family and community development committee inquiry …

FAMILY AND COMMUNITY DEVELOPMENT COMMITTEE

Inquiry on the Impact on the Victorian Community and Public Hospitals of the Diminishing Access to After Hours and Bulk Billing General

Practitioners

September 2004

Ordered to be Printed

No. 84 Session 2003-2004

National Library of Australia Family and Community Development Committee (2004) Inquiry on the Impact on the Victorian Community and Public Hospitals of the Diminishing Access to After Hours and Bulk Billing General Practitioners ISBN: 0-9752253-1-6 Cover Design: Lara Howe Office Manager Family and Community Development Committee Level 8, 35 Spring Street Melbourne, Victoria 3000 Phone: (03) 9651 3526 Fax: (03) 9651 3601 Email: [email protected] Website: http://www.parliament.vic.gov.au/fcdc © State of Victoria

MEMBERS

Mr Robert Smith, MLC Chair

Member for Chelsea Province

Mrs Jeanette Powell, MLA Deputy Chair

Member for Shepparton

Hon. David Davis, MLC Member for East Yarra Province

Member for Evelyn

Ms Lisa Neville, MLA Member for Bellarine

Mrs Helen Shardey, MLA Member for Caulfield

Mr Dale Wilson, MLA Member for Narre Warren South

Ms Heather McTaggart, MLA

STAFF Mr Paul Bourke Executive Officer

Ms Lara Howe Office Manager

Ms Iona Annett Research Officer

http://www.parliament.vic.gov.au/fcdc/Mrs_Helen_Shardey_MLA.htm



http://www.parliament.vic.gov.au/fcdc/Mr_Dale_Wilson_MLA.htm



Table of Contents

TABLE OF CONTENTS

• Committee Function ii • Terms of Reference iii • Chairman’s Foreword v • Recommendations vii • Acronyms and Abbreviations ix

Chapter One: Introduction: An overview of the Australian Health Care System

• Commonwealth and State Responsibilities in Health Care 1 • The Structure of Health Care 2 • Health Service Funding & Delivery 5 • Summary 19

Chapter Two: Patterns of Use in the Victorian Health Care System, 1996-2004

• Introduction 23 • Divisions of General Practice – Profiles 32 • Health Service Areas – Profiles 93 • Data Sources 116

Chapter Three: Dealing with Increased Presentations: Issues, Strategies and Solutions

• Introduction 119 • The Link between General Practice and Increased Emergency Presentations 119 • Other Causes of Increased Presentations 125 • State, Federal and Joint Initiatives 126 • Telephone Triage 138 • Nurse Practitoners 141

Chapter Four: Explaining and Resolving the Decline in Bulk Billing and After Hours General practitioners

• Introduction 149 • The Decline in Bulk Billing 149 • The Decline in After Hours Services 159 • Federal Initiatives to address the problems 169 • Issues with A Fairer Medicare/Medicare Plus/Strengthening Medicare 174

Witnesses and Submissions 185

Minority Report 197

i

Parliamentary Committees Act 2003

PARLIAMENTARY COMMITTEES ACT 2003

S.11. The functions of the Family and Community Development Committee are, if so

required or permitted under this Act, to inquire into, consider and report to the Parliament

on–

(a) any proposal, matter or thing concerned with-

(i) the family or the welfare of the family;

(ii) community development or the welfare of the community;

(b) the role of the Government in community development and welfare

including the welfare of the family.

ii

Terms of Reference

TERMS OF REFERENCE

Inquire into, consider and report to Parliament on: 1. The decline in the bulk-billing of general practitioner (GP) services in Victoria since 1996; 2. The increase in patient presentations to public hospital emergency departments in Victoria since 1996, and the extent to which this includes providing types of medical services that normally would be provided by a GP in a primary care setting (GP-type services); 3. The causes in increased presentations to public hospital emergency departments in Victoria since 1996, including difficulties in patients gaining access to bulk-billed and after-hours GP services; 4. The availability of after-hours GP services in metropolitan, regional and rural Victoria; 5. What effective measures can be taken to reduce the number of presentations to public hospital emergency departments consistent with maintaining the principle of universal access of eligible persons to health care free of charge at the point of access; and 6. the extent to which Commonwealth and Victorian legislation may affect Victoria's ability to develop and implement effective and patient-centred solutions to relieve the pressure on public hospital emergency departments to provide GP-type services. In considering this reference, the Committee should examine: 1. Available bulk-billing, patient out-of-pocket expenses and emergency department data at regional and local levels, highlighting where bulk-billing rates are lowest and where emergency department presentations for urgency categories 4 and 5 are highest; 2. the respective roles and responsibilities of the Commonwealth and the Victorian governments; 3. Relevant Victorian and Commonwealth policies and legislation, including the 1999-2003 and 2003-08 Australian Health Care Agreements; and 4. Innovative and relevant models of care and service delivery in other Australian States and Territories, and overseas. The Committee is required to report to Parliament by 30 June 2004. Dated 6 May 2003.

iii

Inquiry on the Impact on the Victorian Community and Public Hospitals of the Diminishing Access to After Hours and Bulk Billing General Practitioners

iv

Chairman’s Foreword

CHAIRMAN’S FOREWORD

I have great pleasure in presenting the Family and Community Development Committee’s

Final Report on its Inquiry into the Impact on the Victorian Community and Public Hospitals

of the Diminishing Access to After Hours and Bulk Billing General Practitioners.

Current media articles have highlighted trends in the current health care system. As can be

seen from statistics presented in the second Chapter of this report increases in emergency

department presentations have occurred at a time when access to general practitioners,

particularly those who bulk bill or provide after hours service, has fallen in some areas.

While there has been some intuitive argument that there is a correlation between these effects

this Report attempts to identify the existence and strength of this correlation and to examine

proposals which seek to address problems associated with hospital emergency departments

and primary care.

The first Chapter of the report gives a brief summary of the Australian healthcare system and

the split between Commonwealth and State responsibilities- the Commonwealth essentially

for primary care and the states for the hospital and critical care system. It also plots the

evolution of the Medicare system from its inception.

The second Chapter presents a range of data on the use of public hospital EDs in Victoria

during the period 1996-2004 and the rate of patient attendances at General Practices for the

same period. It seeks to present this data in a wider context by including population profiles,

medical workforce and Practice Incentives Program data and rates of bulk billing by

electorate. In order to examine the possible association between the two sets of data it has

been divided according to health service boundaries.

The third Chapter examines the link between increases in emergency department

presentations and the decline in access to bulk billing and after hours general practitioners,

regional differences and factors which may also contribute to increased presentations. The

final section of this chapter examines strategies to minimise these increases including co-

located GP clinics, management of chronic diseases and other primary health care initiatives,

telephone triage, and nurse practitioners.

v


Chapter Four of the report examines the decline in bulk billing in Australia generally, and

more specifically in Victoria with an examination of variations across regions and

demographics. The chapter also examines possible reasons for this decline. The second

section examines a similar decline in the access to after hours General Practitioners. The

final section of this chapter examines strategies to minimise the effects of these changes to

the structure of General Practice and maintain the quality of primary care.

During the course of this Inquiry the Committee has been careful to gain the perspective of

rural, regional and metropolitan Victoria and has noted a high degree of variation. As such

the recommendations the Committee has made do not look for universal solutions but seek to

maintain a degree of flexibility. Programs and initiatives that are appropriate for one area are

often not suitable for another.

The Committee undertook extensive travel through regional Victoria for this Inquiry

conducting hearings and site visits in the following regional centres-

• Mildura; • Geelong; • Warrnambool; • Ballarat; • Bendigo; • Horsham; • Shepparton; • Myrtleford; • Sale; and • Bairnsdale

The Committee received evidence from hospitals and health services, community health

centres, Divisions of General Practice and members of the public. The Committee also met

extensively with health professionals from metropolitan and suburban areas. On behalf of the

Committee I would like to thank those who gave their time to participate in this Inquiry,

either through appearance at Public Hearings or preparing written submissions.

Bob Smith MLC

Chairman

vi

Recommendations

RECOMMENDATIONS

Recommendation 1: That the Commonwealth Government continue to

increase the number of aged care residential places and transition care places to

alleviate pressures on hospitals generally.

Recommendation 2: That Health Service Regions are assisted in a programme

of education for Culturally and Linguistically Diverse communities emphasising

the importance of General Practitioners in primary health care and the

appropriate role of Emergency Departments.

Recommendation 3: That Emergency Departments and General practitioners

be supported in their capacity to provide a range of appropriate after hours care

arrangements for their communities (eg. the Eastern Suburbs After Hours Clinic,

Whitehorse DGP; the Grampians After Hours Medical Care Service, West

Victoria Division of General Practice).

Recommendation 4: That the relevant authorities facilitate the training,

registration and placement of nurse practitioners.

Recommendation 5: That the Commonwealth Government simplify processes

around Medicare Programs to increase access and decrease administrative costs

for General Practitioners and consumers.

Recommendation 6: That the State and Commonwealth Governments

examine the opportunity for microeconomic reforms in the health sector to

reduce General Practitioners surgery costs, allowing doctors to set a lower price

while satisfying their target incomes.

vii


Recommendation 7: That the Commonwealth and State Governments, in

consultation with stakeholders, support the development of flexible strategies to

address issues of medical workforce shortage and the decline of bulk billing. Such

strategies may include:

• an increase in the number of General Practitioners practising in community

health centres

• the creation of co-located General Practitioner clinics at hospitals; and

• the introduction of localised telephone triage centres

Recommendation 8: That in order for the Commonwealth Government to meet

the objectives of its social contract, it make a global increase in the Medicare

Schedule Fee to attract General Practitioners back to bulk billing, ensuring all

Victorians have access to an affordable health care system

Recommendation 9: That a recruitment program be put in place to encourage

Overseas Trained Doctors currently working in other areas back into the medical

workforce.

Recommendation 10: That the Commonwealth Government re-examine the

distribution of medical school places in Victoria under A Fairer Medicare

Initiative to ensure that the overall number of General Practitioner Places is

increased to meet demand.

viii

Acronyms & Abbreviations

ACRONYMS & ABBREVIATIONS ADGP Australian Divisions of General Practice

AH after hours

AHCA Australian Health Care Agreement

ATS Australasian Triage Scale

BHCG Base Health Care Grant

CCT Coordinated Care Trial

CHF Chronic Heart Failure

CHP Community Health Plan

CHS Community Health Services

COPD Chronic Obstructive Pulmonary Disease

DGP Divisions of General Practice

DHS Department of Human Services (Victoria)

DoHA Department of Health & Ageing (Comm)

ED Emergency Department

EPC Enhanced Primary Care (Commonwealth

initiative)

GP General Practitioner

GPDV General Practice Divisions of Victoria

HARP Hospital Admission Risk Program

HDMS Hospital Demand Management Strategy

HIC Health Insurance Commission

IM Information Management

IT Information Technology

LGA Local Government Area

MBS Medicare Benefit Schedule

PCP Primary Care Partnership

(Victorian initiative)

PIP Practice Incentives Program

RACGP Royal Australian College of General Practitioners

RRMA Rural, Remote and Metropolitan Area

SLA Statistical Local Area

SWPE Standard Whole Patient Equivalent

WPE Whole Patient Equivalent

ix


x

CHAPTER ONE INTRODUCTION: AN OVERVIEW OF THE AUSTRALIAN

HEALTH CARE SYSTEM

Commonwealth and State Responsibilities in Health Care The Structure of Health Care Health Service Funding & Delivery Summary

Commonwealth and State Responsibilities in Health Care

Constitutional Responsibilities for Health

1.1 The Australian Constitution (1901) allocates responsibility for the provision of

health services, particularly public hospitals, to the State and Territory governments.

Following a referendum held in 1946, an amendment was approved (Section 51, xxiiiA),

allowing the Commonwealth to legislate with regard to social services including ‘sickness

and hospital benefits, medical and dental services (but not so as to authorize any form of

civil conscription)’.

1.2 On this basis, the Commonwealth has since increased its involvement in the

funding and provision of public hospital health services. It provides direct financial

support for the Medicare Benefits Schedule and the Pharmaceutical Benefits Scheme. It

also has a role in health policy through the National Public Health Partnership, which is

the framework for a nationally co-ordinated public health policy, in conjunction with the

States and Territories.

1.3 The States and Territories remain primarily responsible for the delivery of health

services, specifically public hospital infrastructure and services and the majority of

community health programmes. A range of health services are provided on a co-operative

basis between the Commonwealth, State and Territory governments.

Functional Responsibilities for Health 1.4 In order to manage the functional overlap between Commonwealth, State and

Territory governments in the area of health services, periodic agreements are negotiated

which clarify financial arrangements and the principles underlying the funding provided

by the Commonwealth. These agreements, currently known as Australian Health Care

Agreements and formerly known as Medicare Agreements, are negotiated on a five

yearly, bilateral basis.

1

Inquiry on the Impact on the Victorian Community and Public Hospitals of the Diminishing Access to After Hours and Bulk Billing General Practitioners Commonwealth and Victorian legislation 1.5 Part II, Section 9 of the National Health Act (1953) provides the legislative basis

for Commonwealth action in the areas of:

• aerial and medical services;

• diagnostic and therapeutic services for medical practitioners and hospitals, and for

patients of medical practitioners or hospitals;

• teaching, research and advisory services in relation to maternal and child health;

• teaching, research and advisory services for or in relation to the improvement of

health or the prevention of disease; and

• dissemination of information relating to health or the prevention of disease.

1.6 The Health Insurance Act 1973, the Health Insurance Commission Act 1973 and

the Health Legislation Amendment Act 1983 underpin the operation of Medicare and its

administrator, the Health Insurance Commission.

1.7 In Victoria, the primary piece of legislation relating to the provision of health

services is the Health Act 1958, with a variety of subordinate legislation to support it.

The Structure of Health Care 1.8 There are three levels of health care: primary, secondary and tertiary. Primary care

refers to “health care provided by a medical professional…with whom a patient has initial

contact and by whom the patient may be referred to a specialist for further treatment.”

Secondary care is “care provided by a specialist or facility upon referral by a primary care

physician that requires more specialized knowledge, skill, or equipment than the primary

care physician has.” Tertiary care is “highly specialized medical care usually over an

extended period of time that involves advanced and complex procedures and treatments

performed by medical specialists in state-of-the-art facilities.”1

1.9 Primary care is usually delivered through private practice or community health

centres and, ideally, provides continuity and integration of health care. The aims of

primary care are to “provide the patient with a broad spectrum of care, both preventive

and curative, over a period of time and to coordinate all of the care the patient receives.”2

Secondary care is provided by medical specialists either in private consulting rooms or in

outpatient departments of public hospitals. Tertiary care is provided by hospitals, public

or private, and can be further categorised as acute or sub-acute. Acute care is defined as

an episode of care requiring short-term hospitalisation of the patient. Sub-acute care

2

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An Overview of the Australian Health System

incorporates palliative care, rehabilitation, psychogeriatrics and geriatric evaluation and

management.3

1.10 Emergency departments of hospitals provide specialist medical care for trauma

patients. Upon admission to an Emergency Department (ED), patients are categorised or

‘triaged’ according to clinical urgency by an appropriately qualified triage nurse. In

Australia, this process occurs according to the guidelines of the Australasian Triage Scale

(ATS) which is used in Australia and New Zealand. The categories and their descriptors

are shown in Table 1.1, together with their performance indicator thresholds (% of

patients treated within recommended timeframe):

Table 1.1: Australasian Triage Scale category descriptors4 ATS RESPONSE DESCRIPTION OF CATEGORY CLINICAL DESCRIPTORS (INDICATIVE

ONLY) 1 Immediate

Simultaneous assessment & treatment

Benchmark:

100%

Immediately life-threatening

Conditions that are threats to life (or immediate risk of deterioration) and require immediate aggressive intervention.

Cardiac arrest; respiratory arrest; immediate risk to airway – impending arrest; respiratory rate <10/min; extreme respiratory distress; BP<80 (adult) or severely shocked child/infant; unresponsive or responds to pain only; ongoing/prolonged seizure; IV overdose and unresponsive or hypoventilation; severe behavioural disorder with immediate threat of dangerous violence.

2 Assessment & treatment within 10 min.

(assessment & treatment often simultaneous)

Benchmark: 80%

Imminently life-threatening

The patient’s condition is serious enough or deteriorating so rapidly that there is the potential of threat to life, or organ system failure, if not treated within ten minutes of arrival. Important time-critical treatment The potential for time-critical treatment to make a significant effect on clinical outcome depends on treatment commencing within a few minutes of the patient’s arrival in the ED; humane practice mandates the relief of very severe pain or distress within 10 minutes.

Airway risk; severe respiratory distress; circulatory compromise; chest pain of likely cardiac nature; very severe pain – any cause; drowsy, decreased responsiveness – any cause; acute hemiparesis/dysphasia; fever with signs of lethargy (any age); acid or alkali splash to eye – requiring irrigation; major multi trauma (requiring rapid organised team response); severe localised trauma – major fracture/amputation; high-risk history; behavioural/psychiatric disorder – violent or aggressive, immediate threat to self or others, requires or has required restraint, severe agitation or aggression.

3


3 Assessment & treatment start within 30 min. Benchmark: 75%

Potentially life-threatening The patient’s condition may progress to life or limb threatening, or may lead to significant morbidity, if assessment and treatment are not commenced within 30 min of arrival. Situational urgency There is potential for adverse outcomes if time-critical treatment is not commenced within 30 min.; humane practice mandates the relief of severe discomfort or distress within 30 min.

Severe hypertension; moderately severe blood loss – any cause; moderate shortness of breath; seizure – now alert; any fever if immunosupressed; persistent vomiting; dehydration; head injury with short LOC, now alert; moderately severe pain – any cause, requiring analgesia; chest pain – likely non-cardiac; abdominal pain without high risk features; moderate limb injury; limb – altered sensation, acutely absent pulse; trauma – high-risk history with no other high-risk features; stable neonate; child at risk; behavioural/psychiatric – very distressed, risk of self-harm, acutely psychotic or thought disordered, situational crisis, deliberate self-harm, agitated/withdrawn, potentially aggressive.


Potentially serious The patient’s condition may deteriorate, or adverse outcome may result, if assessment & treatment is not commenced within 60 min of arrival in ED. Symptoms moderate or prolonged. Situational urgency There is potential for adverse outcome if time-critical treatment is not commenced within 60 min. Significant complexity or severity Likely to require complex work-up and consultation and/or inpatient management; humane practice mandates the relief of discomfort or distress within one hour.

Mild haemorrhage; foreign body aspiration, no respiratory distress; chest injury without rib pain or respiratory distress; difficulty swallowing, no respiratory distress; minor head injury, no loss of consciousness; moderate pain, some risk features; vomiting or diarrhoea without dehydration; eye inflammation or foreign body, normal vision; minor limb trauma, normal vital signs, low/moderate pain; tight cast, no neurovascular impairment; swollen ‘hot’ joint; non-specific abdominal pain; behavioural/psychiatric – semi-urgent mental health problem, under observation and/or no immediate risk to self or others.


Less urgent The patient’s condition is chronic or minor enough that symptoms or clinical outcome will not be significantly affected if assessment and treatment are delayed up to 2 hrs from arrival. Clinico-administrative problems Results review, medical certificates, prescriptions only.

Minimal pain with no high-risk features; low-risk history and now asymptomatic; minor symptoms of existing stable illness; minor symptoms of low-risk conditions; minor wounds – not requiring sutures; scheduled revisit eg. wound review, complex dressings; immunisation only; behavioural/psychiatric – known patient with chronic symptoms, social crisis – clinically well patient.

4


Health Service Funding and Delivery

Medicare 1.11 Medicare was established in 1984 as the Commonwealth funded health insurance

scheme providing free or subsidised health care services. It was modelled on Medibank, a

universal health insurance scheme introduced in 1974. Medibank operated until the end of

1975 and was dismantled after the double dissolution election of 1975.

1.12 Medicare is a universal health insurance scheme that covers in-patient services for

public patients in public hospitals and provides free (bulk billed) or subsidised access to

doctors’ services, whether general practitioners or specialists. Medicare also covers

certain pathology, psychiatry and optometry services.

1.13 The objectives of Medicare are:

• to make health care affordable for all Australians;

• to give all Australians access to health care services, with priority assessed on clinical

need; and

• to provide high quality care.5

1.14 The Medicare program, including enrolments and benefit payments, is

administered by the Health Insurance Commission. A Medicare levy of 1.5% is applied

on taxable income as an additional contribution to the funding of the health care system.

A Medicare levy surcharge of 1% is payable by those on higher taxable incomes, though

this is not payable if those income earners have private health insurance hospital cover.

1.15 The Commonwealth Government sets the Medicare Benefits Schedule of fees.

The rebate provided by Medicare is based on a percentage of the schedule fee. For

outpatient services, Medicare will pay 85% of the schedule fee. For inpatient services, the

rebate will be 75% of the Schedule fee or an amount up to $57.10, whichever is the

greater. For example, the Medicare benefit for a standard consultation with a general

practitioner is 85% of the Schedule fee of $27.55 (Medicare Benefit Schedule Item no.

23). Health practitioners are free to charge above this Schedule fee, but the benefit

payable remains constant. Further discussion of Medicare payments and programs in

relation to general practice is found later in this Chapter.

1.16 Medicare provides benefits for the following out-of-hospital services:

• consultation fees for doctors, including specialists;

5

Inquiry on the Impact on the Victorian Community and Public Hospitals of the Diminishing Access to After Hours and Bulk Billing General Practitioners • tests and examinations by practitioners needed to treat illnesses, including X-rays and

pathology tests;

• eye tests performed by optometrists;

• most surgical and other therapeutic procedures performed by doctors;

• some surgical procedures performed by approved dentists; and

• specified items under the Cleft Lip and Palate Scheme.6

Patients have a choice of doctor for out-of-hospital treatments.

1.17 For in-hospital services, Medicare provides different levels of coverage for public

and private patients. Public patients in a public hospital receive treatment by doctors and

specialists nominated by the hospital. The patient is fully covered by Medicare for care

and treatment and for after-care by the treating doctor. Private patients in public or private

hospitals have a choice of treating practitioner. A Medicare benefit of 75% of the

Schedule fee is payable for services and procedures provided by the treating practitioner.

Some or all of the costs in excess of the Schedule fee can be covered by private health

insurance. The private patient will be charged for hospital accommodation and other

items such as theatre fees and medicines, and these costs can also be covered by private

health insurance.

1.18 Medicare benefits do not cover the following services:

• dental examinations and treatment (except for some surgery, as noted above);

• ambulance services;

• home nursing;

• physiotherapy, occupational therapy, speech therapy, eye therapy, chiropractic

services, podiatry or psychology;

• acupuncture (unless part of a doctor's consultation);

• glasses and contact lenses;

• hearing aids and other appliances;

• the cost of prostheses;

• medicines;

• medical and hospital costs incurred overseas;

• medical costs for which someone else is responsible (eg. a compensation insurer,

an employer, a government or government authority);

• medical services which are not clinically necessary;

6


• surgery solely for cosmetic reasons; or

• examinations for life insurance, superannuation or membership of a friendly

society.

1.19 Practitioners may choose to bill Medicare directly, accepting the Medicare

benefits as full payment. This is referred to as bulk-billing. No charge is made to the

patient for the service. The practitioner may choose to charge a fee, in which case the

patient may choose to pay the account in full at the time of services and then make a

claim on Medicare. Otherwise, the patient may choose to make a claim on Medicare for

the unpaid account and a Medicare cheque will be made out in the practitioner’s name

and any balance still owing will be paid by the patient.7

1.20 Medicare is administered by the Health Insurance Commission, a statutory

authority of the Commonwealth Government.

Private Health Insurance 1.21 Private health insurance is voluntary in Australia and in June 2004, 42.9% of the

Australian population (42.2% of Victorians) were covered by private health insurance.8

Since the introduction of Medicare, registered health benefits organisations have offered

hospital insurance for approved services provided in public and private hospitals.

1.22 Under current arrangements, lifetime health cover incentives are in place. These

are designed to encourage people to take up and retain private health insurance cover

throughout their lives. From 1 July 2000, people who joined a health insurance fund

(hospital cover) before their 30th birthday and maintained their coverage pay lower

premiums throughout their lives than those joining after their 30th birthday. For those

joining later, a 2% premium loading applies for each year that their entry age is over 30.

Exemptions apply to those aged 65 or older and those who held cover at 1 July 2000 and

maintain their cover.

1.23 In 1999, the Commonwealth Government introduced a non-means tested 30%

reimbursement of private health insurance premiums (hospital or ancillaries cover).9

Australian Health Care Agreements 1.24 Australian Health Care Agreements (AHCAs) are concerned with in-patient

services for public patients in public hospitals. They detail the scope of Commonwealth

funding for these State-provided services and the principles which guide the provision of

those services.

7

Inquiry on the Impact on the Victorian Community and Public Hospitals of the Diminishing Access to After Hours and Bulk Billing General Practitioners 1.25 The 1999-2003 AHCA between the Commonwealth and Victoria contained the

following Principles of Agreement:

• Eligible persons must be given the choice to receive public hospital services free of

charge as public patients;

• Access to public hospital service by public patients is to be on the basis of clinical

need and within a clinically appropriate period;

• Eligible persons should have equitable access to public hospital services, regardless of

their geographical location.

1.26 The roles and responsibilities of the Commonwealth and Victoria were defined as

funding, policy development for their areas of health responsibility and collaborative

work on a national health policy and sharing the cost of health services. During the course

of the AHCA, Victoria was committed to providing services to public patients at an

indicative public patient weighted separation rate of 276.76/1000 applicable weighted

population. This separation rate would be increased in later grant years to reflect a

utilisation drift (from the public to private hospital sector) of 2.1% per annum.10

1.27 In the years 2000-01 to 2002-03, the Basic Health Care Grant was based on the

Grant payable in previous year. An annual increment of $6,289,777 would apply to the

quality improvement funds, in addition to indexation. The formula for indexation was

established as:

1.28 Index A (applicable to 83.928% of the BHCG) included adjustment for:

1. change in Victoria’s applicable weighted population;

2. movement in the hospital output cost index; and

3. a utilisation growth factor of 1.021.

