Australia's Health 1996

Contents

 5 Health care resources and their use

5.1 Health personnel | 5.2 Institutional facilities | 5.3 Use of hospitals | 5.4 Waiting for elective surgery | 5.5 Care of the aged | 5.6 Medical services | 5.7 Use of dental services | 5.8 Use of prescription drugs | 5.9 Benchmarking | References | Footnotes

5.1 Health personnel

Supply of and demand for health personnel raise many complex issues. One factor currently of great importance in Australia which bears on the need for services is an ageing population. Another important factor is the expectation that all Australians will have equitable access to health services. Australia also uses few financial disincentives to control demand for health services; many services are provided free or at low cost, and health insurance is available to limit costs to individuals of services for which charges can otherwise be significant.

One factor affecting the current and future supply of health professionals is the number of students undertaking tertiary education, but it takes some time before changes to student intakes affect numbers of practising professionals. The retraining of qualified personnel re-entering the labour force after an absence and the use of overseas-trained personnel allow shorter-term needs to be met. However, there are regulatory and professional recognition barriers to the workforce mobility of many health personnel. The professionals themselves must maintain and upgrade their skills, not least for changing roles within the health care system.

Employment in the health industry

The ABS labour force survey provides a measure of changes in health industry employment in the context of general civilian employment. The number of people employed in the health industry has risen from 536,000 in 1989 to 584,100 in 1995 (Table 5.1). This increase of 9.0% is greater than the 6.4% increase which occurred in the total number of employed persons over the same period. Employment in the health industry represented 6.9% of total employment in Australia in 1989 and rose to 7.4% in 1991 but declined to 7.1% in 1995 as general employment improved.

The health industry is a major employer of women, providing 13% of national female employment but only 3% of male employment. Females constitute 76% of those employed in the health industry and this proportion has remained stable from 1989 to 1995. The occupation with the highest proportion of females is nursing; 91% of registered nurses were female in 1989 and this increased to 93% by 1995. In the professional diagnosis and treatment occupations the proportion of females has fluctuated between 40% and 46%.

Population censuses show the changes that have occurred in the distribution of health occupations (Table 5.2, page 140). There has been a continuing change in the relative distribution of occupations which reflects a gradual restructuring of the health workforce and changing roles of various professions. The major change is in the proportion of nurses; the proportion of registered and enrolled nurses has declined from 74.9% of health workers in 1976 to 69.3% in 1991.

Table 5.1: The labour force-employed civilians, health industry and major health occupations, by sex, 1989 to 1995( ¹) ('000 persons)

Nursing

Nursing is the largest health profession. Nurses in Australia must have professional registration as a registered nurse or as an enrolled nurse. Registered nurses, who formerly had a four-year hospital-based course, now require a three-year university degree course. Enrolled nurses may be nurses studying to become registered nurses or may have completed a separate one-year course.

There were 79,786 practising registered nurses in 1976, or 43.6% of all health personnel. In the decade to 1986 there was a 73.2% increase to 138,220 in the number of practising registered nurses to 54.4% of all health personnel. This rapid growth was associated with the move of nurse education from hospitals to tertiary education institutions. Restructuring of the hospital labour force between 1986 and 1991 led to a decrease in hospital employment with only minor growth (0.8%) to 139,380 in the number of registered nurses in 1991; this was a decline to 51.2% of all health personnel.

The nursing labour force in 1992-93 comprised 260,924 nurses with a professional registration. However, 30,696 (11.8%) of these nurses were not in the nurse labour force-7,705 (3.0%) were employed elsewhere and not looking for nursing work, 4,869 (1.9%) were overseas and 18,122 (6.9%) were not seeking work.

There were thus 230,228 nurses with a professional registration working in nursing or seeking to do so. Of these, 18,880 (8.2%) were looking for work in nursing-of these, 52.7% were employed in other occupations and 47.3% were unemployed.

Of the employed nurses, 78.2% were registered nurses and 21.8% were enrolled nurses. Some features of the employed workforce were that 1.1% of its members were on leave for three months or more, that 92.2% of employed nurses are clinicians, and that 69.5% of nurses worked in the public sector and 30.5% worked in the private sector.

Most (61.1%) nurses worked in acute care hospitals (48.1% in the public sector; 13.0% in the private sector), 12.3% worked in nursing homes (8.4% public sector; 3.9% private sector) and 5.7% worked in day procedure centres (0.2% public sector; 5.5% private sector). Many nurses worked part-time; 48.8% of female nurses and 18.6% of male nurses worked 30 hours per week or less.

Medicine

Doctor numbers grew by 89.5% from 20,480 to 38,800 between 1976 and 1991. In 1976, medical practitioners were 11.2% of health personnel; this had increased to 14.2% by 1991. The number of medical practitioners per 100,000 population increased from 156 in 1976 to 230 in 1991.

The medical workforce has been predominantly male, but this is gradually changing. Females constituted 24.7% of doctors in 1992-93, an increase from 13% at the 1971 census. Reflecting the former male preponderance, the proportion of females decreases with age. Women are also under-represented as specialists. The proportion of female medical practitioners will continue to increase as, in 1995, 46.7% of Australian medical students were female.

The distribution of doctors does not match need. Oversupply exists, particularly of general practitioners in the capital cities, but there are shortages in some rural and remote areas. In 1994, capital cities and major urban centres had 120.4 general practitioners per 100,000 population, and rural and remote areas had 80.2.

Specialist doctors are mainly located in the capital cities and large urban centres where major hospital facilities are available. Shortages have been identified in some specialties. In February 1996, the Australian Health Ministers' Advisory Council accepted the advice of the Australian Medical Workforce Advisory Committee concerning undersupply of anaesthetists, orthopaedic surgeons, urologists, and ophthalmologists. A recent study estimated that there are shortages of 62 surgeons in New South Wales and 39 in Tasmania with the other States having no significant shortages. The non-surgical specialist workforce appears to have an oversupply estimated at 110 specialists in New South Wales and shortages of 265 in Queensland, 37 in Western Australia and 63 in Tasmania (AMWAC & AIHW 1996).

Not all of Australia's registered doctors are active; 0.9% were looking for work in medicine and 5.5% were not practising medicine or seeking to do so. Some 6.3% of registered medical practitioners were employed overseas.

In 1992-93, 39,942 (92.2%) medical practitioners employed in medicine were working as clinicians (engaged in diagnosis, care and treatment of patients, Table 5.3), and 3,130 (7.8%) were administrators, educators, researchers and public and occupational health practitioners. Of the clinicians, 46.3% were primarily working as general practitioners, 35.0% were working as specialists, 6.6% were specialists in training and 12.1% were hospital non-specialists.

General practitioners worked an average of 45.7 hours per week, compared with 50.9 hours for specialists and 51.4 hours for hospital non-specialists. Male doctors worked an average of 51.2 hours per week, compared with 37.2 hours for females. Some 60.4% of working medical practitioners were primarily in private practice.

Although most doctors consult only in English, 16.7% of working medical practitioners at times used a language other than English in patient encounters. The main languages used were Chinese, French and German.

Dentistry

Dentists have maintained their proportion of the health occupations at 2.5% from 1976 to 1991. As has occurred for doctors, there has been a substantial increase in the percentage of dentists who are female. In 1966, only 5.4% were female, whereas in 1992 this had risen to 16.5% (AIHW Dental Statistics and Research Unit 1994). The increase will continue, because an even higher proportion, 88 of 236 (37.3%) in 1994, of recent dental graduates from Australian universities are female.

The population pyramid for practising dentists in 1992 (Figure 5.1) shows the age distribution of male and female dentists in Australia. There are few practising female dentists aged 40 years and over and very few aged 55 and over. Even at 25-29 years, two-thirds of practising dentists are male.

The great majority of dentists (79.6%) are in general practice with 9.7% in specialist practice. Only 5.6% of female dentists are in specialist practice, compared with 10.5% of male dentists, although this difference at least partly reflects the differing age distributions of male and female dentists.

Nearly half (48.2%) of practising dentists work 40 or more hours per week, with 30.7% working 30-39 hours per week. Over half (57.2%) of male dentists but only 30.5% of female dentists work 40 or more hours per week.

Over three-quarters (77.4%) of practising dentists are in private practice. A greater percentage of female than male dentists (29.5% compared with 14.5%) report that they work in the public sector.

Other professions

From 1976 to 1991 the proportion of health professionals who were pharmacists declined from 5.4% to 4.0%. The occupations which have shown growth as a proportion of health practitioners include physiotherapists (from 1.6% to 2.6%), chiropractors and osteopaths (0.3% to 0.6%), optometrists (0.5% to 0.7%) and other practitioners including dietitians, orthotists, acupuncturists, herbalists, homoeopaths, naturopaths and prosthetists (0.7% to 2.0%).

