (Royal Australian College of General Practitioners) 2012. Guidelines for preventive activities in general practice, 8th edn. East Melbourne: RACGP.
Sassi F 2010. Obesity and the economics of prevention: fit not fat. Paris: OECD Publishing.
SCRGSP (Steering Committee for the Review of Government Service Provision) 2011. National agreement performance information 2011–12: National Healthcare Agreement. Productivity Commission: Canberra.
Swinburn B & Wood A 2013. Progress on obesity prevention over 20 years in Australia and New Zealand. Obesity Reviews 14 (Supplement 2):60–8.
Tengs TO, Adams ME, Pliskin JS, Safran DG, Siegel JE, Weinstein MC et al. 1995. Five hundred life-saving interventions and their cost-effectiveness. Risk Analysis 15:369–484.
Vos T, Carter R, Barendreg J, Mihalopoulos C, Veerman L, Magnus A et al. 2010. Assessing cost-effectiveness in prevention (ACE–Prevention): final report. Melbourne: University of Queensland and Deakin University.
WHO (World Health Organization) 2004. Global forum on chronic disease prevention and control (4th, Ottawa, Canada). Geneva: WHO.
WHO 2011. Global status report on noncommunicable diseases 2010. Geneva: WHO.
WHO 2013. Global action plan for the prevention and control of noncommunicable diseases 2013–2020. Geneva: WHO.
Population-based cancer screening is an organised, systematic and integrated process of testing for signs of cancer or pre-cancerous conditions in asymptomatic (see Glossary) populations. In Australia, there are 3 national population-based screening programs: for breast, cervical and bowel cancers. They are run through partnerships between the Australian Government and state and territory governments. The programs target particular populations and age groups where evidence shows screening is most effective at reducing cancer-related morbidity and mortality.
BreastScreen Australia, established in 1991, provides free, 2-yearly screening mammograms (see Glossary) to women aged 40 and over, and actively invites women aged 50–69 to participate.
The National Cervical Screening Program, established in 1991, targets women aged 20–69 for a 2-yearly Papanicolau smear, or 'Pap test' (see Glossary).
Sources: AIHW analysis of BreastScreen Australia data; AIHW analysis of state and territory cervical cytology register data.
The National Bowel Cancer Screening Program (NBCSP), established in 2006, targets men and women turning 50, 55, 60 or 65 for a free faecal occult blood test (see Glossary). The program will be expanded from 2015, and once fully implemented will offer free 2-yearly screening for all Australians aged 50–74.
Of those people invited to participate in the NBCSP in 2011–12:
National cancer data do not include whether a new case of cancer was identified through screening, or if cancers identified through screening are diagnosed at an earlier stage to those that present naturally.
There is no national mechanism for reporting Aboriginal or Torres Strait Islander identification on pathology forms. As a result, state and territory cervical cytology (Pap test) registers are unable to report Indigenous status, so the reporting of cervical screening indicators is not possible nationally for Indigenous women. It is not known how the introduction of the national vaccination program against human papillomavirus (HPV ) (see Glossary) in 2007 will affect cervical screening rates among vaccinated women.
Outcome data for the NBCSP is under-reported. The Department of Health is working on a number of steps to improve reporting of outcomes.
The BreastScreen Australia monitoring report 2010–2011, Cervical screening in Australia 2010–2011 and National Bowel Cancer Screening Program monitoring report: July 2011–June 2012 are available for free download.
Primary health care has been described by health ministers in Australia as 'the frontline of Australia's health care system, encompassing a large range of providers and services across public, private and non-government sectors' (SCoH 2013). The primary health care system sets out to provide equitable, high quality and financially sustainable services that are: universally available; delivered appropriately by a suitably skilled workforce; offered as a first point of contact with the health care system in the community near where people live; part of a long-term relationship with patients and their families; and integral in referring patients on to other health or community services (Department of Health 2011; DoHA 2009; Health Canada 2012; Institute of Medicine 1994; New Zealand Ministry of Health 2001; Starfield 2005; WHO 1978).
Health ministers have also recognised that the primary health care system 'needs to be easy for consumers to access and use, and designed towards actively supporting them to manage their health care needs and stay as healthy as possible' (SCoH 2013).
The financial and other challenges faced by the Australian health care system have led governments to reconsider the way the system is structured, which has indicated the need for an increased focus on primary health care and its central role in improving the health of the population (DoHA 2010).
This article provides a brief overview of primary health care in Australia and the extent to which it meets the objectives and challenges outlined above.
In Australia, primary health care is typically the first health service visited by patients with a health concern. It includes most health services not provided by hospitals and involves:
Funding for primary health care services comes from multiple sources, including:
Figure 8.4 illustrates the central role of primary health care in the Australian health care system and the key health, community and aged care services with which it interacts.
Australia's primary health care service delivery system has been described as complex, fragmented and often uncoordinated, with implications for the services people receive and how they are paid for (DoHA 2009). Given this complexity, navigating through this system can be difficult for some people, particularly those with poor health, disability, lower English proficiency or other socioeconomic barriers (see Chapter 2 'Australia's health system' and AIHW 2012a, Section 7.1 'Navigating the health system').
The Australian health care system overall faces a number of challenges in providing effective, timely, coordinated health care now and into the future. Some of these challenges are listed below, with most covered in some detail elsewhere in this Australia's health 2014 report, as indicated:
These factors increase the importance of the health system delivering cost-effective outcomes (see Chapter 2 'How much does Australia spend on health care?'). As a result, there has been a renewed focus on the importance of primary health care and its role in delivering better health outcomes at lower cost (Australian Government 2013; DoHA 2009). This has included a range of strategies to improve access to services, for example, through increased access to after-hours primary health care services and multidisciplinary clinics where patients can access GP, allied health and diagnostic services (DoHA 2013a).
There have also been structural reforms designed to better integrate and coordinate the range of organisations and service providers operating within and beyond the primary health care system. For example, Medicare Locals were established in 2011 to provide an integrated model of care at the local level (see Box 8.1) (DoHA 2010).
A strong and readily accessible primary health care system is also considered vital in reducing pressure on public hospitals through access to advice and services in the early stages of disease and a broader geographic distribution of suitably skilled health professionals compared to the concentration of specialists in urban areas (Australian Government 2013).
In 2011, the Australian Government established 61 new primary health care organisations known as Medicare Locals, to plan and fund extra health services in communities across Australia and to ensure that decisions about health services could be made by local communities in line with their local needs (DoHA 2013b).
Building on the pre-existing divisions of general practice networks, key priority areas for Medicare Locals are improving access and reducing inequity, better management of chronic conditions, an increased focus on disease prevention and improving quality, safety, performance and accountability (Pearce et al. 2012).
Medicare Locals are also subject to performance monitoring and reporting requirements, including a Needs Assessment Report, which is used to inform their planning and decision-making (DoHA 2012).
In December 2013, Australia's former Chief Medical Officer, Professor John Horvath AO, was appointed to oversee a review of Medicare Locals to ensure that Commonwealth health funding is used as productively as possible (Dutton 2013). Following the release of the report in May 2014, the Australian Government announced that Medicare Locals would be replaced with a smaller number of primary health networks.
Similar challenges have been faced internationally in terms of reorienting health systems towards primary care. Also important is developing suitable primary health care information systems to yield performance information and describe the sector's achievements (see Box 8.2 for an example of information development in Canada).
In this article we present a range of available information to illustrate what we know about how Australia is meeting these primary health care objectives and challenges.
The Canadian primary health care experience is of particular relevance to Australia given some similarities in terms of our federated systems. The Canadian primary health care information program highlights the benefits of having an overarching performance indicator framework in combination with both primary care patient experience surveying at the population level and administrative extract data from clinical care systems. It covers:
Primary health care accounts for almost as much health spending as hospital services. In 2011–12, primary health care accounted for 36% (or $51 billion) of total health expenditure compared with 38% ($54 billion) for hospital services (see Chapter 2 'How much does Australia spend on health care?').
In 2011–12, 84% of Australians had consulted a GP at least once in the previous 12 months (ABS 2013a). Most had multiple consultations—67% made at least 2 visits in the last 12 months, 37% made at least 4 visits and 10% made at least 12 visits (ABS 2013b).
Over the same period, 47% of Australians had visited a dentist and 21% had consulted another health professional (ABS 2013a). Of these other health professionals, people most commonly reported consulting physiotherapists or hydrotherapists (6.4%), opticians or optometrists (5.8%), chemists for advice only (5.8%) and chiropractors (4.5%).
By comparison, in the same period, 12% of the population were admitted to hospital, 8% visited a hospital outpatient clinic, 12% an emergency department and 6% a day clinic.
The vast majority of health care services are delivered in primary health care settings. For example, in 2011–12:
In the same year (2011–12), Australian hospitals:
There is limited information about the reasons people present for primary health care, and the health actions recommended. The Bettering the Evaluation and Care of Health (BEACH) ongoing survey of GPs shows that in 2012–13 patients presented to GPs with an average of 1.6 reasons for the visit, and that requests for prescriptions, general check-ups and test results were the most frequently recorded reasons (Britt et al. 2013a).
For every 100 GP–patient encounters, GPs provided, on average, 83 prescriptions, 37 clinical treatments, undertook 17 procedures, made 9 referrals to specialists and 5 referrals to allied health services, and placed 47 pathology test and 10 imaging test orders (Britt et al. 2013a).
Evidence suggests that a strong primary health care system is associated with reduced costs and increased efficiency, lower rates of potentially preventable hospitalisations, reduced health inequities, increased patient satisfaction with care, and better health outcomes, including lower rates of potentially avoidable mortality (DoHA 2009; Macinko et al. 2003; Mosquera et al 2012; Starfield & Shi 2002). In Australia, primary health care aims to achieve these objectives through the provision of accessible and well-delivered services that are effective and appropriate. What do we know about the extent to which we achieve these objectives?
Primary health care is intended to be universally accessible regardless of an individual's health, socioeconomic or other circumstances. A primary health care system that provides access according to health need will target services to those in greatest need.
However, there is some evidence that this is not the case. Analysis of GP attendances across Medicare Locals shows that there are some metropolitan areas where healthier populations (as indicated by the proportion of adults with long-term health conditions) receive higher than average GP services and some regional areas where less healthy populations receive lower than average GP services (NHPA 2013b). It is difficult to fully gauge the meaning of these differences without examining the distribution of GPs and the extent to which a shortfall in GP services is met by alternative primary health care services such as community health and Indigenous-specific health services.
What else do we know about the accessibility of primary health care? In this section we examine this question by presenting a selection of information—on waiting times for GPs, cost barriers, bulk-billing, after-hours services, Indigenous-specific health services and workforce distribution—examining variation by population groups and over time wherever possible.
Most of the population (80%) believe that waiting times to see a GP are appropriate (ABS 2013b). In 2012–13, 20% of people believed they waited an unacceptable time to see a GP in the previous 12 months, a rate which fell midway between 2010–11 (15%) and 2011–12 (27%). The proportion of people waiting an unacceptable time to see a GP was:
Most of the population (over 94%) do not report cost as a barrier to accessing GP services (ABS 2013b). In 2012–13, 5.4% of people who needed to see a GP in the previous 12 months delayed seeing or did not see a GP at least once because of the cost, a rate which was down from 6.8% in 2011–12. The proportion of people who reported cost as a barrier to seeing a GP was:
In contrast, around one-fifth of the population reports cost as a barrier to accessing dental services (ABS 2013b). In 2012–13, 18% of people delayed or did not see a dentist due to cost, a rate which was down from 21% in 2011–12. The proportion of people who reported cost as a barrier to seeing a dentist was:
In 2011–12, 9.6% of Australians reported delaying or not getting a prescription filled in the previous 12 months due to cost, and 5.1% deferred getting pathology or imaging tests. There was no statistically significant difference across remoteness areas (COAG Reform Council 2013a) (Figure 8.5).
Note: Data for 'See a GP' and 'See a dentist' taken from ABS 2012–13 Patient Experience Survey. Data for 'Fill a prescription' and 'Pathology imaging test' taken from ABS 2011–12 Patient Experience Survey.