1.29 Index B (applicable to 16.072% of the BHCG) included adjustment for:

4. growth in Victoria’s weighted population; and

5. movement in the hospital output cost index.11

1.30 The 2003-2008 AHCA between the Commonwealth and Victoria provided for

$10.1 billion of Commonwealth funding to Victoria over the life of the AHCA.12 The

compliance requirements are set out in Clause 25. Victoria is obliged to increase its own

source funding so that the cumulative rate of growth at least matches the cumulative rate

8


of growth of Commonwealth funding to Victoria under the Agreement. Victoria must

adhere to the Principles outlined in Clause 6 and meet the performance requirements set

out in the AHCA. Under Clause 32, if the Commonwealth Health Minister considers that

Victoria has failed ‘over consecutive years’ to meet one or more of the compliance

requirements, its health care grant will be reduced for the remaining term of the

Agreement. Dollar amounts for the BHCG and its components are not provided in the

AHCA, though the formulae contained in Schedule G nominate the final grant entitlement

for the 2002-03 financial year as a base for calculations.13

1.31 Table 1.2 outlines the list of performance indicators used to determine

compliance.

Table 1.2: Minimum List of Performance Indicators, 2003-08 1. Eligible persons are to be given the choice to receive, free of charge as public patients, health and emergency services of a kind or kinds that are currently, or were historically, provided by hospitals. (a) Public patient weighted separation rate per 1,000 weighted population (b) Same day and overnight separations by patient accommodation status (c) Number of separations by care types and mode of separation (d) Emergency department occasions of service (e) Outpatient occasions of service 2. Access to such services by public patients free of charge is to be on the basis of clinical need and within a clinically appropriate period. (a) Waiting times for elective surgery by urgency category (b) Waiting times for emergency departments by triage category (c) Admission from waiting lists by clinical urgency 3. Arrangements are to be in place to ensure equitable access to such services for all eligible persons, regardless of their geographic location. (a) Number of public and private hospital separations by Indigenous and Non-Indigenous Status per 1,000 population (b) Mental health patient days by Psychiatric and Non-Psychiatric hospitals public and private (c) Psychiatric care by Indigenous and Non-Indigenous Status

4. Indicators of efficiency and effectiveness of public hospital services (a) Recurrent expenditure, public acute and psychiatric hospitals (b) Revenue, public acute and psychiatric hospitals (c) Cost per casemix adjusted separation in public hospitals

5. Indicators of quality and patient outcomes in relation to the delivery of public hospital services (a) Number of accredited medical specialist training positions by specialty (using latest available data) (b) Public hospital accreditation status

6. Indicators of Rehabilitation and Stepdown Services (a) Distribution of rehabilitation episodes by mode of separation, sex, age group and accommodation status

9

Inquiry on the Impact on the Victorian Community and Public Hospitals of the Diminishing Access to After Hours and Bulk Billing General Practitioners 1.32 Both parties have a responsibility to work for the development of certain national

programs; act in accordance with agreements on Aboriginal and Torres Strait Islander

health; refrain from instituting or sanctioning arrangements which unreasonably impose

an additional financial burden on the other party. Finally, where it can be demonstrated

that a change in service delivery arrangements would improve patient care, patient safety

or patient outcomes, the Commonwealth and Victoria agree to implement such changes in

an open and consultative manner and, as appropriate, recompense the other party where

costs are transferred to that party.14

Commonwealth Programs in Support of Primary Care Divisions of General Practice

1.33 The Divisions of General Practice work to support local GPs by co-ordinating

population health programs and services, and providing professional development and

practice support. There are 121 Divisions nation-wide, and 30 in Victoria. The Australian

Divisions of General Practice (ADGP) is the national peak body representing all

Divisions, while each State and Territory has its own state-based organisation. Thus the

Divisions of General Practice in Victoria are represented and supported by General

Practice Divisions Victoria (GPDV) and the ADGP.

1.34 Divisions are funded by the Commonwealth, States and Territories and most

Divisions receive some funding from other sources. Funding from the Commonwealth is

in the form of outcomes-based funding or specific program funding. The 2002-03 annual

survey of Divisions gave the following breakdown of funding for all Divisions:

Commonwealth Outcomes Based Funding 48%; other Commonwealth 33%; States and

Territories 7%; other non-profit 4%; other (not specified) 6%; local government 0.3%;

pharmaceutical industry 1%; other commercial 1%.15

1.35 These Divisions provide a number of services and benefits to GPs:

• a structure to enable peer support and to promote the identity of GP;

• a means for fostering communication between GPs, the public and the wider health

system;

• a resource for GPs and other health care providers regarding general practice, primary

health care and primary health research; support services to GPs and practice staff in

program areas such as IM/IT, immunisation, health promotion and disease

management;

10


• continuing medical education for GPs and training for practice staff;

• a vehicle for contributing to GP participation in policy development;

• an interface with GPs at the local level for consumer and community representatives;

and

• a mechanism to assist GPs in providing enhanced services to their patients.16

1.36 DGPV has been, and continues to be, involved in programs concerning quality

accreditation of Divisions and GPs, after hours care, aged care, chronic disease

management, consumer and community involvement in primary health care, enhanced

primary care, GP-hospital education, professional development, indigenous health and

immunisations.17

Practice Incentives Program

1.37 The Practice Incentives Program (PIP) is a Commonwealth program that aims to

“recognise general practices that provide comprehensive, quality care”.18 It is part of a

blended payments system for GPs, being additional to Medicare rebates and patient

payments. Payments under PIP are focused on specific aspects of general practice and as

such have a number of elements under which payments are made: the use of information

management and technology; after hours care; student teaching; quality prescribing

initiative; asthma; diabetes; cervical screening; practice nurses; mental health; and

rurality.19

1.38 In November 2001 (announced in the 2001-02 Budget) the Commonwealth

announced new incentives payments relating to diabetes, asthma, cervical screening and

mental health. Some modifications were made to these incentives under the MedicarePlus

changes announced in November 2003 and March 2004. The Practice Nurse and Allied

Health Worker initiative aims to build on the PIP Practice Nurse incentive by providing

additional practice nurse and allied health workers to work in PIP general practices. The

initiative will allow for an additional 457 full-time practice nurses and/or allied health

workers by 2007 in areas of urban workforce shortage.20

1.39 Table 1.3 outlines the payments payable under each element of the PIP. Most PIP

components are paid in proportion to practice size and this is calculated using the

Standardised Whole Patient Equivalent (SWPE) as a measure of patient load. The SWPE

value for a practice is the sum of the fractions of care it provides to each of its patients,

11

Inquiry on the Impact on the Victorian Community and Public Hospitals of the Diminishing Access to After Hours and Bulk Billing General Practitioners weighted for the age and gender of each patient. It is estimated the average full time

equivalent GP sees 1,000 SWPEs annually.21

Table 1.3: Practice Incentives Payments payable per SWPE22 Element Aspect or Activity Annual

Payments per SWPE

Tier 1 – Providing data to the Australian Government $3.00 Tier 2 – Use of bona fide electronic prescribing software to generate the majority of scripts in the practice

$2.00 1. Information Management/ Information Technology

Tier 3 – The practice has on site and uses a computer(s) connected to a modem to send and/or receive clinical information

$2.00

Tier 1 – Ensuring patients have access to 24 hour care as specified in the application form

$2.00

Tier 2 – On average, the practice covers at least 15 hours per week of its after hours care from within the practice

$2.00

2. After hours care*

Tier 3 – The practice provides 24 hour care from within the practice

$2.00

3. Teaching Teaching of medical students $50 per session (max. 2 sessions per day)

4. Quality Prescribing Initiative

Practice participation in quality use of medicines programs, endorsed by the National Prescribing Service

$1.00

Sign-on Payment: one-off payment for notifying the Australian Government that the practice uses a diabetes register and recall/reminder system

$1.00

Service Incentive Payment: Payment for each annual cycle of care for a patient with diabetes, payable once per year per patient

$40 per diabetic

5. Diabetes

Outcomes Payment: Payment to practices that complete an annual program of care for a target proportion of the patients with diabetes

$20 per diabetic

Sign-on Payment: payment to practices that agree to provide data to the Australian Government

$0.25 6. Asthma

Service Incentive Payment: Payment to practitioners who complete an Asthma 3+ Visit Plan for patients with moderate to severe asthma, payable once per year

$100

12


Sign-on Payment: Payment to practices that agree to provide data to the Australian Government.

$0.25 7. Cervical screening

Service Incentive Payment: Payment to practitioners for screening women between 20 and 69 years who have not had a cervical smear within the last four years.

$35

Outcomes Payment: Payment to practices where a specified proportion of women aged between 20 and 69 years have been screened in the last 24 months

$2.00 per female WPE aged between 20 and 69

8. Practice Nurses Payment to practices that employ or retain the services of a practice nurse and are located in the target area

RRMAs 1-2: $8 per SWPE RRMAs 3-7: $7 per SWPE

Sign-on Payment: One-off payment to individual GPs who register for the incentive

$150 9. Mental Health

Service Incentive Payment: Payment to GPs on completion of the 3-step mental health process

$150

10. Rurality# Total PIPs are loaded for rurality, increasing with extent of remoteness, using RRMA classification

15% to 50% loading

* For the purposes of PIP, after hours refers to any time outside 8am to 6pm weekdays and 8am to noon on Saturday. This differs from the definition of after hours care used in the Medicare Benefits Schedule.

#The Rural, Regional Metropolitan Area (RRMA) classification and their loadings for the

purposes of PIP are:

RRMA number & category

Rural loading RRMA number & category

Rural loading

1. Capital city 0% 5. Other rural centre

40%

2. Other metropolitan centre

0% 6. Remote centre 25%

3. Large rural centre 15% 7. Other remote area

50%

4. Small rural centre 20%

Enhanced Primary Care Package

1.40 In November 1999, the Commonwealth introduced the Enhanced Primary Care

(EPC) package intended to provide more preventive care for aged patients and for those

with chronic or complex conditions requiring a multidisciplinary approach. It involved 28

new Medicare items covering Multidisciplinary Care Planning, Health Assessment for

patients aged 75 years or more (Aboriginal & Torres Strait Islanders over 55),

Multidisciplinary Case Conferencing and Domiciliary Medication Management Review.

13

Inquiry on the Impact on the Victorian Community and Public Hospitals of the Diminishing Access to After Hours and Bulk Billing General Practitioners In May 2004, two yearly Health Checks for adult (15-55 yrs) Aboriginal and Torres Strait

Islanders was included as a new MBS item under the EPC package.

Medicare Plus

1.41 In November 2003 and in March 2004, the Commonwealth announced planned

changes to Medicare.

Table 1.4: MedicarePlus, November 2003 and March 200423

Safety Net

Subject to legislation

80% of out-of-pocket costs (non-hospital services) will be met at certain thresholds for certain groups. Families in receipt of Family Tax Benefit (A) - $300; Commonwealth Concession Card holders (individuals or families) - $300; all other individuals or families - $700.

Bulk billing incentives

Start 1 May 2004

Incentive payment of $5 to GPs who bulk-bill concession card holders, and children under 16; rate increases to $7.50 for GPs in regional, rural and remote areas and Tasmania.

Allied health services and

dental health care

Start 1 July 2004

New MBS item that can be claimed by a GP for certain services provided ‘for and on behalf of the GP’ by an allied health provider (excluding those funded by the State or Commonwealth) – available to PIP general practices; additional MBS item to support access to dental treatment for patients with a chronic or complex condition whose significant dental problems are related to their condition and increase the risk of complication.

Medical school places

Start academic year 2005

246 additional medical school places, bonded to areas of workforce shortage

Areas of consideration

Start 1 July 2004

‘Areas of consideration’ will be established to deal with situations where statistical local area boundaries have resulted in areas that would otherwise be considered rural and/or remote being classified as larger rural centres. Additional factors: GP to population ratio and availability of services.

Health

Connect/MediConnect

Start 1 July 2004

Establishing an integrated electronic health information network based on electronic health records.

State Programs in Support of Primary and Emergency Care 1.42 In the financial year 2004-05, the Victorian Government expects that $5.177

billion will be spent on acute health services and $153.8 million on primary health.24

14


Hospital Demand Management Strategy

1.43 In the area of acute health, the Victorian Government adopted the Hospital

Demand Management Strategy (HDMS) in 2001-2002. This strategy is designed to

improve the capacity of hospitals to manage demand pressures, with particular regard for

emergency and elective surgery services.

1.44 As a component of the HDMS, the Victorian Government also adopted the

Hospital Admission Risk Program (HARP) which identifies those people at increased risk

of hospital admission and co-ordinates a care program to reduce the risk of their illness

becoming acute and requiring an ED presentation or admission. Over the five years to

June 2005, HARP will have received $150 million for initiatives that:

• develop preventive models of care involving the hospital and community;

• focus on people with a manifest health need, often where this condition is chronic or

complex; and

• focus on high volume and/or frequent users of the acute public hospital system.25

In 2003/04, HARP funded the following projects and initiatives.

Table 1.5: Hospital Admission Risk Program: 2003/04 funded projects

HEALTH SERVICE PROVIDER

PROJECT 2003/04 FUNDING

Community Link Rapid Response Service Enhancement

$679,194

Respecting Patient Choices $318,481

Austin Health

Out of Area Bed Coordination $112,688

Barwon Health Integrated Disease Management of Chronic Heart Failure (CHF)

$179,712

Bayside Health Medication Alert Project $521,147

Bendigo Health Care Group Improved Management of Care for People with Congestive Heart Failure

$144,877

City Of Port Phillip Care Coordination for Mental Health & Complex Psychosocial Needs

$463,911

Darebin Community Health Service

Integrated Chronic Disease Management – Chronic Obstructive Pulmonary Disease (COPD) & CHF

$338,851

15


Dianella Community Health Service

A Comprehensive Community Approach to Asthma Management for Children and Families - Phase 2

$187,054

Integrated Response to Complex Needs in the Community

$1,113,400 Eastern Health


Goulburn Valley Health Goulburn Valley Admission Risk Program: Strengthening Acute and Community Partnerships

$213,710

Melbourne Health Comprehensive Community Care Service $675,684

Metropolitan Ambulance Service

Medical Deputising Service link with MAS Referral Service

$139,580

Northern Division Of General Practice

An Integrated Holistic Approach to Diabetes Management

$345,302

Integrated Wound Management Services $392,918

Community Client Orientated Medication Services (C-COMS)

$313,888

Northern Health


Peninsula Health Peninsula Residential Outreach Response Team

$214,454

Royal District Nursing Service

Community Nursing Response to Metropolitan Ambulance Service Referral Service

$297,384

Holding It Together $481,466

Restoring Health $417,314

Treatment, Response & Assessment For Aged Care

$428,580

The COACH Program in the Community $74,241

St Vincent's Health


16


Care in Context for Mental Health Patients $354,335

Supporting the Improved Management of CHF in the Community

$244,652

Southern Health

Health for Kids in the South East $424,764

Western Health An Integrated System for Managing the Care of Older People with Complex Needs

$1,113,208

Primary Care Partnerships Strategy

1.45 The purpose of Primary Care Partnerships (PCPs) is to achieve greater

collaboration and integration of the primary health care system with better service

coordination and an emphasis on prevention of disease and acute episodes of care. The

specific aims of PCPs are to:

• Improve the experience and outcomes for people who use primary care services;

• Plan and deliver more effective health promotion programs and health-promoting

services, underpinned by a social model of health;

• Develop a primary care service system to complement the acute system;

• Enable demands on current services, particularly acute and emergency services, to be

better managed; and

• Lead to the development of a system where interventions are delivered pro-actively

and at appropriate times rather than in response to emergencies.26

1.46 PCPs do this by establishing Community Health Plans (CHPs) which typically

involve the local Division of General Practice, Health Service Area, community health

centres, welfare service providers and other welfare societies, local government and the

district nursing service. PCPs were established in 2002 and will receive $50 million over

four years.

17


1.47 There are currently 32 PCPs operating in Victoria, involving 800 services. These

are set out in Table 1.6.

Table 1.6: Primary Care Partnerships, Victoria Region Primary Care Partnership Local Government Area

Hume-Moreland Hume, Moreland Banyule-Nillumbik Banyule, Nillumbik

Northern Metropolitan

North Central Metropolitan Whittlesea, Darebin & Yarra Booroondara Booroondara Outer East Health & Community Support Alliance

Maroondah, Knox, Yarra Ranges

Eastern Metropolitan

Central East Monash, Manningham, Whitehorse

Inner South East Partnership in Community & Health

Port Phillip, Stonnington, Glen Eira

Kingston-Bayside Kingston, Bayside South East Greater Dandenong, Casey,

Cardinia

Southern Metropolitan

Frankston-Mornington Peninsula

Frankston, Mornington Peninsula

Moonee Valley-Melbourne Moonee Valley, Melbourne Westbay Wyndham, Hobson’s Bay,

Maribyrnong

Western Metropolitan

Brimbank-Melton Brimbank, Melton Southern Grampians-Glenelg Southern Grampians, Glenelg South West Corangamite, Moyne,

Warrnambool

Barwon South Western

Barwon Colac-Otway, Greater Geelong, Surf Coast, Queenscliffe

Wimmera West Wimmera, Hindmarsh, Yarriamback, Horsham

Grampians Pyrenees Ararat, Northern Grampians, Pyrenees

Grampians

Central Highlands Ballarat, Golden Plains, Moorabool, Hepburn

Northern Mallee Mildura (incl. Statistical Local Area of Robinvale)

Southern Mallee Swan Hill (excl. Statistical Local Area of Robinvale), Gannawarra, Buloke

Bendigo-Loddon Bendigo, Loddon Campaspe Campaspe

Loddon Mallee

Central Victorian Health Alliance

Mt Alexander, Central Goldfields, Macedon Ranges

18


Region Primary Care Partnership Local Government Area East Gippsland East Gippsland Wellington Wellington Central West Gippsland Latrobe, Baw Baw

Gippsland

South Coast Health Services Consortium

Bass Coast, South Gippsland

Lower Hume Mitchell, Murrindindi Goulburn Valley Moira, Strathbogie, Greater

Shepparton Central Hume Alpine, Delatite, Wangaratta

Hume

Upper Hume Indigo, Towong, Wodonga

Community Health Services

1.48 A recent report into General Practitioners in Community Health Services (CHSs)

estimated that there were at least 29.4 Full Time Equivalent General Practitioners

engaged in GP service delivery in CHSs. This translates to at least 118 General

Practitioners regularly engaged in CHSs. These positions may be salaried or may involve

part time work with the CHS combined with private practice or hospital work.27 The

funding and management of General Practitioners within CHSs is complicated by the fact

that they are providing federally funded (Medicare) services within a state health delivery

framework.

1.49 The Victorian Government will provide $8 million over four years (from 2004-05)

to recruit General Practitioners into CHSs. It is intended that this initiative will extend the

provision of GP services to communities of low socio-economic status and people with

chronic or complex medical problems. As part of this program, there will be particular

emphasis on extending the provision of bulk-billing and extended hour GP services in

selected CHSs.28

Summary

1.50 The funding and provision of health care in Australia is marked by a complex

structure of Commonwealth and State government responsibilities and arrangements. The

funding of primary health services is mainly a Commonwealth responsibility, while the

funding and provision of secondary and tertiary health services involves various weights

of Commonwealth and State responsibility. Within these complex structures, both levels

of government have put in place programs that support the provision and coordination of

19

Inquiry on the Impact on the Victorian Community and Public Hospitals of the Diminishing Access to After Hours and Bulk Billing General Practitioners primary care. The Victorian Government has also sought to manage the interface between

primary and acute care with specific strategies and initiatives.

20


21

Endnotes

1 Merriam Webster Medical Dictionary. 2 Better Health Channel, www.betterhealth.vic.gov.au 3 Lee, L.A., Eager, K.M., and Smith, M.C. 1998. Subacute and nonacute casemix in Australia. Medical Journal of Australia: S22-S25., p. S22; Hilless, M., and Healy, J. (2001). Health Care Systems in Transition: Australia. Paris: European Observatory on Health Care Systems. AMS 5012667 (AUS), pp 49-53. 4 Australasian College of Emergency Medicine. (2000). Guidelines for the Implementation of the Australasian Triage Scale in Emergency Departments. Melbourne: ACEM.; Australasian College of Emergency Medicine. (2000). The Australasian Triage Scale. Melbourne: ACEM. 5 Health Insurance Commission, at http://www.hic.gov.au, accessed June 2004. 6 Ibid. 7 Ibid. 8 Australian Private Health Insurance Association, Coverage of Private Health Insurance, http://www.ahia.org.au/health%20insurance%20statistics.html. Accessed August 2004. 9 Australian Institute of Health & Welfare. (2002). Australia's Health 2002. Canberra: AIHW., pp. 262-266. 10 Commonwealth of Australia, and State Government of Victoria. (1998). Australian Health Care Agreement, 1998-2003. Canberra., Clause 22. 11 Ibid., Clauses 36-43. The formulae for indexation are located in Schedule E of the AHCA. 12 Metropolitan Health Services and Aged Care. (2003). Hospital Circular. Melbourne: Department of Human Services (Vic). 33/2003 13 Commonwealth of Australia, and State Government of Victoria. (2003). Australian Health Care Agreement, 2003-2008. Canberra. Part 5, Financial Assistance and Associated Terms and Conditions; Schedule G, Financial Assistance to Victoria. 14 (2003). Australian Health Care Agreement (Victoria). Canberra., pp 5-6. 15 Kalucy, E., Hann, K., and Whaites, L. (2003). Divisions: a Matter of Balance: Report of the 2002-03 Annual Survey of Divisions of General Practice. Adelaide: Primary Health Care Research & Informtion Service, Flinders University. , p. 15. 16 Department of Human Services. (2001). A Guide to General Practice Engagement in Primary Care Partnerships. Melbourne: State Government of Victoria. , pp. 7-8. 17 http://www.gpdv.com.au/gpdv/ Accessed July 2004. 18 Commonwealth of Australia. (2001). An Outline of the Practice Incentives Program. Adelaide: Department of Health & Ageing. , p. 3. 19 Ibid. , p. 3. 20 http://www.hic.gov.au/providers/incentives_allowances/pip.htm Accessed June 2004 21 Ibid. 22 http://www.hic.gov.au/providers/incentives_allowances/pip/calculating_payments.htm Accessed June 2004 23 Commonwealth of Australia. (2004). MedicarePlus: Update March 2004. Canberra: Department of Health & Ageing. 24 Department of Human Services. (2004). Victorian Budget Information Kit. Melbourne: State Government of Victoria. , p. 2.

http://www.betterhealth.vic.gov.au/

http://www.hic.gov.au/

http://www.ahia.org.au/health insurance statistics.html

http://www.gpdv.com.au/gpdv/

http://www.hic.gov.au/providers/incentives_allowances/pup.htm

http://www.hic.gov.au/providers/incentives_allowances/pip/calculating_payments.htm


22

25 Department of Human Services, Victoria, HARP website: http://www.health.vic.gov.au/hdms/harp/index.htm Accessed July 2004. 26 Department of Human Services. (2001). Evaluation of the Primary Care Partnership Strategy. Melbourne: Primary & Community Health Branch. , p. 1. 27 Burgell Consulting, O'Leary & Associates, and Dep. of General Practice University of Melbourne. (2002). Study of General Practitioners in Community Health Services: Summary Report. Melbourne: Department of Human Services, Victoria. , p. 27. 28 Department of Human Services. (2004). Victorian Budget Information Kit. Melbourne: State Government of Victoria. , p. 16.

http://www.health.vic.gov.au/hdms/harp/index.htm

CHAPTER TWO PATTERNS OF USE IN THE VICTORIAN HEALTH

CARE SYSTEM, 1996-2004

Introduction Divisions of General Practice – Profiles Health Service Areas – Profiles Data Sources

Introduction 2.1 This Chapter presents a range of data on the use of public hospital EDs in

Victoria during the period 1996-2004 and the rate of patient attendances at General

Practices for the same period. It seeks to present this data in a wider context by

including population profiles, medical workforce and Practice Incentives Program

data and rates of bulk billing by electorate. For ease of reference, this data has been

divided according to health service boundaries. General Practitioner attendances and

associated data are grouped under individual Divisions of General Practice and

admissions and presentations to public hospital EDs are grouped by Health Service

Region.

Divisions of General Practice 2.2 Divisions of General Practice (DGP) were first established in 1992 under a

pilot program. There are now 121 Divisions across Australia; in Victoria there are 15

metropolitan and 15 regional DGPs. Each DGP is incorporated as an association or

company with most of their funding provided by the Commonwealth Department of

Health and Ageing. Nationally, some 95% of General Practitioners are voluntary

members of their local DGP. The purpose of DGPs is to support General Practice and

General Practitioners through continuing professional development, practice support,

and to act as a point of communication between General Practitioners, allied health

professionals, and Commonwealth and State departments of health.

2.3 In this Chapter, each Victorian DGP is profiled. The following data is

presented:

• Population profile;

• Medical workforce, including Full Time Equivalent GP:population ratio where

available;

• Bulk billing rates from 2000-2003 by electorate;

23


• Estimated population growth rates by Local Government Area;

• The rate of General Practitioner attendances during the period 1996-2004; and

• Practice Incentives Program as at May 2004, noting the number of registered

General Practices, rurality, after hours care arrangements and the use of

practice nurses.