Entrants to the health workforce

Students completing undergraduate courses in health disciplines add to the supply of health professionals. Their number has grown steadily from 9,079 in 1990 to 14,834 in 1994 (Table 5.4, page 144). Most of this increase has occurred in nursing, from 5,084 completing nursing in 1990, to 9,610 in 1993 and declining slightly to 9,542 in 1994. This has been due to the phasing-in of university-based nurse training in place of hospital-based training, a process which was completed in 1993.

Continuing concern at the increase in the number of medical practitioners, and oversupply in some areas, led the Commonwealth Government to attempt to limit the net increase in overseas-trained doctors to 200 per year, including New Zealand medical graduates, and, from 1996, to seek to reduce the number of new entrants to undergraduate medical training progressively so that the number of graduating doctors would decrease to 1,000 per year.

Overseas-trained doctors on temporary visas are recruited to fill some positions, particularly in remote areas which do not attract Australian-trained medical practitioners. During 1994, 726 Australian citizen or permanent resident medical practitioners left Australia to take up employment overseas and 1,152 foreign visitor medical practitioners arrived in Australia for the purpose of employment.

The number of medical practitioners who arrived during 1994 with the intention of settling in Australia was 504 (270 males and 234 females). This was offset by the departure of 74 migrant medical practitioners and the permanent departure of 79 Australian-born medical practitioners.

Trends in dental practice

Changes in practice patterns of dentists illustrate the combined effect of factors such as ageing of the population and improving oral health. Between 1960-61 and 1982-83, dentists decreased their working hours, and average appointment times lengthened. A series of three surveys conducted at five-yearly intervals spanning the period 1983-84 to 1993-94 shows what has happened since then.

There was no change in mean hours per year devoted to work from 1983-84 to 1993-94. However, the number of patients per hour declined (Figure 5.2). This decline may be a continuation of the previous trend towards increased length of appointment time. Annual number of patients seen also declined. In part this may be due to increased time between patients associated with sterilisation of equipment and infection control procedures.

The proportion of patients who were 65 and over increased from 4.6% in 1983-84 to 10.5% in 1993-94. For patients aged 45-64 years, the increase was from 18.6% to 27.5%. Over the same period, the average number of services per visit increased from 1.7 to 2.1. When the items of service were classified into areas based on the schedule of dental services (Australian Dental Association 1996) it was found that the increase in total services per visit was made up of increased numbers of diagnostic, preventive, endodontic, crown and bridge, and general/miscellaneous services.

These changes in ages of patients and in services may be related to each other and to the decline in the number of visits per year to general practice dentists and increased length of appointment times. With declining levels of tooth loss, more older patients require dental care. These patients may have complex treatment needs which require more services and take longer to complete.

5.2 Institutional facilities

In Australia in 1993-94 there were 702 public acute care hospitals. Within these there were, on average, 56,140 beds available on any day. Similarly, there were 30 public psychiatric hospitals with 5,106 available beds; 329 private acute and psychiatric hospitals with 21,241 available beds; 1,457 nursing homes with 74,236 beds; and 1,365 hostels with 55,092 beds (Table 5.5, page 146).

A more useful indicator of the supply of health care services is the number of beds per 1,000 population (bed ratio), provided the beds are available to be filled (see Box 5.1, page 148). In 1985-86, following a rapid reduction earlier in the 1980s in length of hospital stay, State and Territory health authorities were planning to reduce their acute hospital bed ratios (Mathers & Harvey 1988). From 1985-86 to 1993-94, the ratio of available beds in the public sector fell from 4.1 to 3.2 beds per 1,000 population.

Over most of this period, the supply of private sector hospital beds, excluding freestanding day hospital facilities, remained at 1.3 beds per 1,000 population, although in 1991-92 this, too, dropped to 1.2 beds per 1,000 population and remained at that level. Excluding beds in freestanding day hospital facilities and in public psychiatric hospitals, there were thus 4.4 hospital beds available for acute care per 1,000 population in Australia in 1993-94.

Some Australian acute hospitals, especially rural hospitals, provide care for patients who could be accommodated in nursing homes, whereas this is not the case in many other countries. Cooper-Stanbury et al. (1994) estimated that 9.7% of acute hospital bed days were taken up by such patients. Accurate comparison with other countries is thus difficult, although the most recent data (for 1993) suggest that Australian acute hospital bed ratios for 1992-93 were then high compared with those of some OECD countries (Table 5.8, page 152). Compared with an Australian ratio of 4.3 beds per 1,000 population in 1992-93, the United Kingdom had 2.1, the Netherlands 4.1, Denmark 4.1, Sweden 3.4 and Ireland 3.2. However, some European OECD countries had higher ratios-Austria 5.4, France 5.0 and Germany 7.2 (OECD 1995).

The number of beds available in public psychiatric hospitals in Australia decreased from 2.3 per 1,000 population in 1970 to 0.3 in 1993-94. During the 1970s and early 1980s, the supply contracted by 6% per year (Mathers & Harvey 1988). Then, between 1985-86 and 1987-88, the annual rate of decrease was nearly 21%. This rapid reduction in beds resulted from moves to de-institutionalise patients formerly thought to require inpatient psychiatric care. From 1987-88 to 1992-93, the reduction in bed supply continued at an average of nearly 4.4% per year, and there has been a further small reduction since then.

Regional variations in bed supply

Within the public sector, the decline in numbers of acute hospital beds per 1,000 population was generally sharper in those States and Territories where the bed supply had been greatest. For example, in Tasmania, the bed ratio was 15% above the national average in 1985-86, but 3% below it in 1993-94.

On the other hand, in Victoria, which formerly had 20% fewer beds per 1,000 population than the national average, the bed supply declined by only 1.7% per year, so that by 1993-94 Victoria's bed supply was 12.5% below the national average.

The availability of beds in all types of health care institutions varies among States and Territories (Table 5.6). For acute public hospitals in 1993-94, the Australian Capital Territory had a lower bed ratio (2.6 beds per 1,000 population) than the other States or Territories. For aged care beds in nursing homes and hostels, the lowest ratio was in Victoria (84.8 beds per 1,000 population aged 70 years or older).

In 1993-94 non-metropolitan areas had higher ratios for beds in acute hospitals (5.0 beds per 1,000 population) than did metropolitan areas (4.0 beds) (Table 5.7). The higher ratio for public hospital beds in non-metropolitan areas (4.0 beds) in comparison with metropolitan areas (2.7 beds) was partly offset by a lower ratio for private hospitals in non-metropolitan areas (1.0 beds), compared with 1.3 beds in metropolitan areas.

Despite the higher total bed ratios, people in non-metropolitan areas generally have limited access to some specialities and to intensive care beds. For example, all teaching hospitals are located in major urban areas. The greater specialisation in major urban areas, essential to maintain skill levels and quality of care, means that rural and non-capital city people are more likely to require inter-hospital transfer than are people living in the major urban areas.

5.3 Use of hospitals

[ Top ]

Admitted patients

In 1992-93, Australia had a rate of 246 hospital admissions per 1,000 population. This rate was higher than other OECD countries for which data were available (Table 5.8, page 152). For these countries, the admission rates ranged from 135 per 1,000 in Ireland to 237 per 1,000 in Finland (OECD 1995). Australia's comparatively high admission rate results from the inclusion of same-day admissions, which most OECD countries exclude from their calculations.

Again because of the inclusion of same-day admissions, Australia has a comparatively short average length of stay, 4.9 days for 1992-93. This is the lowest among the OECD countries reporting, except for Mexico (3.5 days). The United States reported an average length of stay in 1993 of 6.0 days with Switzerland reporting 11.8 days and New Zealand 7.7 days. Excluding same-day admissions increases the Australian average length of stay to 6.7 days, still at the lower end of the range.

Rates of admission to acute (non-psychiatric) hospitals in Australia have fluctuated over the last two decades, an increase during the 1970s being followed by a slight decline in the early 1980s. From 1982-83 to 1985-86, admissions per 1,000 population fluctuated around 212. Table 5.9 (page 152) shows the trend in the use of acute hospitals since 1985-86. Over this period, rates of admission have increased steadily from 212 per 1,000 population to 261 in 1993-94.

The average time spent in acute hospitals by admitted patients has declined. It has always been shorter in private hospitals (4.1 days in 1993-94) than in public hospitals (4.8 days).

The reductions in length of stay are attributable to many factors including: fewer patients who need only nursing home care being cared for in acute hospitals; better anaesthetics and antibiotics; and the use of less invasive surgical techniques. The increasing use of same-day treatments, both those which have long been performed on a same-day basis and those which until recently have required two or three days in hospital, has influenced the decline in length of stay. The continued development and increasing application of these techniques is likely to extend the decline in length of stay (Hirsch & Hailey 1992).

The differences between public and private hospitals at least partly reflect their different roles and casemix. For example, private hospitals perform more surgery. In New South Wales in 1988-89, 64% of private hospital patients underwent surgery, compared with 38% of public hospital patients. Of the patients having surgery, 12% of private hospital patients had surgery on the ear, nose, throat or eye, which generally involve short hospital stays, compared with 5% of public hospital patients. In contrast, only 6% of surgical patients in private hospitals underwent operations involving the circulatory or respiratory systems, many of which are major surgery and involve relatively long hospital stays, compared with 16% in public hospitals.