Sources: ABS 2013b; COAG Reform Council 2013a.
Access to bulk-billed GP attendances (that is, GP visits for which no co-payment is charged to the patient) is a component of Australia's Medicare system (DHS 2014a). In 2012–13, 82% of GP attendances were bulk–billed. The bulk-billing rate was the highest since 1990–91, with the lowest rate recorded in 2003–04. The rate was:
There has been substantial policy interest in recent years in improving access to after-hours primary health care services, particularly to reduce the pressure on public hospital emergency departments (DoHA 2010). In 2012–13, 360 after-hours GP visits per 1,000 population were reimbursed by Medicare (DHS 2013), a rate which:
Some evidence links the availability of after-hours GP services to reduced rates of emergency department presentations in the same area (Buckley et al. 2010; Gafforini & Carson 2013; Hossain & Laditka 2009; O'Malley 2012). However, other factors contribute to emergency department presentations, including patient perception of urgency and/or seriousness of the problem (Masso et al. 2007), the availability of a preferred primary care physician, and distance to hospital (Gunther et al. 2013; NMML 2013). There is also a range of interpretation and data quality issues that makes it difficult to fully assess whether rates of emergency department presentations are falling and what this says about primary health care accessibility (COAG Reform Council 2013b; Nagree et al. 2013). (See Chapter 8 'Emergency departments: at the front line' and Chapter 9 'Indicators of Australia's health' for further information.)
Uptake of telephone health services also provides an indicator of access to services outside business hours. These services provide a substantial and growing volume of health advice to the public (Ng et al. 2012). Healthdirect Australia, established to provide round-the-clock online and telephone advice has responded to:
(Department of Health unpublished data, February 2014).
In the first quarter of 2013 (January to March), there were over 208,000 calls to Healthdirect Australia, of which call frequencies were highest after 8pm and on weekends. The most frequent types of advice given by triage nurses were 'self care at home' (20%) and 'refer to after-hours GP helpline' (17%). Of the more than 40,000 calls received by the after-hours GP helpline, approximately 60% of patients were provided with self-care advice by telephone GPs (Healthdirect Australia 2013), thereby potentially preventing unnecessary visits to emergency departments and after-hours services.
In addition to mainstream services, the Australian Government directly funds about 300 organisations to deliver comprehensive primary health care and other health services to Aboriginal and Torres Strait Islander people, of which around 60% are Aboriginal and Torres Strait Islander community-controlled or managed. These services are designed to enhance access to comprehensive primary health care for Indigenous Australians through access to doctors, nurses, allied health professionals, social and emotional wellbeing staff, and medical specialists. In addition, some receive funding to provide substance use services.
In 2011–12, these services provided 2.6 million episodes of health care to about 445,000 clients. This was a 5% increase in episodes of care compared with 2010–11 and a 3% increase in the number of clients reported. About 4 in 5 clients (79% or 350,000) were Indigenous (AIHW 2013d).
Access to primary health care services is dependent on there being enough primary health care practitioners to meet the needs of the population. There were nearly 26,000 GPs in Australia in 2012 (AIHW 2013c), or 112 full-time equivalent (FTE) GPs per 100,000 population. The supply of GPs:
The increasing supply of GPs by remoteness does not necessarily mean there are enough GPs to meet demand in rural areas for medical care. The supply of all medical practitioners decreased with remoteness, with non-GP specialists tending to be concentrated in urban areas. This can mean that GPs in rural areas are called upon to perform a wider scope of services than in urban areas. Other factors that influence whether there is adequate supply of medical practitioners to meet demand include health seeking behaviour, professional scopes of practice and differing health system efficiencies.
The supply of nurses was also higher in regional and remote areas compared with Major cities (AIHW 2013f). Nurses and their interactions with other health professionals play a vital role in these areas.
In contrast, the supply of dentists, psychologists, pharmacists and other allied health practitioners decreased with increasing remoteness (AIHW 2013a, 2014a). Efforts to remedy these shortfalls in regional and remote areas include expanding or changing the scope of practice for the existing health workforce in these areas and promoting emerging health disciplines better suited to primary health care in regional and remote areas (HWA 2011).
There has also been a shift from standalone general practices to larger practices (AIHW 2012c, 2013e, 2014b; Britt et al. 2013b) and development of multidisciplinary clinics, all of which have the potential to enhance access to care.
In addition to being accessible, the primary health care system strives to deliver care that is effective, coordinated, safe, of high quality, and responsive to patient needs (see Chapter 9, 'Indicators of Australia's health'). In the following sections we present selected information on these aspects of primary care in Australia, including variation by population groups and trends where possible.
It is not possible to routinely assess the broad concepts of effectiveness or appropriateness of primary health care in Australia—for example, whether care adheres to clinical guidelines—using currently available primary health care data (Runciman et al. 2012).
One commonly used indicator of the effectiveness of primary health care is 'potentially preventable hospitalisations'—hospital admissions that could potentially have been prevented through the timely and effective use of non-hospital care (AIHW 2013b; COAG Reform Council 2013b; Jorm et al. 2012; OECD 2013; Rosano et al. 2013). Higher rates of potentially preventable hospitalisations may, however, not be a direct reflection of effectiveness of primary care. They may be a result of: an increased prevalence of particular health conditions in the community; consumer choice; poorer access to the non-hospital care system; or an appropriate use of the hospital system to respond to greater need.
In 2011–12, the rate of potentially preventable hospitalisations was higher for patients from low SES areas compared with high SES areas and increased with increasing remoteness (see Chapter 9 'Indicators of Australia's health'— 'Selected potentially preventable hospitalisations' performance indicator).
Primary health care has a vital role in preventing risk factors and disease through provision of early intervention, prevention and screening programs. Another important indicator of effectiveness of primary health care, therefore, is the extent to which these activities—such as immunisation programs, early childhood development checks and cancer screening—are being delivered across all population groups. Evidence is mixed. For example:
Information is not available about most other health promotion or prevention activities delivered to patients by primary health care professionals (AIHW 2009) . For example, GPs are encouraged to routinely assess patients' smoking status, and while this information is often recorded in general practice records, it is not routinely consolidated.
Improved coordination of health care, particularly management of chronic diseases, is a key goal of the primary health care system in Australia. This is especially important where patient care involves multiple health professionals (Harris et al. 2011).
In 2012–13, 16% of the population aged 15 and over (or 3 million people) saw 3 or more health professionals for the same condition (ABS 2013b). Of these patients, 69% reported that a health professional helped coordinate their care—most likely a GP (54%), medical specialist (30%) or nurse (6%)—the majority of whom (69%) reported that the coordination helped to a large extent. The proportion of people with coordinated care was higher in low SES areas (73%) compared with high SES areas (64%) but they were less likely to report that coordination helped to a large extent (67% compared with 74% respectively).
Another indicator of chronic disease management is use of specific chronic disease management plans, which are available under various arrangements (for example, MBS GP Management Plans and Team Care Arrangements). For a small number of chronic conditions (such as asthma, diabetes and mental illness) some information on the uptake of coordinated care plans can be derived using MBS data. However, there are various limitations when using this information to assess the effectiveness of care coordination, including that care may be coordinated through alternative non-MBS arrangements (for example, by a community or Indigenous-specific health service) and that the presence of a plan alone does not necessarily ensure care is effectively coordinated (see Chapter 9 'Indicators of Australia's health'—'Proportion of people with diabetes with a GP annual cycle of care'; 'Proportion of people with asthma with a written asthma plan'; and 'Proportion of people with mental illness with a GP care plan').
'Continuity of care' is a feature of coordinated care and involves continuity of: information (where patient information from past consultations is available and used in making decisions about current care); management (including adherence to standards and protocols); and relationships between the provider and the patient (Health Quality Ontario 2013). Effective continuity of care is associated with improved patient outcomes, reduced health service use and improved patient satisfaction (Bankart et al. 2011; Browne & Taylor 2013; Freeman et al. 2007; Gunther et al. 2013; Health Quality Ontario 2013; Kemp et al. 2013). The importance of continuity of care is recognised in Australian standards for general practitioners (RACGP 2010).
One indicator of continuity of care is the extent to which the population can access a preferred GP. In 2010–11, among adults who saw a GP in the previous 12 months there were marked differences across Medicare Locals, including:
There may also be opportunities to improve understanding of communication between hospitals and GPs through use of electronic discharge summaries developed under e-Health arrangements, but these data are not yet available.
There are several mechanisms through which high quality primary health care is pursued, including through health professional registration and accreditation processes, and through government payments to GPs and pharmacists as incentives for particular quality improvements (for example, the Practice Incentives Program for GPs). There are measures in place to promote and improve understanding of safety and quality in primary health care (see ACSQHC 2011; RACGP 2010) but there is currently no related national statistical reporting on this subject. This is in contrast to the situation in Australian hospitals, where there is regular reporting of some (albeit limited) safety and quality indicators such as serious adverse events (for example, see SCRGSP 2014).
We do, however, have some (again, limited) quality-related information on 2 of the most common high cost primary care activities—medication prescribing and ordering of diagnostic tests.
With medication prescribing, variation (over time or location) in prescription rates for specific conditions can indicate either differences in disease prevalence and/or differences in prescribing practices, with definitive conclusions being difficult to reach. For example, while there is some evidence that prescription rates for antidepressants in Australia are both increasing and high by international standards (OECD 2013), it is not clear whether this is being driven by over-prescribing, or treatment of previously undiagnosed untreated cases.
And while there is substantial evidence to support judicious prescribing of antibiotics because of the advent of antibiotic resistance issues (McKenzie et al. 2013; NPS 2012), it is not clear why the volume of antibiotics prescribed in Australia is higher than the OECD average (OECD 2013). There are a number of programs aimed at tackling antibiotic resistance and reducing infections in primary health care (NPS 2013) as well as in Australian hospitals (ACSQHC 2012) , but there is currently no systematic monitoring of the prescribing of antibiotics in primary health care settings. Opportunities may be explored for comprehensive monitoring of these and other medications as electronic prescribing is rolled out and matures.
The number of Medicare services claimed per person for imaging and pathology tests have increased in the past decade by 38% and 46% respectively (DHS 2014b). There is some limited evidence that some of this testing may not be necessary, either according to clinical management guidelines or where results are not accessible to health professionals in a timely manner. For example, one study showed that about 1 in 4 Australians presenting at primary health care for low back pain are sent for imaging tests and 5% are sent for pathology although clinical management guidelines discourage the use of these tests (Williams et al. 2010). However, there is no comprehensive authoritative statistical information on this subject.
New features of the national e-Health system, designed to support sharing of pathology and imaging results between health-care providers, may reduce the need for doctors to locate test results or unnecessarily repeat tests (Australian Ageing Agenda 2013), thereby saving time and money, and potentially improving safety and quality in patient care.
In 2012–13, 90% of ABS patient experience survey respondents who saw a GP in the previous 12 months reported that the GP always or often listened carefully to them, while 93% reported that the GP always or often showed them respect (ABS 2013b).
The proportion of patients with positive experiences in Australia has increased in recent years (Commonwealth Fund 2004, 2007, 2010). In 2010, Australia was at about the OECD average in terms of patient ratings of regular doctors spending enough time with them, providing easy-to-understand explanations, giving opportunities to ask questions, and involving them in decisions about care and treatment (OECD 2013).
There is little national information about patient experiences with non-GP primary health care, with one exception being patient perceptions of waiting times for dental services. In 2011–12, among people who had seen a dental professional for urgent care in the previous 12 months, 20% were seen within 4 hours and 43% waited 2 or more days between making the appointment and seeing the dental professional (ABS 2012).
As noted previously, international evidence suggests that a strong primary health care orientation within the health service system exerts a positive effect on both population health outcomes and overall health system costs. For this reason, various countries, including Canada, the United Kingdom and New Zealand, have embarked on health system reforms to reorient their health systems towards primary health care. For example, reforms in Canada (with similar objectives to those in Australia) over the last decade have been linked to the higher levels of health among Canadians compared to their US neighbours (Hutchinson et al. 2011; Starfield 2010).