2.4 The ‘Emergency After Hours’ subgroup of General Practitioner attendances

under the Medicare Benefits Schedule have particular conditions which apply before a

benefit is payable. The following excerpts from the Medicare Benefits Schedule

(General Medical Services, Professional Attendances, Category 1: p. 31) describes the

circumstances under which Items 1, 2, 97, 98, 448, 449, 601, 602, 697 and 698 apply:

“A.10.1.

• The consultation is initiated by or on behalf of the patient in the same

unbroken after hours period;

• The patients’ medical condition must require immediate treatment; and

• If more than one patient is seen on the once occasion, these items can be

used but only in respect of the first patient. The normal items for the

particular location should be itemised in respect of the second and

subsequent patients attended on the same occasion.

Where the patient is seen at a public hospital the following additional provisions

would apply in relation to Items 1, 97, 601 and 697:

• The first or only patient is a private in-patient; or

• The first or only patient is seen in the out-patient or casualty department

and the hospital does not provide at the time a medical out-patient or

casualty service.

Where any of the above conditions do not apply the normal Schedule items should

be itemised.

A.10.2 Items 2, 98, 448, 449, 602 and 698 are intended to allow benefit for

returning to and specially opening up consulting rooms to attend a patient who

needs immediate treatment after hours. As the extra benefit is for the

inconvenience of actually returning to and opening the surgery it is payable only

once on any one occasion – to the first patient seen after opening up. If other

patients are seen on the same occasion they are itemised as ordinary surgery

attendances.

24

Patterns of Use in the Victorian Health Care System, 1996-2003

A.10.3. An after hours consultation or visit is a reference to an attendance(s) on a

public holiday, on a Sunday, before 8am or after 1pm on a Saturday, or at any time

other than between 8am and 8pm on a week day not being a public holiday.

A.10.4. Where a practice or clinic routinely conducts its business during hours

other than those quoted above, it would be necessary for the emergency service to

be initiated and rendered outside the hours normally observed by that practice or

clinic for it to attract a Medicare rebate.”

2.5 In each Division profile, basic data is provided on the medical workforce.

Unless otherwise stated, the medical workforce and GP:population ratios are based on

raw numbers: that is, simply the number of General Practitioners practising within

that Division, with the Division’s population divided by the number of General

Practitioners to provide a GP:population ratio. Where a Full Time Equivalent (FTE)

number has been used, this is clearly stated. The FTE number takes into account the

proportion of General Practitioners working part time and produces an equivalent

number of full time General Practitioners. For example, the GP Association of

Geelong has 195 General Practitioners; some of these work part time, so the FTE

number of General Practitioners is 152. Without taking full time equivalency into

account, the GP:population ratio for this Division is 1:1066; taking into account full

time equivalency this ratio increases to 1:1368. This latter figure more accurately

reflects patient access to General Practitioners.

2.6 The Commonwealth uses FTE GP:population ratio data to determine ‘areas of

need’ and ‘districts of workforce shortage’. Areas with a population ratio higher than

the national average may be eligible for Commonwealth programs addressing

shortages in the medical workforce. Currently, the national average is calculated at

approximately 1:1385 (Department of Health and Ageing, health.gov.au/medicare).

2.7 When considering the GP:population ratios contained within the following

Division profiles it should be noted that

“The simple GP:population ratio does not take account of the facts that GPs

practise in different ways and provide different services, that the morbidity patterns

of communities are not homogeneous, and that the availability of other health

services varies from place to place.” (General Practice: Changing the future

through partnerships, Report of the General Practice Strategy Review Group,

Department of Health & Ageing, 1999: 164)

25

Inquiry on the Impact on the Victorian Community and Public Hospitals of the Diminishing Access to After Hours and Bulk Billing General Practitioners The GP:population ratio varies from capital cities, to urban, regional, rural and remote

areas. For example, figures from 1996 indicate that the ratio for capital cities was

1:1045; for other urban areas it was 1:1120 and for rural areas it was 1:1466

(Department of Health and Family Services, General Practice in Australia, 1996). A

more detailed discussion of medical workforce issues takes place in Chapter Four.

2.8 Given that the boundaries of Divisions of General Practice do not coincide

with Health Service Regions, Local Government Areas or federal electorates, data

drawn from the latter units of analysis are allocated to Divisions based on the greater

proportion of that area falling within Division boundaries.

2.9 In summary, General Practitioner attendances data are presented by regional

DGPs, metropolitan DGPs and for the whole of Victoria. Health Service Regions

2.10 Each Health Service Region (HSR) is profiled, with the following data

presented:

• Population profile;

• Hospital services with EDs (public & private); and

• Admissions and presentations to EDs during the period 1996-2004.

2.11 The presentations and admissions data are for the whole of the HSR, by

hospital, and by categories of the Australasian Triage Scale (ATS).

2.12 In summary, admissions and presentations to EDs by ATS category are

presented by regional EDs, metropolitan EDs and for the whole of Victoria. Health Service boundaries

2.13 The Victorian Department of Human Services has five regional and four

metropolitan Health Service Regions (HSRs). These boundaries are themselves based

on Local Government Areas. The following table aligns each HSR with its Local

Government Areas, major public hospitals with EDs, and with the appropriate DGPs.

Please note that there is no coincidence of boundaries between DGPs and HSRs.

DGPs were established as communities of professional interest and were not aligned

with their State or Territory health service boundaries. Consequently, HSRs will often

have multiple DGPs within their boundaries.

26


2.14 Following the table are maps of metropolitan and regional HSRs (indicating

the location of public health services) and maps of regional and rural DGPs.

METROPOLITAN Health Service Region

Local Government Areas Public Hospitals with EDs

Divisions of General Practice

Eastern Yarra Ranges, Knox, Manningham, Monash, Maroondah, Whitehorse, Boroondara

Maroondah Hospital Box Hill Hospital Angliss Hospital Monash Medical Centre

Inner Eastern Melbourne, North East Valley, Whitehorse, Greater South Eastern,

Northern Hume, Nillumbik, Whittlesea, Moreland, Darebin, Banyule, Yarra

Northern Hospital Austin & Repat St Vincent’s

Central Highlands, North East Valley, Melbourne, North Western, Northern

Southern Cardinia, Casey, Mornington Peninsula, Frankston, Greater Dandenong, Kingston, Bayside, Glen Eira, Stonnington, Port Phillip

Frankston Hospital Dandenong Hospital The Alfred

Central Bayside, Inner Eastern, Inner South East, Greater South Eastern, Monash, Central Bayside, Knox, Dandenong, Mornington Peninsula

Western Melton, Brimbank, Moonee Valley, Wyndham, Hobson’s Bay, Maribyrnong, Melbourne

Royal Melbourne Sunshine Hospital Western Hospital

Westgate, Western Melbourne, Melbourne, North West Melbourne

RURAL DHS Region Local Government Areas Public Hospitals with

EDs Divisions of General Practice

Barwon South Western

Glenelg, Southern Grampians, Moyne, Warrnambool, Colac Otway, Corangamite, Surf Coast, Queenscliff, Greater Geelong

Barwon Health GP Association of Geelong, Otway, West Victoria, Ballarat

Gippsland Bass Coast, South Gippsland, La Trobe, Baw Baw, Wellington, East Gippsland

Latrobe Regional Hospital

Central West Gippsland, East Gippsland, South Gippsland

Grampians West Wimmera, Hindmarsh, Yarriambiack, Horsham, Northern Grampians, Ararat, Pyrenees, Ballarat, Hepburn, Moorabool, Golden Plains

Ballarat Health Services, St John of God Health Care,

Ballarat, Bendigo, Central Highlands, GP Association of Geelong

Hume Mitchell, Strathbogie, Greater Shepparton, Moira, Benalla, Murrindindi, Mansfield, Milawa, Indigo, Alpine, Wodonga, Towong

Goulburn Valley Health Goulburn Valley, North East Victoria, Border, Eastern Ranges

Loddon Mallee Mildura, Swan Hill, Buloke, Gannawarra, Campaspe, Loddon, Central Goldfields, Greater Bendigo, Macedon Ranges, Mt Alexander

Bendigo Health Care Group

Mallee, Murray Plains, Bendigo, Goulburn Valley, West Victoria

27


Source: Department of Human Services, Victoria (2004). http://www.health.vic.gov.au/maps/index.htm

28


Source: Department of Human Services, Victoria (2004). http://www.health.vic.gov.au/maps/index.htm

29

Inquiry on the Impact on the Victorian Community and Public Hospitals of the Diminishing Access to After Hours and Bulk Billing General Practitioners Divisions of General Practice boundaries

Metropolitan Divisions of General Practice:

Division No. Division Name

301 Melbourne 302 North East Valley 303 Inner Eastern Melbourne 304 Inner South East Melbourne (Southcity) 305 Westgate 306 Western Melbourne 307 North West 308 Northern 310 Whitehorse 311 Greater South Eastern 312 Monash 313 Central Bayside 314 Knox 315 Dandenong 316 Mornington Peninsula

Source: Divisions of General Practice Victoria, 2004: http://www.gpdv.com.au

30


Regional Divisions of General Practice:

Division No. Division Name

317 Geelong

318 Central Highlands

319 North East Victoria

320 Eastern Ranges

322 South Gippsland

323 Central West Gippsland

324 Otway

325 Ballarat & District

326 Bendigo & District

327 Goulburn Valley

328 East Gippsland

329 Border

330 West Victoria

331 Murray Plains

332 Mal e leSource: Divisions of General Practice Victoria, 2004: http://www.gpdv.com.au

31


DIVISIONS OF GENERAL PRACTICE – PROFILES

BALLARAT & DISTRICT DIVISION OF GENERAL PRACTICE Population 3330 Rokewood; 3334 Elaine; 3341 Myrniong; 3342 Ballan; 3345 Gordon; 3350 Ballarat; 3351 Lake Bolac, Smythesdale, Snake Valley; 3352 Cardigan Village, Learmonth, Miners Rest; 3355 Wendouree; 3356 Sebastopol; 3357 Buninyong; 3360 Linton; 3361 Skipton; 3363 Creswick; 3364 Ascot, Coghills Creek; 3370 Clunes; 3371 Talbot; 3460 Daylesford; 3461 Hepburn Springs, Bullarto

Population Number Division State

Persons aged 0-4 (2001) 7,545 6.6% 6.5%

Persons aged over 65 (2001) 15,004 13.1% 12.6%

Total Persons 2001 114,233


Population Profile Female 51.2% 50.9%

Non-English Speaking Background 3.% 19.8%

Aboriginal & Torres Strait Islanders 0.8% 0.5%

Medical Workforce

Number of General Practices 27

General Practitioners 86 (not FTE)

GP:Population 1:1328 (not FTE)

32


General Practitioner Attendances, 1996-2004

GP Attendances: MBS Categories A1 & A2, 1996-2004Ballarat & District Division of General Practice

400,000420,000440,000460,000480,000500,000520,000

1996/1

997

1997/1

998

1998/1

999

1999/2

000

2000/2

001

2001/2

002

2002/2

003

2003/0

4

Serv

ices Emergency AH

GP Attendances

1996-1997 2003-2004 % Variation GP Attendances (not Emergency)

483,862 441,528 -8.75

Local Government Area Estimated Population Growth, 1996-2004 Greater Ballarat 13.70% Golden Plains 19.71%

Hepburn 11.10% Moorabool 19.01%

Electorate Bulk Billing Rate

June 2000 Bulk Billing Rate

Dec 2003 % Variation

Ballarat 67.1% 43.2% -23.9%

Wannon 55.7% 42.2% -13.5%

Practice Incentives Program, May 2004 No. of Practices in PIP 23 RRMA Category Large Rural – 19

Other Rural – 4 Ensuring patients have access to 24 hr care 22 Provision of at least 15 hours (AH) care from within the practice 19 Provision of all after hours care for practice patients 6 Practice Nurses 10

33


BENDIGO & DISTRICT DIVISION OF GENERAL PRACTICE Population 3450 Castlemaine; 3451 Campbells Creek, Chewton; 3453 Harcourt; 3462 Newstead; 3463 Maldon, Shelbourne; 3472 Dunolly; 3475 Logan, Archdale; 3515 Marong; 3523 Heathcote; 3550 Bendigo; 3551 Strathfieldsaye, Ravenswood, Newbridge; 3555 Kangaroo Flat; 3556 Eaglehawk; 3557 Goornong

Population Number Division State Persons aged 0-4 6,565 6.5% 6.5% Persons aged over 65 14,761 14.1% 12.6% Total Persons 2001 102,119 Total Persons 1996 89,300 Various Information Female 51.5% 50.9% Non-English Speaking Background 2.1% 19.8% Aboriginal & Torres Strait Islanders 0.9% 0.5%

Medical Workforce Number of General Practices 40 Number of General Practitioners 96 (not FTE) GP: Population 1:2000 (FTE)


GP Attendances: MBS Categories A1 & A2, 1996-2004Bendigo & District Division of General Practice

360,000365,000370,000375,000380,000385,000390,000395,000

1996/9

7

1997/9

8

1998/9

9

1999/0

0

2000/0

1

2001/0

2

2002/0

3

2003/0

4

Serv

ices Emergency AH

GP Attendances

34


1996-1997 2003-2004 % Variation 1996-2004

GP Attendances (not Emergency)

391,383 387,808 -0.91

Local Government Area Estimated Population Growth, 1996-2004 Greater Bendigo 15.68% Mount Alexander 10.25% Central Goldfields 6.62%

Electorate Bulk Billing Rate June 2000

Bulk Billing Rate Dec 2003

% Variation

Bendigo 52.3% 48.2% -4.1%

Practice Incentives Program, May 2004 No. of Practices in PIP 24

RRMA Category Large rural – 19 Other rural - 5

Ensuring patients have access to 24 hr care 23

Provision of at least 15 hours (AH) care from within the practice 18

Provision of all after hours care for practice patients 8

Practice Nurses 12

35


CENTRAL BAYSIDE DIVISION OF GENERAL PRACTICE

Population 3172 Dingley; 3186 Brighton; 3187 Brighton East; 3188 Hampton; 3190 Highett; 3191 Sandringham; 3192 Cheltenham; 3193 Beaumaris, Black Rock; 3194 Mentone; 3195 Mordialloc, Aspendale, Parkdale; 3196 Chelsea, Edithvale

Population Division State Persons aged 0-4 10,751 6.0% 6.5% Persons aged over 65 27,890 15.7% 12.6% Total Persons 2001 177,823 Various Information Division State Female 52.1% 50.9% Non-English Speaking Background 16.2% 19.8% Aboriginal & Torres Strait Islanders 0.2% 0.5%

Medical Workforce Number of General Practices 78 Number of General Practitioners 300 (not FTE) GP: Population 1:592 (not FTE)


GP Attendances: MBS Categories A1 & A2, 1996-2004Central Bayside Division of General Practice

700,000

750,000

800,000

850,000

900,000

950,000

1996/9

7

1997/9

8

1998/9

9

1999/0

0

2000/0

1

2001/0

2

2002/0

3

2003/0

4

Serv

ices Emergency AH

GP Attendances


928,215 791,713 -14.71

36


Local Government Area Estimated Population Growth, 1996-2004 Bayside 14.44% Kingston 12.74%



% Variation

Goldstein 72.1% 55.7% -16.4%

Isaacs 85.3% 65.1% -20.2%


RRMA Category Capital City – 46




Practice Nurses unknown

37


CENTRAL HIGHLANDS DIVISION OF GENERAL PRACTICE Population 3335 Rockbank; 3337 Melton; 3338 Melton South; 3340 Bacchus Marsh; 3427 Diggers Rest; 3428 Bulla; 3429 Sunbury; 3430 Clarkefield; 3431 Riddells Creek; 3433 Monegeetta; 3434 Romsey; 3435 Lancefield; 3437 Gisborne; 3438 New Gisborne; 3440 Macedon; 3441 Mount Macedon; 3442 Woodend; 3444 Kyneton, Tylden; 3446 Malmsbury; 3447 Taradale; 3448 Elphinstone; 3450 Castlemaine; 3451 Campbells Creek, Chewton; 3458 Blackwood, Trentham; 3460 Daylesford; 3461 Hepburn Springs, Bullarto; 3521 Pyalong; 3523 Heathcote; 3658 Broadford; 3659 Tallarook; 3660 Seymour; 3662 Avenel; 3664 Avenel; 3665 Longwood; 3753 Beveridge; 3756 Wallan; 3758 Wandong, Heathcote Junction; 3762 Bylands; 3764 Kilmore

Population Division State Persons aged 0-4 12,571 7.3% 6.5% Persons aged over 65 15,763 9.1% 12.6% Latest figure available 172,697 Total Persons 2001 144,966 Total Persons 1996 130,478 Various Information Female 50.4% 50.9% Non-English Speaking Background 6.4% 19.8% Aboriginal & Torres Strait Islanders 0.6% 0.5%


38



GP Attendances: MBS Categories A1 & A2, 1996-2004Central Highlands Division of General Practice

540,000560,000580,000600,000620,000640,000660,000680,000

1996/9

7

1997/9

8

1998/9

9

1999/0

0

2000/0

1

2001/0

2

2002/0

3

2003/0

4

Serv

ices Emergency AH

GP Attendances


592,260 653,727 +10.38

Local Government Area Estimated Population Growth, 1996-2004

Hume 26.80% Melton 78.61%

Macedon Ranges 22.69% Mitchell 23.20%




Calwell 87.7% (Dec 2003) 81.5% -6.2%

Lalor 91.6% 77.2% -14.4%

McEwan 73.6% 60.9% -12.7%


RRMA Category Capital City – 7 Other Rural – 23




Practice Nurses 21

39


CENTRAL-WEST GIPPSLAND DIVISION OF GENERAL

PRACTICE Population 3816 Longwarry; 3818 Drouin; 3820 Warragul; 3821 Neerim Junction; 3822 Darnum; 3823 Yarragon; 3824 Trafalgar; 3825 Moe, Yallourn North, Rawson; 3831 Neerim; 3833 Noojee; 3835 Thorpdale; 3840 Morwell; 3842 Churchill; 3844 Traralgon, Tyers; 3847 Rosedale; 3854 Glengarry; 3856 Toongabbie; 3869 Yinnar

Population Division State

Persons aged 0-4 7,066 6.8% 6.5%

Persons aged over 65 12,885 12.4% 12.6%



Various Information

Female 51.0% 50.9%

Non-English Speaking Background 5.5% 19.8%

Aboriginal & Torres Strait Islanders 1.0% 0.5%

Medical Workforce Number of General Practices 30 Number of General Practitioners 102 (75 full time; 27 part time) GP: Population 1:1016 (not FTE)


GP Attendances: MBS Categories A1 & A2, 1996-2004Central-West Gippsland Division of General Practice

440,000

450,000

460,000

470,000

480,000

490,000

1996/9

7

1997/9

8

1998/9

9

1999/0

0

2000/0

1

2001/0

2

2002/0

3

2003/0

4

Serv

ices Emergency AH

GP Attendances

40



486,390 478,133 -1.70


Baw Baw 14.42% La Trobe 6.82%




Gippsland 56.8% 46.1% -10.7%

McEwan 73.6% 60.9% -12.7%%


RRMA Category Small Rural – 14 Other Rural – 6




Practice Nurses 14

41


DANDENONG & DISTRICT DIVISION OF GENERAL

PRACTICE Population 3802 Endeavour Hills; 3803 Hallam; 3805 Narre Warren; 3806 Berwick; 3912 Somerville, Pearcedale; 3975 Lyndhurst; 3976 Hampton Park; 3977 Cranbourne; 3980 Tooradin, Warneet

Population Division State Persons aged 0-4 15,010 8.8% 6.5% Persons aged over 65 11,112 6.5% 12.6% Total Persons 2001 169,824 Various Information Female 50.2% 50.9% Non-English Speaking Background 19.5% 19.8% Aboriginal & Torres Strait Islanders 0.4% 0.5%



GP Attendances: MBS Categories A1 & A2, 1996-2004Dandenong & District Division of General Practice

1,420,0001,440,0001,460,0001,480,0001,500,0001,520,0001,540,0001,560,0001,580,000

1996/9

7

1997/9

8

1998/9

9

1999/0

0

2000/0

1

2001/0

2

2002/0

3

2003/0

4

Serv

ices Emergency AH

GP Attendances


1,473,315 1,506,158 +2.03

42


Local Government Area Estimated Population Growth, 1996-2004 Greater Dandenong 2.63%

Casey 41.95%



% Variation

Holt 91.4% 76.1% -15.3%

Isaacs 85.3% 65.1% -20.2%

La Trobe 79.7% 62.5% -17.2%






Practice Nurses 29

43


EAST GIPPSLAND DIVISION OF GENERAL PRACTICE

Population 3847 Rosedale; 3850 Sale; 3851 Loch Sport, Seaspray; 3857 Cowwarr; 3858 Heyfield, Licola; 3859 Newry; 3860 Maffra, Briagolong, Coongulla; 3862 Stratford, Dargo; 3864 Fernbank; 3865 Lindenow; 3875 Bairnsdale, Lucknow; 3878 Eagle Point; 3880 Paynesville; 3882 Nicholson; 3885 Bruthen; 3886 Newmerella; 3887 Nowa Nowa; 3888 Orbost, Marlo; 3889 Cabbage Tree Creek; 3890 Cann River; 3891 Genoa; 3892 Mallacoota; 3895 Ensay; 3896 Swifts Creek; 3898 Omeo, Dinner Plain; 3900 Benambra; 3902 Johnsonville; 3903 Swan Reach; 3904 Metung; 3909 Lakes Entrance, Lake Tyers Beach Population Division State Persons aged 0-4 4,371 6.1% 6.5% Persons aged over 65 11,347 15.8% 12.6% Total Persons 2001 71,740 Total Persons 1996 71,376 Various Information Female 50.2% 50.9% Non-English Speaking Background 3.0% 19.8% Aboriginal & Torres Strait Islanders 1.8% 0.5%



GP Attendances: MBS Categories A1 & A2, 1996-2004East Gippsland Division of General Practice

265,000270,000275,000280,000285,000290,000295,000300,000

1996/9

7

1997/9

8

1998/9

9

1999/0

0

2000/0

1

2001/0

2

2002/0

3

2003/0

4

Emergency AHGP Attendances

1996-1997 2003-2004 % Variation

GP Attendances (not Emergency)

295,800 278,750 -5.76

44


Local Government Area Estimated Population Growth, 1996-2004 Wellington 3.15%

East Gippsland 5.27%



% Variation

Gippsland 56.8% 46.1% -10.7%






Practice Nurses 15

45


EASTERN RANGES DIVISION OF GENERAL PRACTICE

Population 3115 Wonga Park; 3116 Chirnside Park; 3136 Croydon; 3137 Kilsyth; 3138 Mooroolbark; 3139 Seville, Launching Place, Woori Yallock; 3140 Lilydale; 3159 Selby; 3160 Belgrave, Tecoma; 3765 Montrose; 3766 Kalorama; 3767 Mount Dandenong; 3770 Coldstream; 3775 Yarra Glen, Dixons Creek; 3777 Healesville; 3778 Narbethong; 3779 Marysville; 3781 Cockatoo; 3782 Emerald; 3783 Gembrook; 3787 Sassafras; 3788 Olinda; 3789 Sherbrooke; 3791 Kallista; 3792 The Patch; 3793 Monbulk; 3795 Silvan; 3796 Mount Evelyn; 3797 Yarra Junction, Powelltown; 3799 Warburton, Millgrove; 3804 Narre Warren North; 3807 Beaconsfield; 3808 Beaconsfield Upper; 3809 Officer; 3810 Pakenham; 3812 Nar Nar Goon; 3813 Tynong; 3814 Garfield; 3815 Bunyip; 3871 Mirboo North; 3874 Woodside; 3921 Tankerton; 3922 Cowes; 3923 Rhyll; 3925 Newhaven, San Remo; 3945 Loch; 3946 Bena; 3950 Korumburra; 3951 Kongwak, Ranceby; 3953 Leongatha; 3956 Meeniyan, Venus Bay, Tarwin; 3957 Stony Creek; 3958 Buffalo; 3959 Fish Creek; 3960 Foster; 3962 Toora; 3964 Port Franklin; 3965 Port Welshpool; 3966 Welshpool; 3967 Hedley; 3971 Yarram, Port Albert, Alberton; 3978 Cardinia; 3979 Glen Alvie; 3981 Koo Wee Rup; 3984 Corinella, Coronet Bay, Lang Lang; 3987 Nyora; 3988 Poowong; 3990 Glen Forbes; 3991 Bass; 3992 Dalyston; 3995 Wonthaggi, Cape Paterson; 3996 Inverloch



46



GP Attendances: MBS Categories A1 & A2, 1996-2004Eastern Ranges Division of General Practice

600,000

650,000

700,000

750,000

800,000

850,000

1996/9

7

1997/9

8

1998/9

9

1999/0

0

2000/0

1

2001/0

2

2002/0

3

2003/0

4

Serv

ices Emergency AH

GP Attendances


830,123 701,029 -15.55


Yarra Ranges 7.67%



% Variation

Casey 77.1% 59.6% -17.5%

Holt 91.4% 76.1% -15.3%

La Trobe 79.7% 62.5% -17.2%

McEwan 73.6% 60.9% -12.7%

McMillan 68.2% (Dec 2002) 67.6% -0.6%






Practice Nurses 18

47


GP ASSOCIATION OF GEELONG

Population 3212 Lara, Avalon; 3214 Corio; 3215 Geelong North; 3216 Belmont, Highton; 3218 Geelong West; 3219 Newcomb; 3220 Geelong; 3221 Anakie; 3222 Drysdale, Clifton Springs; 3223 Portarlington, St Leonards, Indented Head; 3224 Leopold; 3225 Queenscliff; 3226 Ocean Grove; 3227 Barwon Heads; 3228 Torquay; 3230 Anglesea; 3231 Aireys Inlet, Fairhaven; 3240 Moriac, Modewarre; 3321 Inverleigh; 3328 Teesdale; 3331 Bannockburn; 3332 Lethbridge; 3333 Meredith Population Division State Persons aged 0-4 13,480 6.5% 6.5% Persons aged over 65 30,434 14.6% 12.6% Total Persons 2001 208,061 Total Persons 1996 195,592 Various Information Female 51.3% 50.9% Non-English Speaking Background 9.6% 19.8% Aboriginal & Torres Strait Islanders 0.7% 0.5%

Medical Workforce Number of General Practices 67 Number of General Practitioners 195 (152 EFT) GP: Population 1:1368


GP Attendance: MBS Categories A1 & A2, 1996-2004GP Association of Geelong

880,000900,000920,000940,000960,000980,000

1,000,0001,020,000

1996/9

7

1997/9

8

1998/9

9

1999/0

0

2000/0

1

2001/0

2

2002/0

3

2003/0

4

Serv

ices Emergency AH

GP Attendances

48



991,420 939,180 -5.27


Greater Geelong 14.37% Surf Coast 32.05%




Corangamite 56.4% 41.8% -14.6%

Corio 68.9% 57.9% -11%


RRMA Category Other Metropolitan – 33 Small Rural – 7 Other Rural – 6




Practice Nurses 22

49


GOULBURN VALLEY DIVISION OF GENERAL PRACTICE

Population 3558 Elmore; 3559 Colbinabbin; 3607 Tabilk; 3608 Nagambie; 3610 Murchison; 3612 Rushworth; 3614 Toolamba; 3616 Tatura; 3618 Merrigum; 3620 Kyabram; 3621 Tongala; 3622 Strathallan; 3623 Stanhope; 3624 Girgarre; 3629 Mooroopna; 3630 Shepparton; 3631 Arcadia, Cosgrove, Kialla; 3633 Congupna; 3634 Tallygaroopna; 635 Wunghnu; 3636 Numurkah; 3638 Nathalia; 3639 Barmah; 3640 Katunga; 3641 Strathmerton; 3644 Cobram; 3646 Dookie; 3649 Katamatite; 3660 Seymour; 3662 Avenel; 3664 Avenel; 3665 Longwood Population Division State Persons aged 0-4 7,566 7.3% 6.5% Persons aged over 65 13,170 13.4% 12.6% Total Persons 2001 103,208 Total Persons 1996 92,818 Various Information Female 49.9% 50.9% Non-English Speaking Background 6.9% 19.8% Aboriginal & Torres Strait Islanders 1.9% 0.5%

Medical Workforce Number of General Practices 23 Number of General Practitioners 82 (not FTE) GP: Population 1:1706

GP: population ratio data contained in the Division’s submission to the Australian Medical Workforce Advisory Committee’s Review of the General Practice Workforce in Australia.