The use of acute hospitals is also measured by the number of bed-days used by admitted patients. The total number of bed-days has changed little, with a fall of less than 1% from 21,657,000 to 21,462,000 between 1985-86 and 1993-94. This has been achieved despite an increasing and increasingly aged population.

Table 5.9 shows the use of hospitals measured by occupied bed-days per 1,000 population and highlights the relationships among admissions, length of stay and bed-days. The sustained reductions in length of hospital stay are reflected in the number of bed-days per 1,000 population in acute hospitals. Between 1985-86 and 1993-94, the number of bed-days per 1,000 population fell from 1,390 to 1,209. During this period, private hospital bed-days declined from 301 per 1,000 population in 1985-86 to 276 per 1,000 in 1987-88 then increased to 291 in 1993-94. This contrasted with a fall in the use of public acute hospitals, as measured by number of bed-days per 1,000 population. Since 1991-92 there has been little change in the number of bed-days per 1,000 population in acute hospitals.

Between 1985-86 and 1993-94, occupancy rates for acute hospitals increased, from 69% to 77%. This result was the combination of an increase in occupancy rate from 72% to 80% in the public sector, and a slightly lesser increase from 62% to 67% in the private sector, where occupancy rates have recovered from a low of 58% in 1987-88.

Population growth, shorter lengths of stay including a greater use of same-day admissions, and admission rates have all influenced demand for beds, and the desire for occupancy levels to be high has itself been a factor influencing bed supply.

Trends in admission rates have been different for public and private hospitals. From 1985-86 to 1993-94, admissions in the public sector increased by 2.5% per year from 157 to 191 per 1,000 population. In the private sector this increase was somewhat larger, 3.1% per year, from 55 to 70 admissions per 1,000 population (Table 5.9). The increase in admission rates had more effect on occupancy levels in private hospitals.

Same-day surgery

The trend over recent years to same-day treatment of hospital patients reflects changing medical practice and pressure for increasing productivity. Improved quality of care may be achieved with same-day surgery through lower infection and embolism rates. For many diagnostic procedures, and some surgical procedures, most patients now receive same-day care. The trend has been encouraged through incentives under the Medicare Agreements for public hospitals to treat suitable surgical patients on a same-day basis. The availability of private health insurance benefits for designated procedures performed in hospital on same-day patients has also had a major influence.

The proportion of same-day patients in public acute hospitals increased from 20% in 1987-88 to over 31% in 1992-93. In 1992-93, nearly 39% of admissions to private hospitals were same-day patients. In the private sector, much of the increase in same-day activity took place in freestanding same-day hospitals. In 1989-90 there were 39 freestanding same-day hospitals (Gillett & Solon 1992), and in 1993-94 there were 111 (ABS 1995a), 30% of them dedicated to endoscopy. These freestanding same-day hospitals had a total of 917 beds, some 4.3% of private hospital beds; these 'beds' included chairs and recliners, mainly for post-operative use. Same-day hospitals accounted for 12.7% of all private hospital admissions.

Non-admitted patients

The data available on non-admitted patients treated in public hospitals have limited reliability because they have not been collected in a consistent manner, either over time or among States and Territories (Cooper-Stanbury et al. 1994).

In 1993-94 an estimated 30.5 million non-admitted patient occasions of service and group sessions or 1,722 occasions of service per 1,000 population were provided by Australia's public acute hospitals. This represents a 0.2% decrease from the 30.7 million occasions of service and group sessions, and a 1.1% decrease from the 1,761 occasions of service per 1,000 population provided in 1991-92.

Private hospitals, which generally do not offer non-admitted patient care, provided another 903,000 occasions of service and group sessions in 1993-94. This represents a 6% increase on the 850,700 occasions of service provided in 1991-92.

Regional variations in acute hospital use

Classification of areas is different for public and for private hospitals, so comparisons cannot be exact in all States. For public hospitals the capital cities and Newcastle, Wollongong, Geelong and Launceston are classified as 'metropolitan'; all other areas are 'non-metropolitan'. The ABS survey of private hospitals classifies areas into 'capital cities' and 'rest of State'.

In 1993-94 there were 2.3 million admissions (184 per 1,000 population) to public acute hospitals in metropolitan areas, and 1.1 million (206 per 1,000) in non-metropolitan areas. Patients admitted to metropolitan public acute hospitals had a slightly shorter length of stay of 4.8 days than patients in non-metropolitan hospitals (4.9 days) (Table 5.10).

Metropolitan public acute hospitals provided 878 bed-days per 1,000 metropolitan population in 1993-94. Non-metropolitan public hospitals provided 1,013 bed-days per 1,000 population. The bed-day use per 1,000 population was 13% higher for public acute hospitals outside the metropolitan areas than in metropolitan areas. In 1991-92 this differential was 18%. The metropolitan and non-metropolitan differential in the use of public hospitals is thus diminishing.

In the private sector in 1993-94 there were 934,200 admissions to capital city private hospitals, and 316,400 to other (rest of State) private hospitals. The capital city hospitals had 75 admissions per 1,000 capital city population, other private hospitals having 59 admissions per 1,000 rest of State population. The average length of stay of 4.2 days in capital city private hospitals was slightly higher than the 4.1 days in other private hospitals. Capital city private hospitals provided 314 bed-days per 1,000 population, and other private hospitals provided 239 bed-days per 1,000 population (ABS 1995a).

These differences in acute hospital use may result from factors such as differences in the demographic structure and health of the population, specialised facilities being available only in cities, and generally lower levels of private health insurance outside capital cities. There are also variations in choice of admitted or non-admitted treatment for patients, and in the extent to which surgery is used for particular conditions.

Where people live does not determine where they will attend hospital, and many rural and smaller city residents may have to attend hospitals in major urban centres, particularly when specialised services are required. Comparison of regional hospital use is thus complicated by inter-regional flows, some of which may be significant. For example, the catchment population for hospitals in the Australian Capital Territory includes neighbouring areas of south-eastern New South Wales. Lack of data on catchment populations of specific hospitals or groups of hospitals precludes analysis of inter-regional flow of patients.

State and Territory variations in acute hospital use

There are substantial differences among States and Territories in the use of acute hospitals (Tables 5.11 and 5.12). In 1993-94, Tasmania had the lowest level of public hospital admissions, 159 admissions per 1,000 population, but the highest average length of stay of 5.6 days. In contrast, South Australia had an admission rate of 208 per 1,000 population but an average length of stay of 4.9 days.

States with relatively high public hospital admission and bed-day rates appear to have relatively low private hospital admission and bed-day rates (Figure 5.3).

The exceptions to this trend are South Australia which has high rates of both public and private hospital admission and to a lesser extent Queensland which has relatively high rates of admissions and bed-days for private hospitals only.

As noted earlier, differences in population age structures can contribute to the differences in admission rates between the States and Territories. For example, 13% of the South Australian population is aged 65 years or more, compared with only 7% of the population of the Australian Capital Territory, where the admission rate is relatively low.

Other reasons for the differences are not entirely clear. Variation in the supply of doctors and admission practices may also influence the use of hospitals. Some of the variation in admission rates may result from different classification of same-day patients as admitted patients or as non-admitted patients. The lack of data on same-day admissions for all States and Territories, and for public and private hospitals, precludes a complete evaluation of this factor.

Conditions treated

The conditions that hospitals treat are of interest to health service managers, planners and funders. Data from administrative and clinical systems provide information on patient attributes and treatments. Such data collated at the national level allow various analyses of hospital use, including analyses of the most common conditions treated. A number of classification systems can organise these data (see Box 5.3, page 157).

Table 5.13 shows the most common conditions treated in Australian public and private acute hospitals during 1993-94, using the AN-DRG (version 3.0) classification. The first part of the list excludes same-day episodes to permit comparison with most other OECD countries. The second part of the list contains an additional five procedures accounting for a high number of same-day episodes.

The most common hospital treatment category during 1993-94 was renal dialysis, accounting for almost 230,000 admissions to public and private hospitals. Most of these were same-day cases. If all same-day episodes are excluded, then the most common category was for normal delivery, which alone accounted for over 5% of non-same-day cases. This category does not include deliveries by caesarean section or complicated deliveries.

The next most common AN-DRG was that for neonate (newborn) admission. In 1993-94, a baby born in hospital was not counted as an admission unless it received treatment in its own right, was the second or subsequent baby of a multiple birth, remained in hospital without its mother, or remained in hospital with its mother after day nine.

5.4 Waiting for elective surgery

A firm admission date is not always given when hospital admission for elective (non-urgent) surgery is first requested. This is because hospitals cannot accurately predict the resources required to treat emergencies. Consequently, hospitals often do not allocate admission dates for elective surgery patients until available operating theatre times are comparatively close.