The primary health care system in Australia is broad and complex and it is difficult to consistently define what services and health professionals it encompasses, and describe in detail the nature of the services delivered to patients. It is therefore not surprising that there are challenges in describing its contribution to improved population health outcomes and health system financial sustainability. What can we say about these high-level outcomes?
There is great interest in better understanding health outcomes to ensure that people are receiving the best available care, and in order to invest in interventions that offer the greatest benefit. Primary health care is expected to improve overall health outcomes through strong contributions to reductions in tobacco smoking, excessive alcohol consumption and obesity, and by identifying and managing diseases early, thereby reducing disease incidence, prevalence and death.
Australia's health 2014 provides many examples of where health outcomes are improving (for example, increased cancer survival, reduced smoking levels) and deteriorating (for example, rising obesity levels). Ongoing monitoring of these outcomes will provide information about further progress. In addition, limited population health information is currently available at the Medicare Local level (see, for example, NHPA 2013c; PHIDU 2013).
Of more critical importance is the challenge of attributing improvements in health outcomes to the primary health care system or to the health system more broadly when responsibility for outcomes is shared across governments, non-government entities and individuals. In addition, the lag time between health interventions and improved health outcomes (for example, a reduction in deaths due to lung cancer) can be considerable. For this reason, there is often interest in measuring improvements in processes, such as the delivery of anti-smoking advice during GP consultations, where evidence demonstrates a given intervention is linked to improved outcomes. Australia's limited data on the activities of primary health care practitioners currently limits our capacity to describe this activity.
Ideally, a well-functioning primary health care system will deliver effective care at least cost, and avoid progression to more serious illnesses and more costly hospital care, with associated risks such as hospital-acquired infections, or the risks associated with surgery. While this makes intuitive sense, we currently have limited information about the efficiency of the Australian primary care system and the extent to which it is contributing to improved financial sustainability of the health system as a whole.
Much of hospital financing in Australia is moving toward a relatively sophisticated activity-based funding model, with significant effort being dedicated to determining a national 'efficient price' and cost-weighting for services based on their complexity and costliness. This has been possible because of the relatively high quality data that has been collected over a long time from hospitals on their activities and expenditure. This type of data is not collected from primary health care providers. General practice and some other primary health care services are funded on a less sophisticated activity-based model than applies in hospitals, with government funding (through Medicare) largely determined by the reported length of the consultation. Other areas of primary health care are funded through block payments or at a program or service level.
As a result of poor primary health care data quality in Australia, it is difficult to gauge the cost-effectiveness of different types of primary care providers, or to compare the primary health care sector generally with other parts of the health system, or to other countries. For example, if a patient cannot or will not use a particular type of primary health care service due to, say, lack of availability or cost, they may attempt to access alternative hospital or community health services that may be available free of charge—for example, hospital outpatient services, or nutrition advice from a state-funded community health centre. Or they may seek other private services, perhaps partly reimbursed through private health insurance. Gaps in primary health care information make it difficult to assess the extent of substitution between these services and thereby readily understand the extent to which the system is cost-effective.
Primary health care has not experienced the same national focus on data capture, collation and reporting as other parts of the Australian health system. As a result, there is:
The statistical information that may be derived from Australia's emerging e-Health system may improve our understanding of primary health care. However, with the current participation arrangements, and legislative restrictions on the use of data, the contribution of e-Health to an improved understanding of population health and health care is not yet clear.
There are several opportunities to improve primary care information, including:
Local and international experiences in primary health care information show that information improvement is possible. A number of Medicare Locals, through collaborative efforts, have used existing data to effectively support their needs assessment and quality improvement processes. This has been possible through the cooperation of member GPs and extraction of selected de-identified data from GP computerised electronic patient records (Monash University 2013).
Several other countries, such as Canada, the United States of America, the United Kingdom and New Zealand, have made significant progress in primary health care information development, which Australia could adopt or adapt (see, for example, CIHI 2013 Box 8.2).
See previous editions of Review and evaluation of Australian information about primary health care: a focus on general practice (AIHW 2008).
Search for 'primary health care' on the Australian Government Department of Health website.
ABS (Australian Bureau of Statistics) 2012. Patient experiences in Australia: summary of findings, 2011–12. ABS cat. no. 4839.0. Canberra: ABS.
ABS 2013a. Australian Health Survey: health service usage and health related actions, 2011–12. ABS cat. no. 4364.0.55.00. Canberra: ABS.
ABS 2013b. Patient experiences in Australia: summary of findings, 2012–13. ABS cat. no. 4839.0. Canberra: ABS.
ACSQHC (Australian Commission on Safety and Quality of Health Care) 2011. Practice-level indicators of safety and quality for primary health care: consultation paper. Sydney: ACSQHC.
ACSQHC 2012. Antibiotics Awareness Week 12–18 November 2012 Preserve the miracle of antibiotics&. Sydney: ACSQHC. Viewed 27 February 2014.
AIHW 2012a. Australia's health 2012. Cat. no. AUS 156. Canberra: AIHW.
AIHW 2012b. Australian hospital statistics 2011–12: emergency department care. Cat. no. HSE 126. Canberra: AIHW.
AIHW 2012c. Medical workforce 2010. National health workforce series no. 1. Cat. no. HWL 47. Canberra: AIHW.
AIHW 2013a. Allied health workforce 2012. National health workforce series no. 5. Cat. no. HWL 51. Canberra: AIHW.
AIHW 2013b. Australian hospital statistics 2011–12. Health services series no. 50. Cat. no. HSE 134. Canberra: AIHW.
AIHW 2013d. Aboriginal and Torres Strait Islander health services report 2011–12: online services report—key results. Cat. no. IHW 104 Canberra: AIHW.
AIHW 2013e. Medical workforce 2011. National health workforce series no. 3. Cat. no. HWL 49. Canberra: AIHW.
AIHW 2013f. Nursing and midwifery workforce 2012. National health workforce series no. 6. Cat. no. HWL 52. Canberra: AIHW.
AIHW 2014a , forthcoming. Dental workforce 2012. National health workforce series no. 7. Cat. no. HWL 53. Canberra: AIHW.
AIHW 2014b. Medical workforce 2012. National health workforce series no. 8. Cat. no. HWL 54. Canberra: AIHW.
Australian Ageing Agenda 2013. Pathology and imaging next for PCEHR. Sydney: Australian Ageing Agenda. Viewed 21 January 2014.
Australian Government 2013. The Coalition's policy to support the Australian health system. Canberra: Australian Government.
Bankart MJ, Baker R, Rashid A, Habiba M, Banerjee J, Hsu R et al. 2011. Characteristics of general practices associated with emergency admission rates to hospital: a cross-sectional study. Emergency Medicine Journal 28:558–63.
Britt H, Miller G, Henderson J, Bayram C, Valenti L, Harrison C et al. 2013a. General practice activity in Australia 2012–13. General practice series no.33. Sydney: Sydney University Press.
Britt H, Miller GC, Henderson J, Bayram C, Valenti L, Harrison C et al. 2013b. A decade of Australian general practice activity 2003–04 to 2012–13. General practice series no. 34. Sydney: Sydney University Press.
Browne J & Taylor J 2013. 'It's a good thing…': women's views on their continuity experiences with midwifery students from one Australian region. Midwifery doi: 10.1016/j.midw.2013.11.006.
Buckley D, Curtis P & McGirr J 2010. The effect of a general practice after-hour clinic on emergency department presentations: a regression time series analysis. Medical Journal of Australia 192:448–51.
CIHI (Canadian Institute of Health Information) 2013. Primary health care. Ottawa: CIHI. Viewed 4 November 2013.
COAG (Council of Australian Governments) Reform Council 2013a. Healthcare 2011–12: comparing performance across Australia—statistical supplement. Sydney: COAG Reform Council.
COAG Reform Council 2013b. Healthcare 2011–12: comparing performance across Australia: report to the Council of Australian Governments: 30 April 2013. Sydney: COAG Reform Council.
Commonwealth Fund 2004. Commonwealth Fund international health policy survey of adults' experience with primary care. New York: Commonwealth Fund.
Commonwealth Fund 2007. International health policy survey in seven countries, chartpack. New York: Commonwealth Fund.
Commonwealth Fund 2010. International health policy survey in eleven countries, chartpack. New York: Commonwealth Fund.
Department of Health 2011. Background—the need for change. Dublin: Department of Health. Viewed 4 November 2013.
Department of Health 2014. Annual Medicare statistics. Canberra: Department of Health. Viewed 30 January 2014.
DHS (Department of Human Services) 2013. Medicare Australia statistics. Canberra: DHS. Viewed 5 December 2013.
DHS 2014a. Bulk-billing frequently asked questions. Canberra: DHS. Viewed 21 January 2014.
DHS 2014b. Monthly and quarterly standard reports. Canberra: DHS. Viewed 9 January 2014
DoHA (Department of Health and Ageing) 2009. Primary health care reform in Australia—report to support Australia's first national primary health care strategy. Canberra: DoHA.
DoHA 2010. Building a 21st century primary health care system; Australia's first national primary health care strategy. Canberra: DoHA.
DoHA 2012. Background paper: Medicare Locals health needs assessment and planning. Canberra: DoHA.
DoHA 2013a. Annual report 2012–13. Canberra: DoHA.
DoHA 2013b. Medicare Local&. Canberra: DoHA. Viewed 28 November 2013.
Dutton, the Hon. P 2013. Medicare Locals review. Media release by Minister for Health and Minister for Sport. 16 December 2013. Canberra.
Freeman GK, Wolosynowych M, Baker R, Boulton M, Guthrie B, Car J et al. 2007. Continuity of care 2006; what have we learned since 2000 and where are the policy imperatives now? Report for the National Co-ordinating Centre for NHS Service Delivery and Organisation R & D. London: National Co-ordinating Centre for NHS Service Delivery and Organisation R & D.
Gafforini S & Carson N 2013. Primary-care type presentations to public hospitals. A local in-hours and after-hours population comparison. Final report. Melbourne: Inner North West Melbourne Medicare Local.
Gunther S, Taub N, Rogers S & Baker R 2013. What aspects of primary care predict emergency admission rates? A cross sectional study. BMC Health Services Research 13:11.
Harris M, Jayasinghe U, J T, Christl B, Proudfoot J, Crookes P et al. 2011. Multidisciplinary Team Care Arrangements in the management of patients with chronic disease in Australian general practice. Medical Journal of Australia 194(5):236–9.
Health Canada 2012. What is primary health care? Ottawa: Health Canada. Viewed 4 November 2013.
Health Quality Ontario 2013. Continuity of care to optimize chronic disease management in the community setting: an evidence-based analysis. Ontario Health Technology Assessment Series 13:1–41. Ottawa: Health Quality Ontario.
Healthdirect Australia 2013. Quarterly report, Quarter 1, January to March 2013. Sydney: Healthdirect Australia.
Hossain M & Laditka J 2009. Using hospitalization for ambulatory care sensitive conditions to measure access to primary healthcare: an application of spatial structural equation modelling. International Journal of Health Geographics 8:51–65.
Hutchison B, Levesque J-F, Strumpf E & Coyle N 2011. Primary health care in Canada: systems in motion. The Milbank Quarterly 89:256–88.
HWA (Health Workforce Australia) 2011. National health workforce innovation and reform strategic framework for action 2011–2015. Adelaide: HWA.
Institute of Medicine 1994. Defining primary care: an interim report. Washington: National Academy of Sciences.
Jorm LR, Leyland AH, Blyth FM, Elliott RF, Douglas KMA & Redman S 2012. Assessing preventable hospitalisation indicators (APHID): protocol for a data-linkage study using cohort study and administrative data. BMJ Open 2: doi:10.1136/bmjopen-2012-002344.
Kemp L, Harris E, McMahon C, Matthey S, Vimpani G, Anderson T et al. 2013. Benefits of psychosocial intervention and continuity of care by child and family health nurses in the pre- and postnatal period: process evaluation. Journal of Advanced Nursing 69:1850–61.