50



GP Attendances, MBS Categories A1 & A2, 1996-2004Goulburn Valley Division of General Practice

310,000320,000330,000340,000350,000360,000370,000380,000

1996/9

7

1997/9

8

1998/9

9

1999/0

0

2000/0

1

2001/0

2

2002/0

3

2003/0

4

Serv

ices Emergency AH

GP Attendances


375,083 350,188 -6.64


Campaspe 12.01% Greater Shepparton 15.72%

Moira 11.17% Strathbogie 11.10%




Murray 42.3% 31.5% -10.8%

McEwan 73.6% 60.9% -12.7%

Bendigo 52.3% 48.2% -4.1%


RRMA Category Large Rural – 8 Other Rural – 12




Practice Nurses 14

51


GREATER SOUTH EASTERN DIVISION OF GENERAL

PRACTICE Population 3145 Darling, Caulfield East; 3146 Glen Iris; 3147 Ashburton; 3148 Malvern East, Chadstone; 3149 Mount Waverley; 3150 Wheelers Hill, Glen Waverley; 3166 Oakleigh; 3168 Clayton; 3170 Mulgrave, Brandon Park


Medical Workforce Number of General Practices 111 Number of General Practitioners 255 GP: Population 1:766


GP Attendances: MBS Categories A1 & A2, 1996-2004Greater South Eastern Division of General Practice

0200,000400,000600,000800,000

1,000,0001,200,0001,400,000

1996/9

7

1997/9

8

1998/9

9

1999/0

0

2000/0

1

2001/0

2

2002/0

3

2003/0

4

Serv

ices Emergency AH

GP Attendances


1,204,074 974,545 -19.06

52


Local Government Area Estimated Population Growth, 1996-2004 Maroondah 12.81%




Bruce 86.0% 76.0% -10.0%

Chisholm 83.6% 72.7% -10.9%







53


INNER EASTERN MELBOURNE DIVISION OF GENERAL

PRACTICE Population 3101 Kew; 3102 Kew East; 3103 Balwyn; 3104 Balwyn North; 3105 Bulleen; 3107 Lower Templestowe; 3108 Doncaster; 3122 Hawthorn, Glenferrie; 3123 Auburn; 3124 Camberwell; 3125 Burwood; 3126 Canterbury; 3127 Surrey Hills, Mont Albert; 3129 Box Hill North; 3146 Glen Iris; 3147 Ashburton




GP Attendances: MBS Categories A1 & A2, 1996-2004Inner Eastern Melbourne Division of General Practice

850,000

900,000

950,000

1,000,000

1,050,000

1,100,000

1996/9

7

1997/9

8

1998/9

9

1999/0

0

2000/0

1

2001/0

2

2002/0

3

2003/0

4

Serv

ices Emergency AH

GP Attendances


1,087,571 957,777 -11.93

54


Local Government Area Estimated Population Growth, 1996-2004 Boroondara 8.96%




Chisholm 83.6% 72.7% -10.9%

Higgins 74.0% 60.5% -13.5%

Kooyong 70.8% 58.3% -12.5%







55


INNER SOUTH EAST MELBOURNE (SOUTHCITY) DIVISION

OF GENERAL PRACTICE Population 3004 Melbourne; 3141 South Yarra; 3142 Toorak; 3143 Armadale; 3144 Malvern; 3161 Caulfield North; 3162 Caulfield; 3181 Prahran; 3182 St Kilda; 3183 St Kilda East, Balaclava; 3184 Elwood; 3185 Elsternwick, Gardenvale; 3205 South Melbourne; 3206 Albert Park, Middle Park

Population Division State Persons aged 0-4 7,947 4.4% 6.5% Persons aged over 65 24,137 13.4% 12.6% Total Persons 2001 180,498 Various Information Female 51.5% 50.9% Speak Non-English 20.0% 19.8% Indigenous Persons 0.2% 0.5%



GP Attendances: MBS Categories A1 & A2, 1996-2004Inner South East Melbourne (Southcity) Division of General Practice

1,000,0001,050,0001,100,0001,150,0001,200,0001,250,0001,300,0001,350,000

1996/9

7

1997/9

8

1998/9

9

1999/0

0

2000/0

1

2001/0

2

2002/0

3

2003/0

4

Serv

ices Emergency AH

GP Attendances


1,291,097 1,123,956 -12.95

56


Local Government Area Estimated Population Growth, 1996-2004 Glen Eira 10.94%

Port Phillip 21.13% Stonnington 10.21%




Higgins 74.0% 60.5% -13.5%

Melbourne Ports 83.8% 70.5% -13.3%







57


KNOX DIVISION OF GENERAL PRACTICE

Population 3172 Dingley; 3186 Brighton; 3187 Brighton East; 3188 Hampton; 3190 Highett; 3191 Sandringham; 3192 Cheltenham; 3193 Beaumaris, Black Rock; 3194 Mentone; 3195 Mordialloc, Aspendale, Parkdale; 3196 Chelsea, Edithvale




GP Attendances: MBS Categories A1 & A2, 1996-2004Knox Division of General Practice

800,000

850,000

900,000

950,000

1,000,000

1,050,000

1996/9

7

1997/9

8

1998/9

9

1999/0

0

2000/0

1

2001/0

2

2002/0

3

2003/0

4

Serv

ices Emergency AH

GP Attendances


1,014,122 904,948 -10.77

58


Local Government Area Estimated Population Growth, 1996-2004 Knox 15.91%




Aston 86.2% 71.1% -15.1%






Practice Nurses 17

59


MALLEE OF DIVISION OF GENERAL PRACTICE

Population Population and medical workforce data for this Division excludes the 9 NSW postcodes that lie within its borders.

3396 Hopetoun; 3413 Ozenkadnook; 3420 Serviceton; 3485 Woomelang; 3487 Lascelles; 3490 Ouyen; 3491 Patchewollock; 3496 Red Cliffs, Cullulleraine, Meringur, Merrinee; 3498 Irymple; 3500 Mildura; 3501 Hattah; 3505 Merbein; 3506 Galah; 3507 Walpeup; 3509 Underbool; 3512 Murrayville; 3530 Culgoa; 3531 Boigbeat; 3533 Sea Lake; 3544 Ultima; 3546 Manangatang; 3549 Robinvale; 3583 Tresco; 3584 Lake Boga; 3585 Swan Hill; 3586 Bulga; 3588 Woorinen South; 3589 Woorinen; 3591 Vinifera; 3594 Nyah; 3595 Nyah West; 3596 Wood Wood; 3597 Piangil Population Division State Persons aged 0-4 5,574 7.5% 6.5% Persons aged over 65 10,378 14.0% 12.6% Total Persons 2001 74,236 Total Persons 1996 71,902 Various Information Female 50.1% 50.9% Non-English Speaking Background 7.9% 19.8% Aboriginal & Torres Strait Islanders 2.7% 0.5%

Medical Workforce Number of General Practices 23 Number of General Practitioners 60 (54 FTE) GP: Population 1:1374

The Division itself has provided an estimate of its Victorian population as 86,000. This would alter the GP: Population ratio to 1:1592.

60


General Practitioner Attendances, 1996-2004 General practitioner attendances and Practice Incentives Program data include NSW.

GP Attendances: MBS Categories A1 & A2, 1996-2004Mallee Division of General Practice

280,000

290,000

300,000

310,000

320,000

330,000

340,000

1996/9

7

1997/9

8

1998/9

9

1999/0

0

2000/0

1

2001/0

2

2002/0

3

2003/0

4

Serv

ices Emergency AH

GP Attendances


322,841 307,327 -4.81


Mildura 12.04% Swan Hill 6.61%




Mallee 56.9% 54.1% -2.8%


RRMA Category Small Rural – 10 Other Rural - 6




Practice Nurses 14

61


MELBOURNE DIVISION OF GENERAL PRACTICE

Population 3000 Melbourne; 3002 East Melbourne, Jolimont; 3003 West Melbourne; 3004 Melbourne; 3006 Southbank; 3031 Kensington, Newmarket; 3051 North Melbourne; 3052 Parkville; 3053 Carlton; 3054 Carlton North; 3055 Brunswick West; 3056 Brunswick; 3057 Brunswick East; 3065 Fitzroy; 3066 Collingwood; 3067 Abbotsford; 3068 Clifton Hill; 3121 Richmond, Burnley

Query low population numbers compared to those provided by the Division.



The Division has noted that it deals with a transient population of city workers, students and tourists.


GP Attendances: MBS Categories A1 & A2, 1996-2004Melbourne Division of General Practice

1,150,0001,200,0001,250,0001,300,0001,350,0001,400,0001,450,0001,500,0001,550,0001,600,000

1996/9

7

1997/9

8

1998/9

9

1999/0

0

2000/0

1

2001/0

2

2002/0

3

2003/0

4

Serv

ices Emergency AH

GP Attendances

62



1,537,874 1,300,557 -15.43


Melbourne 29.62% Yarra 7.67%




Melbourne 89.8% 79.9% -9.9%






Practice Nurses 4

63


MONASH DIVISION OF GENERAL PRACTICE

Population 3163 Murrumbeena, Glenhuntly, Carnegie; 3165 Bentleigh East; 3167 Oakleigh South; 3169 Clayton South; 3171 Springvale; 3189 Moorabbin; 3202 Heatherton; 3204 Ormond, Bentleigh

Population Division State Persons aged 0-4 7,943 6.0% 6.5% Persons aged over 65 20,371 15.5% 12.6% Total Persons 2001 131,710 Various Information Female 51.2% 50.9% Speak Non-English Background 37.0% 19.8% Aboriginal & Torres Strait Islanders 0.2% 0.5%



GP Attendances: MBS Categories A1 & A2, 1996-2004Monash Division of General Practice

0

200,000

400,000

600,000

800,000

1,000,000

1,200,000

1996/9

7

1997/9

8

1998/9

9

1999/0

0

2000/0

1

2001/0

2

2002/0

3

2003/0

4

Serv

ices Emergency AH

GP Attendances


947,218 784,691 -17.16

64


Local Government Area Estimated Population Growth, 1996-2004 Monash 9.54%

Electorate Bulk Billing

Rate June 2000


% Variation

Hotham 87.4% 76.4% -11.0%







65


MORNINGTON PENINSULA DIVISION OF GENERAL

PRACTICE Population 3196 Chelsea, Edithvale; 3197 Carrum, Patterson Lakes; 3198 Seaford; 3199 Frankston; 3200 Frankston North; 3201 Carrum Downs; 3910 Langwarrin; 3911 Baxter; 3912 Somerville, Pearcedale; 3913 Tyabb; 3915 Hastings; 3916 Merricks, Shoreham; 3918 Bittern; 3919 Crib Point; 3920 HMAS Cerberus; 3926 Balnarring Beach; 3927 Somers; 3929 Flinders; 3930 Mount Eliza; 3931 Mornington; 3933 Moorooduc; 3934 Mount Martha; 3936 Dromana; 3937 Red Hill; 3938 McCrae; 3939 Rosebud; 3940 Rosebud West; 3941 St Andrews Beach, Rye; 3942 Blairgowrie; 3943 Sorrento; 3944 Portsea




GP Attendances: MBS Categories A1 & A2, 1996-2004Mornington Peninsula Division of General Practice

0200,000400,000600,000800,000

1,000,0001,200,0001,400,0001,600,000

1996/9

7

1997/9

8

1998/9

9

1999/0

0

2000/0

1

2001/0

2

2002/0

3

2003/0

4

Serv

ices Emergency AH

GP Attendances

66



1,342,451 1,126,198 -16.11


Frankston 13.32% Mornington Peninsula 26.99%


Rate June 2000


% Variation

Dunkley 79.4% 47.6% -31.8%

Flinders 71.5% 44.5% -27.0%

Isaacs 85.3% 65.1% -20.2%






Practice Nurses 29

67


MURRAY PLAINS DIVISION OF GENERAL PRACTICE

Population Population data for this Division excludes the three NSW postcodes within its borders.

3516 Bridgewater on Loddon; 3517 Inglewood, Serpentine; 3518 Wedderburn; 3520 Korong Vale; 3525 Charlton; 3527 Wycheproof; 3529 Nullawil; 3537 Boort; 3540 Quambatook; 3542 Lalbert; 3561 Rochester; 3562 Torrumbarry; 3563 Lockington; 3564 Echuca; 3566 Gunbower; 3567 Leitchville; 3568 Cohuna; 3570 Kamarooka; 3571 Dingee; 3572 Prairie; 3573 Mitiamo; 3575 Pyramid Hill; 3578 Appin; 3579 Kerang; 3580 Koondrook; 3622 Strathallan

Population Division State Persons aged 0-4 2,979 7.0% 6.5% Persons aged over 65 7,161 16.7% 12.6% Total Persons 2001 (Victoria only) 42,858 Total Persons 1996 (Victoria only) 42,915 Various Information Female 49.6% 50.9% Non-English Speaking Background 1.7% 19.8% Aboriginal & Torres Strait Islanders 1.4% 0.5%


68


General Practitioner Attendances, 1996-2004 General Practitioner attendances and Practice Incentives Program data include the three NSW postcodes excluded from the population data.

GP Attendances: MBS Categories A1 & A2, 1996-2004Murray Plains Division of General Practice

210,000

220,000

230,000

240,000

250,000

260,000

270,000

1996/9

7

1997/9

8

1998/9

9

1999/0

0

2000/0

1

2001/0

2

2002/0

3

2003/0

4

Serv

ices Emergency AH

GP Attendances


251,041 231,584 -7.75


Gannawarra -1.19% Loddon -0.23% Buloke -0.81%


Rate June 2000


% Variation

Mallee 56.9% 54.1% -2.8%

Murray 42.3% 31.5% -10.8%


RRMA Category Other Rural – 12




Practice Nurses 15

69


NORTH WEST MELBOURNE DIVISION OF GENERAL

PRACTICE Population 3032 Maribyrnong; 3033 Ascot Vale, Keilor East; 3034 Avondale Heights; 3036 Keilor; 3039 Moonee Ponds; 3040 Essendon; 3041 Strathmore; 3042 Niddrie, Airport West; 3043 Tullamarine, Gladstone Park; 3044 Pascoe Vale; 3046 Glenroy, Oak Park; 3047 Broadmeadows, Upfield; 3048 Meadow Heights, Coolaroo; 3049 Westmeadows; 3058 Coburg; 3059 Greenvale; 3063 Yuroke; 3064 Craigieburn, Roxburgh Park; 3332 Lethbridge




GP Attendances: MBS Categories A1 & A2, 1996-2004North West Melbourne Division of Practice

1,300,0001,350,0001,400,0001,450,0001,500,0001,550,0001,600,0001,650,0001,700,000

1996/9

7

1997/9

8

1998/9

9

1999/0

0

2000/0

1

2001/0

2

2002/0

3

2003/0

4

Serv

ice

Emergency AHGP Attendances

70



1,638,788 1,429,416 -12.78


Hume 26.80% Moreland 7.01%


Rate June 2000


% Variation

Calwell 87.7% (Dec 2003)

81.5% -6.2%

Maribyrnong 92.4% 82.4% -10.0%

Melbourne 89.8% 79.9% -9.9%

Wills 90.5% 79.0% 11.5%






Practice Nurses 24

71


NORTH-EAST VALLEY DIVISION OF GENERAL PRACTICE

Population 3070 Northcote; 3071 Thornbury; 3078 Fairfield, Alphington; 3079 Ivanhoe; 3081 Heidelberg Heights; 3083 Bundoora; 3084 Heidelberg, Rosanna; 3085 Macleod; 3087 Watsonia; 3088 Greensborough; 3089 Diamond Creek; 3090 Plenty; 3091 Yarrambat; 3093 Lower Plenty; 3094 Montmorency; 3095 Eltham; 3096 Wattle Glen; 3097 Kangaroo Ground; 3099 Hurstbridge; 3105 Bulleen; 3759 Panton Hill; 3760 Smiths Gully; 3761 St Andrews; 3763 Kinglake Population Division State Persons aged 0-4 15,039 6.2% 6.5% Persons aged over 65 28,866 11.9% 12.6% Total Persons 2001 242,992 Various Information Female 51.3% 50.9% Non-English Speaking Background 20.4% 19.8% Aboriginal & Torres Strait Islanders 0.4% 0.5%

Medical Workforce Number of General Practices 87 Number of General Practitioners 275 (175 FTE) GP: Population 1:1388 (FTE)


GP Attendances: MBS Categories A1 & A2, 1996-2004North East Valley Division of General Practice

1,000,000

1,050,000

1,100,000

1,150,000

1,200,000

1,250,000

1996/9

7

1997/9

8

1998/9

9

1999/0

0

2000/0

1

2001/0

2

2002/0

3

2003/0

4

Serv

ices Emergency AH

GP Attendances

72



1,218,444 1,105,150 -9.30


Banyule 5.97% Manningham 13.81%

Nillumbik 12.70%


June 2000


% Variation

Batman 92.9% 83.3% -9.6%

Jagajaga 78.0% 72.6% -5.4%

McEwan 73.6% 60.9% -12.7%







73


NORTH-EAST VICTORIAN DIVISION OF GENERAL

PRACTICE Population Population data includes the two Victorian postcodes (3698, 3690 – Wodonga) that reside in the Border Division of General Practice. That Division has not been included in the Profiles because its borders lie overwhelmingly in NSW.

3666 Euroa; 3669 Violet Town; 3670 Warrenbayne; 3672 Benalla; 3673 Tatong, Winton; 3675 Glenrowan; 3677 Wangaratta; 3678 Peechelba, Cheshunt; 3682 Springhurst; 3683 Chiltern; 3685 Rutherglen; 3687 Wahgunyah; 3688 Barnawartha; 3691 Bellbridge, Tangambalanga, Gundowring; 3694 Bandiana; 3695 Sandy Creek; 3697 Tawonga; 3698 Tawonga South; 3699 Mount Beauty; 3700 Tallangatta; 3701 Eskdale, Mitta Mitta; 3705 Cudgewa; 3707 Corryong; 3708 Tintaldra; 3709 Walwa; 3711 Buxton; 3712 Thornton; 3713 Eildon; 3714 Alexandra; 3715 Merton; 3717 Yea, Glenburn; 3719 Yarck; 3720 Bonnie Doon; 3722 Mansfield; 3723 Jamieson, Mount Buller; 3725 Goorambat; 3726 Devenish; 3727 Lake Rowan; 3728 Tungamah; 3730 Yarrawonga; 3732 Moyhu; 3733 Whitfield; 3735 Whorouly; 3737 Myrtleford; 3740 Porepunkah; 3741 Bright, Harrietville; 3744 Wandiligong; 3746 Eldorado; 3747 Beechworth; 3749 Yackandandah

Population Division State Persons aged 0-4 8,538 5.9% 6.5% Persons aged over 65 19,097 15% 12.6% Total Persons 2001 135,865 Various Information Female 50.5% 50.9% Non-English Speaking Background 4.2% 19.8% Aboriginal & Torres Strait Islanders 0.7% 0.5%

This Division experiences strong seasonal increases in population due to agricultural activity and tourism (Lakes Mulwala & Eildon, Murray River, Alps).

Medical Workforce This data includes the 43 Victorian members of the Border Division of General Practice. Number of General Practices 28 Number of General Practitioners 120 (90 FTE) GP: Population 1:1509 (FTE)

74



GP Attendances: MBS Categories A1 & A2, 1996-2004North-east Victorian Division of General Practice

370,000

380,000

390,000

400,000

410,000

420,000

430,000

1996/9

7

1997/9

8

1998/9

9

1999/0

0

2000/0

1

2001/0

2

2002/0

3

2003/0

4

Serv

ices Emergency AH

GP Attendances


422,528 401,735 -4.92


Murrindindi 11.60% Benalla -30.52%

Mansfield 34.02% Wangaratta 7.14%

Indigo 9.16% Wodonga (Border Division) 15.49%

Towong -0.29% Alpine -26.74%




Indi 42.3% 29.8% -12.5%

McEwan 73.6% 60.9% -12.7%






Practice Nurses 23

75


NORTHERN DIVISION OF GENERAL PRACTICE Population 3056 Brunswick; 3058 Coburg; 3060 Fawkner; 3061 Campbellfield; 3072 Preston; 3073 Reservoir; 3074 Thomastown; 3075 Lalor; 3076 Epping; 3082 Mill Park; 3083 Bundoora; 3750 Wollert; 3751 Woodstock; 3752 South Morang; 3754 Mernda; 3757 Whittlesea, Pheasant Creek


Medical Workforce Number of General Practices 128 Number of General Practitioners 264 (57% FT; 35% PT) GP: Population 1:1464 (FTE)


GP Attendances: MBS Categories A1 & A2, 1996-2004Northern Division of General Practice

1,300,000

1,350,000

1,400,000

1,450,000

1,500,000

1,550,000

1996/9

7

1997/9

8

1998/9

9

1999/0

0

2000/0

1

2001/0

2

2002/0

3

2003/0

4

Serv

ices Emergency AH

GP Attendances


1,488,274 1,379,508 -7.31

76


Local Government Area Estimated Population Growth, 1996-2004 Hume 26.80%

Moreland 7.01%



% Variation

Scullin 91.0% 84.8% -6.2%

Wills 90.5% 79.0% -11.5%






Practice Nurses 7

77


OTWAY DIVISION OF GENERAL PRACTICE

Population 3232 Lorne; 3233 Apollo Bay; 3235 Deans Marsh; 3236 Forrest; 3237 Beech Forest; 3238 Lavers Hill, Glenaire; 3239 Gellibrand; 3241 Winchelsea; 3242 Birregurra; 3243 Whoorel; 3249 Elliminyt, Coragulac; 3250 Colac; 3251 Beeac; 3254 Cororooke; 3260 Camperdown, Pomborneit; 3264 Terang; 3265 Noorat, Panmure; 3266 Cobden, Simpson; 3268 Timboon, Curdie Vale; 3269 Port Campbell; 3270 Peterborough; 3271 Darlington; 3272 Mortlake; 3274 Caramut; 3276 Woolsthorpe; 3277 Allansford; 3280 Warrnambool; 3281 Winslow; 3282 Koroit; 3283 Killarney; 3284 Port Fairy; 3285 Codrington, Narrawong; 3286 Macarthur; 3287 Hawkesdale; 3289 Penshurst; 3292 Nelson; 3293 Glenthompson; 3294 Dunkeld; 3300 Hamilton; 3302 Branxholme, Grassdale; 3303 Condah; 3304 Heywood, Dartmoor; 3305 Portland, Mount Richmond; 3309 Digby; 3310 Merino; 3311 Casterton; 3312 Ardno, Strathdownie; 3314 Cavendish; 3322 Cressy; 3323 Berrybank; 3324 Lismore; 3325 Derrinallum; 3407 Balmoral

Population Division State Persons aged 0-4 8,093 6.8% 6.5% Persons aged over 65 17,439 14.7% 12.6% Total Persons 2001 118,565 Total Persons 1996 115,106 Various Information Female 50.4% 50.9% Non-English Speaking Background 1.7% 19.8% Aboriginal & Torres Strait Islanders 0.7 % 0.5%