Waiting times are used by hospital administrators as a management tool for planning and resource allocation purposes, and by patients and doctors when making decisions concerning referral for hospital care. Regional health services can use the information to determine transfers of resources from areas of excess capacity to areas with insufficient capacity. At national and State levels, the information is useful to monitor equity of access to services in relation to such factors as patient accommodation status, location and type of treatment or care. Health consumer advocacy groups and independent researchers also find the data useful.

The size of a waiting list is the result of many factors, including the size of the hospital, the number of people in the associated community and the health needs of that community. It does not necessarily indicate the system's ability to cope with the demand for surgery. A more important consideration is the length of time patients spend waiting. This can depend on many factors, including the clinical urgency of treatment, the clinical urgency for others on the list and the specialty of treatment.

Until relatively recently, there were little available national data concerning waiting for surgery in public hospitals. In March 1994, the Australian Institute of Health and Welfare produced a report (Gillett & Mays 1994) on elective surgery waiting lists based on data collected in the second half of 1993. The report highlighted varying practices of States and Territories in the collection and reporting of waiting list data. Consequently, it was not possible to use the data for planning, performance monitoring and policy purposes at a national level.

National surveys aiming to collect nationally consistent information relating to as many public hospital waiting lists as possible have since been conducted for 1994 (Mays 1995) and 1995 (Moon 1996).

Waiting times in 1995

Two types of information were collected in the survey:

• during a six-month period, about patients added to and removed from waiting lists (including those admitted for elective surgery and those removed from the list for other reasons)
• on a census date, about patients waiting to be admitted for elective surgery.

Patients were classified into two groups based on the clinical urgency of the awaited procedure:

• Category 1: admission desirable within 30 days; 30% of patients admitted during the survey period were classified into this category
• Category 2: all other patients, with no desirable time set for admission.

Although much effort has been expended to make the data from each State and Territory comparable, some areas for improvement remain. These include improvements in comparability of the urgency categorisation and of the scope of the data.

Performance measures

As length of time spent on the waiting lists indicates system performance, the following measures relating to waiting times were made:

• clearance time: the theoretical time it would take to clear the waiting list of all patients waiting on the census date, if the clearance rate remained constant and patients could be treated at any hospital
• proportion of Category 1 patients waiting over 30 days for admission
• proportion of Category 2 patients waiting over 12 months for admission.

The clearance time for Category 1 patients was estimated to be 0.6 months (Table 5.14). During the survey period, 11% of Category 1 patients admitted for elective surgery had waited over 30 days for admission. On the census date 27% of Category 1 patients on the waiting lists had been waiting over 30 days for admission.

For Category 2 patients, the estimated clearance time is 3.5 months (Table 5.15). For these patients, there is considerable variation in the estimates of clearance time for the different specialties, ranging from 1.5 months for cardiothoracic surgery to 5.2 months for orthopaedic surgery. During the survey period, 4% of Category 2 patients admitted had been waiting for over 12 months before admission. On the census date, 11% of Category 2 patients on waiting lists had already waited over 12 months for admission.

Other issues

Under the 1993-98 Medicare Agreements, access to public hospital services is to be based on clinical need. Using the urgency categories as a guide to clinical need, the 1995 survey showed that for all the categories reported, the clearance times for Category 1 patients were lower than for all patients. This suggests that admission from waiting lists is influenced by clinical need.

Also under the Medicare Agreements, priority for receiving hospital services should not be determined by intended status as a public or private patient. It is difficult to assess whether there is any systematic difference between the priority given to public patients compared with other patients because the survey data do not permit allowance for severity of illness, age, treatment required and other factors.

A comparison without allowance for these factors of 1995 survey data showed that an individual admitted as a public Category 1 patient was 1.4 times more likely to have waited over 30 days for admission than a patient in the 'other' category, which mostly consisted of private patients (Moon 1996). For Category 2 patients, the difference was greater, with public patients being 11 times more likely to have waited over 12 months for admission. Without allowance for factors affecting urgency, it is not possible to draw any conclusions from these findings.

With continued data quality improvement, particularly in relation to the categorisation of patients on the basis of clinical need, more knowledge will be gained on the equity of access to hospital services. In addition, with annual assessments of waiting times, questions such as whether they are increasing or decreasing can be answered.

5.5 Care of the aged

[ Top ]

Residential services

For the last decade, while the number of aged Australians has been increasing rapidly, Australia has been substantially reforming its residential aged care services, reducing the supply of nursing home care and expanding the lower dependency hostel sector. These changes have occurred in a context of increasing outlays on community-based, rather than residential, services for the frail and disabled aged (AIHW 1995).

Under the Aged Care Reform Strategy, the planned level of provision is 40 nursing home beds per 1,000 persons aged 70 and over, and 50 hostel places, to be available by the year 2011 (earlier strategies had provided for up to 60 hostel places per 1,000). These residential care places are to be supplemented by the availability of 10 community aged care packages per 1,000 persons aged 70 and over (Department of Human Services and Health 1995b). The community aged care packages provide an intensive form of community-based support, and are intended as a viable alternative for persons who might otherwise require residential care.

Implementation of the strategy has led to changes in the supply of residential care, based on both absolute numbers and provision ratios. In absolute numbers, the supply increased by 2,754 nursing home beds, and by 22,219 hostel places from 1985 to 1994, and 2,381 community aged care packages were established (Table 5.16).

In 1985, before the implementation of the reforms, there were 67 nursing home beds and 32 hostel places per 1,000 persons aged 70 and over. By 1994, there were 52 nursing home beds and 40 hostel places per 1,000 persons aged 70 and over. The period was thus characterised by a substantial reduction in nursing home bed supply ratios, and an increase in hostel place supply ratios. The net effect was a loss of 7 residential care places per 1,000 persons aged 70 and over, partially offset by the establishment of 2 community aged care packages per 1,000 persons aged 70 and over.

Table 5.16 also reveals decreased variability of residential care supply, particularly if the Northern Territory, with its relatively large Aboriginal population which has a different usage of residential services, is excluded from the comparison. In 1985, nursing home bed provision ranged from 51 in the Australian Capital Territory to 74 beds per 1,000 persons aged 70 and over in Tasmania. By 1994 the range was from 42 in the Australian Capital Territory to 58 in New South Wales.

For hostels, the number of available places per 1,000 persons 70 and over in 1985 ranged from 21 in Tasmania to 44 in South Australia; in 1994 the range was from 34 in Tasmania to 48 in Queensland. For nursing home care in 1994, New South Wales could be characterised as a high provider (58 beds per 1,000), Tasmania, Western Australia, Queensland and South Australia as medium providers (53 to 50 beds per 1,000), and Victoria and the Australian Capital Territory as low-level providers (47 to 42 beds per 1,000). In terms of total residential care, the high-level providers in 1994 were Queensland, Western Australia, South Australia and New South Wales (98 to 94 places per 1,000), and the Australian Capital Territory, Tasmania and Victoria were low-level providers (87 to 84 places per 1,000).

Occupancy rates

Since 1989-90, the national occupancy rates for nursing homes have been stable remaining between 97% and 98% (Table 5.17). Although data for hostels are available only from 1991-92, occupancy rates again appear relatively stable between 92% and 94%. There is some State variation, but disparities are quite small. Moreover, low levels of provision do not necessarily imply high occupancy rates. For example, Victoria and the Australian Capital Territory have the lowest levels of nursing home provision; nursing home occupancy rates are very high in the Australian Capital Territory, but lower than average in Victoria.

Admissions and turnover

The number of admissions, excluding transfers, to nursing homes per year increased from 1989-90 to 1993-94, partly as a consequence of the increase in number of beds (Table 5.18). The ratio of admissions to total number of beds (commonly referred to as turnover) measures the number of people accessing available beds. It increased from 0.54 in 1989-90 to 0.58 in 1993-94.

More detailed scrutiny of the data reveals that this modest increase in turnover is part of a substantial shift in patterns of nursing home usage. Readmissions and respite admissions together accounted for 17% of total admissions in 1989-90, but 29% by 1993-94. The growth is largely accounted for by increases in respite care admissions, that is, movement between community care and the nursing home and back again. Respite care is a valuable support service for those caring for frail elderly people in the community and has been encouraged by government in a variety of ways. Readmissions, which have increased marginally, are likely to represent movement from both the acute hospital and community care sectors.

If turnover is examined in relation to permanent (i.e. non-respite) admissions, there is no increase in rates of bed usage since 1989-90; in fact, there is a small decrease.

For hostels, turnover increased slightly from 1991-92 to 1993-94 (Table 5.18). So, too, have the proportions of readmissions and respite admissions. When only permanent (non-respite) admissions are considered, the turnover rate has remained essentially constant.

Accessibility and gross utilisation

Accessibility is defined as the number of admissions per 1,000 persons aged 70 and over. For nursing homes, it was relatively steady from 1989-90 to 1993-94, ranging between 30 and 33 admissions per 1,000 persons aged 70 and over (Table 5.19). An increasing proportion was admitted for respite care. In terms of permanent (non-respite) care, accessibility declined during the period, from 31 to 26 admissions per 1,000 persons aged 70 and over.