Macinko J, Starfield B & Shi L 2003. The contribution of primary care systems to health outcomes within Organisation for Economic Co-operation and Development (OECD) countries, 1970–1998. Health Services Research 38:831–865.
Masso M, Bezzina AJ, Siminski P, Middleton R & Eagar K 2007. Why patients attend emergency departments for conditions potentially appropriate for primary care: Reasons given by patients and clinicians differ. Emergency Medicine Australasia 19:333–40.
McKenzie D, Rawlins M & Del Mar C 2013. Antimicrobial stewardship: what's it all about? Australian Prescriber 36:116–20.
Monash University 2013. MAGNET (Melbourne East Monash GeNeral PracticE DaTabase). Clayton: Monash University. Viewed 28 November 2013.
Mosquera PA, Hernández J, Vega R, Martínez J, Labonte R, Sanders D et al. 2012. Primary health care contribution to improve health outcomes in Bogota-Colombia: a longitudinal ecological analysis. BMC Family Practice 13:1–8.
Nagree Y, Gosbell A, McCarthy C, Moore K & Mountain D 2013. Determining the true burden of general practice patients in the emergency department: getting closer. Emergency Medicine Australia 25:487–90.
New Zealand Ministry of Health 2001. The primary health care strategy. Wellington: New Zealand Ministry of Health.
Ng JY, Fatovich DM, Turner VF, Wurmel JA, Skevington SA & Phillips MR 2012. Appropriateness of healthdirect referrals to the emergency department compared with self-referrals and GP referrals. Medical Journal of Australia 197(9):498–502.
NHPA (National Health Performance Authority) 2013a. Healthy communities: Australians' experience with primary health care in 2010–11. Sydney: NHPA.
NHPA 2013b. Healthy communities: Australians' experiences with access to health care in 2011–12. Sydney: NHPA.
NHPA 2013c. Healthy communities: overweight and obesity rates across Australia, 2011–12. Sydney: NHPA.
NMML (Northern Melbourne Medical Local) 2013. Challenging myths and perceptions: understanding primary care patients in the emergency department. Summary report. Melbourne: NMML.
NPS (National Prescribing Service) 2012. Antibiotic resistance and respiratory tract infections. Sydney: NPS. Viewed 17 February 2014.
NPS 2013. NPS Medicinewise: join the fight against antibiotic resistance. Sydney: NPS. Viewed 10 February 2014.
O'Malley A 2012. After-hours access to primary care practices linked with lower emergency department use and less unmet medical need. Health Affairs, December. doi: 10.1377/hlthaff.2012.0494.
OECD (Organisation for Economic Co-operation and Development) 2013. Health at a glance 2013: OECD indicators. Paris: OECD Publishing.
Pearce C, Shearer M, Gardner K, Kelly J & Xu TB 2012. GP Network as enablers of quality of care: implementing a practice engagement framework in a General Practice Network. Australian Journal of Primary Health 18(2):101–4.
PHIAC (Private Health Insurance Administration Council) 2013. PHIAC A Report. Canberra: PHIAC.
PHIDU (Public Health Information Development Unit) 2013. Social health atlases of Australia. Adelaide: PHIDU. Viewed 8 November 2013.
RACGP (Royal Australian College of General Practitioners) 2010. Standards for general practices (4th edn) including interpretive guide for Aboriginal and Torres Strait Islander health services. East Melbourne: RACGP.
Rosano A, Loha CA, Falvo R, van der Zee J, Ricciardi W, Guasticchi G et al. 2013. The relationship between avoidable hospitalization and accessibility to primary care: a systematic review. European Journal of Public Health 23:356–60.
Royal Flying Doctor Service 2012. Annual report 11/12. Sydney: Royal Flying Doctor Service.
Runciman WB, Coiera EW, Day RO, Hannaford NA, Hibbert PD, Hunt TD et al. 2012. Towards the delivery of appropriate health care in Australia. Medical Journal of Australia 197:78–81.
SCoH (Standing Council on Health) 2013. National primary health care strategic framework. Canberra: Commonwealth of Australia.
SCRGSP (Steering Committee for the Review of Government Service Provision) 2014. Report on government services 2014. Canberra: Productivity Commission.
Starfield B 2005. Primary care in the context of health services system. Montreal: University of Montreal. Viewed 4 November 2013.
Starfield B 2010. Reinventing primary care: lessons from Canada for the United States. Health Affairs 29:1030–36.
Starfield B & Shi L 2002. Policy relevant determinants of health: an international perspective. Health Policy 60:201–18.
WHO (World Health Organization) 1978. Declaration of alma-ata—international conference on primary health care. USSR: WHO.
Williams C, Maher C, Hancock M, McAuley J, McLachlan A & Britt H 2010. Low back pain and best practice care. Archives of Internal Medicine 170:271–7.
The Australian Government and state and territory governments fund a range of alcohol and other drug treatment services provided by non-government and government organisations. Services are delivered in residential and non-residential settings and include detoxification and rehabilitation programs, information and education courses, counselling, and pharmacotherapy, which involves long-acting medicines to manage opioid dependence.
The Alcohol and Other Drug Treatment Services National Minimum Data Set (AODTS NMDS) contains information on a large subset of publicly funded alcohol and other drug treatment agencies. These agencies provide services to people seeking assistance for their own drug use, people diverted from the criminal justice system and those seeking assistance for someone else's drug use.
Note: These data include episodes relating to clients seeking treatment for their own drug use and clients seeking treatment for someone else's drug use.
The ageing profile of clients is particularly apparent for those using heroin and other opioids. The National Opioid Pharmacotherapy Statistics Annual Data Collection reveals that, from 2006 to 2013, the proportion of clients aged under 30 more than halved (from 28% to 11%) and the proportion of those aged 50 and over more than doubled (from 8% to 19%).
Illicit Drug Reporting System data also show a rise in the age of injecting drug users, with the average age rising from about 30 to 39 over the decade to 2012 (Stafford & Burns 2013).
Possible reasons for these trends include fewer premature deaths as a result of treatment availability, and a group of long-term recipients now moving into older age while continuing treatment. The 2010 National Drug Strategy Household Survey (NDSHS) showed a fall in the proportion of younger people using illicit drugs, suggesting these trends seem likely to continue.
The 2013 NDSHS, due for release in the second half of 2014, will provide up-to-date information on population-level drug use patterns, which will help us to better understand the ageing trends.
To date, the AODTS NMDS has contained data only on completed treatment episodes rather than on people seeking treatment. However, from the 2012–13 collection onwards, a unique person identifier included in the collection will make it possible to count client numbers and analyse treatment patterns within and across service providers.
While the majority of drug and alcohol treatment is reported through the AODTS NMDS, consolidated data on the diversion of drug offenders from the criminal justice system into treatment could be improved through development of a National Minimum Data Set.
Note: These data only include episodes relating to clients seeking treatment for their own drug use.
For more information see alcohol and other drug use and treatment services in Australia.
For more information on issues related to alcohol and other drug treatment services, see Chapter 5 'Tobacco smoking', 'Alcohol risk and harm' and 'Illicit drug use—current and future issues'.
Stafford J & Burns L 2013. Australian drug trends 2012. Findings from the Illicit Drug Reporting System (IDRS). Australian drug trend series no. 91. Sydney: National Drug and Alcohol Research Centre, University of New South Wales.
Mental illness contributes substantially to the burden of disease in the community (see Chapter 4 'Mental health in Australia'). In Australia, people with mental illness have access to a variety of support services provided by a range of health-care professionals in a number of care settings (Figure 8.8).
A large number of support services are provided to people with a mental illness each year. For example, community mental health care services provided more than 7 million contacts in 2011–12 (Table 8.1).
Medicare-subsidised services are provided by psychiatrists, general practitioners (GPs), psychologists, and other allied health professionals (social workers, mental health nurses and occupational therapists). The services are provided in a range of settings—in hospitals, consulting rooms, home visits and over the phone.
There was an average annual increase of 11.2% in the number of Medicare-subsidised mental health-related services over the 5-year period to 2011–12 (Figure 8.9). This can be mainly attributed to the uptake of the Better Access initiative (implemented in November 2006) which gave patients Medicare-subsidised access to psychologists and other allied health providers after the preparation of a Mental Health Treatment Plan by a GP.
Source: Medicare Benefits Schedule data (Department of Health and Ageing).
There were an estimated 32.7 million prescriptions for mental health-related medications dispensed in 2011–12, of which 72.3% (23.4 million) were subsidised by the Australian Government under the Pharmaceutical Benefits Scheme (PBS). Of these, the majority (86.1%) were prescribed by GPs, with another 8.1% prescribed by psychiatrists and 5.8% by non-psychiatrist specialists. Most of the prescriptions were for antidepressant medications (61.7%, or 14.4 million), followed by anxiolytics (13.1%), antipsychotics (13.0%) and hypnotics and sedatives (9.7%) (Figure 8.10).
It is not possible to definitively count the total number of people delivering care and support to those with a mental illness; however, we do know that:
Note: ATC = Anatomical Therapeutic Chemical classification system (WHO 2011).
Source: Pharmaceutical Benefits Scheme and Repatriation Pharmaceutical Benefits Scheme data (Department of Health and Ageing).
Outcome measures for consumers, such as changes in symptoms, and experiences of care, are essential to quality improvement for mental health services. National level data for a set of measures for public services is already collected through the Mental Health National Outcomes and Casemix Collection, and services in both the public and private sectors are investing in an expanded range of measures as a priority.
It is anticipated that the National Disability Insurance Scheme (NDIS) will change the way some services are delivered, including those described here and specialised community support services provided by non-government organisations. The latter are not well described in current data collections.
More information on mental health and mental health services is available at Mental health services in Australia.
DoHA (Department of Health and Ageing) 2013. National mental health report 2013: tracking progress of mental health reform in Australian 1993–2011. Canberra: Commonwealth of Australia.
WHO (World Health Organization) 2011. ATC: structure and principles. Oslo: WHO Collaborating Centre for Drug Statistics Methodology. Viewed March 2013.
Ambulance services are often critical to a person's chances of surviving an acute illness or trauma. They provide emergency pre-hospital patient care, offer transport in response to sudden illness or injury, transport patients between hospitals, conduct specialised rescue services and coordinate patient services in multi-casualty events.
An incident is an event that results in a response by an ambulance service. A response is where an ambulance vehicle or vehicles are sent to an incident. There can be multiple responses to a single incident.
Source: SCRGSP 2014.
An ambulance patient is a person who has been assessed, treated or transported by an ambulance service.
Aero-medical health services include services using helicopters and aeroplanes. In Australia these services are provided by many different organisations, including the Royal Flying Doctor Service, CareFlight Australia, the Newborn and Paediatric Emergency Transport Service and the Australian Defence Force.
The Steering Committee for the Review of Government Service Provision, with the assistance of the Australasian Fire and Emergency Services Authorities Council, the Australian Council of State Emergency Services and the Council of Ambulance Authorities, is working to improve the comparability and accuracy of ambulance services data and to expand the scope of performance reporting.
More information on ambulance services in Australia is available at the Council of Ambulance Authorities website. More information on the Royal Doctor Flying Service is available.
SCRGSP (Steering Committee for the Review of Government Service Provision) 2014. Report on Government Services 2014. Vol. D, emergency management, Chapter 9, fire and ambulance services. Canberra: Productivity Commission. Viewed 30 January 2014.
Australia's hospital services are provided by public and private hospitals in all states and territories. This snapshot provides an overview of public and private hospitals and the services they provide. For more information on private hospitals, see Chapter 8 'The rise of private hospitals', and for information on hospital funding and spending, see Chapter 2 'How much does Australia spend on health care?'.
Australian public hospitals range from very large principal referral hospitals found predominantly in metropolitan areas to small hospitals typically located in regional and remote areas. The numbers of beds varies markedly—principal referral hospitals, the largest hospitals, had on average 417 beds; however, more than 70% of hospitals had 50 or fewer beds. Some hospitals perform a specialised role, such as psychiatric and rehabilitation hospitals, and have longer average lengths of stay than others, reflecting a greater focus on longer-stay sub-acute and non-acute care (see Chapter 8 'Sub-acute and non-acute care') than the predominantly shorter-stay acute care provided by larger hospitals (Table 8.2).