78



GP Attendances: MBS Categories A1 & A2, 1996-2004Otway Division of General Practice

440,000450,000460,000470,000480,000490,000500,000510,000

1996/9

7

1997/9

8

1998/9

9

1999/0

0

2000/0

1

2001/0

2

2002/0

3

2003/0

4

Serv

ices Emergency AH

GP Attendances


496,856 466,386 -6.13


Colac-Otway 7.17% Corangamite 2.21%

Moyne -2.71% Glenelg 0.18%




Corangamite 56.4% 41.8% -14.6%

Wannon 55.7% 42.2% -13.5%






Practice Nurses 21

79


SOUTH GIPPSLAND DIVISION OF GENERAL PRACTICE

Population The population transiently increases by an estimated 80,000 in the summer holiday season. 3870 Boolarra; 3871 Mirboo North; 3874 Woodside; 3921 Tankerton; 3922 Cowes; 3923 Rhyll; 3925 Newhaven, San Remo; 3945 Loch; 3946 Bena; 3950 Korumburra; 3951 Kongwak, Ranceby; 3953 Leongatha; 3956 Meeniyan, Venus Bay, Tarwin; 3957 Stony Creek; 3958 Buffalo; 3959 Fish Creek; 3960 Foster; 3962 Toora; 3964 Port Franklin; 3965 Port Welshpool; 3966 Welshpool; 3967 Hedley; 3971 Yarram, Port Albert, Alberton; 3979 Glen Alvie; 3981 Koo Wee Rup; 3984 Corinella, Coronet Bay, Lang Lang; 3987 Nyora; 3988 Poowong; 3990 Glen Forbes; 3991 Bass; 3992 Dalyston; 3995 Wonthaggi, Cape Paterson; 3996 Inverloch

Population Division State Persons aged 0-4 3,579 6.0% 6.5% Persons aged over 65 10,490 17.7% 12.6% Total Persons 2001 59,421 Total Persons 1996 54,688 Various Information Female 50.7% 50.9% Non-English Speaking Background 3.9% 19.8% Aboriginal & Torres Strait Islanders 0.6% 0.5%


80



GP Attendances: MBS Categories A1 & A2, 1996-2004South Gippsland Division of General Practice

190,000200,000210,000220,000230,000240,000250,000260,000

1996/9

7

1997/9

8

1998/9

9

1999/0

0

2000/0

1

2001/0

2

2002/0

3

2003/0

4

Serv

ices Emergency AH

GP Attendances


225,774 246,330 +9.10


Cardinia 26.36% South Gippsland 12.71%

Bass Coast 36.25%



% Variation

McMillan 68.2% (Dec 2002) 67.6% -0.6%


RRMA Category Other Rural – 8




Practice Nurses 8

81


WEST VICTORIA DIVISION OF GENERAL PRACTICE

Population 3292 Nelson; 3311 Casterton; 3315 Coleraine; 3317 Harrow; 3318 Edenhope; 3319 Apsley; 3373 Beaufort; 3375 Buangor; 3377 Ararat, Great Western; 3379 Willaura; 3380 Stawell; 3381 Halls Gap, Pomonal; 3388 Rupanyup; 3390 Murtoa; 3391 Brim; 3392 Minyip; 3393 Warracknabeal; 3395 Beulah; 3396 Hopetoun; 3400 Horsham; 3401 Wallup, Pimpinio, Vectis, Drung Drung; 3409 Natimuk; 3412 Goroke; 3414 Dimboola; 3418 Nhill, Kiata; 3419 Kaniva; 3423 Jeparit; 3424 Rainbow; 3464 Carisbrook; 3465 Maryborough; 3467 Avoca; 3468 Amphitheatre; 3469 Elmhurst; 3478 St Arnaud; 3480 Donald, Litchfield; 3482 Watchem; 3483 Birchip Population Division State Persons aged 0-4 4,953 6.3% 6.5% Persons aged over 65 14,484 18.3% 12.6% Total Persons 2001 79,306 Total Persons 1996 79,763 Various Information Female 50.2% 50.9% Non-English Speaking Background 1.5% 19.8% Aboriginal & Torres Strait Islanders 0.7% 0.5% Medical Workforce Number of General Practices 29 Number of General Practitioners 76 (not FTE) GP: Population 1:1043 (not FTE)


GP Attendances: MBS Categories A1 & A2, 1996-2004West Victoria Divison of General Practice

340,000345,000350,000355,000360,000365,000370,000375,000380,000385,000

1996/9

7

1997/9

8

1998/9

9

1999/0

0

2000/0

1

2001/0

2

2002/0

3

2003/0

4

Serv

ices Emergency AH

GP Attendances

82



381,261 370,386 -2.74


West Wimmera -5.32% Hindmarsh -0.40%

Southern Grampians -1.55% Northern Grampians 0.15%

Yarrambiack -5.10% Ararat 4.98%

Pyrenees 0.23%



% Variation

Mallee 56.9% 54.1% -2.8%

Wannon 55.7% 42.2% -13.5%






Practice Nurses 16

83


WESTERN MELBOURNE DIVISION OF GENERAL PRACTICE

Population 3011 Footscray; 3012 Maidstone, Tottenham; 3013 Yarraville; 3019 Braybrook; 3020 Sunshine; 3021 St Albans, Kings Park; 3022 Ardeer; 3023 Deer Park; 3032 Maribyrnong; 3037 Delahey; 3038 Sydenham, Taylors Lakes; 3335 Rockbank; 3337 Melton; 3338 Melton South




GP Attendances: MBS Categories A1 & A2, 1996-2004Western Melbourne Division of General Practice

1,400,000

1,450,000

1,500,000

1,550,000

1,600,000

1,650,000

1,700,000

1996/9

7

1997/9

8

1998/9

9

1999/0

0

2000/0

1

2001/0

2

2002/0

3

2003/0

4

Serv

ices Emergency AH

GP Attendances

84



1,606,573 1,497,455 -6.79


Brimbank 17.19% Maribyrnong 8.97%

Moonee Valley 6.22%



% Variation

Gellibrand 94.5% 85.0% -9.5%

Maribyrnong 92.4% 82.4% -10.0%






Practice Nurses 18

85


WESTGATE DIVISION OF GENERAL PRACTICE

Population 3015 Newport, Spotswood; 3016 Williamstown; 3018 Altona; 3024 Wyndham Vale; 3025 Brooklyn, Altona North; 3028 Laverton; 3029 Hoppers Crossing; 3030 Werribee; 3211 Little River




GP Attendances: MBS Categories A1 & A2, 1996-2004Westgate Division of General Practice

660,000680,000700,000720,000740,000760,000780,000800,000820,000

1996/9

7

1997/9

8

1998/9

9

1999/0

0

2000/0

1

2001/0

2

2002/0

3

2003/0

4

Serv

ices Emergency AH

GP Attendances


758,682 717,712 -5.40

86


Local Government Area Estimated Population Growth, 1996-2004 Wyndham 34.86%

Hobson’s Bay 14.51%



% Variation

Gellibrand 94.5% 85.0% -9.5%

Lalor 91.6% 77.2% -14.4%






Practice Nurses 11

87


WHITEHORSE DIVISION OF GENERAL PRACTICE

Population 3106 Templestowe; 3108 Doncaster; 3109 Doncaster East; 3111 Donvale; 3113 Warrandyte; 3114 Park Orchards; 3125 Burwood; 3128 Box Hill; 3129 Box Hill North; 3130 Blackburn; 3131 Nunawading; 3132 Mitcham; 3133 Vermont; 3134 Ringwood; 3135 Heathmont; 3151 Burwood East


Medical Workforce Number of General Practices 117 Number of General Practitioners 395 (FTE 257) GP: Population 1:1050 (FTE)


GP Attendances: MBS Categories A1 & A2, 1996-2004Whitehorse Division of General Practice

1,100,0001,150,0001,200,0001,250,0001,300,0001,350,0001,400,0001,450,000

1996/9

7

1997/9

8

1998/9

9

1999/0

0

2000/0

1

2001/0

2

2002/0

3

2003/0

4

Serv

ices Emergency AH

GP Attendances


1,413,181 1,228,049 -13.10

88


Local Government Area Estimated Population Growth, 1996-2004 Manningham 13.81% Whitehorse 8.64%




Deakin 80.6% 64.6% -16.0%

Menzies 80.7% 70.0% -10.7%






Practice Nurses 5

89


ALL REGIONAL DIVISIONS OF GENERAL PRACTICE

General Practitioner Attendances, 1996-2004 Does not include Emergency AH attendances.

GP Attendances: MBS Categories A1 & A2, 1996-2004Regional Victoria

7,100,0007,200,0007,300,0007,400,0007,500,0007,600,0007,700,0007,800,000

1996/9

7

1997/9

8

1998/9

9

1999/0

0

2000/0

1

2001/0

2

2002/0

3

2003/0

4

Serv

ices

GP Attendances


7,765,066 7,359,685 -5.22

Note on bulk billing rates: latest available figures, by electorate, were for December 2003.

Provincial For the cities of Ballarat, Bendigo and Geelong, the average rate of bulk billing fell

from 52.8% in December 2000 to 47.8% in December 2003. In that period, Ballarat

experienced the greatest decline of 14.9% (58.1% to 43.2%). Regional variation is

highlighted by the fact that the highest provincial bulk billing rate is 57.9% in the

Corio electorate, while neighbouring Corangamite recorded the provincial low of

41.8%.

Rural The average rate of bulk billing in rural areas fell from 51.7% in December 2000 to

47.1% in December 2003. The highest rate of decline was recorded in Wannon (9.6%

to 42.2%, Ballarat/Otway DGPs). The lowest rate of bulk billing was recorded in Indi

with 29.8% (North East Victoria DGP) with Murray next on 31.5% (Murray

Plains/Mallee DGPs). The highest rate of bulk billing in rural Victoria was recorded

in McMillan with 67.6% (South Gippsland, Central West Gippsland DGPs).

90


McMillan recorded the only rise in bulk billing rates in Victoria, increasing 0.6%

from December 2002 to December 2003.

ALL METROPOLITAN DIVISIONS OF GENERAL PRACTICE


GP Attendances: MBS Categories A1 & A2, 1996-2004Metropolitan Victoria

0

5,000,000

10,000,000

15,000,000

20,000,000

1996/9

7

1997/9

8

1998/9

9

1999/0

0

2000/0

1

2001/0

2

2002/0

3

2003/0

4

Serv

ices

GP Attendances


18,949,879 15,719,673 -17.05

Inner Metropolitan The average rate of bulk billing fell from 76.2% in December 2000 to 71.7% in

December 2003. The highest rate of decline occurred in northern Melbourne, 5.7% in

the electorate of Wills (Northern/North West Melbourne DGPs). The bulk billing

rates ranged from 58.3% in the Kooyong electorate (Inner Eastern DGP) to 85% in the

Gellibrand electorate (Westgate/Western Melbourne DGPs).

Outer Metropolitan The average rate of bulk billing fell from 72.3% in December 2000 to 70.9% in

December 2003. The highest rate of decline was in the Maribyrnong electorate (10%

to 82.4%, Western Melbourne/North West Melbourne DGPs), closely followed by

Casey (9% to 59.6%, Dandenong & District DGP) and Deakin (8.9% to 64.6%,

Whitehorse DGP). Bulk billing rates ranged from 47.6% in Dunkley (Mornington

Peninsula DGP) to 84.8% in Scullin (Northern DGP).

91

Inquiry on the Impact on the Victorian Community and Public Hospitals of the Diminishing Access to After Hours and Bulk Billing General Practitioners Outer Urban Growth Areas There were three DGPs where GP attendances did not decline in the survey period, all

of them located in the outer urban growth areas. Central Highlands, incorporating the

Shire of Melton with its estimated population growth of 78.61%, recorded an increase

in GP attendances of 10.38%. Dandenong & District DGP, incorporating the City of

Casey with its estimated population growth of 41.95%, recorded an increase in GP

attendances of 2.03%. South Gippsland DGP, incorporating the City of Cardinia

(estimated population growth of 26.36%) and Bass Coast Shire (estimated population

growth of 36.25%), recorded a 9.10% rise in GP attendances.

VICTORIAN DIVISIONS OF GENERAL PRACTICE


GP Attendances: MBS Categories A1 & A2, 1996-2004Victoria

21,500,00022,000,00022,500,00023,000,00023,500,00024,000,00024,500,00025,000,00025,500,00026,000,000

1996/9

7

1997/9

8

1998/9

9

1999/0

0

2000/0

1

2001/0

2

2002/0

3

2003/0

4

Serv

ices

GP Attendances


25,496,501 23,079,358 -9.48

Victoria 1996-1997 2003-2004 % Variation

Bulk Billing Rate (Non-referred GP

attendances, GP/VRGP)

78.5% 64.5% -14.00%

92


HEALTH SERVICE REGIONS – PROFILES

EASTERN METROPOLITAN HEALTH SERVICE REGION Population Population Region State Persons aged 0-4 56,188 6.0% 6.5% Persons aged over 65 118,318 12.7% 12.6% Total Persons 2001 931,714 Total Persons 1996 889,296 Various Information Female 51.5% 50.9% Non-English Speaking Background 21.2% 19.8% Aboriginal & Torres Strait Islanders 0.3% 0.5%

Hospital Services with Emergency Departments Unless otherwise stated, EDs are open 24 hours.

PUBLIC Hospital Town Data included

in HSR Angliss Health Service Ferntree Gully Yes Box Hill Hospital Box Hill Yes Maroondah Hospital Ringwood East Yes Monash Medical Centre Clayton, Moorabbin Yes Knox Private Wantirna No The Valley Private Hospital Mulgrave No Vimy House Kew No

93

Inquiry on the Impact on the Victorian Community and Public Hospitals of the Diminishing Access to After Hours and Bulk Billing General Practitioners Admissions & Presentations to EDs, 1996-2004

ED Presentations & Admissions, 1996-2004Eastern Metropolitan Health Region

020,00040,00060,00080,000

100,000120,000140,000160,000180,000

1996-1997

1997-1998

1998-1999

1999-2000

2000-2001

2001-2002

2002-2003

2003-2004

All

Admitted

Presentations

ED Presentations & Admissions, 1996-2004Eastern Metropolitan Health Region - By Hospital

020,00040,00060,00080,000

100,000120,000140,000160,000180,000

1996-1997

1997-1998

1998-1999

1999-2000

2000-2001

2001-2002

2002-2003

2003-2004

Angliss

Box Hill

Maroondah

Monash MedicalCentreTOTAL

ED Presentations by ATS Category, 1997-2004Eastern Metropolitan Health Region

020,00040,00060,00080,000

100,000120,000140,000160,000180,000

1997-1

998

1998-1

999

1999-2

000

2000-2

001

2001-2

002

2002-2

003

2003-2

004*

AllCategories 1, 2 & 3Categories 4 & 5

94


NORTHERN METROPOLITAN HEALTH SERVICE REGION

Population Population Region State Persons aged 0-4 49,069 6.6% 6.5% Persons aged over 65 85,459 11.5% 12.6% Total Persons 2001 741,275 Total Persons 1996 701,970 Various Information Female 51.0% 50.9% Non-English Speaking Background 34.6% 19.8% Aboriginal & Torres Strait Islanders 0.5% 0.5%



in HSR Austin & Repatriation Medical Centre Heidelberg Yes Northern Hospital Epping Yes St Vincent’s Hospital Fitzroy Yes Epworth Richmond No John Fawkner Coburg No

95

http://www.med.monash.edu.au/mrh/resources/cgi-bin/echidna/vicresults.pl?town=Heidelberg

http://www.med.monash.edu.au/mrh/resources/cgi-bin/echidna/hosp.pl?index=82

http://www.med.monash.edu.au/mrh/resources/cgi-bin/echidna/vicresults.pl?town=Epping

http://www.med.monash.edu.au/mrh/resources/cgi-bin/echidna/hosp.pl?index=93

http://www.med.monash.edu.au/mrh/resources/cgi-bin/echidna/vicresults.pl?town=Fitzroy


ED Presentations & Admissions, 1996-2004Northern Metropolitan Health Region

020,00040,00060,00080,000

100,000120,000140,000

1996-1

997

1997-1

998

1998-1

999

1999-2

000

2000-2

001

2001-2

002

2002-2

003

2003-2

004*

AllAdmittedPresentations

ED Presentations & Admissions, 1996-2004

Northern Metropolitan Health Region - By Hospital

0

20,000

40,000

60,000

80,000

100,000

120,000

140,000

1996

-1997

1997

-1998

1998

-1999

1999

-2000

2000

-2001

2001

-2002

2002

-2003

2003

-2004

Austin & Repat

Northern Hospital

St Vincent's

TOTAL

ED Presentations by ATS Category, 1997-2004Northern Metropolitan Health Region

0

20,000

40,000

60,000

80,000

100,000

120,000

140,000

1997

-1998

1998

-1999

1999

-2000

2000

-2001

2001

-2002

2002

-2003

2003

-2004

All

Categories 1, 2 & 3

Categories 4 & 5

96


WESTERN METROPOLITAN HEALTH SERVICE REGION

Population Population Region State Persons aged 0-4 40,160 6.5% 6.5% Persons aged over 65 62,015 10.1% 12.6% Total Persons 2001 614,573 Various Information Female 50.3% 50.9% Non-English Speaking Background 21.1% 19.8% Aboriginal & Torres Strait Islanders 0.2% 0.5%



in HSR Mercy Public Werribee No

Royal Children’s Parkville Yes*

Royal Melbourne Parkville Yes

Royal Women’s Hospital Carlton No

Sunshine Hospital St Albans Yes

Western Hospital Footscray Yes

Williamstown Hospital Williamstown No

Freemasons Hospital East Melbourne No *Due to differences in the type of data recorded in the Hospital Services Report, the Royal Children’s Hospital has been separated from the data group. Its presentationsby ATS Category have been reported separately.

97


ED Presentations & Admissions, 1996-2004Western Metropolitan Health Region

020,00040,00060,00080,000

100,000120,000140,000160,000

1996

-1997

1997

-1998

1998

-1999

1999

-2000

2000

-2001

2001

-2002

2002

-2003

2003

-2004


ED Presentations & Admissions, 1996-2004Western Metropolitan Health Region - By Hospital

020,00040,00060,00080,000

100,000120,000140,000160,000

1996-1

997

1997-1

998

1998-1

999

1999-2

000

2000-2

001

2001-2

002

2002-2

003

2003-2

004*

Royal MelbourneSunshineWesternTOTAL

ED Presentations by ATS Category, 1997-2004Western Metropolitan Health Region

020,00040,00060,00080,000

100,000120,000140,000160,000

1997

-1998

1998

-1999

1999

-2000

2000

-2001

2001

-2002

2002

-2003

2003

-2004

*

All

Categories 1, 2 & 3

Categories 4 & 5

98


ED Presentations by ATS Category, 1997-2004Royal Children's Hospital

010,00020,00030,00040,00050,00060,00070,000

1997-1

998

1998-1

999

1999-2

000

2000-2

001

2001-2

002

2002-2

003

2003-2

004*


99


SOUTHERN METROPOLITAN HEALTH SERVICE REGION

Population Population Region State Persons aged 0-4 69,158 6.4% 6.5% Persons aged over 65 140,101 13.0% 12.6% Total Persons 2001 1,079,547 Total Persons 1996 998,844 Various Information Female 51.1% 50.9% Non-English Speaking Background 21.9% 19.8% Aboriginal & Torres Strait Islanders 0.4% 0.5%



in HSR Alfred Prahran Yes Dandenong Hospital Dandenong Yes Frankston Hospital Frankston Yes Koo Wee Rup Regional HS (AH) Koo Wee Rup No Rosebud Hospital Rosebud No Sandringham & District Hospital Sandringham No Cabrini Hospital Malvern No Southeastern Hospital Noble Park No The Avenue Hospital (AH) Windsor No

100


Admissions & Presentations to EDs, 1996-2004

ED Presentations & Admissions, 1996-2004Southern Metropolitan Health Region

0

20,00040,000

60,000

80,000

100,000120,000

140,000

1996-1997

1997-1998

1998-1999

1999-2000

2000-2001

2001-2002

2002-2003

2003-2004


ED Presenations & Admissions, 1996-2004

Southern Metropolitan Health Region - by Hospital

020,00040,00060,00080,000

100,000120,000140,000

1996

-1997

1997

-1998

1998

-1999

1999

-2000

2000

-2001

2001

-2002

2002

-2003

2003

-2004

Dandenong

Frankston

The Alfred

TOTAL

ED Presentations by ATS Category, 1997-2004

Southern Metropolitan Health Region

020,00040,00060,00080,000

100,000120,000140,000

1997-1

998

1998-1

999

1999-2

000

2000-2

001

2001-2

002

2002-2

003

2003-2

004*


101

Inquiry on the Impact on the Victorian Community and Public Hospitals of the Diminishing Access to After Hours and Bulk Billing General Practitioners METROPOLITAN HEALTH SERVICE REGIONS – SUMMARY

ED Presentations & AdmissionsMetropolitan Victoria: 1996-2004

0

100,000

200,000

300,000

400,000

500,000

600,000

1996-1997

1997-1998

1998-1999

1999-2000

2000-2001

2001-2002

2002-2003

2003-2004


ED Presentations by ATS CategoryMetropolitan Victoria: 1997-2004

0

100,000

200,000

300,000

400,000

500,000

600,000

1997-1998

1998-1999

1999-2000

2000-2001

2001-2002

2002-2003

2003-2004


ATS Categories as a % ofED Presentations & Admissions

Metropolitan Health Service Regions: 1997-2004

0%

20%

40%

60%

80%

100%

1997-1998

1998-1999

1999-2000

2000-2001

2001-2002

2002-2003

2003-2004

Categories 4 & 5Categories 1, 2 & 3

102


BARWON SOUTH WESTERN HEALTH SERVICE REGION

Population Population Region State Persons aged 0-4 21,288 6.6% 6.5% Persons aged over 65 47,988 14.8% 12.6% Total Persons 2001 323,416 Total Persons 1996 311,750 Various Information Female 50.9% 50.9% Non-English Speaking Background 6.6% 19.8% Aboriginal & Torres Strait Islanders 0.7% 0.5%



in HSR Barwon Health Geelong Yes Beaufort & Skipton HS (limited AH) Skipton No Casterton Memorial (AH) Casterton No Coleraine & District (limited AH) Coleraine No Colac Community HS (limited AH) Colac No Hesse Rural HS (AH) Winchelsea No Heywood & District Hospital (limited AH) Heywood No Lorne Community Hospital (AH) Lorne No Moyne HS (limited AH) Port Fairy No Otway HS (limited AH) Apollo Bay No Portland & District Hospital (AH) Portland No South West Health Care Warrnambool No Terang & Mortlake HS Mortlake No Terang & Mortlake HS (limited AH) Terang No Timboon & District HS (limited AH) Timboon No Western District HS Hamilton No Western District HS (limited AH) Penshurst No Cobden District HS (limited AH) Cobden No St John of God Health Care (limited AH) Warrnambool No

103



ED Presentations, 1996-2004Barwon Health

05,000

10,00015,00020,00025,00030,00035,00040,00045,000

1996-1997

1997-1998

1998-1999

1999-2000

2000-2001

2001-2002

2002-2003

2003-2004

All

ED Presentations by ATS Category, 1997-2004Barwon Health

05,000

10,00015,00020,00025,00030,00035,00040,00045,000

1997-1

998

1998-1

999

1999-2

000

2000-2

001

2001-2

002

2002-2

003

2003-2

004*


104


LODDON MALLEE HEALTH SERVICE REGION Population Population Region State Persons aged 0-4 19,288 6.9% 6.5% Persons aged over 65 40,173 14.3% 12.6% Total Persons 2001 280,447 Total Persons 1996 269,194 Various Information Female 50.7% 50.9% Non-English Speaking Background 4.0% 19.8% Aboriginal & Torres Strait Islanders 1.4% 0.5%



in HSR Bendigo Health Care Group Bendigo Yes Boort District Hospital (limited AH) Boort No Cohuna District Hospital (AH) Cohuna No East Wimmera HS (limited AH) Birchip, Charlton,

Donald, Wycheproof No

Echuca Regional Health Echuca No Goulburn Valley Health (limited AH) Rushworth No Inglewood & District HS (limited AH) Inglewood No Kerang & District Hospital (AH) Kerang No Kyabram & District Memorial Hospital (AH) Kyabram No Kyneton District HS (AH) Kyneton No Maldon Hospital (limited AH) Maldon No Mallee Track HS (limited AH) Ouyen No Manangatang & District Hospital (limited AH) Manangatang No Maryborough District HS (limited AH) Dunolly No Maryborough District HS (AH) Maryborough No McIvor HS (limited AH) Heathcote No Mildura Base Hospital Mildura No Mount Alexander Hospital (limited AH) Castlemaine No Swan Hill District Hospital Swan Hill No Sea Lake & District HS (AH) Sea Lake No

105

Inquiry on the Impact on the Victorian Community and Public Hospitals of the Diminishing Access to After Hours and Bulk Billing General Practitioners ED Presentations & Admissions, 1996-2004

ED Presentations & Admissions, 1996-2004Bendigo Health Care Group

0

5,000

10,000

15,000

20,000

25,000

30,000

35,000

1996-1997

1997-1998

1998-1999

1999-2000

2000-2001

2001-2002

2002-2003

2003-2004

All


Bendigo Health Care Group

05,000

10,00015,00020,00025,00030,00035,000

1997-1

998

1998-1

999

1999-2

000

2000-2

001

2001-2

002

2002-2

003

2003-2

004*


106


GIPPSLAND HEALTH SERVICE REGION Population Population Region State Persons aged 0-4 14,516 6.4% 6.5% Persons aged over 65 33,864 14.9% 12.6% Total Persons 2001 227,748 Total Persons 1996 222,489 Various Information Female 50.8% 50.9% Non-English Speaking Background 4.3% 19.8% Aboriginal & Torres Strait Islanders 1.2% 0.5%