Gross utilisation refers to all persons who were resident in the nursing home at any time during the year in question, rather than the number of people who were resident at any one time. It is the sum of the number of residents at the start of a financial year and the number of admissions in the financial year. It indicates changes in the number of persons gaining access to nursing home care, particularly if it is hypothesised that the number of short-stay usages is increasing, so that more people are using the available beds.

Gross utilisation has increased, with 108,847 people using nursing home care in 1989-90 and 115,064 in 1993-94. When the increasing numbers of aged people are taken into account, however, there has been a decline in the gross utilisation rate for nursing home care, from 90 per 1,000 aged 70 and over in 1989-90, to 82 in 1993-94.

For hostels, accessibility has increased since 1991-92 (Table 5.19). This increase is accounted for by respite care admissions, with accessibility to permanent care being essentially stable. In terms of gross utilisation, the total number of persons accommodated and the gross utilisation rate per 1,000 persons aged 70 and over have both increased. This latter increase is larger than the comparable decrease in the gross utilisation rate for nursing homes, giving a net increase in the total proportion of the aged population accommodated in residential care in recent years. As already noted, this increase is an increase in persons admitted for respite care.

Care in the home

Only a small proportion of the care given to older people and people with a disability is provided in institutions. The 1993 ABS Survey of Disability, Ageing and Carers shows that only 17% of people with a severe or profound handicap who needed assistance or supervision with personal daily activities lived in institutions (Table 5.20). The overwhelming majority lived in households. Even at 80 years and over, 58% of the people with a severe or profound handicap lived in households, cared for by relatives or others with or without formal assistance.

Most care in the household is provided informally by family or other individuals, rather than by government or non-government agencies; 60% of people with a handicap who lived in households received informal assistance (from a relative or friend) only, another 32% received both formal and informal assistance, but only 8% received formal assistance only (Table 5.21). Most in the last group do not live with family in a household.

The 1.5 million family members and others providing informal care is a much larger number than is generally realised. Over 500,000 of these were principal carers (ABS 1995b). About 230,000 carers cared for people with a severe or profound handicap (DHSH 1995a).

Governments provide support to carers through service programs and income support schemes, such as the Home and Community Care program, the Domiciliary Nursing Care Benefit, the Carer Pension and the Child Disability Allowance. However, much of the work undertaken by carers is unpaid. In 1992, the estimated value of informal care provided by volunteers to frail and disabled adults in the household was $3.4 billion (AIHW 1995).

5.6 Medical services

Services provided by doctors are a mainstay of Australia's health care system. But why do Australians visit doctors? Some answers to this question are provided by the National Survey of Treatment in General Practice (Bridges-Webb 1995 pers. comm.).

Respiratory conditions are the most common reason for consultation with general practitioners; 18.7% of a general practice workload relates to respiratory conditions, 8.5% in males and 10.1% in females (Figure 5.4, page 171). The second most frequent group of reasons females consult general practitioners is known as V codes; these are reasons for consultation other than current disease and include immunisation, care of normal pregnancy, and health screening services such as Pap smears. It is therefore to be expected that the proportion of services classified to these codes is much higher for females (6.1%) than for males (2.8%).

Box 5.4: Medicare Medicare, a universal system of health insurance, came into operation in 1984. Administered by the Health Insurance Commission (HIC), the scheme covers everyone normally resident in Australia, except foreign diplomats and their dependants. Short-term visitors, except those from countries with which agreements have been made, are not eligible. A schedule of fees has been established, and benefits for services provided by private practitioners relate to that schedule. Doctors are not obliged to adhere to the schedule fees, but if they direct bill the HIC for any service, the amount payable is the Medicare benefit and the patient must not pay any additional amount. Otherwise, for non-hospital services, a benefit of up to 85% of the schedule fee is payable. Some types of medical services do not qualify for Medicare benefits. These include services to eligible veterans and their dependants, services covered by motor vehicle third party insurance and workers' compensation schemes, services provided by public authorities and most government-funded community health services, as well as services not necessary for patient care (for example, examinations for employment purposes). Benefits are also paid for services provided by optometrists and for oral surgery performed by dental surgeons. For private patients in hospitals, the Medicare benefit is 75% of the schedule fee, but the gap between benefit and schedule fee is insurable. In other circumstances, gaps cannot be covered by private insurance, and insurance to cover amounts paid in excess of the schedule fee is prohibited. For all beneficiaries (individuals and registered families), if the sum of the gaps between benefits and schedule fees exceeds a specified amount in any year, the full schedule fee is reimbursed for services during the remainder of the year. This 'safety net' threshold is linked to the Consumer Price Index, and is adjusted each year. Agreements between the Commonwealth and State and Territory governments provide for all Medicare beneficiaries to obtain inpatient and non-inpatient care at public hospitals without charge. Medical care is provided for such 'public' patients (at no cost to them) by doctors appointed by the hospitals. Inpatients in public hospitals may choose to be private patients, in which case they are liable for medical fees and for accommodation and nursing charges set at levels agreed by the Commonwealth. Private health insurance can be purchased to cover these charges and charges in private hospitals. Private health insurance arrangements are described in greater detail in Box 4.2, page 130.

For almost all diagnostic groups, use of services is greater for female patients than for males. The major exception is injury, where the workload relating to males (4.4%) exceeds that for females (4.1%).

V codes are also the most frequent reason for use of specialist services, care in normal pregnancy accounting for a substantial proportion of the 9.8% of specialist consultations that relate to V code reasons in females. The second most frequent reason for specialist consultation, accounting for 8.1% of consultations, relates to genitourinary conditions in females; these include most gynaecological conditions.

Use of private medical services

Medicare claims relate to private medical services outside of hospital and medical services for private patients in public and private hospitals. Services for public patients in hospital are not reported on here, as these services are not chargeable and therefore are not processed by the Health Insurance Commission.

In 1994-95, Medicare provided benefits for 188.1 million services. This represents an increase of 9.3% over the 172.3 million services in 1992-93. The increase over this period was in part due to the effects of population growth (2.1%) and a rise in the number of services per person (7.0%).

Over half (52.4%) of the medical services in 1994-95 were unreferred attendances, that is, general practitioner services, emergency attendances after hours, other prolonged attendances, group therapy and acupuncture. A further 25.0% of the services were pathology and 9.3% were specialist attendances (Figure 5.5, page 172).

The largest increase in total services from 1992-93 to 1994-95 occurred in pathology. The second largest increase was for a group of other services including assistance at operations, and radio- and nuclear therapy. The smallest increase was in anaesthetic services, somewhat less than the increase in the number of services which were oper-ations, indicating a small increase in the average number of procedures per operating theatre episode.

On average, each person received 10.4 medical services in 1994-95 (or 9.6 services if patient episode initiation items, which cover administrative costs associated with collection of specimens for pathology services, are excluded). These services included 5.5 unreferred (mainly general practitioner) attendances, 1.0 specialist attendance and 2.6 pathology services. Since 1992-93 the number of services per person (including patient episode initiation items) has increased from 9.8 to 10.4, an increase of 6.9%, or an average annual increase of 3.4% (Table 5.22, page 173).

Although the average use per person was 10.4 services, the actual number of services per person ranges widely. For example, in 1993-94, 1.8% of Medicare-enrolled persons received 51 or more services. These people accounted for 17.7% of total benefits paid. At the other end of the scale, 20.1% received no services, and 33.1% of persons received between one and five services, accounting for 8.4% of total benefits.

Between 1984 and 1995, the annual number of medical consultations per person increased steadily (Figure 5.6, page 174). Medical consultations include services provided by general practitioners and specialist consultations. The data exclude obstetrics, pathology, radiology, anaesthetics, optometry and surgery.

In 1984-85, males consulted a GP or specialist on average 4.1 times per year and females 5.9 times per year, after age adjustment. By 1994-95, this rate had increased to 5.8 consultations per year for males and 7.4% for females, representing average annual increases of 3.7% and 2.4% respectively.

The increase in consultation rates may in part be due to improved access to doctors, as there was a 35% increase in the number of general practitioners between 1984-85 and 1992-93 (AIHW 1995). An increased awareness of steps which individuals can take to maintain their own health and that of their families, such as immunisation, Pap smears, blood pressure measurements and general health checkups, may also have contributed to the increased consultation rates.

Use of medical services by age

There are considerable age variations in the use of medical services. In the 1994-95 National Survey of Treatment in General Practice (Bridges-Webb 1995 pers. comm.) babies and children under 5 years of age averaged 8 visits to the doctor in a year. Women aged 25-34 years averaged 7 visits per year and men in this age group 4 visits per year, the difference reflecting services relating to childbearing and to female reproductive health. As would be expected, people over the age of 75 years visit a doctor more frequently than younger people do. Women in this age group went to the doctor on average 15 times per year and men 12 times per year.

Medicare data show generally similar trends. Beyond 10 years of age there is a steady increase in the number of services with age (Figure 5.7, page 175).