In 2011–12, the most common specialised services offered in public hospitals were domiciliary care (403 hospitals), services provided by nursing home care units (265) and obstetric/maternity services (231). These services are mainly located in smaller regional and large metropolitan hospitals. Principal referral and large hospitals typically operate 24-hour emergency departments and intensive care units, though these facilities are also provided in some other larger hospitals. Principal referral hospitals also typically have specialised service units for cardiac surgery, neurosurgery, infectious diseases and organ transplantation.
In 2011–12, there were 396 private hospitals with operating theatres. These hospitals contained a total of 1,372 operating theatres (ABS 2013). For more information on specialised services provided by private hospitals, see Chapter 8 'The rise of private hospitals'.
Source: Australian hospital statistics 2011–12.
Australia's hospitals provide a range of services for admitted and non-admitted patients. These services vary, depending on the patients, the reasons for the hospital care and the type of care provided. Admitted patient services are provided either on the same day or involve an overnight stay of 1 or more nights in hospital. Services for non-admitted patients include those provided by emergency departments (see Chapter 8 'Emergency departments: at the front line') and outpatient clinics.
Public and private hospitals provide somewhat different services. In 2011–12, public hospitals provided most emergency department (94%) and outpatient (97%) services, while private hospitals accounted for 2 out of 3 hospitalisations involving elective surgery.
Although well-developed hospitalisation data are available, there are variations in how hospital services are defined and counted. The data are based on each admission, and it is not possible to link records for a single patient's care—for example, to analyse care patterns in patients hospitalised several times or to count the number of individual patients. Similarly, it is not possible to analyse patterns of care across admitted and non-admitted patient settings (including non-hospital settings such as primary care).
Data on hospital services for outpatients and other non-admitted patients are less well-developed, with current data collections mainly consisting of basic service counts and some demographic information about the patients. National work is currently under way to collect more detailed information on the type of care received in these settings.
More information on hospitals in Australia is available. The reports Australian hospital statistics 2011–12 and Australia's hospitals 2011–12: at a glance are available for free download.
ABS (Australian Bureau of Statistics) 2013. Private hospitals, Australia, 2011–12. ABS cat. no. 4390.0. Canberra: ABS. Viewed 11 December 2013.
Emergency departments are a critical component of the health system because they provide care for patients who have life-threatening or other conditions that require urgent medical care. For some patients, they serve as the first or only point of contact with the health system, due to combinations of patient preference, unavailability of other services, and lack of need for ongoing care after the care provided in the emergency department. For some patients, they serve as a gateway to care as an admitted patient in a hospital, or to other specialised or ongoing health care.
Because of their important front-line role, the role and performance of emergency departments is under constant public scrutiny, and is the subject of a range of public performance reporting.
Lengthy waiting times have caused concern for patients and the Australian community more generally. Accordingly, emergency department waiting times are key performance indicators under a number of national health agreements with a focus on improving accessibility of health services. The quality of emergency department care is an emerging area of interest, with a measure of unplanned re-attendances at emergency departments having been agreed as a first step towards better information being available on this important topic.
The performance of emergency departments is influenced by other components of the health-care system. People sometimes attend emergency departments for reasons that could be addressed by non-hospital services such as general practitioners. Similarly, many presentations involve an admission of a patient to hospital and are dependent on the hospital's capacity to admit the patient. Hence, information on these types of interfaces between emergency departments and other health-care providers is important to understanding the role and performance of emergency departments.
This article highlights the activities of emergency departments in Australia and the changes in these activities over time. It also presents information on waiting times for emergency department care and describes work under way on other indicators of emergency department performance.
There were more than 6.7 million emergency department presentations (see Box 8.3) reported in Australian public hospitals in 2012–13, equivalent to just over 18,000 presentations each day. About 86% of these occurred in Principal referral and specialist women's and children's hospitals and Large hospitals.
Between 2008–09 and 2012–13, the number of emergency department presentations increased by 16.9%, with an average annual increase of 4.0% (Figure 8.13). However, over this period the coverage of the National Non-Admitted Emergency Department Care Database (NNAPEDCD) collection also increased, with the number of hospitals reporting rising from 184 to 204. This coverage change should be taken into account in interpreting changes over time. After adjusting for coverage changes, the number of presentations increased by an average of 2.9% each year.
Most larger Australian public hospitals have a formal emergency department. Smaller public hospitals do not, but can provide emergency services through more informal arrangements.
The data presented in this article apply to care in the 204 formal emergency departments in public hospitals in Australia. These data are provided to the AIHW's National Non-Admitted Emergency Department Care Database (NNAPEDCD). For information on emergency department services in private hospitals, see Chapter 8 'The rise of private hospitals'.
Patients can present to an emergency department for an emergency, a return or planned visit, or a pre-arranged admission. Patients can also be provided with care while in transit, or may be dead on arrival.
A patient presentation at an emergency department is regarded as occurring following the arrival of the patient at the emergency department and is the earliest occasion of being registered clerically or triaged.
The triage category assigned to a patient indicates the urgency of the patient's need for medical and nursing care. It is usually assigned by an experienced registered nurse or medical practitioner at, or shortly after, the time of presentation to the emergency department. The National Health Data Dictionary (AIHW 2012a) defines 5 categories— based on the Australasian Triage Scale (ACEM 2013)—that incorporate the time by which the patient should receive care:
In 2012–13, the majority (almost 75%) of people presenting to emergency departments arrived by private transport, public transport, community transport or taxis (Table 8.3). Ambulance and aero-medical transport services made up 24% of arrivals.
The means of arrival to the emergency department varied with the triage category (see Box 8.3). For example, the proportion of presentations where the patient arrived by ambulance and aero-medical transport services ranged from 4% for Non-urgent patients to 85% for Resuscitation patients.
Source: AIHW 2013a.
Note: The number of public hospital emergency department presentations for the Northern Territory is very similar to Tasmania and is partially obscured in the above figure.
Males accounted for just over half of emergency department presentations, and there were more presentations for males than females in each age group, except those aged 15–34 and those aged over 74 (Figure 8.14).
People in the 15–24 year age group accounted for 15% of emergency department presentations. This group was consistently responsible for the highest numbers between 2008–09 and 2012–13. This age group represents just under 14% of the total population so is slightly over-represented in emergency department presentations.
People aged under 5 years and those aged 75 and over were also over-represented. They accounted for 12% and 11% of emergency department presentations, respectively, and 7% and 6% of the total population, respectively.
In 2012–13, there were more than 260,000 emergency department presentations in public hospitals — over 5% of the total— for Indigenous Australians, who represent 3% of the total Australian population. An AIHW study showed that the actual number of hospital admissions for Indigenous Australians was estimated at about 9% higher than currently recorded (AIHW 2013b); it is possible that presentations to emergency departments are similarly underestimated for Indigenous patients. In addition, because most of the data available relate to formal emergency departments in hospitals in major cities, emergency presentations may not all be captured in regional and remote areas where the proportion of Indigenous people (compared with other Australians) is higher than average.
More information on ambulance services is in Chapter 8 'Ambulance services'.
Emergency department services are available 24 hours a day 7 days a week. In 2012–13, a higher number of presentations occurred over weekends and on Mondays than on other days. On average, over two-thirds (69%) of patients arrived between the hours of 8 am and 8 pm. (Figure 8.15).
The triage category indicates the urgency of the patient's need for medical and nursing care (see Box 8.3). In 2012–13:
Since 2007–08, the number of emergency department presentations has increased every year for all triage categories with the exception of Non-urgent presentations, which have steadily decreased (AIHW 2012b).
Emergency department waiting time is the time elapsed for each patient from presentation in the emergency department to commencement of clinical care. Information is presented in this section on the time elapsed during which half and 90% of emergency department patients were seen, and on the proportion of patients seen within the time specified for their triage category. The time elapsed during which half the patients were seen is also known as the 50th percentile or median waiting time.
Patients who present to an emergency department with a visit type of Return visit, Planned, Pre-arranged admission or Patient in transit (see Box 8.3) do not necessarily undergo the same processes as those for Emergency presentations, and their waiting times may rely on factors outside the control of the emergency department. Therefore, waiting time statistics are presented for Emergency presentations only.
In 2012–13, 50% of patients received treatment by a medical officer or a nurse within 19 minutes of presenting to the emergency department (the median waiting time) and 90% received treatment within 101 minutes of presentation. From 2008–09 to 2012–13, the median waiting time decreased from 23 minutes to 19 minutes and the waiting time for 90% of patients reduced by 18 minutes from 119 to 101 minutes (Figure 8.16).
Waiting times for emergency department care: proportion seen on time is a National Healthcare Agreement (NHA) performance indicator in the outcome area of 'hospital and related care' (COAG Reform Council 2012). Its scope is emergency departments in public hospitals classified as Principal referral and specialist women's and children's hospitals and Large hospitals.
The proportion of patients 'seen on time' is the proportion of presentations for which the waiting time to commencement of clinical care was within the time specified in the definition of the triage category, usually represented as a percentage. From 2008–09 to 2012–13, the overall proportion of emergency patients 'seen on time' increased from 70% to 72%.
In 2012–13, this proportion varied across the states and territories, from 50% in the Northern Territory, to 76% in New South Wales. The proportion of presentations seen on time also varied by triage category, with the more urgent presentations generally more likely to be seen on time. Almost 100% of Resuscitation patients and 82% of Emergency patients were seen on time.
Of emergency department presentations for Indigenous Australians, 70% were seen on time, compared with 72% for other Australians. (Note: The quality of the Indigenous status data has not been formally assessed and so should be interpreted with caution.)
See Chapter 9 'Indicators of Australia's health' for more information on the proportions of patients seen on time.
Targets can be important tools to drive process and system improvements in health care delivery, and are used in monitoring emergency department activity. The National Emergency Access Target (NEAT ), agreed by all jurisdictions under the National Partnership Agreement on Improving Public Hospital Services (NPA IHPS), sets an overall target that, by 2015, 90% of people attending an emergency department will be admitted to hospital, referred to another hospital, or discharged home within 4 hours of their initial presentation.
This target was based on advice from the Council of Australian Governments (COAG) Expert Panel established to review targets under the NPA IPHS to ensure clinical appropriateness and safety. The target is incorporated in the NHA financial year indicator Waiting time for emergency hospital care: proportion completed within four hours. The COAG Reform Council measures progress against this indicator, as well as progress for each state and territory against their own calendar year annual targets and against baseline data for 2010 (COAG Reform Council 2013b).
The calculation of this performance indicator includes all presentations to emergency departments (not just Emergency presentations). As stated previously, patients are considered to have started their visit to the emergency department when they are registered clerically or triaged, whichever happens first, and completed when they physically leave the department (regardless of whether they were admitted to the hospital, referred to another hospital, were discharged or left at their own risk).
During 2012–13, 67% of presentations nationally were completed in 4 hours or less. This was a small increase from 2011–12 (64%) (AIHW 2012b). Western Australia achieved the highest proportion (77%) of emergency department visits completed in 4 hours or less and the Australian Capital Territory had the lowest (57%).
Presentations for patients who required more urgent treatment were not as likely to be completed in 4 hours or less. For example, 53% of Resuscitation visits and 49% of Emergency visits were completed in 4 hours or less, compared with 75% of Semi-urgent visits and 90% of Non-urgent visits.
The COAG Reform Council's assessment of performance for calendar year 2012 was that in Western Australia the proportion of patients admitted from the emergency department to hospital, referred on, or discharged, within 4 hours, was 78.5% and exceeded the 76.0% target for that state. Four jurisdictions partially achieved their targets—Queensland met 49.8% of its 2012 target, South Australia met 86.3%, Tasmania met 16.0% and the Australian Capital Territory met 11.2%. Performance in New South Wales, Victoria and the Northern Territory was below the 2010 baseline (COAG Reform Council 2013b).