Hospital Services with Emergency Services Unless otherwise stated, EDs are open 24 hrs.


in HSR Bairnsdale Regional Health Service Bairnsdale No Central Gippsland Health Service Sale No Far East Gippsland Health & Support Service (AH)

Orbost No

Gippsland Southern Health Service (AH) Korumburra No Gippsland Southern Health Service (AH) Leongatha No Latrobe Regional Hospital Traralgon Yes Omeo District Hospital (limited AH) Omeo No South Gippsland Hospital (limited AH) Foster No West Gippsland Healthcare Group Warragul No Wonthaggi & District Hospital Wonthaggi No Yarram & District Health Service (AH) Yarram No Warley Hospital (AH) Cowes No

107



ED Presentations & Admissions, 1996-2004Latrobe Regional Hospital

0

5,000

10,000

15,000

20,000

25,000

30,000

35,000

1996-1997

1997-1998

1998-1999

1999-2000

2000-2001

2001-2002

2002-2003

2003-2004

All

ED Presentations by ATS Category, 1997-2004Latrobe Regional Hospital

05,000

10,00015,00020,00025,00030,00035,000

1997-1

998

1998-1

999

1999-2

000

2000-2

001

2001-2

002

2002-2

003

2003-2

004*


108


GRAMPIANS HEALTH SERVICE REGION Population Population Region State Persons aged 0-4 13,194 6.6% 6.5% Persons aged over 65 27,922 14.1% 12.6% Total Persons 2001 198,675 Total Persons 1996 192,846 Various Information Female 50.8% 50.9% Non-English Speaking Background 2.7% 19.8% Aboriginal & Torres Strait Islanders 0.8% 0.5%


PUBLIC

Hospital Town Data included in HSR

Ballarat Health Services Ballarat Yes

Beaufort & Skipton Health Service (AH) Beaufort No

Djerriwarrh Health Services (AH) Bacchus Marsh No

Dunmunkle Health Services (limited AH) Murtoa No

East Grampians Health Service (AH) Ararat No

East Wimmera Health Service (AH) St Arnaud No

Edenhope & District Hospital (AH) Edenhope No

Hepburn Health Service (AH) Creswick No

Hepburn Health Service (AH) Daylesford No

Rural Northwest Health (AH) Hopetoun No

Rural Northwest Health (limited AH) Warracknabeal No

Stawell District Hospital Stawell No

West Wimmera Health Service (limited AH) Jeparit No

West Wimmera Health Service (limited AH) Kaniva No

West Wimmera Health Service (AH) Nhill No

West Wimmera Health Service (AH) Rainbow No

109


Wimmera Health Care Group (AH) Dimboola No

Wimmera Health Care Group Horsham No

Ballan & District Soldiers Memorial (AH) Ballan No

St John of God Health Care Ballarat No


ED Presentations & Admissions, 1996-2004Ballarat Health Services

05,000

10,00015,00020,00025,00030,00035,00040,000

1996-1997

1997-1998

1998-1999

1999-2000

2000-2001

2001-2002

2002-2003

2003-2004

All


Ballarat Health Services

05,000

10,00015,00020,00025,00030,00035,00040,000

1997-1

998

1998-1

999

1999-2

000

2000-2

001

2001-2

002

2002-2

003

2003-2

004*


110


HUME HEALTH SERVICE REGION Population Population Region State Persons aged 0-4 16,751 6.8% 6.5% Persons aged over 65 32,142 13.0% 12.6% Total Persons 2001 246,722 Total Persons 1996 237,467 Various Information Female 50.1% 50.9% Non-English Speaking Background 5.6% 19.8% Aboriginal & Torres Strait Islanders 1.2% 0.5%

Hospital Services with Emergency Services Unless otherwise stated, EDs are open 24 hours.


in HSR Alpine Health (limited AH) Bright, Mount Beauty,

Myrtleford No

Beechworth Hospital (AH) Beechworth No Benalla & District Hospital (AH) Benalla No Cobram District Hospital (limited AH) Cobram No Goulburn Valley Health Shepparton Yes Kilmore & District Hospital (limited AH) Kilmore No Mansfield District Hospital (AH) Mansfield No Nathalia District Hospital (AH) Nathalia No Numurkah and District HS (limited AH) Numurkah No Seymour District Hospital Seymour No Tallangatta HS (limited AH) Tallangatta No Upper Murray HS (AH) Corryong No Wangaratta District Hospital Wangaratta No Wodonga Regional HS Wodonga No Yarrawonga District HS (limited AH) Yarrawonga No Yea & District Hospital (limited AH) Yea No Nagambie Hospital (AH) Nagambie No Shepparton Private Hospital Shepparton No Walwa Bush Nursing (AH) Walwa No Yackandandah Bush Nursing (AH) Yackandandah No

111



ED Presentations & Admissions, 1996-2004Goulburn Valley Health

0

5,000

10,000

15,000

20,000

25,000

30,000

35,000

1996-1997

1997-1998

1998-1999

1999-2000

2000-2001

2001-2002

2002-2003

2003-2004

All

ED Presentations by ATS Category, 1997-2004Goulburn Valley Health

05,000

10,00015,00020,00025,00030,00035,000

1997-1

998

1998-1

999

1999-2

000

2000-2

001

2001-2

002

2002-2

003

2003-2

004*


112


REGIONAL HEALTH SERVICE REGIONS – SUMMARY

ED Admissions & PresentationsRural Health Service Regions: 1996-2004

020,00040,00060,00080,000

100,000120,000140,000160,000180,000

1997-1998

1998-1999

1999-2000

2000-2001

2001-2002

2002-2003

2003-2004

AllCategories 1, 2 & 3Categories 4 &5

ATS Categories as a % of ED Presentations & AdmissionsRegional Health Service Regions: 1997-2004

0%

20%

40%

60%

80%

100%

1997-1998

1998-1999

1999-2000

2000-2001

2001-2002

2002-2003

2003-2004

Categories 1, 2 & 3Categories 4 &5

Data for these HSRs is not comprehensive, as only one major ED from each region has been included. Consequently, any intraregional variations are not detectable. Overall, regional Victoria recorded an increase of 4.54% in ATS Category 4 & 5 presentations to Emergency Departments. These Categories represent nearly 70% of the workload of regional Emergency Departments.

The regional variations in ATS Category 4 & 5 presentations to Emergency Departments are as follows:

Barwon (Geelong) -4.10%

Loddon (Bendigo Health Care) -18.78%

Grampians (Ballarat Health Services) +30.47%

Hume (Goulburn Valley Health) +47.00%

Gippsland (Latrobe Regional Hospital) -26.93%

113


METROPOLITAN HEALTH SERVICE REGIONS – SUMMARY


0

100,000

200,000

300,000

400,000

500,000

600,000

1997-1998

1998-1999

1999-2000

2000-2001

2001-2002

2002-2003

2003-2004




0%

20%

40%

60%

80%

100%

1997-1998

1998-1999

1999-2000

2000-2001

2001-2002

2002-2003

2003-2004

Categories 1, 2 & 3Categories 4 & 5

There was a marked increase in ATS Category 4 & 5 presentations to Emergency Departments in the Northern and Western HSRs in the period 2001-2002 to 2003-2004. In the Northern HSR these presentations increased by 23% while in the Western HSR, the increase was 32.72%. During the period 1996-2004, ATS Category 4 & 5 presentations in the Eastern and Southern HSRs remained stable.

Overall, ATS Category 4 & 5 presentations in metropolitan HSRs rose by 12% in the period 1997-2004. These presentations currently account for nearly 60% of all

presentations to metropolitan Emergency Departments.

114


VICTORIAN HEALTH SERVICE REGIONS - SUMMARY

ED Presentations & Admissions by ATS CategoryVictoria 1997-2004

0100,000200,000300,000400,000500,000600,000700,000800,000

1997-1998

1998-1999

1999-2000

2000-2001

2001-2002

2002-2003

2003-2004


ED Presentations & Admissions by % of ATS CategoryVictoria 1997-2004

0%

20%

40%

60%

80%

100%

1997-1998

1998-1999

1999-2000

2000-2001

2001-2002

2002-2003

2003-2004


Major Victorian Emergency Departments experienced an increase of 8.81% in ATS Category 4 & 5 presentations during the period 1997-2004. These categories represent nearly 60% of all presentations to major Emergency Departments in Victoria.

115

Inquiry on the Impact on the Victorian Community and Public Hospitals of the Diminishing Access to After Hours and Bulk Billing General Practitioners Data sources Except where otherwise stated, the following categories of data have these sources:

Division Profiles Population

Population data has been compiled on the basis of aggregate postcode data. Echidna, health services profiles for Victorian rural and metropolitan regions, Monash University, School of Rural Health, accessed July 2004. http://www.med.monash.edu.au/mrh/resources/echidna/geog.html

Local Divisions of General Practice

Medical Workforce

Local Divisions of General Practice

Echidna, health services profiles for Victorian rural regions, Monash University, School of Rural Health, accessed July 2004. http://www.med.monash.edu.au/mrh/resources/echidna/geog.html

Medicare Benefits Schedule

MBS data retrieved from the Health Insurance Commission, General Practice Reports, defined by Divisions of General Practice. Types of data: A1 General Practitioner attendances. Accessed May - August 2004. http://www.hic.gov.au/statistics/imd/forms/gpStatistics.shtml.

Bulk Billing Rates

Bulk billing rates, by electorate, are provided by the Health Insurance Commission by calendar year. Latest figures available were for the 12 months to December 2003. http://www.hic.gov.au/providers/health_statistics/statistical_reporting/medicare.htm

Estimated Population Growth

Data drawn from the Department of Sustainability & Environment statistical database, “Know Your Area”. Estimated population growth for each Local Government Area for the period 1996-2004 was calculated using 1996 Census data and the Department’s estimated residential population for 2004. http://www.doi.vic.gov.au/doi/knowyour.nsf

116


Practice Incentives Program

PIP data retrieved from the Health Insurance Commission, General Practice Reports, defined by Divisions of General Practice. Accessed May & July 2004.

http://www.hic.gov.au/statistics/imd/forms/gpStatistics.shtml

Health Service Region Profiles

Population

Echidna, health services profiles for Victorian rural regions, Monash University, School of Rural Health, accessed July 2004.

http://www.med.monash.edu.au/mrh/resources/echidna/geog.html

ED Presentations and Admissions

Hospital Services Report, 1996 – 2004. Compiled by the Department of Human Services, Victoria. Accessed May & July 2004. Admissions and presentations were not separated in the Hospital Services Report until 2000. Data for June Quarter 2004 not available at time of printing; financial year data for 2003/04 completed with data from June Quarter 2003 (indicated by *). Datasets: Victorian Emergency Minimum Dataset, Victorian Admitted Episode Minimum Dataset.

http://www.health.vic.gov.au/hsr/

117


118

CHAPTER THREE DEALING WITH INCREASED EMERGENCY

PRESENTATIONS: ISSUES, STRATEGIES AND SOLUTIONS

Introduction The Link between General Practice and Increased Emergency Presentations Other Causes of Increased Presentations State, Federal and Joint Initiatives Telephone Triage Nurse Practitoners

Introduction 3.1 This Chapter examines the link between increases in emergency department

presentations and the decline in access to bulk billing and after hours general

practitioners, regional differences and factors which may also contribute to increased

presentations. The final section examines strategies to minimise these increases including

co-located GP clinics, management of chronic diseases and other primary health care

initiatives, telephone triage, and nurse practitoners.

The Link between changes in General Practice and Increased Emergency Presentations 3.2 One of the most important issues for the Committee to determine has been the

level of correlation between the decline in the availability of bulk billing and after hours

general practitioners and increases in emergency department presentations. Making this

determination has been complicated by the lack of substantial research:

I want to talk about the impact on emergency departments, because I know that is the

main focus of your inquiry. I have to say that the link between a patient using general

practice and using an emergency department is not well researched. We all say that we

all know A, B and C and have a lot of theories, and in a way the Victorian Medicare

Action Group has a whole lot of anecdotal evidence which seems to suggest that there

are clear links and that the data, partly because it is not kept as well as it could be, has

not been analysed enough. 1

3.3 The reasons for the decline in bulk-billing and increase in out-of-pocket expenses

outlined in the previous Chapter are also the subject of debate. Factors cited include the

number and geographical distribution of GPs, the level of the MBS schedule fee,

119

Inquiry on the Impact on the Victorian Community and Public Hospitals of the Diminishing Access to After Hours and Bulk Billing General Practitioners compliance costs, the corporatisation of general practice and anti-competitive practices.

These will be discussed in greater detail in the next chapter.

3.4 What became apparent during the Committee’s consultations however was the

differences between rural and metropolitan Victoria:

I think you have got different stories in different situations. You have got the city story,

you have got regional centre stories and you have got rural centres; so you cannot

categorise the whole thing together, that would be a mistake…2

3.5 From the evidence presented to the Committee it is possible to identify three

distinct areas where the decline in the availability of bulk billing and after hours general

practitioners has markedly different effects

• Metropolitan Tertiary Hospitals

• Suburban Hospitals

• Regional Hospitals

3.6 Interestingly in some areas the decline in bulk billing is not credited with having

as major an effect as the absence of after hours service while in others both are seen to be

equally responsible. Differences in demographic and regional characteristics seem to

largely dictate the effect that any change to the profile of general practitioner service has

on emergency department presentations.

Metropolitan Tertiary Hospitals 3.7 Victorian Metropolitan tertiary hospitals have seen no discernable rise in

emergency department presentations with the decline in bulk billing and after hours GPs.

The Committee received evidence from Melbourne Health that over the past five years

the presentations in category 5 have only increased from 6 per cent to 8 per cent, while in

triage Category 4 numbers have gone from 50 per cent to 49 per cent changes which are

small given the overall significant attendance figures.

In summary the Committee was told:

To answer your question around those, that is where I would have expected to see a

change in proportions if there were an increase in primary care type patients attending

the emergency department at the Royal Melbourne.

If I had looked at those numbers in any other number of hospitals around Melbourne, I

know – having worked and been responsible for three – I would be certain that that

120

Dealing with Increased Emergency Presentations: Issues, Strategies and Solutions

would be a different picture. There is a phenomenon that is tertiary hospitals and inner-

city hospitals have a different demography to outer-urban hospitals – different

population, different issues, different needs.3

Although it could be argued that inner Melbourne may be immune from changes in GP

activity more pronounced in other areas, the Melbourne Division of General Practice has

recorded a 15 per cent drop in GP attendances in the period 1996-7 to 2003-4 in a period

when the population in inner Melbourne has increased.

Suburban Hospitals 3.8 For suburban hospitals the position is different. During the course of the Inquiry

the Committee spoke with a number of suburban health services. Nearly all reported a

decline in after hours and bulk billing GPs and a subsequent increase in emergency

department presentations.

Western Health have been interested in the problems of presentations to the hospital from

the emergency department and the relationship with GPs and other health care providers

in the region for a number of years. They have completed surveys and other

investigations to try to obtain a background. One of the key things they discovered was

that the absolute number of GPs in the region per capita was significantly less than in

other suburbs:

The number per capita is down. It is very clear when you talk to our GPs, most of them

say they have too many patients, not too few patients and a number have recently

closed their books and are not accepting new patients, which reaffirms this. As part of

the problems that arise out of this, because the GPs are so busy they then limit the

services they provide to the region so 61 per cent of the GPs in our survey provide no

after-hours service, which is quite a high percentage, and only 15 per cent actually

provide regular after-hours services, which is a relatively low percentage. 4

3.9 On after-hours running, only a quarter — 24 per cent — of GP clinics are open

until 8.00 p.m. in the evening and only 3 per cent are open to 10.00 p.m., so after-hours

services are very limited in the region.

This is exacerbated in terms of emergency presentations because the population is

growing rapidly

The high rate of growth is encouraged because there are a lot of ethnic groups working

in the area which means they often have difficulty establishing relationships with GPs

if they do not speak their own language and come to a hospital where interpreting

services are available. They are often quite transient and they move their addresses very

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regularly, not through any wish of theirs but just because they get their accommodation

and such organised. That makes it hard for them to attach to a GP as well. That creates

a bigger load through the emergency department so we are always looking at ways to

improve and encourage the relationship in other areas.

3.10 Eastern Health has also reported an increase in presentations due to changes in GP

activity however their emergency department demand is determined by a different

demographic change:

I think perhaps the only thing I would like to add is just a little more about the age

distribution. One thing we see in our outer east departments is that we have quite a high

percentage of children at the Angliss, and that certainly impacts on the emergency

department attendances. Those of us with children find that they rarely seem to get sick

when the GPs are available between 9.00 a.m. and 5.00 p.m., so that compounds the

out–of–hours problems, and as far as the central east department at Box Hill is

concerned, the elderly demographic in that area really makes the presentations more

complex. Something that is a relatively minor problem in someone aged 40 can be a

significant problem in someone aged 80. We have a very elderly demographic, so

across our catchment we have both the very young and the very old, which makes

planning a bit of a challenge. They are probably the two things I wanted to add.5

3.11 The problem with older patient presentations is that this can sometimes be

compounded by a lack of access to residential care:

We are trying to manage that demand. It would be fair to say that we are also

experiencing access problems in relation to residential care for elderly patients, which

has meant that many times our emergency departments are full waiting for beds to

become available so that patients can be admitted. That is a compounding problem,

along with the GP access problem.6

3.12 The situation at Northern Health resembles that of Western Health with a growing

population, characterised by a diversity of ethnic background. Lack of after hours GPs

has been identified as a strong determinate of an increase in emergency department

presentations:

We have identified in particular the peak times in the evenings when effectively if

general practices were not closed they would stop taking any more patients that day, so

from 6 or 7 in the evening on through to about midnight or 1.00 a.m. we are peaking

Monday to Friday; and again on a Saturday after lunchtime, when the practices are

closed, and all day Sunday. Our proposal was to put in an after-hours practice in those

hours commencing at about 2 o’clock, maybe until 11 or midnight on a Saturday; from

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10.00 a.m. to 10.00 p.m. on a Sunday and probably from 7 to midnight or maybe

1.00 a.m., Monday to Friday.7

3.13 A similar situation at Peninsula Health lead to changes in the structure of the

relationship between the hospital and local general practitioners discussed later in the

chapter.

Recommendation 1 : That the Commonwealth Government continue to

increase the number of aged care residential places and transition care

places to alleviate pressures on hospitals generally.

Regional Hospitals 3.14 Health Services in regional centres expressed concern with increasing emergency

department attendances, however the increases were generally credited to a lack of GP

numbers rather than the absence of the provision of certain services such as bulk billing

provision or after hours service.

3.15 In Mildura, which has one of the lowest GP to population ratios in Victoria, there

has been a dramatic increase in the level of emergency department presentations in both

triage categories 4 and 5:

Having said that, to give you some more numbers, the number of general

practitioner-type patients going through Mildura Base Hospital is increasing at about

6 per cent per annum. In this community we put the same number of admissions

through our emergency department as Bendigo Base Hospital, which serves

considerably more than twice our population. I think comparative to other rural centres

we have a very high proportion of patients attending our hospital that would otherwise

attend general practitioners.

At Mildura Base Hospital of triage categories 4 and 5, which would normally be

considered appropriate for general practitioner practice, triage 4 constitutes 36 per cent

of patient admissions to emergency and triage category 5 constitutes 32 per cent of

admissions to our department. That is a total of 68 per cent of all patients presenting at

our hospital could quite rightly be considered general practice patients and be better

seen in general practice setting.8

3.16 The situation was similar at Barwon Health

Over the past couple of years I have seen an unprecedented growth in presentations to

the emergency department. For example in 2002 we saw a total of 41 000 patients

whereas in 2001 we saw approximately 37 000 patients, so it was up by about 3000 last

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year. In our emergency department we are now seeing a similar number of patients to

some of the major metropolitan hospitals. We are seeing more patients than the Alfred

hospital and St Vincent’s Hospital, and we are pretty much on a par with hospitals such

as Box Hill and the Austin and repatriation hospital. The growth in these tendencies has

essentially been across the board, but also in particular last year we saw a 25 per cent

increase in category 5 patients, which are Australasian triage category 5 patients. Up

until about 1999 or 2000 we were seeing probably around about 1 per cent or 2 per cent

category 5 patients. Last year it went up to about 15 per cent, and it has eased back to

about 10 per cent. So we are shouldering the burden if you like, of reduced general

practitioner services around Geelong to a certain extent.9

3.17 The Bendigo Division of General practice undertook a study in 2002 to determine

the availability and access of general practitioners and community demand. A survey was

conducted publicly. It was found that the region could take another 12 to 15 general

practitioners into the City of Greater Bendigo. The survey also found that regional issues

were of great importance. The general practitioner population in outlying towns was

ageing dramatically. The latest statistics show the average age of a general practitioner is

in excess of 55. The region is also experiencing “inward migration”, and as the smaller

communities decrease in size changes have been experienced at local hospitals which

flow on to Bendigo.

With regard to the after-hours service, and in particular primary care or general practice

services, Bendigo is very similar to other rural towns — there are not many bulk-billing

general practitioners or after-hours services. There is a primary care clinic, which is

located adjacent to the hospital. It is not the hospital’s clinic; it is a private clinic run

from Monash University, and it is usually open until 9 or 10 pm most nights. There are

two community health centre services, but they do not provide after-hours services, so

far as I am aware, beyond 6 o’clock at night. After that it comes back to the general

practitioners or the emergency department. Most of the solo general practitioners do not

do after hours, or if they do, it is in a cooperative fashion with four or five colleagues.

A number of the bigger clinics provide after hours within themselves. Those who

choose not to provide after hours usually direct patients to the emergency department as

a matter of first course. Our volume of activity would indicate that it increases

dramatically about midafternoon and keeps going right through to midnight. We start to

slack off or slow down after that. I guess that reflects again general practitioner hours,

access issues and the like. On weekends the department is very busy, and we can see up

to 100 patients a day. That would be unusual busy, but we can see up to 100. The

average works out to around the 80-plus mark.10

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3.18 From the evidence presented to the Committee it would appear that the

distribution of GPs is uneven as between the inner metropolitan area, and some outer

metropolitan and rural areas and this coupled with demographic changes may result in

fluctuations in attendances to both General Practitoners and hospital emergency

departments.

Other Causes of Increased Presentations Evidence received by the Committee identifies two other factors which may lead to

increased emergency department presentations.

Cultural Metropolitan Health Services in the both the North and West have reported a cultural

identification with the hopital as the place to go to for initial medical treatment amongst

the migrant community. This can occur for two reasons :

• general practitioners do not form a major sector of health care services in the

country of origin; and

• lack of English makes it preferable to attend a hospital where there is an increased

likelihood of finding interpreting services.

Coupled with this maybe cultural practices which are more appropriately dealt with in a

large organisation setting than a small community clinic.

Recommendation 2 : That Health Service Regions are assisted in a

programme of education for Culturally and Linguistically Diverse

communities emphasising the importance of General Practitioners in

primary health care and the appropriate role of Emergency

Departments.

One Stop Shop The Committee also received evidence that there is a preference amongst some patients

for the emergency department over General Practioner clinics due to the access to a wide

range of services:

The other reason people give for coming to the ED is that they can access X-rays or

pathology easily. They say, ‘I know I have to see the GP, I know I have to get an X-ray.

I might as well come here and get the X-ray done and it will save me trekking around’.

So the ED is in one sense a sort of a one-stop shop where they can get their blood test

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or their urinary test or their pregnancy test or whatever fairly easily rather than having

to locate a GP and then still come to the hospital and get their X-ray. 11

Access to such services on a twenty four hour basis only increases the attraction:

…the workload we are seeing has been sustained and is going to continue to grow

irrespective of what is done outside the emergency department. Some of the reasons for

that are that we are open 24 hours a day, seven days a week; we are staffed by

employees so we are always there and we provide high-quality care. We provide on-site

pathology and imaging: it is a bit of a one-stop-shop if you want to get your health

issues sorted out.12

State, Federal and Joint Initiatives 3.19 The increase in the number of PCT patients presenting at EDs is one element

contributing to demand pressures on public hospitals. The Victorian government has

introduced a number of strategies designed to manage hospital demand and to improve

service integration, particularly between primary care and acute care, and acute care and

post-acute care and rehabilitation. The Hospital Demand Management (HDM) strategy

and the Hospital Admission Risk Program (HARP) have been in place for some time.

Other more recent initiatives currently under implementation include the establishment of

super clinics, and an array of community health care strategies such as the primary care

partnerships. An ambulatory care project is under development.

3.20 Two joint projects are currently under negotiation with the Commonwealth - the

trialling of several co-located clinics at sites of public hospitals under the greatest

pressure from PCT patients in EDs, and agreement on a national health call centre

network.

3.21 The pressure on public hospitals’ EDs from the increasing number of patients

seeking primary care is only one of many factors driving demand for acute services in

Victoria. In Victoria, a range of policies has been developed to deal with demand

pressures on public hospitals, and Victoria is engaged in negotiation with the

Commonwealth of two joint initiatives to deal with PCT patients in EDs in particular via

the establishment of co-located clinics, and development of a national call centre triage

facility.

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Recommendation 3 : That Emergency Departments and General

practitioners be supported in their capacity to provide a range of

appropriate after hours care arrangements for their communities (eg.

the Eastern Suburbs After Hours Clinic, Whitehorse DGP; the

Grampians After Hours Medical Care Service, West Victoria Division

of General Practice).

