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medical politics « Previous | |Next »
June 12, 2008

As we know health is back on the reform agenda --in terms of private health insurance and primary care in the context of an ageing population, the increasing incidence of chronic disease, national workforce shortages and ageing infrastructure.

Private health insurance continues to churn away under the surface as it irritates many because it props up the private health insurance industry. Kenneth Davidson in The Age addresses the issue of private health insurance. He says that the unstated policy of the Howard government was designed to prop up private health insurance and maximise the incomes of doctors at the expense of the public health system but not, as far as he is aware, the policy of the Rudd Government. He says:

But one thing is incontrovertible. The carrots and sticks didn't take the pressure off Medicare. In the situation where there is a shortage of GPs, specialists and nurses, a shift in funding away from public to private provision of health services will lead to a similar shift in health professionals.It follows that if the imposition of the 1% Medicare levy surcharge (and the 30% health insurance rebate) didn't take the pressure off Medicare and the public hospital system, reversing the surcharge (and the 30% rebate) won't cause a mass exit from private health insurance as has been predicted by the AMA and the private health insurance industry

Charles Livingstone, senior lecturer in the Department of Health Science at Monash University, says that what private health insurance does is help people jump the queue, as Howard government advertising highlighted. It does this by paying practitioners more in the private system, and exploiting the differential created between public sector rates of remuneration and those on offer in the private sector

What Davidson misses is that hospital care is not everything. Primary care is crucial, even if it is usually overrlooked. In primary care there is a shift towards opening up Medicare to nurses allied health professionals working in a team headed by a GP.That basically means the patient does not need to see the GP for health care. This way of addressing a chronic shortage of general practitioners will be opposed by the Australian Medical Association which has long-campaigned to maintain the monopoly of GPs in delivering primary health services in the name of quality and safety.

The proposed reforms does not mean that allied health professionals are accepted as primary care practitioners in their own right, even though people do see them independently of the GP. They can be seen as a step in this direction. We have a long way to go to break the monopoly of GP's in delivering primary health care services to allow allied health professionals to deliver primary health care.

Davidson also misses the way health services in rural and regional Australia are being reformed with due to the pressures resulting from ageing population, the increasing incidence of chronic disease, national workforce shortages and ageing infrastructure. There is a greater shift to the hubs (hospitals) and spokes (primary care) model, greater co-ordination, better greater integration of services and an increased focus on community need. This means that the role of hospitals will change with an emphasis on upgrading several acute care regional general hospitals with the smaller country hospitals acting as feeders. The smaller hospitals will provide palliative care, primary health care, community based mental health, overnight and day surgery, rehabilitation etc.

| Posted by Gary Sauer-Thompson at 8:29 AM | | Comments (19)


Opening up Medicare to nurses and allied health professionals sounds very sensible. That and the prescriptions and referrals stuff Roxon was talking about last night seem more efficient than clogging the whole thing up with GP waiting lists.

I see an allied health professional more than I see a GP.

Same here.

Nan + Lyn,
'tis the same for myself and Suzanne working independently of each other. Interesting huh? How many are doing this I wonder? My guess is a lot given the shift to wellness and staying healthy amongst the middle class. Of course, according to the AMA, this wellness type of primary care is low quality and unsafe. It can only be high quality and safe if under the medical supervision of a GP.

For me its allied health once a month, GP once a year generally for a referral for a test or a specialist or for treatment for an infection.

We rely on the private insurance (Gold extra's) to do the allied health bit, which for me is mostly chiropractor, masseur and naturpath. All folk devils according to the AMA.

Opening up medicare fee-for-service to other than GPs will not solve many problems.

Sure there is a shortage of GPs but there also is a shortage of nurses. Yes a lead time to graduation of 3 or 4 years compared to 10 years will help but not by as much as a lot of enthusiasts hope.

Sadly the latest AMA Pres is a throwback to turf war ranting days but her illogic should not be allowed to obscure the fact that there is a systemic issue involved - without any doubt the superiority of the Australian Health system (and it is arguably the worlds best) in terms of cost and access is due in majority part, not to their clinical skills, but to the gatekeeping roles of GPs. We abandon this at our peril.

In the past yes. However, cannot see the point in paying a GP $50 just to be able to see a psychologist because I'm depressed about my life. Why cannot I go straight to the psychologist instead of through the gatekeeper? I can do that by paying myself so why doesn't Medicare pay the subsidy to the psychologist without thee GP

How does the GP gatekeeper provide safer and higher quality health care in this case? GP's know sweet little about mental illness compared to bodily disease.

Gatekeeping here seems to be more about ensuring the monopoly of GP's over primary care and providing them with a source of income a the expense of the public purse. Its about politics not medicine.