The episode end status describes the status of the patient at the conclusion of the non-admitted patient episode in the emergency department. The episode end status can be reported as:
For 2012–13, almost two-thirds of presentations (for all types of visit) reported an episode end status of Departed without being admitted or referred, and this proportion was higher for less urgent triage categories (Table 8.4). About 27% of all presentations were Admitted to this hospital at the conclusion of treatment in the emergency department, and this proportion was lower for less urgent triage categories—76% for Resuscitation patients and less than 5% for Non-urgent patients.
About 4% of emergency department presentations had an episode end status of Did not wait. This proportion varied by triage category, and was highest for Non-urgent patients.
A key issue for hospitals is 'access block', the term for when a person has presented to an emergency department and has been judged by the attending doctor to require admission for further care, but cannot be admitted promptly because of lack of beds available in wards (National Health and Hospitals Reform Commission 2009).
In 2011, the COAG Expert Panel noted that 'access block is associated with increased mortality, along with medical errors and adverse events, time delays and discomfort for patients, increased staff turnover, staff burnout and ambulance diversion' (Commonwealth of Australia 2011).
Nationally in 2012–13, 36% of emergency department presentations resulting in admission were completed within 4 hours. The proportion ranged from 24% in the Northern Territory to 46% in Western Australia.
The percentage of emergency department stays completed within 4 hours varied by triage category. For patients subsequently admitted, resuscitation and non-urgent patients were more likely to be admitted within 4 hours than those in other triage categories.
Nationally, 90% of emergency department visits for patients subsequently admitted were completed within 13 hours and 41 minutes, ranging from 9 hours and 42 minutes in Western Australia to 20 hours and 47 minutes in Tasmania.
Potentially avoidable GP-type presentations to emergency departments indicate the number of attendances at public hospital emergency departments that potentially could have been avoided through the provision of non-hospital health services. This is an NHA performance indicator in the outcome area of 'Australians receive appropriate high quality and affordable primary and community health services' (COAG Reform Council 2013b); it is not an indicator of hospital performance.
Such service use may reflect the availability and ease-of-access to primary and community health, and the lack of cost to the patient for emergency department attendance. This type of service use has important resource implications for hospitals.
Potentially avoidable GP-type presentations are defined for NHA reporting purposes as presentations to public hospital emergency departments in Principal referral and specialist women's and children's hospitals (peer group A) and Large hospitals (peer group B) with a type of visit of Emergency presentation where the patient:
It should be noted that this is an interim specification and the definition of potentially avoidable GP-type presentations is presently under review (see 'What is missing from this picture?' below).
In 2012–13, potentially avoidable GP-type presentations were estimated to account for almost 2.2 million emergency department presentations: over 1.6 million in Principal referral and specialist women's and children's hospitals and almost 570,000 in Large hospitals (see Chapter 9 'Indicators of Australia's health' for more information).
When the Australian Bureau of Statistics (ABS) asked respondents to the 2012–13 Patient Experience Survey if they had been to a hospital emergency department for their own health in the last 12 months, 23% of people aged 15 and over who had visited an emergency department felt that a GP could have provided the care received instead (ABS 2013a).
As the scope of the NNAPEDCD includes all public hospitals with a formal emergency department, most of the data received relates to hospitals in capital cities or major centres. As noted in Box 8.3, smaller public hospitals, including those in more remote regions, provide some levels of emergency care for patients. Data on these services are not included in this article. For 2012–13, it is estimated that the emergency department presentations data reported to the NNAPEDCD captured 84% of all emergency occasions of service.
At present, the NNAPEDCD does not include information on the reason for presenting to an emergency department. From late 2014, national diagnosis information will be available as part of the NNAPEDCD, and work will commence on how best to use it to describe why patients attend emergency departments.
The AIHW is developing a number of new performance indicators to support the priorities agreed by the Australian Government and state and territory governments under the NPA IPHS. A performance indicator to measure unplanned re-attendances to emergency departments has been agreed. Indicators on the use of emergency department short-stay units, and patient access to emergency surgery, are under development. The AIHW is also leading work to revise the existing NHA performance indicator, Selected potentially avoidable GP-type presentations to emergency departments. This work is being undertaken in consultation with a range of stakeholders, including representatives from primary care and emergency department services, and is due for implementation in 2014.
More information on elective surgery in Australia is available. The report Australian hospital statistics 2012-13: emergency department care and other recent publications are available for free download.
Information on emergency departments in individual hospitals is available on myhospitals.gov.au .
ABS (Australian Bureau of Statistics) 2013a. Patient experiences in Australia: summary of findings, 2012–13. ABS cat. no. 4839.0. Canberra: ABS. Viewed 25 November 2013.
ABS 2013b. Private hospitals, Australia, 2011–12. ABS cat. no. 4839.0. Canberra: ABS. Viewed 28 November 2013.
ACEM (Australasian College for Emergency Medicine) 2013. P06 Policy on the Australasian triage scale. Melbourne: ACEM.
AIHW (Australian Institute of Health and Welfare) 2013a. Australian hospital statistics 2012–13: emergency department care. Health services series no. 52. Cat. no. HSE 142. Canberra: AIHW.
AIHW 2013b. Indigenous identification in hospital separations data: quality report. Cat. no. IHW 90. Canberra: AIHW.
AIHW 2012a. National health data dictionary, version 16. Cat. no. HWI 119. Canberra: AIHW.
AIHW 2012b. Australian hospital statistics 2011–12: emergency department care. Health services series no. 45. Cat. no. HSE 126. Canberra: AIHW.
AIHW 2010. Australian hospital statistics 2008–09. Health services series no. 34. Cat. no. HSE 84. Canberra: AIHW.
COAG (Council of Australian Governments) Reform Council 2012. National Healthcare Agreement review report July 2012. Sydney: COAG Reform Council. Viewed 18 November 2013.
COAG Reform Council 2013a. Healthcare 2011–12: comparing performance across Australia. Report to the Council of Australian Governments. Sydney: COAG Reform Council. Viewed 11 November 2013.
COAG Reform Council 2013b. National Partnership Agreement on Improving Public Hospital Services: performance report for 2012. Sydney: COAG Reform Council.
Commonwealth of Australia 2011. Expert panel review of elective surgery and emergency access targets under the National Partnership Agreement on Improving Public Hospital Services. Canberra: Department of Health. Viewed 11 November 2013.
National Health and Hospitals Reform Commission 2009. A healthier future for all Australians—final report of the National Health and Hospitals Reform Commission. Canberra: Department of Health. Viewed 20 November 2013.
Hospital care is often characterised as acute care, where the aim is to cure a condition, alleviate symptoms or manage childbirth. While acute care dominates hospital care, many hospitals also provide sub-acute or non-acute care, which aim to optimise a patient's functioning and quality of life. There were about 424,000 hospitalisations for sub-acute and non-acute admitted patient care in 2011–12, accounting for about 4.6% of all hospitalisations and 16.5% of days of patient care in public and private hospitals.
Sub-acute care includes services with a primary clinical purpose or treatment goal of:
Non-acute care is where the primary clinical purpose or treatment goal is support for a patient with impairment, activity limitation or participation restriction due to a health condition. This is also known as 'maintenance care'.
Patients receiving sub-acute and non-acute care usually stay in hospital for longer than those receiving acute care.
Data on admitted patient sub-acute and non-acute care are based on the overall nature of the clinical service provided to the patient during their episode of care. This might not capture all the types of care involved. For example, palliative care can be provided during episodes of care where the overall nature of the care is not palliative care. Chapter 6 'Palliative care in Australia' includes more information on this broader range of 'palliative care' services.
Sub-acute and non-acute services can also be delivered to non-admitted patients, for which very limited data are currently available. Work is under way to develop a patient-level non-admitted patient data collection for national reporting.
More information on sub-acute and non-acute hospital care in Australia is available on the AIHW website. The reports Australian hospital statistics 2011–12 and Trends in palliative care in Australian hospitals and other recent publications are available for free download.
Elective surgery is a term used for non-emergency surgery that is medically necessary, but for which admission can be delayed for at least 24 hours. Prioritising and scheduling patients for elective surgery is an important consideration for Australian hospitals, with the larger public hospitals managing waiting lists for this type of surgery.
Although private hospitals perform about two-thirds of elective surgery in Australia (1.3 million admissions for private hospitals compared with 673,000 for public hospitals in 2012–13), waiting time information is only collected for public hospitals.
During the 5 years from 2008–09 to 2012–13, median waiting times for elective surgery in public hospitals increased from 33 to 36 days and the number of days within which 90% of patients were admitted rose from 219 to 265. However, the proportion of patients who were admitted after a year or more remained at about 3%. Median waiting times rose for the surgical specialties of: cardio-thoracic surgery; ear, nose and throat surgery; gynaecological surgery; ophthalmic surgery; and orthopaedic surgery. Median waiting times fluctuated or remained fairly steady for other specialties.
The National Elective Surgery Target (NEST) is a performance measure required to be reported under the National Partnership Agreement on Improving Public Hospital Services (NPA IHPS). The aim of the NEST is to increase the proportion of people seen within the clinically recommended time, to reduce overdue wait times, and to treat those who have waited longest beyond the clinically recommended time. The Council of Australian Governments (COAG) Reform Council reports progress towards specific state and territory targets, and against baseline performance in 2010. The first report covered the 2012 calendar year (COAG Reform Council 2013).
There are 2 parts to the NEST covering 3 requirements. Part 1 sets targets for the proportion of patients seen within clinically recommended times. Part 2 sets targets for the average number of days waiting, for patients who waited longer than clinically recommended times. Part 2 also requires governments to ensure that, in a given year, of all the patients who have waited longer than clinically recommended, the 10% who have waited the longest are seen in that year.
Each of these 3 requirements is assessed with regard to the 3 clinical urgency categories that determine clinically recommended times for procedures—surgery required within 30, 90 and 365 days. Hence, there are 9 specific targets for each state and territory. Variations in the assignment of clinical urgency categories mean that the measures based on these categories are not comparable between jurisdictions.
For 2012, the COAG Reform Council assessed that:
For 2012–13, the National Elective Surgery Waiting Times Data Collection (NESWTDC) covered most public hospitals that undertook elective surgery and about 93% of public hospital elective surgery. Private hospitals do not report to the NESWTDC.
In 2011, an expert panel established by the Council of Australian Governments noted inconsistencies in clinical urgency categorisation for elective surgery among the states and territories. In response, the AIHW, in collaboration with the Royal Australasian College of Surgeons, developed a package of integrated reforms for national definitions for elective surgery urgency categories (AIHW 2013b). Health ministers have agreed with these recommendations, which are being implemented. Once this has occurred, waiting times can be meaningfully compared for each state and territory for each urgency category; the same will apply to proportions of patients who had their surgery within the clinically recommended time.
More information on elective surgery in Australia is available. The report Australian hospital statistics 2012-13: elective surgery waiting times and other recent publications are available for free download.
AIHW (Australian Institute of Health and Welfare) 2013a. Australian hospital statistics 2012–13: elective surgery waiting times. Health services series no. 51. Cat. no. HSE 140. Canberra: AIHW.
AIHW 2013b. National definitions for elective surgery urgency categories: proposal for the Standing Council on Health. Cat. no. HSE 138. Canberra: AIHW.
COAG (Council of Australian Governments) Reform Council 2013. National Partnership Agreement on Improving Public Hospital Services: performance report for 2012. Sydney: COAG Reform Council.
Private hospitals are a long-standing and important part of Australia's health-care delivery arrangements. In 2011–12, the 592 private hospitals in Australia accounted for 44% of Australia's 1,345 hospitals and 33% of all available hospital beds (ABS 2013; AIHW 2013). More than 40% of all hospitalisations occurred in private hospitals, including 2 out of every 3 hospitalisations involving elective surgery.
The volume of private hospital hospitalisations increased over the 10 years to 2011–12 by 47%—a faster rate than public hospitals (35%). The shift toward same-day hospital care contributed to this, with same-day hospitalisations accounting for 69% of private hospital hospitalisations in 2011–12, compared with 60% 10 years previously.