In 1994-95, the average number of services processed by Medicare was 8.4 per enrolled male, and 12.5 per enrolled female. In terms of numbers of services per person, 23.8% of males and 16.3% of females received no services in 1993-94 (the latest year such data are available).

These Medicare data also show that 50.6% of males and 42.0% of females over 75 years did not receive any services. Recent work has suggested that these findings, and similar ones which have been presented in previous editions of Australia's Health, are misleading. It appears that the Health Insurance Commission has not been able to identify all who die and remove them from its files of enrolled persons, and it is likely that the great majority of those not receiving services are, in fact, dead.

Use of medical services by State

Variations in the use of medical services occur across States. In 1994-95, the highest use was in New South Wales with 11.5 services per person, 9.8% above the national average of 10.4 services per person. Indeed, New South Wales was the only State to exceed the national average. The next greatest use per person occurred in Victoria (10.3 services), followed by Queensland (10.1 services). The lowest per person use occurred in the Northern Territory (6.2 services). One reason for the low rate in the Northern Territory is that a number of services are provided to Aboriginal and Torres Strait Islander people through programs other than Medicare, and these services are not included in the data reported here.

The differences among the States may, in part, reflect the different mix of public and private patients in hospital (since public patients in public hospitals receive non-chargeable services) and the differences in age structures between States. In 1993-94, 70.8% of bed-days in public hospitals in New South Wales were for public patients, compared with 94.1% of public hospital bed-days in the Northern Territory.

An analysis of the age structure of the States provides further insight into these differences. In New South Wales, at 30 June 1995, the proportion of males aged 65 and over was 10.8%, slightly greater than the national average of 10.4%; the proportion of women in these age groups in New South Wales was 14.1%, compared with the national average of 13.4%. The proportion in these age groups in the Northern Territory was 3.2% for males and females.

5.7 Use of dental services

All dental care is initiated by some form of stimulus, which may vary between a perceived need for a checkup and the resolution of a dental problem. When deciding to visit a dental professional, individuals assess the possible benefits against the potential costs or disadvantages in terms of money, time, pain, inconvenience of travel and other factors. All of these factors influence not only whether care is sought, but also the type of care received.

Most dentate Australians (i.e. people with at least one natural tooth) over 18 who made a dental visit in the previous 12 months sought care in response to a problem at their last visit; this was the case for 72.7% of Health Care Card holders whose last visit was to a public clinic, 55.0% of card holders whose last visit was to a private clinic, and 51.0% of non-card holders whose last visit was to a private clinic.

Among those whose last dental visit was in response to a dental problem, the group with the highest extraction rate-card holders whose last visit was to a public clinic-had the lowest filling rate. The group with the lowest extraction rate-non-card holders whose last visit was to a private clinic-had the highest filling rate (Figure 5.8).

Persons whose last dental visit was for a checkup were far less likely to have had extractions or fillings in the previous 12 months than those who last visited for a problem. Persons visiting for a checkup within the private sector were more likely to receive restorative care than those who last visited a public clinic.

Reasons for seeking dental care and the level of untreated problems people have influence the care they are likely to receive. Those who visit for a dental checkup are most likely to benefit from early detection and treatment of oral disease and to receive ongoing preventive care. In contrast, those who seek care only when they are experiencing a dental problem are more likely to present with a problem that may be difficult to treat adequately, and are less likely to receive preventive services.

Health Care Card holders are more likely to make dental visits because of a problem than are non-card holders. But for both reasons for visit, the distribution of times since the last visit is remarkably similar for card holders and other patients (Figure 5.9). The usual reason for making a dental visit is thus a greater determinant of visiting patterns than is card holder status.

The differences in the time since the last dental visit between those who usually visit for a checkup and those who usually visit for a problem are well demonstrated in Figure 5.9. About 70% of those who usually visited for a checkup had done so in the preceding 12 months compared with about 40% of those who usually visited for a problem. Nearly 90% of those who usually visited for a checkup had visited in the previous 2 years. Almost 20% of those who usually visit for a problem had not visited for 5 years or more.

Many reasons can be offered for some people usually making dental visits because of problems. Financial constraints may prevent them from having checkups as regularly as would be desired, resulting in dental visits only when problems become intolerable, and when restorative treatments may no longer be an option.

The waiting time before being able to obtain dental care is another crucial measure of access. Those who must wait unduly long periods can be subject to a prolonged period of preventable pain, or experience a further deterioration of dental health. At worst, some may develop problems which, if a timely visit had been possible, could have been treated in a more effective and efficient manner. Some instances where restorative procedures may have been appropriate may become cases where extractions are needed.

It can be argued that card holders who use public clinics experience access disadvantage preventing them from following a more desirable visiting pattern. Table 5.23 provides the distribution of times waited from the time of contacting the dental clinic to the time of making the dental visit (among people who attended in the last 12 months). To account for any factors associated with the urgency of a dental visit, the data are presented separately for the reason for the last visit.

Regardless of the reason for the visit, there was very little difference in waiting time between card holders and non-card holders who went to a private dentist. However, major differences existed between persons who visited a public clinic and those who visited a private dentist. Of persons who went to a private dentist, over 94% of those who went for a checkup, and nearly 97% of those who went for a problem, were seen within a month. Public patients had a less favourable outcome, with only 65.9% of those with problems and 47.5% of those going for a checkup being seen within one month, 6.2% of those with problems and 21.1% of those seeking a checkup reporting that they had to wait for 12 months or longer. These waits are undesirable by any standards and indicate the existence of barriers to dental care.

Provision of public dental services to Aboriginal and Torres Strait Islander patients

Previous reports have demonstrated social inequalities in the use of dental services and in the dental care received by Australian adults (Brennan & Stewart 1993). Differences in access and receipt of dental services between card holders and those who do not hold entitlement cards have been highlighted (Allister et al. 1995), and some have been illustrated earlier in this section. However, little is known about variations among subgroups of card holders. In interpreting the comparison of provision of publicly funded dental services between Aboriginal and Torres Strait Islander and other patients which follows, it should be remembered that there are differences in oral health between these groups (see Section 1.5.1, page 21).

Emergency dental visits

Emergency visits are defined as those which are part of a course of care initiated for relief of pain. They provide a measure of the extent to which dental care is aimed at immediate treatment rather than maintenance and prevention, and hence may reflect the types of services which are likely to be received. The percentage of care which is emergency care is similar for both Aboriginal and Torres Strait Islander and other patients up to age 25. At higher ages the percentage of care which is emergency care is higher for Aboriginal and Torres Strait Islander patients.

Extractions

Tooth extraction is counter to the desired goal of maintaining a functional natural dentition for life, and is in contrast to the currently advocated minimum intervention treatment philosophy for dental care which emphasises monitoring and prevention (Elderton & Dowell 1989).

Figure 5.10 shows that a higher percentage of Aboriginal and Torres Strait Islander patients compared with other patients received extractions for both emergency (43.6% vs 25.4%) and non-emergency care (21.9% vs 6.7%). The percentage of patients receiving extractions increased across age groups for both kinds of visit for Aboriginal and Torres Strait Islander patients, but remained steady for others. Some differences were large. For example, among patients aged 25-44 years attending for a non-emergency visit, 25.7% of Aboriginal and Torres Strait Islander patients but only 6.4% of other patients received extractions, and for those aged 45 years and over, 33.3% of Aboriginal and Torres Strait Islander patients received extractions compared with 6.9% of other patients.

Fillings

The receipt of a filling reflects an attempt to restore a damaged tooth and prevent further deterioration which may lead to the need for extraction. For all ages combined there was no difference between the proportion of Aboriginal and Torres Strait Islander and other patients receiving fillings at non-emergency visits (34.3% vs 36.7%, Figure 5.11). However, at emergency visits a lower percentage of Aboriginal and Torres Strait Islander patients (23.4%) received fillings than did others (40.5%). For both kinds of visit the trend across age groups was for the percentage of persons receiving fillings to decrease for Aboriginal and Torres Strait Islander patients, whereas for other patients the percentage receiving fillings remained high.

These contrasting trends resulted in differences in the percentages receiving fillings which was most marked for emergency visits at 45 years and over, 12.5% of Aboriginal and Torres Strait Islander and 39.1% of other patients receiving them. Older Aboriginal and Torres Strait Islander patients thus receive a pattern of dental care which involves more extractions and fewer fillings. This pattern indicates less favourable treatment processes.

5.8 Use of prescription drugs

Prescription drugs are dispensed under the Pharmaceutical Benefits Scheme (PBS) and Repatriation Pharmaceutical Benefits Scheme (RPBS) programs, as private prescriptions, through hospitals, and through a group of smaller Commonwealth Government programs.

Australia's Health 1994 provided an economic analysis of total prescription drug use. The present analysis updates that report with regard to prescriptions subsidised under the PBS.