Did you catch that doco on SBS the other night comparing the US health system with the UK, Germany, Japan, and Taiwan? It was extremely interesting. Anybody who advocates national health system based totally on free enterprise has got rocks in their head.

No I didn't . I agree.

However, I'm not sure anyone is advocating this in Australia ---maybe the Centre of Independent Studies is moving in this direction. Most accept the public private mix and are thinking of ways to make both sectors work together more effectively.

One of the ways to do this is to remove the distortions in the system through Medicare funding the gatekeeper role of the GP when it is no longer needed. That money should follow the patient not prop up medical dominance.

its clear that we dont need to see GP's for all our health needs. Why would I see a GP about diet when I can see a Dietician? And, as Gary points out, why do I need to go through a GP to see a psychologist when the GP is not trained to treat mental illness?

GP's are about treating illness with drugs. Not a good way to deal with a bad diet based on old habits and ignorance. Nor is referral to surgery for obesity a good treatment for many.

I heard on the news that half of Adelaide's emergency department doctors have quit. At least 44 doctors from metropolitan hospitals, who are seeking a pay rise of up to $111,000 a year and improved conditions, yesterday told the State Government they would walk off the job in two weeks.

I also heard that 200 rural doctors are threatening to resign over changes to country health in SA. What's going on?

Peter, Under the plan, released a week ago, about two-thirds of country hospitals will have their services reduced. The Rural GP's are protesting at the way hospitals are changing. I'm not sure what the changes mean.

Gary might know more.

the SA Country Health Plan can be found here It is about providing health services in the context of an ageing population, the increasing incidence of chronic disease, national workforce shortages and ageing infrastructure. The plan says that:

A new approach is needed to the way services are delivered in country SA. An integrated system will be established with the four Country General Hospitals [Mt Gambier, Whyalla, Port Lincoln, Berri] and Country Community Hospitals becoming the “hub” for health service provision. Other health services will form the “spokes” linking into the
hub to ensure access to the most appropriate health care for the local community in a geographical cluster. The “hub and spoke” approach to health care across country
SA will establish a system of coordinated and integrated care, making the best use of the health and medical workforce, equipment and technology and community resources. Country Health SA Inc will be the entity responsible for the multiple
campuses and hospital sites to deliver services and coordinate health care across country SA.

The rural doctors are protesting about the community hospitals and the community based care provided by the local health professionals.

On FXH's point about shortages, am I right in thinking that both GPs and nurses have been quitting in droves for years now, same as teachers? If that's the case, then wouldn't a bit of recognition of their skills bring some back?

I see GPs as drug dispensers too. You go to them when you need antibiotics, and we only take them when there's no choice. The first stop for us is the naturopath/accupuncturist. He's cheaper, not as busy and harassed as the GP, charges the same whether you're there for 15 minutes or an hour, and can fix just about anything.

the GP as a gatekeeper is a historical relic inherited from the 20th century. Why should the nation's top sports physiotherpist still need to refer a patient back to the GP to get a referral to an orthopeadic surgeon? Its a waste of public money and there are a shortage of GP's.

What does the GP consultation add in this case or that of the psychologist?

If you wish to make an appointment at your local bulk bill medical center you can get a referral to a specialist for free.

I have read in the past that Anti-depressants are the drug that is most prescribed in Australia.
In my opinion many people taking these are just unhappy.

But my point that ties it to this argument is what percentage of these prescriptions are being written by psychologists and what percentage by "The Gatekeeper"?

Good point about anti depressants Les. Same could be said of ADHD medications. They're both given out like lollies.

Do psychologists deal with drugs? Or is that psychiatrists? Don't we have different approaches to mental health here?

its worse that you mentioned re your comment about half of Adelaide's emergency department doctors tendered their resignations to take effect in two weeks unless their pay demands are met.

About half of the general surgeons in each of Adelaide's three major public hospitals are preparing to resign, as the crisis in the state's health system worsens.

Psychologists don't prescribe but they do get some training in physiological stuff including prescribed medications. Psychiatrists prescribe, as do GPs.

In my family experience psychiatrists tend to prescribe first, ask questions later. GPs and psychiatrists hand out anti-depressants like lollies which has caused some people no end of trouble when the wrong medication exacerbates the problem and/or causes more problems.

Psychologists are seen as the longer term option because counselling generally takes months of appointments, which not everybody can do. Psychologists are often the ones left to sort out the disaster when the wrong, or unnecessary medications, have been prescribed by GPs and psychiatrists who didn't take the time to listen. Time is money.

I think we also have a problem with the "pill will fix it" mentality in our society.