The growing role for private hospitals in Australia's health system has been supported by the Australian Government through measures such as the Private Health Insurance Rebate, and reflected in the inclusion of private hospitals in national performance monitoring initiatives such as those of the National Healthcare Agreement, and in the Performance and Accountability Framework of the National Health Reform Agreement (COAG 2012; NHPA 2013).
This article highlights the role that private hospitals play in the provision of hospital services in Australia and recent changes in the nature of the services that they deliver.
Private hospitals are generally grouped into those hospitals that provide services on a day-only basis (free-standing day hospital facilities, or 'day hospitals') and those that provide overnight care (referred to here as 'overnight hospitals'). This distinction reflects that, under state and territory regulatory arrangements, overnight care requires the provision of 24-hour qualified nursing care that permits a broader range of medical and surgical procedures to be undertaken. Some hospitals offering overnight care also provide same-day services.
Private hospitals are those that are owned and managed by private organisations, whether for-profit or not-for-profit. They exclude privately owned hospitals contracted by governments to provide public hospital services (11 hospitals in 2011–12). Private hospitals generally fall into 5 main 'ownership' types:
Not-for-profit hospitals are those that qualify as non-profit organisations with either the Australian Taxation Office or the Australian Securities and Investments Commission.
Nearly 60% of private overnight hospitals in Australia in 2011–12 operated on a for-profit basis. A further 30% were religious or charitable not-for-profit hospitals, with the remainder considered other not-for-profit hospitals (ABS 2013).
The number of private day hospitals increased from 236 to 311 between 2001–02 and 2011–12, a 32% increase. There were 2,973 beds or chairs available in private day hospitals in 2011–12, up 69% from 2001–02 (Figure 8.19).
In 2011–12, there were 281 private overnight hospitals operating in Australia, 7% fewer than the 301 hospitals reported for 2001–02 (ABS 2013). However, the number of available beds or chairs in private overnight hospitals rose by 5% over this period, from 24,748 to 26,031.
As a point of comparison, the number of public hospitals rose by 1% and the number of public hospital beds rose by about 14% over the same decade.
Note: Data on private hospitals are not available for 2007–08, and have been estimated. Small numbers of hospitals may be re-categorised as public or private between or within years.
Sources: ABS 2003, 2004, 2005, 2006, 2007, 2009, 2010, 2011, 2012, 2013.
On average, day hospitals had about 10 beds and chairs in 2011–12 and overnight hospitals, 93 beds. For day hospitals, 35% had 5 or fewer beds and chairs and 41% had 9 or more beds and chairs. About 18% of overnight hospitals had 25 or fewer beds and 10% had over 200 beds (ABS 2013).
Over recent years, there have been shifts in the patterns of specialised services and facilities offered at both day hospitals and overnight hospitals.
In 2011–12, there were 198 overnight hospitals with operating theatres, similar to the 201 in 2001–02. However, these hospitals had a total of 1,051 operating theatres, 268 more than in 2001–02 (ABS 2003, ABS 2013).
The profile of the specialised services provided by private hospitals has changed markedly in the last decade. Among the most commonly reported specialist services in 2011–12, the following had risen in number since 2001–02:
The following decreased in number:
Private day hospitals often specialise in a select group of procedures to a greater extent than overnight hospitals (Productivity Commission 2009). In 2011–12, specialised day hospitals included:
In line with the 69% increase in day hospital beds between 2001–02 and 2011–12, the number of operating theatres in day hospitals increased by 49% to 321. In the same period the number of procedure rooms increased by 45% to 260 rooms.
Private hospitals—both day hospitals and overnight hospitals—mainly provide care to admitted patients. Some overnight private hospitals also provide emergency department and outpatient services.
In 2011-12, there were 3.7 million hospitalisations in private hospitals (AIHW 2013). As mentioned earlier, the volume of private hospital hospitalisations increased in Australia between 2001–02 and 2011–12 by 47%, which was a faster rate than the increase in hospitalisations in public hospitals (35%). The proportion of all hospitalisations provided by private hospitals rose 2 percentage points to 40% between 2001–02 and 2011–12 (AIHW 2007, 2013).
Same-day hospitalisations are accounting for an increasing proportion of private hospital activity. As mentioned earlier, in 2011–12, same-day hospitalisations accounted for 69% of private hospital hospitalisations, compared with 60% in 2001–02 (Figure 8.20).
In 2011–12, private hospitals provided more than 30% of all days of patient care for admitted patients in hospital, with a 4% increase in the number of days provided from 2001–02 (compared with an increase of 3% for public hospitals). So, even though the number of private hospitalisations rose markedly between 2001–02 and 2011–12 (by 47%), the total number of days of patient care did not rise to the same extent, reflecting the increasing proportion of same-day hospitalisations in private hospital activity.
For each hospitalisation, a principal diagnosis is reported. This describes the chief reason for the patient's hospitalisation and is usually a disease, injury or poisoning. The most common principal diagnoses for private hospital hospitalisations related to Factors influencing health status and contact with health services, which includes care involving dialysis and chemotherapy (around a million hospitalisations), Diseases of the digestive system (around 500,000 hospitalisations) and Neoplasms (malignant or benign tumours) (around 320,000 hospitalisations).
Compared with public hospitals, a greater proportion of hospitalisations in private hospitals were for Neoplasms (8% of all hospitalisations in private hospitals compared with 5% of all hospitalisations in public hospitals), Diseases of the eye and adnexa (6% and 2% respectively), Diseases of the digestive system (13% and 8% respectively) and Diseases of the musculoskeletal system and connective tissue (8% and 3% respectively).
Between 2007–08 and 2011–12, the largest increases in the numbers of hospitalisations in private hospitals were for chemotherapy (by 32% to 217,246 hospitalisations) and haemodialysis (by 29% to 226,998 hospitalisations).
Note: Not all private hospitalisations are included in the National Hospital Morbidity Database across this time period, so counts presented here may be under-estimates.
Sources: AIHW 2008, 2013.
In 2011–12, more than one-third of hospitalisations (37%) were reported as Medical (did not involve an operating room procedure), more than one-third (37%) were Surgical (involved an operating room procedure) and about 20% were Other care (involved a non-operating room procedure, such as endoscopy). Childbirth admissions accounted for 2% of hospitalisations and Specialist mental health for 4%.
A larger proportion of private hospital admissions involved Surgical care than in public hospitals (37% compared with 21%), and a smaller proportion involved Medical care (37% compared with 77%). Private hospitals accounted for 1 out of every 4 admissions for childbirth. They also provided 61% of same-day hospitalisations for chemotherapy (AIHW 2013).
The complexity of hospital care provided to admitted patients can be estimated using average cost weights. The cost weight for a hospital is the ratio of the average cost of its hospitalisations compared with the average cost for all acute hospitalisations. Where a hospital has a cost weight above 1.0, on average its hospitalisations have an above-average cost, and the hospital is likely to provide more complex care than average.
In 2011–12, public hospitals and private overnight hospitals had similar average cost weights (0.99 and 1.01 respectively). Private day hospitals had a much lower average cost weight (0.47), suggesting that private day hospitals generally provide less complex care (AIHW 2013).
Between 2007–08 and 2011–12, private hospital admissions for sub-acute and non-acute care rose by an average of 17% per year, from about 130,000 admissions to about 242,000. In 2011–12, almost 6% of private hospital admissions were for sub-acute and non-acute care compared with 3% for public hospitals.
Of the different types of sub-acute and non-acute care, private hospitals provided about:
More information on these types of care is in Chapter 8 'Sub-acute and non-acute hospital care'.
Hospitalisations can be categorised as Emergency (required within 24 hours), or Elective (required at some stage beyond 24 hours). Some hospitalisations, for example obstetric care and planned care such as dialysis, are not assigned an emergency/elective status. In 2011–12, 5% of private hospital hospitalisations were Emergency admissions, whereas, for public hospitals, 40% were Emergency admissions. In 2011–12, 89% of private hospital hospitalisations were Elective (or other planned care), rising from 86% in 2001–02 (AIHW 2013).
Private hospitals accounted for 2 out of every 3 elective hospitalisations involving surgery, with lens procedures being the most common procedure (144,300 private hospital admissions).
The average length of hospital stay (including same-day hospitalisations) was longer in public hospitals, at 3.4 days, than in private hospitals, at 2.3 days in 2011–12. Excluding same-day hospitalisations (so overnight patients only), the average length of stay was 6.0 days in public hospitals and 5.3 days for private hospitals (AIHW 2013). The average length of stay for overnight patients in private hospitals remained stable over the 5 years to 2011–12.
Relative stay indexes (RSIs) summarise the length of stay for admitted patients, with adjustments for casemix (the types of patient treated and the type of treatment provided). An RSI greater than 1.0 indicates that an average patient's length of stay is higher than expected, given the casemix for the hospital. Conversely, an RSI less than 1.0 indicates that the length of stay was less than expected. The directly standardised RSI for private hospitals was 1.1 compared with 1.0 for public hospitals in 2011–12, indicating comparatively slightly longer lengths of stay for the private sector overall. There were relatively longer lengths of stay for medical admissions in private hospitals (RSI of 1.24 compared with 0.96 in public hospitals), and relatively shorter lengths of stay for surgical admissions in private hospitals (RSI of 0.98 compared with 1.04 in public hospitals) (AIHW 2013).
There were 2.1 million non-admitted patient occasions of service in overnight hospitals in 2011–12, an increase of 18% from 2001–02. The main driver of this increase was allied health services, which rose by 47% from 2001–02, to 602,300 occasions of service in 2011–12.
The other most commonly provided non-admitted patient services were accident and emergency (530,600 in 2011–12, an increase of 11% from 2001–02), and pathology (249,800, an increase of 24% from 2001–02) (ABS 2013).
There is no national information on patient characteristics for people receiving emergency department and outpatient care from private hospitals. However, this information is available for people admitted to private hospitals.
In 2011–12, females accounted for 55% of all private hospital admissions. By age group, the highest proportion of female admissions was for those aged 55–64 (18%) (Figure 8.21). There were more female patients than male patients in almost all age groups, with the differences being most marked where women were of child-bearing age.
Source: AIHW 2013.
In 2011–12, more than 1.5 million admissions in private hospitals were for patients aged 65 and over, representing 41% of all private hospital admissions (AIHW 2013). The proportion of private hospitalisations for patients aged 65 and over rose steadily between 2006–07 and 2011–12, from 36% to 41% (Figure 8.22). The proportion for patients aged 85 and over rose from 5% to 6%.
Private hospitalisation rates vary across remoteness areas and socioeconomic groups. Access to private hospital care is highest for those living in Major cities (175 hospitalisations per 1,000 population, compared with 70 hospitalisations per 1,000 in Very remote areas). People living in areas of least socioeconomic disadvantage are much more likely to use private hospitals than those living in areas of most socioeconomic disadvantage (227 hospitalisations per 1,000 compared with 103) (AIHW 2013).
In 2011–12, total income for private hospitals was estimated to be $11.2 billion, with day hospitals accounting for $876 million (8%) and overnight hospitals accounting for $10.4 billion (92%) (ABS 2013). When income is adjusted to remove the effects of price changes, the average annual increase over the 5 years from 2006–07 was 11% for day hospitals and 5% for overnight hospitals, reflecting the relative growth in activity of the 2 hospital types (ABS 2008, 2013).
Private hospitals are mainly funded by private health insurance and compensation schemes. More than three-quarters of private hospitalisations were funded by private health insurance, with most of the rest funded by the Department of Veterans' Affairs or under compensation scheme arrangements, with a small proportion self-funded. Between 2001–02 and 2011–12, the proportion of hospitalisations covered by private health insurance increased from 63% to 67% for private day hospitals and from 80% to 87% for overnight hospitals (ABS 2003, 2013).
Private hospitals provided care for 84% of hospitalisations funded by private health insurance and 80% of self-funded hospitalisations in 2011–12. They also provided care for 63% of hospitalisations for Department of Veterans' Affairs patients (AIHW 2013).