All prescription items purchased under the PBS by concessional beneficiaries attract a subsidy, and data relating to all these purchases are available because pharmacists claim the balance of the dispensed price from the Health Insurance Commission. However, many prescription items purchased by general beneficiaries have PBS dispensed prices below the limit, currently $16.80, beyond which a benefit applies; pharmacists do not claim in respect of these lower-priced prescriptions, and only general beneficiary purchases of drugs priced above the limit are included in this analysis.

Expenditure on pharmaceuticals for general beneficiaries has increased substantially since 1991-92, with the greatest relative increase being 36% between that year and 1992-93 (Table 5.24). This increase appears to be due mainly to a change from prescribing older drugs to prescribing newer, more expensive ones which had entered the Scheme.

Expenditure on pharmaceuticals for concessional beneficiaries has increased more evenly. Concessional beneficiaries' prescription use was influenced by increases in the number of people eligible for PBS prescriptions as concessional beneficiaries, which were in turn due, in part, to increased unemployment. More importantly, it was influenced by the introduction of a co-payment for pensioners which created some price consciousness among the patients and reduced demand, at least in the two years after its introduction. However, co-payments do not affect trends in the underlying demand or change from prescribing older drugs to prescribing newer, more expensive ones.

Greater price consciousness by the patient has also been encouraged by the Minimum Pricing Policy whereby the patient pays a brand premium if a more expensive brand is dispensed. In 1994, brand substitution was introduced, so that the patient can request the pharmacist to change to a cheaper, equivalent brand. A slow increase in market share of generic brands has followed, and at the end of 1995, 5% of all PBS prescriptions were for these brands. In a further 9% of all PBS prescriptions, no particular brand was prescribed, and the pharmacist would have been able to dispense any minimum price brand of the item concerned

Information on the 10 highest cost drugs in 1994-95 is given in Table 5.25 (page 184). These 10 drugs (of 540 drugs included in the PBS) constituted 30% of the cost of the PBS in 1994-95. In that year, nearly $260 million was spent on prescriptions for antihypertensive drugs, and nearly $250 million for antacids and other drugs for treatment of peptic ulcer. A large part of the latter was spent on H2 antagonists, a group of drugs which has been used for treating peptic ulcer for the last 20 years. Yet during this 20-year period it has been discovered that peptic ulcer is not primarily due to excessive acid secretion, which H2 antagonists counter, but to a bacterial infection. Major changes in the drug treatment of peptic ulcer are expected over the next few years; it must be expected they will be accompanied by equally great changes in this aspect of PBS expenditure.

An unusual feature of PBS usage is that the number of prescriptions dispensed varies with time of year, until recently being 50% greater in the last quarter than in the first quarter (Figure 5.12). The operation of the safety net explains this phenomenon. Once a general beneficiary family has reached the limit of expenditure for the year, all its prescriptions become available at the concessional price for the rest of the year. While the family was paying general beneficiary prices, many of its prescriptions would not have appeared in the PBS statistics because they were priced below the standard contribution; once the family has passed the limit all its prescriptions are recorded.

Beyond this expected effect of the safety net, there appears to have been some hoarding of drugs especially by concessional beneficiaries, who obtained prescriptions late in the calendar year when they had spent to the safety net threshold and could obtain prescriptions at lower prices than at the start of the following year. The effect was reduced in 1994 when the period of time before a drug could again be dispensed to a patient as a Pharmaceutical Benefit was increased. For drugs used for ongoing treatment, the period was increased to 20 days, whereas for other items it became 4 days. The usage in the last quarter of 1994 was only 25% greater than in the first quarter of 1994, but there was still a fall in dispensing in the first quarter of 1995.

5.9 Benchmarking

Australia, like other developed countries, is faced with rising health care costs, rising demands for health care services, and greater consumer expectations of quality of health care and improved health outcomes.

Achieving efficiency gains is an appropriate response to these pressures, but this must be done without compromising effectiveness. To monitor efficiency and effectiveness, performance indicators have been developed that measure key processes and outputs in health service delivery and enable the setting and monitoring of best practice levels of performance.

The process of systematically searching for and incorporating international best practice into an organisation is known as benchmarking. The moves by private industry to benchmark with competitors in order to make itself more competitive in world markets prompted the health sector to look at the potential of this movement for its own purposes. In this context, the Australian Health Ministers' Conference of March 1994 agreed to the development of nationally consistent benchmarks for the health sector in a number of areas, including efficiency, productivity, quality and access.

Health sector benchmarks have been developed to provide an incentive for improved efficiency, effectiveness and equity in the health sector through defining an acceptable national standard of performance in health service delivery, creating a greater focus on measurement of performance, and providing governments, other funders and managers with a core set of performance information to help in management and policy development.

A working group compiled a set of hospital performance indicators in the areas of efficiency, productivity, quality and access (National Health Ministers' Benchmarking Working Group 1996). These indicators were developed in the light of current national collections and, for some measures, in liaison with other working groups and programs. The scope was limited to acute hospitals initially, with possible future extension to other areas of the industry. The main purpose of the document was to define and report on the hospital performance indicators developed to date. It was found that the quality of available data was highly variable, and in only a few cases were collected data based on nationally consistent definitions.

Table 5.26 lists the performance indicators from the First National Report on Health Sector Performance Indicators. Its main findings on efficiency of public hospitals in 1993-94 were:

• the average cost per casemix-adjusted separation ranged from $2,208 in South Australia to $3,237 in the Australian Capital Territory, with the national average being $2,327 (Figure 5.13); and
• there was high consistency in average length of stay among States and Territories for the top 20 treatment categories.

In the area of productivity, indicative data were provided, although results could not be compared directly.

Data relating to quality of care indicators come from a report of the Australian Council on Healthcare Standards (ACHS) Care Evaluation Program. These data from a small, non-representative sample of hospitals in each State and Territory showed:

• the rate of unplanned readmissions ranged from 0.8% in the Australian Capital Territory to 6.3% in the Northern Territory;
• the rate of return to operating theatre ranged from 0.1% in Tasmania to 4.2% in the Northern Territory; and
• the rate of hospital-acquired bacteraemia ranged from 0.03% in South Australia to 0.3% in Tasmania.

The proportion of hospital facilities accredited by ACHS is an indicator of the quality of the processes of care. The proportion of public and private acute hospitals accredited ranged from 16% in Queensland to 64% in New South Wales.

The main findings on access were:

• the average clearance time for elective surgery patients on public hospital waiting lists ranged from 1.8 months in New South Wales to 9.9 months in the Northern Territory. Clearance time (see Section 5.4) is a measure of the capacity of the system to clear patients from the waiting list;

• there were large variations among States and Territories in the separation rates for selected procedures;
• total admissions per 1,000 population ranged from 226.5 in the Australian Capital Territory to 283.4 per 1,000 population in South Australia (Figure 5.14); and
• for public acute hospitals, the highest rate of public patient admissions was in the Northern Territory (91%) and the lowest in New South Wales (72%).

The future of benchmarking

The Working Group proposed an agenda for developing indicators and establishing benchmarking practices in the health sector. It wished to improve indicators from those in the first national report. The indicators were to be extended to cover all components of the framework, such as outcomes and locational disadvantage, within 18-24 months. Other proposed activities included facilitation of benchmarking networks, investigation of indicators to cover the continuum of hospital and non-hospital components of care, and investigation of options for international networks.

References

[ Top ]