The changing configuration of health services in Victoria

Hospital Demand Management strategy 3.22 In 2001, the Victorian government set out a Hospital Demand Management

(HDM) strategy to deal with growth in demand for acute services driven by an ageing

population, the availability of new treatments and technology, and increased community

expectations. There was a need to continue to manage annual 7-8 per cent growth in

metropolitan emergency presentations, and three per cent growth in overall demand for

hospital services in Melbourne.13

3.23 Subsequently, the Victorian government developed a wider set of policy goals and

interrelated initiatives, including service substitution and diversion through the Victorian

Metropolitan Health Services Strategy, the Community Health Policy, development and

implementation of the ambulatory care services framework, establishment of Super

Clinics and the development of health precincts, and the continued implementation of the

Hospital Admission Risk Program.

3.24 A key element of the HDM strategy was to engage clinicians and administrators to

negotiate a tailored package of initiatives at each Metropolitan Health Service to increase

capacity and better manage demand. Another key element was implementation of the

Hospital Admission Risk Program (HARP), a four-year prevention strategy to reduce the

need for hospital admission by better managing the treatment of people with chronic and

complex conditions. The HDM also included the management of hospital patients'

transition to residential care.

3.25 The Department of Human Services has argued that since 2001 achievements

from the HDM strategy have included:

• Annual growth in emergency admissions cut from 10 per cent to 3 per cent

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• Ambulance bypass down by 69 per cent

• Elective waiting list reduced by 9 per cent

• Semi urgent waits for elective surgery reduced by 20 days

• Patients in hospital beds waiting for residential aged care down by 42 per cent

• Emergency patients admitted to inpatient beds within target time up from 76 per

cent to 83 per cent. 14

3.26 The primary policy outcomes for 2004-2005 are expected to include:

• Achievement of a target of no more than 1,800 ambulance bypasses system-wide

• 95 per cent of emergency patients requiring admission being admitted within 12

hours

• All triage Category 1 emergency patients seen immediately

• All Category 1 elective patients admitted within 30 days

• 5 per cent reduction in the average waiting time of Category 2 patients from that

reported on 30 June 2004

• The number of patients on the elective surgery waiting list to continue to remain at

or below 40,000 by 30 June 2005. 15

Hospital Admission Risk Program (HARP) 3.27 The Hospital Admission Risk Program (HARP) is the ‘prevention’ component of

the Hospital Demand Management Strategy that the Victorian Government funds in

response to increased demand pressure on public hospitals. The implementation of a

diverse range of models and interventions is expected to improve people’s health

outcomes and reduce the preventable use of emergency departments and inpatient

services.

3.28 HARP projects comprise a range of prevention initiatives that have the potential to

affect hospital emergency demand. In many cases, the initiatives are continually

evolving, and the developmental nature of models and interventions is apparent within the

projects’ core components. The projects target both service system functioning and

service provision activities, with particular emphasis on patients who are high current

users of hospital emergency services. The number of patients presenting to emergency

departments on four or more occasions (within one financial year) rose by 18 per cent

between 1999–2000 and 2002–03. Typically, these patients have chronic and complex

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conditions, with many having one or more conditions—frequently, chronic obstructive

pulmonary disease (COPD), chronic heart failure (CHF) and/or diabetes.

3.29 HARP is a program designed to enable certain groups of chronically ill patients to

manage their health more effectively in the community and thus reduce the need for them

to use hospital services. The intention of HARP is to bring together many key goals of

global health policy – patient needs drive the integrated care models employed, service

gaps are bridged, and barriers to accessing appropriate care are removed. By fostering

better integration of care across service types HARP aims to avert avoidable use of

emergency departments and inpatient services. Implementation of HARP commenced in

November 2001.

3.30 In November 2002, the Department of Human Services appointed BearingPoint to

undertake an independent evaluation of HARP to identify interventions and models of

care that are effective in producing outcomes consistent with HARP objectives.

3.31 The HARP Interim Evaluation Report, July 2001 to June 2003, identified that

HARP projects are contributing to reducing emergency demand pressures in participating

hospitals, however the magnitude of this effect was not quantified.

3.32 At the system level, a review of indicators for relevant HARP hospitals indicated

that demand pressure on emergency departments continues to increase in absolute terms,

but that the relative rate of increase over time has slowed..16System level analysis of the

19 hospitals (14 metropolitan and 5 regional) participating in HARP indicates a reduced

rate of growth between 2001-02 and 2002-03 for a number of indicators as outlined in the

table below.

HARP Interim Evaluation results

Indicator Annual % change

2000/01 - 2001/02

Annual % change

2001/02 - 2002/03

Emergency admissions 8.5% 4.0%

Emergency presentations 7.0% 4.4%

Emergency occupied bed days 5.5% 0.1%

Representations to ED for any

reason within 28 days

6.8% 4.5%

Source: DHS, Victorian Admitted Episodes Dataset and Victorian Emergency Minimum Dataset

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Inquiry on the Impact on the Victorian Community and Public Hospitals of the Diminishing Access to After Hours and Bulk Billing General Practitioners 3.33 At the project and system level this report considered clusters of priority

conditions such as Chronic Obstructive Pulmonary Disease (COPD), Congestive Heart

Failure (CHF) and Diabetes. Other important clusters were also examined. An example

is the cluster of people with high volume acute service usage.

3.34 The Interim Evaluation Report identified that projects have generally taken longer

than originally anticipated to become operational and that considerable effort has been

expended on meeting the demands of the evaluation. The report makes recommendations

to support the further development of HARP in the following areas – staffing,

implementation, governance, target groups, service system function, models and

activities, fund holding arrangements, evaluation, information systems, brokerage, service

system pressure and models and interventions. 17

3.35 Challenges for future reporting include further investigation of the HARP

contribution to reducing demand pressure, identifying the effectiveness of projects in

terms of HARP outcomes, and a focus on cluster development and investigation for

priority conditions.

Super Clinics 3.36 Super clinics were announced in the Victorian Government's Hospitals for the

Suburbs policy and have been flagged as an important component of the Metropolitan

Health Strategy (MHS). Super clinics are designed to be an alternative to hospital-based

services for many day procedures and outpatient visits that require specialist medical

care, but do not require an overnight stay in hospital.

3.37 It is intended that patients will be able to have many health problems diagnosed,

treated and reviewed locally, including specialist medical treatment, renal dialysis,

chemotherapy and associated cancer services, nursing care, day procedures (emphasis on

medical not surgical), pathology, radiology, allied health, and after hours GP services

(depending on local needs).

3.38 In order for this holistic approach to work it is important that there are effective

links between service providers so that the patient’s health care is well planned and co-

ordinated and it is envisaged that the super clinics will provide an important link with

GPs, community health centres, hospitals and other community agencies such as local

government. Funding of $40m has been committed for super clinics in Melton, Lilydale

and Craigieburn, and planning for the three super clinics is now underway.

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Primary health care strategies 3.39 Primary health care strategies have focussed on extending and embedding reform

through the Primary Care Partnerships Strategy, continued implementation of Service

Coordination and Integrated Health Promotion, and further integration between General

Practitioners (GPs) and State-funded primary care services, including through the GPs in

Community Health Services Strategy.

3.40 The 2004-05 Victorian Budget provides $2m ($8m over four years) to implement

the Government’s Healthy Communities policy for the General Practitioners (GPs) to

Community Health Services (CHSs) Strategy.

GPs in Community Health Services Strategy 3.41 Victoria’s network of 100 Community Health Services (CHSs) provide a range of

primary health care services and health promotion programs, primarily for people with

chronic or complex health problems and communities with low socio-economic status.

The philosophy behind the strategy is investment that GPs in CHSs have an emphasis on

delivering integrated services to people with chronic conditions and complex needs, and

that this is time and resource intensive.

3.42 The GPs in CHSs Strategy aims to improve access to primary medical care by

substantially increasing GP services available through CHSs. Iniatives under the strategy

include:

• funding formal links with existing private GP practices,

• the establishment of new GP clinics in CHSs,

• recruitment of more GPs,

• improvements to existing GP services to increase capacity through improved

business practices,

• more effective billing services and

• stronger administrative support.

3.43 The strategy also designed to focus on increasing the number of CHSs that offer

bulk-billing and extended hours GP services, particularly in high needs areas and to high

needs groups. There will also be an emphasis on improving access to nursing and allied

health services.

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Inquiry on the Impact on the Victorian Community and Public Hospitals of the Diminishing Access to After Hours and Bulk Billing General Practitioners The GPs in CHSs Strategy aims to complement the Strengthening Medicare incentives by

assisting CHSs and GPs to offer bulk billing to clients of socioeconomic disadvantage

and those with chronic and complex health needs.

Ambulatory care project 3.44 The Department of Human Services is currently developing an ambulatory care

strategy. The various strategies and policies developed over the past five years have

created the need to focus future service development on building capacity for integrated

care across ambulatory care services as a means of improving equity and access to health

care, improving efficiency and managing future hospital demand. The ambulatory care

project seeks to provide a coherent direction and set of enablers for the development of

integrated ambulatory services across Victoria.18

Co-located Clinics 3.45 Over a number of years, co-located clinics have been developed in various parts of

Australia. Two basic models have been trialled – one where a GP is recruited into the ED

of a public hospital (with the hospital meeting the cost) and the other where GPs run after

hours clinics (with GPs billing MBS).

3.46 In the 2004-05 budget, the federal government announced that it will allow up to

10 after hours clinics to be set up jointly with the states. The clinics may be co-located

with public hospitals or stand alone. Exemption from subsection 19(2) of the Health

Insurance Act 1973 will be provided on a case-by-case and time limited basis, so that the

services will be eligible for the MBS rebate. Victoria is currently negotiating with the

Australian government for the establishment of four co-located clinics in terms which are

broadly consistent with the announcement in the budget.

3.47 Co-location of GP clinics with a public hospital may represent an effective

response in that they can:

• provide care for PCT patients;

• lead to an improvement in the efficient use of emergency departments by allowing

the allocation of resources to be better tailored to the demand;

• maximise use of existing infrastructure; and

• improve waiting times in emergency departments by more effective streaming of

patients.

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GPDV/AMA Position On Co-Located Clinics and After Hours Primary Care 3.48 General Practice Divisions Victoria (GPDV) released a policy issues paper on GP

Clinics and Emergency Departments in April 2002.19 This paper identified several

issues and concerns related to the establishment of co-located GP clinics.

• That the establishment of such clinics will reinforce public perceptions of

hospitals as the place to seek all medical attention, therefore increasing demand.

• That the availability of such a service will increase the number of patients who do

not have a regular GP.

• That there is no compelling evidence of the effectiveness of such clinics

• That identifying patients suitable for diversion to a GP clinic is complex.

3.49 The GPDV concluded that GP clinics may be desirable out of hours but should not

operate during normal hours.

3.50 The Australian Medical Association produced a position statement on After Hours

Primary Medical Care in July 2001.20 While this statement addresses a broader range of

issues, in respect of co-located GP clinics it included the following recommendations:

• That general practice maintain the central role in providing after hours primary

medical care

• That service provision reflects local need.

• Emergency Departments are a vital service and need to be adequately resourced.

• Where appropriate to the model used, establishment of after hours primary care

services should

a. Involve consultation with the relevant Emergency Department(s) to ensure

efficient integration of services including patient transfer and continuity of

care and the identification of mutual skills transfer opportunities;

b. Complement rather than detract from the provision of service to emergency

patients;

c. Enable the community to clearly identify the service through appropriate

nomenclature of general practice out of hours services.

Issues for the Establishment of Co-located Clinics 3.51 Emergency departments provide the only currently established infrastructure with

sufficient geographical coverage to provide 24-hour access. As previously stated the

Committee heard from a number of health services who reported closure of GP services,

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Inquiry on the Impact on the Victorian Community and Public Hospitals of the Diminishing Access to After Hours and Bulk Billing General Practitioners reduction in operating hours or termination of bulk-billing services in their catchment

areas. The Committee also received evidence from a number of health services that the

public perception is that EDs are the main providers of out of hours service. In this

context, it could be argued that fears co-location of GP services would draw patients to

the hospital system could be overstated. PCT patients are already attending EDs in

significant numbers.

3.52 However the Committee received evidence from a number of health services who

were not in favour of co-located clinics as they felt that they destroyed the perception of

the GP as a community resource. Concerns expressed by Northern Health were

characteristic:

I guess we would tend not to be in favour of co-located GP clinics. The view would

tend to be that the GP is a community resource and the patient should see the GP as

being someone in the community to see when they are unwell and that it is not

equivalent to a hospital visit; it is not something that should be provided at a hospital

with emergency departments and separate from general-practice types of problems.

Also the fact that patients may then, as you say, attend and make the whole problem

worse. The one-stop shop effect would be a problem.21

3.53 It has been argued that the marginal cost of providing GP care within or adjacent

to EDs is minimal compared to the cost of establishing GP practices. Thus provision of

co-located GP practices recognises the existing overlap in the provision of primary

medical care and enables more efficient allocation of resources.22

3.54 However, patient profiles and consultation patterns for an after hours co-located

GP clinic will differ from normal GP practice. A higher proportion of patients will be

“new” patients, with no history at the clinic. This will necessitate longer and more

complex assessment leading to longer consultation times and therefore lower patient

throughput. This is likely to put pressure on the ability of such a clinic to bulk bill

universally.

3.55 Ensuring an adequate GP workforce is certainly a risk for establishment of such a

service. Evidence received by the Committee from Peninsula Health on the closure of the

co-located clinic based at Rosebud Hospital illustrates the difficulties in maintaining GP

numbers.23 While the most likely mechanism for staffing in regional and rural areas is

that local GPs staff the clinic on a rotational basis many of the divisions of practice the

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Committee consulted explained the difficulty of attracting GPs to after hours work even

on a roster basis.

3.56 Identification of suitable patients to refer to GP clinics is also a complex matter.

Many category 4 & 5 patients require hospital management. Both emergency department

and general practice staff must agree on criteria for referral. In order to maintain

continuity of care, effective and timely systems for transfer of patient information to

patients’ regular GP must be established.

In order to address many of these issues it is vital that any such project be a cooperative

venture between the hospital and the local GP community, represented by the divisions of

general practice.

3.57 A number of principles have been identified as being essential to the

establishment of co-located GP clinics. These follow from the aims set out above:

• Provide quality GP care

• Add to the availability of GP care

• Maintain continuity of care

• Provide a one stop experience

• Impact positively on ED overcrowding and waiting times.

• Ensure billing practices reflect local context and community expectations.

• Provide care in an efficient and cost effective manner

• Share of costs between State and Commonwealth

• Target service delivery to areas and times of need.

3.58 It has also been argued that co-located clinics must be closely co-located with

EDs. There is evidence that even relatively short distances separating clinics from EDs

can deter patients from using them. Close co-location provides advantages in terms of

patient transfer, clinical integration, sharing of overhead costs and consumer confidence.

Operation of a clinic from a designated area within the ED should be allowed where the

physical infrastructure favours such an arrangement.

3.59 A key element in identifying priority locations for co-located clinics is a lack of

GP resources in the catchment area of the proposed clinics. The clinics are intended to

relieve pressure on EDs, not to compete with general practice. In many cases, areas of

GP shortage coincide with those with high numbers of PCT patients. The establishment

of these clinics should not substitute for existing GP services, nor should recruitment of

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Inquiry on the Impact on the Victorian Community and Public Hospitals of the Diminishing Access to After Hours and Bulk Billing General Practitioners GPs for these practices adversely impact on existing services. When considering the

effect on local GP services, consultation with local GPs, through divisions of local

practice is vital. The times of operation of the co-located clinic will reflect times of high

demand. This will result in co-located clinics operating in the after hours period.

3.60 Access to the GP clinics will be either through the ED triage system, direct walk-

up access to the clinic or by referral from regular GP. Where services such as telephone

advice or triage exist, these may be referral sources for the clinic.

3.61 Under proposed federal/state model the majority of consultations are expected to

be bulk-billed. Any co-payment must reflect local market conditions and community

expectations. The potential effect on the ability to divert ED attendances must be

considered. Clinics must demonstrate integration with other services, both in the acute

hospital sector and the primary care sector. The model must enable patients to be

transferred smoothly between the ED and the clinic, and referred back to the usual

primary care provider. This requires a collaborative approach between the ED, the clinic

providers and the local GPs.

3.62 Using the above principles, a number of hospital sites present themselves as

candidates for the establishment of co-located clinics. Four health services have been

identified as being suitable for the initial round of establishment of co-located GP clinics,

and are currently under negotiations with the Commonwealth- Northern, Sunshine,

Geelong, and Maroondah. Each will have in excess of 15,000 PCT type presentations in

2003-04 and each has areas of GP shortage as a significant part of its catchment. In June

2004 Wodonga Regional Health Service opened a bulk billing co-located clinic without

formal approval from the Federal Government.

Peninsula Health Frankston Hospital GP Clinic 3.63 In 1992 Peninsula Health set up a co-located GP clinic at the Frankston Hospital.

The service was specifically set up to decrease the pressure on the emergency department

and runs after hours and on weekends inside the hospital grounds. Although Frankston

Hospital emergency department presentations in triage categories 4 and 5 are relatively

constant, there are now 15 000 to 16 000 patients a year presenting to the GP service after

hours and on weekends who would otherwise present to the Frankston Hospital

emergency department.24

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3.64 The GP clinic is run by a group of local general practitioners who work in the area

who do not keep their rooms open after hours and are not available after hours. They

formed a consortium and responded to an expression of interest that was put out for a

service to run in what used to be the outpatient department for after hours when the

outpatient department was closed. It has been successfully running for 11 years. The

GP’s work in the clinic on a roster basis.

3.65 Patients have the opportunity to directly walk off the street into the GP clinic or

they can be triaged from the emergency department. Patients cannot be formally triaged

at the clinic, but when they arrive at the emergency department if the triage officer or

triage nurse determines that the patient has a condition that could be managed within the

capacity of the medicentre, they are given the option to attend the clinic.

3.66 Apart from taking the pressure of attendances from the emergency department

patients found it a positive that the clinic is based in the hospital, thus if a patient is

diagnosed with a condition that requires further attention the emergency department is

adjacent.

If somebody comes in with what they think is a sprain and it turns out to be a fracture,

you can send them to the emergency department, which is just next door, and we use

the same investigative services, so it is the same pathology service and radiography

service that the emergency department in the hospital uses that the clinic uses as well.25

3.67 At present the service is not free. Up until May 2003 the clinic was bulk-billing,

thus it was of no financial burden for patients to attend the clinic. However since the GPs

restructured the service each practitioner charges a surcharge depending on the status of

the patient. The hospital notifies patients of the availablilty of the clinic and the

possibility of a surcharge and gives them an opportunity to go there voluntarily, where the

waiting time and the transit time is shorter.

3.68 The hospital experienced a noticable increase in emergency department

presentations with the decline in the bulk billing service:

I think May is when they started to talk to us about the fact that they were going to stop

bulk-billing, and it took its toll. The reason they stopped bulk-billing is that the big

clinic over the road here, the Heritage Medical Clinic, stopped bulk-billing and the

patients started to come to this clinic, and they just could not cope with the numbers. So

they introduced a relatively modest fee to try to keep the numbers down, which meant

that a few people started drifting back into the emergency department. There was a

flow-on effect. 26

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Inquiry on the Impact on the Victorian Community and Public Hospitals of the Diminishing Access to After Hours and Bulk Billing General Practitioners 3.69 Peninsula Health also set up a similar GP clinic at Rosebud hospital in December

1996. At the time general practitioners helped with the emergency department which

operated more like an urgent medical centre than a formal emergency department. The

clinic was set up in a building that was leased adjacent to the emergency department.

However it proved difficult for the clinic to consistently recruit to the service and it

folded in July 2002.

Once again the impact was noticeable

You can see the impact on our emergency department at Rosebud Hospital when that

clinic closed. It closed because people could not be recruited to come to work at the

service down in Rosebud. We would be quite happy to have a co-located general

practice-type service down at Rosebud — seeing general practice-type patients, not

emergency patients. It was very hard to recruit to that area. Two different private

companies ran that service. One took over from the other. They both had extreme

difficulty recruiting people to come down to work in that service. 27

3.70 Peninsula Health also run a service, which is HDM funded, called Streamline at

Frankston Hospital. It is a service in the emergency department where the hospital funds a

GP-type service to treat categories 4 and 5 patients at certain times of the week.28

We have put in that service for two reasons. The first reason is to manage patients who

do not wish to move around to the medicentre, or those who are a little unsure of

whether the medicentre is the appropriate place, but do not need the full resources of

the emergency department. Therefore we admit those patients and register them to the

emergency department, but they are seen in a side clinic, which is within the

department, by a dedicated practitioner who is supported by a dedicated nurse to that

particular area.29

3.71 The other reason for moving a patient using the Streamline system is that there are

patients who present to the emergency department with an existing diagnosis and that

patient can be quickly moved through the Streamline service into hospital in the home or

into a ward without spending hours and hours in the emergency department. This service

has also proven effective in alleviating some pressure on the emergency department.

Telephone triage centre trials and National Call Centre negotiations 3.72 In 2002 Victorian Governments election platform ("Health Care When You Need

It") included a commitment to "establish a 24-hour health assist line initially as a pilot in

Geelong". The service was intended to provide "information, referral and triage to help

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divert unnecessary emergency presentations". Planning for the service to date proposed

that it operate along similar lines to existing services in Western Australia and the

Australian Capital Territory. These services are staffed by Registered Nurse call-takers

who provide callers with information, referral and triage using a computerised clinical

decision support system.

3.73 As part of its health reform agenda, the Australian Health Ministers' Council

(AHMC) currently has under consideration a National Health Call Centre Network. A

draft “National Health Call Centre Network – national action plan” was endorsed at the

10 June 2004 Australian Health Ministers' Advisory Council (AHMAC) meeting and this

paper will be presented to the 29 July 2004 AHMC meeting for endorsement.

3.74 The Commonwealth Government's national evaluation report on the After Hours

Primary Medical Care trials found that telephone triage services of this kind result in

reduced call outs of GPs after hours, and savings in the use of after hours MBS items.30

Particularly in rural areas, such services can have an impact on recruitment and retention

of GPs. (The evaluation of the Central Grampians after hours telephone advice trial

found that GPs were receiving a reduced number of after hours calls, their own and their

families' quality of life had improved, and the service had a positive impact on their

intentions to stay in rural practice.) Evidence of the impact of such services on the

numbers of people presenting at emergency departments is more limited. 3.75 There

is clear evidence from the Healthline health call centre service in New Zealand that the

majority of people who intended to present at emergency before they contacted the

service, were appropriately advised to seek less urgent care.31 However, a Western

Australian study suggests that only a small number of people contact the HealthDirect

health call centre prior to presenting at the emergency department, which limits the ability

of the service to impact on emergency demand.32

3.76 Planning for the implementation of a health assist line based in Geelong is

currently awaiting the outcome of discussions with the Australian Government and other

States and Territories on a national action plan for a national health call centre network,

being conducted under the auspices of the AHMC.

3.77 In January 2003 Moruya and Narooma on the far south coast of New South

Wales implemented an after hours nurse triage network to assist GPs who historically

staffed the local hospital's emergency department on an on-call basis. Previously services

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Inquiry on the Impact on the Victorian Community and Public Hospitals of the Diminishing Access to After Hours and Bulk Billing General Practitioners in both towns had been under threat as general practitioners reconsidered their

commitment to after hours services.

3.78 However the implementation of the system complemented by a successful

`Primary Care Medical Officer' solution, with general practice and emergency care

provided by a single doctor at the hospital has been found to be ‘efective as a means to

make more efficient use of the medical workforce, improve access to primary medical

care, and improve provider and patient satisfaction.ensuring the ongoing availability of

services.’33

3.79 Similarly the Western Victorian Division of General Practices established a nurse

telephone triage system which is highly effective in dealing with the needs of the

community. This model of nurse telephone triage involves GPs switching their practice

phones through to a dedicated 1800 after hours telephone number. When a patient calls a

practice after hours the call is automatically diverted to a trained telephone triage nurse

located in a rural hospital. The nurse takes the patient details and via a set of agreed

evidence based protocols, assesses whether the patient requires nursing advice and

reassurance, a medical appointment the next day, advice/treatment from the doctor on call

or emergency care. It is important to note that the Telephone Triage Nurse does not make

a diagnosis over the phone. 34

3.80 The telephone system permits calls to be transferred from the telephone triage

nurse to the on call doctor in the appropriate area for the patient or for the nurse to put the

patient on hold, speak to the doctor and then relay the doctor’s advice to the patient.

Should a patient require assessment they are directed to their local hospital. 35

3.81 The Committee heard that:

As a result of the service we have found that 61 per cent of calls can be handled by the

nurse — or you could look at it as in only 39 per cent of cases is the GP required;

49 per cent of clinical calls are handled by the triage nurse over the phone; and a further

12 per cent are handled once the patient attends the ED and is actually assessed at the

ED by the nurse. 36

3.82 In order to operate successful the system also introduces a high level of service

integration:

It operates on four levels: the individual practitioner — that is, the nurse; the group or

team level; the organisation level; and the system level. If we look at the individual

nurse, she has specialised training which is updated constantly and she is given

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continual support. At the group or team level we have a strong QA review process,

whereby records are actually reviewed. At the organisation level there is the

understanding of the local needs and the systems. We also provide the satellite hospitals

with training for their nurses. There are contracts and service agreements between all

parties involved. At the system level we have the telephone software to enable this to

happen. There are reporting mechanisms, professional and documented processes and

also a degree of flexibility.37

Nurse Practitioners

Definition of nurse practitioner 3.83 The International Council of Nurses provides the following definition. “A Nurse

Practitioner/Advanced Practice Nurse is a registered nurse who has acquired the expert

knowledge base, complex decision-making skills and clinical competencies for expanded

practice, the characteristics of which are shaped by the context and/or country in which

s/he is credentialed to practice. A master's degree is recommended for entry level.”38

3.84 In Victoria a nurse practitioner is defined as “… a registered nurse educated for

advanced practice who is an essential member of an interdependent health care team and

whose role is determined by the context in which s/he practices.”39

3.85 The title nurse practitioner is protected in an amendment to the Nurses Act 1993 to

prevent any persons who have not met the requirements of the Nurses Board of Victoria

from using the title nurse practitioner.