In many instances, public and private hospitals do not operate in isolation from each other, but instead provide health-care services in a coordinated manner. Interactions between public and private hospitals include contracted care arrangements, co-location and resource sharing, and private sector involvement in hospital infrastructure development for public patients. More details on these arrangements are provided below.
In some circumstances, hospitals provide care to admitted patients through inter-hospital contracted care arrangements, in which the care is organised and paid for by 1 hospital but provided by another. In 2011–12, about 62,000 hospitalisations were contracted by public hospitals to private hospitals—that is, the public hospitals paid for the care and the private hospitals provided the care. This represented 78% of all inter-hospital contracted patients, up from 66% (33,500 hospitalisations) in 2007–08 (AIHW 2009, 2013).
The remaining contracts were either between public hospitals, or by private hospitals to public hospitals.
Co-locating a private hospital with a public hospital allows for the sharing of facilities, equipment and staff, provides greater convenience for doctors, and enhances patient choice, allowing them access to a wider range of services. In 2011–12 there were 9 private day hospitals and 41 overnight hospitals co-located with public hospitals in Australia (ABS 2013).
Another form of public–private relationship is 'build, own, operate and transfer' arrangements. Under these arrangements, the private sector finances and builds new hospital facilities to treat public patients in return for the right to operate the facilities and receive funding from state and territory governments. In 2011–12, there were 11 hospitals that were privately owned and/or operated that provided public hospital services predominantly or substantially funded by state governments (AIHW 2013).
Private hospital data are collected, analysed and disseminated through multiple reporting pathways including the Australian Bureau of Statistics' Private Health Establishments Collection, the Australian Government Department of Health's Private Hospital Data Bureau and the Hospital Casemix Protocol, and the AIHW's National Hospital Morbidity Database. This diversity of data sources creates the risk that private hospital data could be inconsistent across the various collections and possibly inconsistent with data for public hospitals. Because data on financial and establishment characteristics are collected separately from hospital activity data, it can be difficult to link the data and so analyse relationships between financial and activity trends. That type of analysis would be important for the improved assessment of the relative performance of public and private hospitals that is a priority reform area identified in the National Healthcare Agreement.
As with public hospitals, work is under way to improve the measurement and public reporting of private hospital safety and quality indicators.
More information on private hospital activity in Australia is available on the AIHW and ABS websites at Australia's hospitals at a glance 2011-12. Other AIHW publications on hospitals.
ABS (Australian Bureau of Statistics) 2003. Private hospitals, Australia, 2001–02. ABS cat. no. 4390.0. Canberra: ABS. Viewed 11 December 2013.
ABS 2004. Private hospitals, Australia, 2002–03. ABS cat. no. 4390.0. Canberra: ABS. Viewed 28 November 2013,.
ABS 2005. Private hospitals, Australia, 2003–04. ABS cat. no. 4390.0. Canberra: ABS. Viewed 28 November 2013.
ABS 2006. Private hospitals, Australia, 2004–05. ABS cat. no. 4390.0. Canberra: ABS. Viewed 28 November 2013.
ABS 2007. Private hospitals, Australia, 2005-06&. ABS cat. no. 4390.0. Canberra: ABS. Viewed 28 November 2013.
ABS 2009. Private hospitals, Australia, 2006–07. ABS cat. no. 4390.0. Canberra: ABS. Viewed 28 November 2013.
ABS 2010. Private hospitals, Australia, 2008–09. ABS cat. no. 4390.0. Canberra: ABS. Viewed 28 November 2013.
ABS 2011. Private hospitals, Australia, 2009–10. ABS cat. no. 4390.0. Canberra: ABS. Viewed 28 November 2013.
ABS 2012. Private hospitals, Australia, 2010–11. ABS cat. no. 4390.0. Canberra: ABS. Viewed 28 November 2013.
ABS 2013. Private hospitals, Australia, 2011–12. ABS cat. no. 4390.0. Canberra: ABS. Viewed 28 November 2013.
AIHW (Australian Institute of Health and Welfare) 2008. Australian hospital statistics 2006–07. Health services series no. 31. Cat. no. HSE 55. Canberra: AIHW.
AIHW 2009. Australian hospital statistics 2007–08. Health services series no. 33. Cat. no. HSE 71. Canberra: AIHW.
AIHW 2013. Australian hospital statistics 2011–12. Health services series no. 50. Cat. no. HSE 134. Canberra: AIHW.
AIHW, forthcoming. Australian hospital peer groups. Canberra: AIHW.
COAG (Council of Australian Governments) 2012. National Healthcare Agreement. Canberra: Treasury. Viewed 4 February 2014.
NHPA (National Health Performance Authority) 2013. Our work&. Sydney: NHPA. Viewed 18 November 2013.
Productivity Commission 2009. Public and private hospitals. Research report. Canberra: Productivity Commission.
The safety and quality of our hospital services is often under public scrutiny. Safety is defined as the avoidance or reduction to acceptable limits of actual or potential harm from health-care management or the environment in which health care is delivered. Quality is a broad concept about whether health care achieved the desired effect for the patient and whether it was delivered in line with standards or guidelines. Both relate to the broader concept of health service performance in the National Health Performance Framework (NHPF), as outlined in Chapter 9 'Indicators of Australia's health'.
There are several indicators of the safety and quality of hospital care being implemented nationally, under the following arrangements: to monitor the performance of jurisdictions under the National Healthcare Agreement; indicators specified in the Performance and Accountability Framework for monitoring the performance of hospitals under the National Health Reform Agreement (NHPA 2013); indicators being developed by the Australian Commission for Safety and Quality in Health Care to support its various hospital safety and quality initiatives (ACSQHC 2013); and as set out in the National Health Performance Framework and reported by AIHW (see Chapter 9 'Indicators of Australia's Health'—'Adverse events in hospitals' and 'Falls resulting in patient harm').
Two indicators with nationally consistent data are reported in this snapshot: Staphylococcus aureus bacteraemia ('SAB' or 'golden staph') in hospitals; and readmissions to hospitals after surgery.
Staphylococcus aureus is a cause of health-care-associated bloodstream infection (bacteraemia), which can cause significant illness and death. Hospitals aim to have as few cases as possible.
The proportion of hospitalisations for selected types of surgery that result in readmission to hospital within 28 days is regarded as an indicator of the safety and quality of admitted patient care in hospitals. In 2011–12, rates of readmission to the same public hospital for selected surgeries were highest for hysterectomy (30 per 1,000 hospitalisations) and cataract extractions (3 per 1,000 hospitalisations) (see Figure 8.23).
SAB rates are not available for some private hospitals as the data are provided voluntarily.
The readmission rates reported here are based on readmissions to the same hospital in which the surgery was performed. As readmissions to other hospitals are not included, the rates are likely to be underestimated. Methodology for calculating rates of readmission to any hospital is being developed by the AIHW in collaboration with national stakeholders; records from different hospitals (public and private, and across state boundaries) will need to be linked under appropriate privacy protections (such as those used by AIHW for other national data linkage work). There is also national work under way on developing indicators for hospital-associated mortality and infections other than SAB (ACSQHC 2013).
More information on safety and quality in public hospitals in Australia is available.
Information about SAB rates in public hospitals is in the report Australian hospital statistics 2012–13: Staphylococcus aureus bacteraemia in Australian public hospitals. Information on readmission rates and other safety and quality indicators is in the report Australian hospital statistics 2011–12. Both reports are available for free download.
Safety and quality information for individual hospitals is available at www.myhospitals.gov.au.
ACSQHC (Australian Commission on Safety and Quality in Health Care) 2013. Indicators of safety and quality. Sydney: ACSQHC. Viewed 18 November 2013.
HHA (Hand Hygiene Australia) 2013. Hand hygiene Australia 2013. Melbourne: HHA. Viewed 13 December 2013.
NHPA (National Health Performance Authority) 2013. Our work. Sydney: NHPA. Viewed 18 November 2013.
Medicines are used to prevent and manage a wide range of health conditions. Some can be bought over the counter at a pharmacy or other retail outlet without a prescription. Prescription medicines are provided largely through community pharmacies and hospitals. There is little information collected nationally regarding the medications provided to patients by hospitals. Data on medicines dispensed through community pharmacies comes from government subsidy schemes and the Pharmacy Guild of Australia.
The Pharmaceutical Benefits Scheme (PBS) and the Repatriation Pharmaceutical Benefits Scheme (RPBS) are the 2 main government subsidy schemes for medicines dispensed through community-based pharmacies (see Box 8.4). Some medicines can be very expensive and/or very commonly used. The Australian Government places no cap on the amount of money spent through the PBS, so the introduction of new expensive or highly used medicines can drive expenditure up significantly. The removal of medicines, or the listing of 'generic' (non-branded) versions can have the reverse effect on overall expenditure.
The PBS subsidises the cost of a wide range of prescription medicines. The RPBS provides assistance to eligible war veterans and their dependants. It is similar to the PBS but covers a broader range of medicines.
Before a medicine can be subsidised by the PBS, it is assessed by the Pharmaceutical Benefits Advisory Committee, which includes medical practitioners, other health professionals and a consumer representative. Once the committee has recommended a medicine it is considered by the Pharmaceutical Benefits Pricing Authority. The price is negotiated between the manufacturer and the Australian Government Department of Health.
Broadly speaking, patients are grouped into 2 classes: general and concessional. Concessional patients receive a greater subsidy and pay less for medicines than general patients.
Source: AIHW health expenditure database.
General practitioners (GPs) play a critical role in prescribing medicines, and providing advice on purchasing over-the-counter medicines. The Bettering the Evaluation and Care of Health (BEACH) survey of general practice collects information on medicines prescribed by GPs (Britt et al. 2013). According to this survey, the most frequently prescribed medicines are antibiotics, and medicines used for pain management. Amoxicillin, paracetamol and cephalexin have been the 3 most commonly prescribed medications for more than a decade. Amoxicillin and cephalexin are both antibiotics. The BEACH survey also suggests that between 2003–04 and 2012–13, the number of medications recommended or prescribed per 100 GP encounters did not change, however, the number of problems managed in each GP encounter increased. This suggests that the frequency with which medications were used as a management tool for problems presented to a GP decreased over the decade.
In most cases where a medicine is prescribed, there is little information captured and collated at a national level on the purpose for which it was prescribed, whether the medicine was taken, and the outcome that occurred from use of the medicine. This information at the patient level would greatly enhance monitoring of the use of medicines in Australia.
Nationally collected information on medicines dispensed through hospitals would add extra clarity on the use of medicines in Australia.
For more information on medicines in Australia, visit the Medicare website.
Britt H, Miller GC, Henderson J, Bayram C, Valenti L, Harrison C et al. 2013. General practice activity in Australia 2012–13. General practice series no. 33. Sydney: Sydney University Press.
Feature articles & snapshot downloads
8.1 Prevention for a healthier future (Feature) (203KB PDF)
8.2 Cancer screening in Australia (Snapshot) (119KB PDF)
8.3 Primary health care in Australia (Feature) (725KB PDF)
8.4 Alcohol and other drug treatment services (Snapshot) (159KB PDF)
8.5 Mental health services at a glance (Snapshot) (209KB PDF)
8.6 Ambulance services (Snapshot) (115KB PDF)
8.7 Overview of public and private hospitals (Snapshot) (130KB PDF)
8.8 Emergency departments: at the front line (Feature) (297KB PDF)
8.9 Sub-acute and non-acute care (Snapshot) (118KB PDF)
8.10 Elective surgery waiting times (Snapshot) (122KB PDF)
8.11 The rise of private hospitals (Feature) (285KB PDF)
8.12 Safety and quality of hospital care (Snapshot) (122KB PDF)
8.13 Medicines in the health system (Snapshot) (112KB PDF)
Data tables for figures
Data for figures in Australia's health 2014 (Chapter 8) (1.6MB XLS)
Download PDF or order a printed copy
Australia's health 2014
Australia's health 2014: in brief