• Allister J, Brennan D, Carter K, Davies M et al. 1995. Commonwealth Dental Health Program baseline evaluation report 1994. Adelaide: AIHW Dental Statistics and Research Unit.
• AIHW Dental Statistics and Research Unit 1994. Dental practitioner statistics, Australia, 1992. Dental Statistics and Research Series No. 6. Adelaide: University of Adelaide.
• AIHW Dental Statistics and Research Unit 1995a. National dental telephone interview survey 1994. Adelaide: University of Adelaide.
• AIHW Dental Statistics and Research Unit 1995b. Adult dental programs survey (cross-sectional) 1994. Adelaide: University of Adelaide.
• Australian Bureau of Statistics. Characteristics of persons employed in health occupations, Australia, Census of Population and Housing. Catalogue No. 4346.0. Canberra: ABS.
• Australian Bureau of Statistics. Labour force Australia. Catalogue No. 6203.0. Canberra: ABS.
• Australian Bureau of Statistics 1995a. Private hospitals Australia, 1993-94. Catalogue No. 4390.0. Canberra: ABS.
• Australian Bureau of Statistics 1995b. Caring in families: support for persons who are older or have disabilities. Catalogue No. 4423.0. Canberra: AGPS.
• Australian Bureau of Statistics 1995c. Australian demographic statistics June quarter 1995. Catalogue No. 3101.0. Canberra: ABS.
• Australian Dental Association 1996. An Australian schedule of dental services and glossary, 5th ed. Sydney: ADA.
• Australian Institute of Health and Welfare 1995. Australia's welfare 1995: services and assistance. Canberra: AGPS.
• Australian Medical Workforce Advisory Committee & Australian Institute of Health and Welfare 1996. Australian medical workforce benchmarks. AMWAC Report No. 1. Sydney: Australian Medical Workforce Advisory Committee.
• Brennan DS, Spencer AJ & Szuster FSP 1995. Productivity among Australian private general dental practitioners across a ten year period. Unpublished manuscript.
• Brennan D & Stewart J 1993. Use of dental care. In: AIHW Dental Statistics and Research Unit. Dental care for adults in Australia. Proceedings of a workshop. Adelaide: AIHW Dental Statistics and Research Unit: 37-42.
• Cooper-Stanbury M, Solon R & Cook M 1994. Hospital utilisation and costs study 1990-91, volume 1: a survey of public hospitals and related data. Australian Institute of Health and Welfare, Health Services Series No. 5. Canberra: AGPS.
• Department of Health, Housing and Community Services 1991. Aged care reform strategy mid-term review 1990-91. Canberra: AGPS.
• Department of Human Services and Health 1995a. Supporting the carers: a Commonwealth perspective. Paper presented to a workshop 'Towards a National Agenda for Carers' organised by the Department of Human Services and Health, Canberra, August.
• Department of Human Services and Health 1995b. Department of Human Services and Health budget statement 1995-1996: Budget paper No. 1. Canberra: Department of Human Services and Health.
• Elderton RJ & Dowell TB 1989. Decisions in forward-looking oral health care: summary statement. Br Dent J 166:467-69.
• Gillett S & Mays L 1994. Australians waiting for elective surgery. Canberra: AIHW.
• Gillett S, Parslow R, Scholes D & Renwick M 1991. Hospital utilisation and costs study 1987-88. Australian Institute of Health, Health Services Series No. 1. Canberra: AGPS.
• Gillett S & Solon R 1992. Hospital utilisation and costs study 1989-90, volume 1: a survey of public hospitals and related data. Australian Institute of Health and Welfare, Health Services Series No. 3. Canberra: AGPS.
• Health Insurance Commission 1995. Annual report 1994-95. Canberra: HIC.
• Hirsch N & Hailey D 1992. Minimal access surgery. Canberra: AIHW.
• Mathers C & Harvey R 1988. Hospital utilisation and costs study, volume 2: survey of public hospitals and related data. Canberra: AGPS.
• Mays L 1995. National report on elective surgery waiting lists for public hospitals 1994. Canberra: AIHW.
• Moon L 1996. Elective surgery waiting lists in Australian public hospitals 1995. Canberra: AIHW.
• National Health Data Committee 1995. National health data dictionary-institutional health care. Canberra: AIHW.
• National Health Ministers' Benchmarking Working Group 1996. First national report on health sector performance indicators: public hospitals-the state of play. Canberra: AIHW.
• Organisation for Economic Co-operation and Development 1995. OECD health data: a software package for the cross-national comparison of health systems, Version 3.6. Paris: OECD.

---

Footnotes

[ Top ]

1

Average of February, May, August and November of each year to minimise the fluctuations arising from the sampling methodology.

Source: ABS Catalogue No. 6203.0

2

A clinician is a person mainly involved in the area of clinical practice, i.e. diagnosis, care and treatment, including recommended preventative action, of patients. Clinical practice may involve direct client contact or may be practised indirectly through individual case material (as in radiology and laboratory medicine).

3

Age data not available for NT. NT is included in the total.

4

Included in the 60-64 age group.

5

Age data not available for NSW and NT. NSW and NT are included in the total.

Source: AIHW

6

Includes Department of Veterans' Affairs General and Auxiliary hospitals. Qld outpatient clinics aggregated with associated hospitals in 1985-86, 1987-88 and 1989-90. Qld clinics were not aggregated in 1991-92, 1992-93 or 1993-94. The 1985-86 data include approximately 19 WA nursing posts which have been excluded from later years.

7

Private hospitals include private psychiatric hospitals and exclude freestanding day hospital facilities.

8

Excludes numbers of institutions in NSW which are not predominantly psychiatric hospitals, but have psychiatric programs.

9

Figures do not include approximately 70 nursing homes for the young disabled.

10

Average available beds where possible, otherwise available beds at 30 June.

11

Available beds for NSW are estimated.

12

Rates per 1,000 population calculated using total population for hospitals and population aged 70 and over for nursing homes and hostels.

Sources: Mathers & Harvey 1988; Gillett et al. 1991; Gillett & Solon 1992; Cooper-Stanbury et al. 1994; AIHW preliminary data; DHHCS 1991; ABS 1995a

13

Rates per 1,000 population calculated using total population for hospitals and population aged 70 and over for nursing homes and hostels.

14

Includes Department of Veterans' Affairs General and Auxiliary hospitals.

15

Private hospitals include private psychiatric hospitals and exclude freestanding day hospital facilities.

16

Included with New South Wales.

17

Included with South Australia.

Source: AIHW preliminary data

18

Includes Department of Veterans' Affairs General and Auxiliary hospitals.

19

Private hospitals include private psychiatric hospitals and exclude freestanding day hospital facilities. Hospitals were classified by ABS as 'capital city' or 'rest of State'.

Sources: Mathers & Harvey 1988; Gillett et al. 1991; Gillett & Solon 1992; Cooper-Stanbury et al. 1994; AIHW preliminary data; ABS 1995a; DHHLGCS

20

Data for Australia refer to financial year 1992-93.

21

1992 data.

Sources: OECD 1995; AIHW preliminary data

22

Public hospitals include Department of Veterans' Affairs General and Auxiliary hospitals. Private hospitals include private psychiatric hospitals and exclude freestanding day hospital facilities.

23

The number of separations was taken as the number of admissions.

24

Number of services was estimated as the number of treatments plus three times the number of visits for 1985-86, 1987-88 and 1989-90, but as reported for 1991-92, 1992-93 and 1993-94.

Sources: Mathers & Harvey 1988; Gillett et al. 1991; Gillett & Solon 1992; Cooper-Stanbury et al. 1994; AIHW preliminary data; ABS 1995a

25

Public hospitals include Department of Veterans' Affairs General and Auxiliary hospitals. Private hospitals include private psychiatric hospitals and exclude freestanding day hospital facilities.

26

For public hospitals, 'metropolitan' equates to 'capital city' plus the major regional centres of Newcastle, Wollongong, Geelong and Launceston. 'Non-metropolitan' equates to 'rest of State'. Rates were calculated using 'metropolitan' and 'non-metropolitan' population bases.

27

For private hospitals, 'metropolitan' equates to 'capital city' and 'non-metropolitan' equates to 'rest of State'. Private hospitals include private psychiatric hospitals. Rates were calculated using 'capital city' and 'rest of State' population bases.

28

Totals may be affected by rounding. Rates were calculated using 'metropolitan' and 'non-metropolitan' population bases.

Sources: AIHW preliminary data; ABS 1995a

29

Public hospitals include Department of Veterans' Affairs General and Auxiliary hospitals.

30

Total bed-days / total admissions.

31

Non-admitted patient occasions of services.

Source: AIHW preliminary data

32

Private hospitals include private psychiatric hospitals.

33

Total bed-days / total separations.

34

Non-admitted patient occasions of services.

Source: ABS 1995a

35

Excludes Queensland data.

36

Calculation for each specialty is: (Category 1 patients on waiting list at census date)/(Category 1 patients cleared, i.e. admitted or removed per month during the survey period).

37

Calculation for each specialty is: [(Category 1 patients admitted during survey period after waiting >30 days)/(all Category 1 patients admitted during survey period)] x 100.

38

Calculation for each specialty is: [(Category 1 patients waiting >30 days at census date)/(all Category 1 patients on waiting list at census date)] x 100.

Source: Moon 1996

39

Excludes Queensland data.

40

Calculation for each specialty is: (patients on waiting list at census date)/(patients cleared, i.e. admitted or removed per month during the survey period).

41

Calculation for each specialty is: [(patients admitted during survey period after waiting >12 months)/(all patients admitted during survey period)] x 100.

42

Calculation for each specialty is: [(patients waiting >12 months at census date)/(all patients on waiting list at census date)] x 100.

Source: Moon 1996

43

Based on whole-year occupancy.

44

Hostel data not available before 1991.

Source: AIHW 1995

45

Hostel data not available before 1991.

Source: AIHW 1995

46

Accessibility is defined as the number of admissions per 1,000 persons aged 70 and over.

47

Average population in a financial year is used for calculating the accessibility and utilisation rates.

48

Hostel data not available before 1991.

Source: AIHW 1995

49

Includes general practitioner services, emergency attendances after hours, other prolonged attendances, group therapy and acupuncture.

50

Patient episode initiation items. These items were designed to cover the administrative costs associated with the collection of specimens.

51

Includes assistance at operations, radio- and nuclear therapy, and miscellaneous services.

Sources: DHFS; ABS 1995c

52

Dentate persons aged 18 and over whose last visit was less than 12 months ago.

53

Time from first contacting the dental clinic to the time of making the visit.

Source: AIHW Dental Statistics and Research Unit 1995a