Development of the role in Victoria 3.86 Work on the nurse practitioner role in Victoria began in July 1998. The

Department of Human Services has been developing the nurse practitioner role in an

action-learning model by funding and evaluating demonstration projects and working

with key stakeholders. A Ministerial Taskforce guided the role development and made a

number of recommendations for implementing the role.

3.87 The Minister for Health launched the implementation of the nurse practitioner role

in Victoria and released the Victoria Nurse Practitioner Project Final Report of the Task

Force - December 1999. The release of the Taskforce report represented the first phase of

the process for nurse practitioner role implementation in Victoria. The Taskforce has

developed a framework for role implementation under which to progress.

3.88 The Ministerial Nurse Practitioner Implementation Advisory Committee has

guided the second phase process for nurse practitioner role implementation. The main

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Inquiry on the Impact on the Victorian Community and Public Hospitals of the Diminishing Access to After Hours and Bulk Billing General Practitioners work of the committee has been developing recommendations for consideration by the

Minister for Health on options for incorporating the extended practices of prescribing,

initiating diagnostics, referring to medical specialists, and admitting into hospital into the

Victorian nurse practitioner role. The committee also developed a framework for funding

further nurse practitioner models of practice (demonstration models).

Framework for nurse practitioner role 3.89 The nurse practitioner role is about the development of an advanced nursing

framework to enhance health care delivery and improve the convenience of services for

patients and carers.

3.90 The role has evolved (and will continue to do so) over many years from attempts

to address concerns of individuals and communities, including their demands for diverse

options in health care, improved service access and increased flexibility in models of

health care delivery. The development of the role is in keeping with international trends

where advanced nursing roles have been developed and practised for some time.

3.91 The focus of the Victorian nurse practitioner role is on health promotion,

education, and the complementary nature of the advanced nursing role. A distinguishing

characteristic of the nurse practitioner is that their practice extends the nursing role

outside the current scope of practice for the registered nurse in at least two of the five

extended practice areas:

• Limited prescribing

• Initiation of diagnostics

• Referral to medical specialists

• Admitting and discharging privileges

• Approval of absence of work certificates

3.92 However, the ‘extended’ practices of the nurse practitioner role are merely tools

necessary to competently practise in an expanded area of nursing expertise.

Demonstration projects 3.93 As part of the action research, demonstration projects have been funded by the

Department of Human Services to further inform the implementation of the nurse

practitioner role. Eleven nurse practitioner models of practice were funded in the first

phase of the project. A further twenty-three models of practice have been funded to date

as part of the second phase of the project.

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3.94 The role can be delivered in all spectrums of nursing practice and in all regions of

the State. The spectrum of the funded demonstration projects includes:

• Emergency nursing

• Haematology

• Diabetes (3)

• Community midwifery

• Palliative care (2)

• Youth (2)

• Paediatrics (2)

• Wound management

• Maternal and Child Health.

• Aboriginal health (midwifery & women's

health)

• Haematology

• Peri-operative

• ICU liaison

• Custodial nursing

• Homeless persons

• Primary health care

(3)

• Women's health

• Aged care (3)

• Neonatal nursing

• Cystic Fibrosis

• Mental health (3)

• Men's health

• Dialysis

The Position of the AMA and other Organisations 3.95 The AMA’s position statement on Nurse Practitioners released in 1994 actively

discourages their practice use other than in under- resourced or remote areas, and then

under the suprevion of a medical practitoner;

1. Medical practitioners provide services which cannot be replaced by those rendered

by nurses or nurse practitioners.

2. Primary health care is the role of general medical practitioners who provide

comprehensive, safe, efficient and cost effective care.

3. All patients admitted to hospitals and to other approved health care facilities

should be under the care of medical practitioners.

4. Medical education and training are prerequisites for medical practice. Nurses and

nurse practitioners’ lack of medical education and training precluded them other than

under medical supervision, from:

a. requesting pathology tests;

b. making medical diagnoses;

c. requesting X-rays or other investigations;

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d. prescribing medication;

e. referring patients to specialists; and

f. deciding on the admission of patients to, and discharge from, hospital.

g. The delivery of high quality health care is dependent upon a co-ordinated

approach by all involved health professionals. Appropriately trained nurses or

nurse practitioners have a role in the provision of health education and in health

promotion.

h. In remote, under-resourced and rural areas unable to support a resident medical

practitioner, it is permissible for care to be provided by appropriately trained

nurses or nurse practitioners utilising treatment protocols in consultation with a

medical practitioner, who carries the ultimate clinical responsibility.

i. The AMA does not accept that medical practitioners should be legally responsible

when errors of omission or commission by medically unsupervised independent

nurse practitioners warrant subsequent medical intervention. Medical

practitioners are not responsible for professional acts over which they have no

control.40

3.96 The Victorian President of the AMA Dr Sam Lees recently commented “It’s

potentially the thin end of the wedge, if the Government decides that nurses can used

instead of doctors” he also added that he did not believe nurse practitioners should be able

to prescribe medication or refer patients to specialists, because they will not be as highly

trained as doctors. “ There’s no call for nurses prescribing medication ouside of a unit

headed by a senior doctor”.41

3.97 However the Doctors' Reform Society of Australia has questioned some of the

AMA’s assumptions:

My experiences working with nurse practitioners in palliative care teams, drug and

alcohol units, sexual health clinics, correctional centres and Aboriginal health services

have been positive. I have never felt they were competing for my job or undermining

my authority. Rather, there have been tremendous opportunities to work as a team and

assist each other in areas of difficulty. 42

3.98 It is argued that far from providing an inferior service, a range of studies suggest

that suitably trained and assisted nurse practitioners can perform as well as, if not better

than, doctors in diverse areas. These include studies allowing nurse practitioners to

144


prescribe the potentially hazardous drug warfarin,43 and research with nurses providing

ongoing management of asthma, diabetes, palliative care and even rheumatology

patients.44

Recommendation 4 : That the relevant authorities facilitate the

training, registration and placement of nurse practitioners.

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146

Endnotes 1 Mr Tony McBride, Medicare Action Group, Public Hearings, 19 April 2004 2 Mr R. Wilson, convenor, Medicare Action Group, Public Hearings Melbourne 19 April 2004 3 Assoc. Prof. Kennedy, Melbourne Health, Public Hearings, 2003 4 Dr Kronberg, Western Hospital , Public Hearings, 19 April 2004 5 Dr Hamley, Eastern Health, Public Hearings, 19 April 2004 6 Prof Rasa, Eastern Health, Public Hearings, 19 April 2004 7 Dr Carson, Northern Hospital, Public Hearings, 2003 8 Mr Dane Huxley, Mildura Base Hospital, Public Hearings, 2003 9 Dr Fawcett, Barwon Health, Public Hearings, 2003 10 Dr Ferguson, Bendigo Health Car Group, Public Hearings, 13 August 2003 11 Dr O’Brien, Southwest Health, Public Hearings 12 Dr Cruikshank, Ballarat Health Services, 2003 13 DHS Submission 14 DHS Submission 15 DHS Submission 16 HARP evaluation report: July 2001 to June 2003 17 HARP evaluation report: July 2001 to June 2003 18 DHS Submission 19 “After Hours General Practice Services”, GPDV Policy Issues Paper No 18, September 2002,

www.gpdv.com.au/gpdv/documents/PolicyIssue_18AfterHours.pdf 20 See www.ama.com.au/web.nsf/doc/SHED-5FY6RG 21 Dr Hamley, Eastern Health Public Hearings. 22 DHS Submission 23 Dr Devanesen Peninsula Health, Public Hearings 24 Dr Devanesen, Peninsula Health, Public Hearings 25 Dr Devanesen, Peninsula Health, Public Hearings 26 Dr Devanesen, Peninsula Health, Public Hearings 27 Dr Devanesen, Peninsula Health, Public Hearings 28 Dr Bradford, Peninsula Health, Public Hearings 29 Assoc. Prof. Wassertheil, Peninsula Health, Public Hearings 30 After Hours Primary Medical Care Trials National Evaluation Report,

www.health.gov.au/pcd/programs/ahpmc/publications/ahpmctne, pp. 210-211.


147

31 The Evaluation of the Healthline Service Interim Report (BRC Marketing and Social Research, 2001)

p.54 32 Report on the Outcome of a Data Linkage Study of Health Direct Patient Referrals to Fremantle Hospital

Emergency Department (Curtin University of Technology, 2001) p. 11. 33 Jon Mortimer - "Telephone triage and integrated after hours primary care: two successful strategies to

support general practitioners", www.archi.net.au/content/index.phtml/itemId/125347 34 McGrath A, Nurse Telephone Triage After Hours Service, West Victorian Division of General Practice

Inc, www.westvicdiv.asn.au 35 McGrath A, Nurse Telephone Triage After Hours Service, West Victorian Division of General Practice

Inc, www.westvicdiv.asn.au 36 Ms A. McGrath, After-Hours Service Manager, West Vic Division of General Practice Public Hearings. 37 Ms A. McGrath, After-Hours Service Manager, West Vic Division of General Practice Public Hearings. 38 International Council of Nurses (ICN) Definition and Characteristics for Nurse Practitioner/Advanced

Practive Nursing Roles http://www.icn.ch/networks_ap.htm#definition 39 Department of Human Services (2000) Victorian Nurse Practitioner Project: Final Report of the

Taskforce, Melbourne. 40 Australian Medical Association, www.ama.com.au/web.nsf/doc/WEEN-

5KZ2TH/$file/nurse%20prac%20web%20info.doc 41 The Age, Saturday 3 July 2004. 42 Dr Andrew Gunn, Nurse Practitioners Are a Benefit Not a Threat, Doctors Reform Society column,

Australian Doctor 13 March 1998. 43 Grahame R; West J Br J, The role of the rheumatology nurse practitioner in primary care: an experiment

in the further education of the practice nurse Rheumatol 1996 Jun;35(6):581-8 44 Vadher et al, Comparison of oral anticoagulant control by a nurse-practitioner using a computer

decision-support system with that by clinicians Clin Lab Haematol 1997

Sep;19(3):203-7


148

CHAPTER FOUR EXPLAINING AND RESOLVING THE DECLINE IN BULK

BILLING AND AFTER HOURS GENERAL PRACTITIONERS

Introduction The Decline in Bulk Billing The Decline in After Hours Services Federal Initiatives to address the problems Issues with A Fairer Medicare/Medicare Plus/Strengthening Medicare

Introduction 4.1 This Chapter examines the decline in bulk billing in Australia generally, and more

specifically in Victoria with an examination of variations across regions and

demographics. The chapter also examines possible reasons for this decline. The second

section examines a similar decline in the access to after hours General Practitioners. The

Final section examines strategies to minimise the effects of these changes to the structure

of General Practice and maintain the quality of primary care.

The Decline in Bulk Billing 4.2 Various press reports have stated that general practitioners are gradually

withdrawing from bulk billing health care card holders, patients on low incomes and older

patients.1 In addition, there have long been concerns that the rate of bulk billing in rural

and regional Australia is much lower than that in metropolitan areas.

4.3 From the tables below it can be seen that the level of bulk billing in Australia has

declined in the period 1996-2003. There has been a similar decline in the Victorian

figures. With an overall decline in the proportion of Medicare services being bulk billed,

and an almost three per cent decline in the number of services provided by VRGPs, it is

likely that there has been a shift in the demographics of bulk billing for Medicare

services.2 However, the Medicare Statistics compiled and published by the Department of

Health and Ageing do not include details that identify the proportion of services provided

to health care card holders and low income earners. Until more extensive data is publicly

available it is likely that the anecdotal claims made about variations in bulk billing will

remain unverified.

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4.4 Evidence received by the Committee tends to suggest that while the overall rate of

bulk billing has fallen, GPs in most areas choose to bulk bill on an individual basis

largely dependant on the status of the patient–pensioner, health card recipient, or financial

difficulty (see table below). Most of the rural divisions of general practice to whom the

Committee spoke had low overall rates of bulk billing–a situation, it was claimed patients

had grown to accept–yet maintained a ‘safety net’ approach of bulk billing those patients

perceived to be vulnerable.3

4.5 Suburban divisions of general practice in the north and west, however, reported

high levels of bulk billing:

On bulk-billing, GPs in the western suburbs have been slower to move away from

bulk-billing than their colleagues in the other parts of Melbourne. This is evidenced by

the bulk-billing rates identified in our survey of members. Even within those GPs who

have moved away, most have continued to bulk-bill selected patients. The division is

also aware that in the practices that have moved to private-billing, the patient numbers

have returned to bulk-billing levels after an initial decline. 4

This has been explained by the low socio economic status of many members of these

communities coupled with a large itinerant migrant population.

150

Explaining and resolving the decline in bulk billing and after hours general practitioners

Yet while the rates of bulk billing may vary from region to region the divisions of general

practice were largely in agreement as to the reasons for the overall decline.

Explanations for the Decline 4.6 Public discussion about the decline in the rate of bulk billing has focused on the

proportion of general practitioner services being bulk billed. Consequently, explanations

of the decline in the rate of bulk billing have primarily centred on two competing claims:

the level of the Schedule fee, and the geographical distribution of GPs. Other issues that

have been raised include Medicare compliance costs, the corporatisation of general

practice and anti-competitive practices.

4.7 A 2003 survey conducted by the Ronald Henderson Research Foundation in the

Yarra Valley Region was designed to analyse the accessibility of bulk billing GPs to

people with low socioeconomic background. As can be seen from the following tables

the overwhelming reason to abandon bulk billing as stated by those surveyed was the

inadequacy of the rebate. Although other reasons stated including ‘workload’ and ‘lack

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of support facilities’ could be interpreted as pertaining to the reduction in the GP

workforce the research concluded that:

It appears that GPs in the Yarra Ranges are finding it tough to provide affordable (that

is, free) health care. With increases in practice costs combined with an inadequate

rebate and the associated difficulties of practicing in a low socioeconomic area, GPs are

discovering that no alternative exists to either deserting the area or changing their

pricing structures to survive. 5

Source: Ronald Henderson Research Foundation (2003) The Accessibility of Bulk Billing Practitioners to

People with a low Socioeconomic Status, A Report for the Royal Distict Nursing Services et al.

4.8 While it is important to acknowledge that the major limitation of this analysis is

that it is not a random sample, it is argued that ‘this analysis did obtain reasonable

152


response rates, 35% of practices and 21%, given that they are an over surveyed group,

which provides some scope to infer the trends and beliefs of the group in a reasonably

accurate manner.’ 6

The Scheduled Fee and Medical Workforce Numbers 4.9 Debate about the decline in the proportion of Medicare services bulk billed has

seen a difference of emphasis between the Federal government and the AMA.

4.10 The AMA argues that because the Scheduled fee has not kept pace with either the

cost of running a practice or the Consumer Price Index, rates of bulk billing are declining

as doctors increasingly charge above the rebate level.7 Consequently, the AMA claims

that an increase in the Scheduled fee in line with the CPI would improve bulk billing

rates.8

4.11 In addition to pointing to the failure of the Medicare rebate to keep up with

inflation, the AMA has increasingly lobbied the Federal government to act on the findings

of the Relative Value Study of the General Medical Services Table of the Medicare

Benefits Schedule (RVS). The RVS was a review carried out by the Department of Health

and Ageing and the AMA that focused to a large extent on increasing compliance with

the Medicare Scheduled fee. The AMA claims that the RVS indicates that the Scheduled

fee for GP services should be increased by approximately 50 per cent and that

implementation of the study is necessary for the long-term survival of Medicare.9

4.12 The Federal government offers a different explanation to that of the AMA,

arguing that rather than being driven by inadequate rebates and high practice costs,

declining bulk billing rates and growing out of pocket expenses are the result of the size

and location of the medical workforce.10

4.13 Arguing that there is currently a geographical misdistribution of doctors, the

Commonwealth views below average bulk billing rates as an indicator of an under supply

of doctors in a geographical area and there is evidence to suggest that this is the case.11

An oversupply of practitioners can drive prices down to the Medicare rebate, increasing

bulk billing rates.12 Conversely, the AMA has argued that there is a general shortage of

doctors, at least partly due to inadequate remuneration.13

4.14 Evidence presented to the Committee suggests that both of these factors operate

coincidentally:

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So we hypothesise that the cause of the decline in attendances is related to two things.

One is the affordability of GPs and the second one is the lack of availability of GPs. It

is obviously extremely difficult to go to a GP if GPs are not available in that particular

town.14

4.15 While most divisions of general practice with whom the Committee met conceded

that the disparity between the scheduled rate and the AMA estimate was a determinant in

the decision to abandon bulk billing:

I think the big trigger that I have seen for the fall off — the decrease in the percentage

of services that are bulk-billed — was when the relative value study was released by the

college of general practitioners, which was about five years ago, and then subsequently

ignored by the federal government. I do not think doctors ignored it; I think they looked

at the outcome, which said that the average consultation should be worth about $45 —

five years ago — and said, ‘That is not what I am getting’. It was probably about $21

then. The inclination to undervalue ourselves decreased; it was basically as simple as

that. Doctors saw themselves as worth more per consultation, especially when

compared to other professionals15

The lack of GP numbers in some areas was seen to put pressure on the quality of service

delivery and an incentive to limit the number of consultations to maintain the standard of

care.16

4.16 Not all research points to a strong relationship between the supply of doctors, bulk

billing rates and higher patient costs.17 The market for GP services is complex and

distorted by a number of factors, including the existence of bulk billing and the fact that

GPs can generate demand for their services. Fee setting is not simply a product of supply

of GPs. Interestingly, there is some evidence to suggest that an increase in the supply of

doctors can lead to both increases in out of pocket expenses for patients and an increase in

the rate of bulk billing. 18

4.17 This research, noting the complexity of the market for GP services, tentatively

concludes that: ‘… an increase in the doctor supply does not reduce fees; that it increases

extra billing but promotes a compensating increase in bulk billing.’19

4.18 Both the AMA and the Federal Government recognise that the market for GP

services is complex. However, there continues to be contention over the most effective

means of influencing it. This disagreement about the primary cause of the decline in bulk

billing has meant that the AMA has focused on lobbying government for an increase in

the Scheduled fee and the implementation of the RVS. In contrast, the Commonwealth

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policy focus has been on encouraging the redistribution of doctors (particularly to rural

and outer metropolitan areas) through incentive payments and other schemes.

Containment of Cost 4.19 It has been argued that the failure to adequately reimburse doctors is an indication

that the Commonwealth is undermining Medicare as a universal system, while publicly

maintaining that Medicare has the government's full support.20 It is important to note that

a decline in bulk billing does not necessarily lead to a significant decline in the cost to

government of Medicare.21 If a doctor does not bulk bill the Commonwealth, patients can

claim the Medicare rebate back from Medicare. Figures have shown that in the 2001-

2002 period the overall number of services for which Medicare benefits were paid rose by

3.2 per cent and the amount of benefits paid increased by 6.9 per cent.22 Consequently,

although the Commonwealth has not increased the Scheduled fee for Medicare services,

the cost of the MBS is continuing to increase as more services are provided. In the year

ending June 2002, the Commonwealth paid approximately $7.8 billion in Medicare

benefits compared to $7.3 billion in 2000-2001. 23

4.21 It has been argued that regardless of whether the Commonwealth increases the

Scheduled fee for GPs or not, it is likely that the cost of financing the MBS will continue

to increase.24 However, by deciding not to increase the Schedule fee, the Federal

Government is containing the growth in costs. The point that increases in out of pocket

expenses for patients diminish the universal access to medical care that is at the heart of

Medicare is one that is argued by a wide range of commentators and stakeholders. This

argument is based on the understanding that the decline in bulk billing is most likely to

impact on the medical care available to those least able to afford an up front fee.25

Compliance Costs 4.22 The AMA and individual doctors have often pointed to the compliance and

running costs involved in bulk billing patients as being another reason that GPs are

deserting bulk billing.26

Although the impact of compliance costs on participation in bulk billing is unclear, a

recent survey of doctors commissioned by Australian Doctor found that GPs spend

approximately seven hours a week completing paperwork generated by participation in

Commonwealth and State government programs.27 The Federal government has recently

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commissioned a study to examine GP compliance costs associated with Commonwealth

Programs.28

Recommendation 5: That the Commonwealth Government simplify

processes around Medicare Programs to increase access and decrease

administrative costs for General Practitioners and consumers.

Corporatisation 4.23 There is some anecdotal evidence that some larger GP management companies

oppose bulk-billing, and that in some location doctors may decide as a group not to bulk

bill.29 There are several different models of general practice corporatisation, however, the

models that have received the most attention are those defined as 'vertically integrated'. 30

4.24 Vertical integration within medical practice is characterised by the co-location and

management of a number of different medical services, including for instance, general

practitioners, pathology services and diagnostic imaging. Vertically integrated medical

services are often owned by large corporations and the range of different medical services

are provided under one corporate umbrella. Inter-referrals (between co-located services)

are another feature of vertically integrated medical services. Of particular concern to the

AMA is that this form of corporatisation usually generates profits for third parties, such

as shareholders, rather than to the actual providers of the medical services.31

4.25 The AMA has argued that increasing corporatisation of general practice is to some

extent a result of the Medicare rebate for GPs not keeping pace with inflation.32 However,

there have been suggestions that the corporatisation of general practice may have some

impact on bulk billing rates. Some of the larger GP management companies, such as

Endeavour Health Care and Foundation Health, actively oppose bulk billing and GPs

working for them are being encouraged not to bulk bill.33

Anti-Competitive Practices 4.26 There has been anecdotal evidence to suggest that in some geographical areas

doctors are deciding, as a group of practitioners, not to bulk bill certain or all patients.

Under the Australian Constitution the Commonwealth cannot coerce or force doctors to

bulk bill patients. However, the Australian Competition and Consumer Commission

(ACCC) has raised some serious questions about collusion between doctors, price setting

and primary boycotts.34

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Impact on Health Outcomes 4.27 The increase in the out of pocket expenses for medical services provided by GPs

has begun to cause concern over the likely impact this may have on the health of

individuals.35

4.28 Since 1996, a particular focus of Commonwealth health policy has been on

developing an integrated primary health care system that addresses chronic disease

management.36 A significant role for GPs has been established in the management of

diabetes and asthma, immunisation programs, mental health and health screening. It is

foreseeable, although not yet substantiated, that recent gains in primary health care will

be unsustainable in the face of declining bulk billing rates and higher out of pocket

expenses for patients with complex needs.37

GP Costs 4.29 As has been examined in this chapter, the supply of GPs in Australia in general

and Victoria in particular is decreasing. This lack of price depressing competition,

coupled with the increasing costs of running a business and the level of the Medicare

rebate are significantly reducing the incidence of consultations that are bulk billed. Whilst

the impact of a reduction in competition has been discussed, rising practice costs remain

an unavoidable problem facing GPs and contribute to the increasing costs faced by

patients.

All those things tend to mitigate against the doctors being able to provide services that

are effectively free of charge. We have to provide premises, we have to provide staff,

we have to provide adequate communication. If there is an after-hours call and a female

practitioner is on call, in a lot of instances security has been provided for that as well.38

4.30 Research has suggested that whilst the real value of the Medicare rebate has

generally risen more than the CPI39 since 1984,40 it is not a good indicator of the

increasing pressures that doctors are facing, noting that “staff expenses are significant,

and in a period of rising real incomes, salaries have risen more than prices generally.”

Additionally, the cost of medical supplies, often imported, have increased by more than

the price level”. The threat of litigation is also having a significant impact on the cost of

lioability insurance and hence take home incomes.

4.31 Medical practices and GPs are subject to stringent codes of conduct and often

incur severe pecuniary penalties in the courts for malpractice. As such, indemnity

insurance premiums have increased considerably in recent years41 and have further

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exacerbated the costs problem facing GPs. One respondent in the Yarra Valley survey

quantified their cost problem stating, “our practice overheads are about $30,000 per

month to survive reasonably we rely on income from employee/sessional doctors”.42 4.32

These costs are higher than those generated by the Relative Value Study,

conducted by the Government and the medical community to determine the value of a GP

consultation, which attempted to “develop fair and reasonable estimates of practice

costs”43 and reported that costs for a sole doctor practice can be as high as $127,330 per

annum.

4.33 The pecuniary costs that GPs face, in addition to the supplementary non-pecuniary

costs of being overworked, having few support services, etc., are particularly notable in

areas characterised by a low socioeconomic status on the urban fringe. These areas suffer

from a disproportionately low supply of doctors for their share of the population (7.6% of

the population, 7.19% of the GPs Australia wide).

4.34 This is creating additional hardships for GPs in these regions as stated by Access

Economics:

Despite the growing shortages of GPs in socioeconomically disadvantaged areas, bulk

billing rates remain high. This is most notable for GPs working in outer urban areas

with a low SEIFA44 who are under constant pressure to make ends meet – bulk billing

(as it currently stands) jeopardises their ability to provide quality of care to patients, but

because of entrenched patient expectations there is often little or no pricing option.

They lose heart, leave and are often not replaced.45

4.35 Moreover, they noted that many doctors were:

moving to a location in a higher SEIFA area where they feel comfortable about private

billing and which is worth the change in terms of ability to practice quality care and

maintain self esteem. 46

4.36 Financial viability depends on incomes and practice costs. On the basis of

numerous submissions and hearings attended by interested parties, the Senate Select

Committee on Medicare concluded in its first report47 that GPs still earn incomes well

above average weekly ordinary time earnings, but that real incomes for GPs who bulk-bill

all patients would have fallen over the past ten years. For GPs who also receive out-of-

pocket charges, the trend is not clear, given the significant increase in out-of-pocket

charges. The Senate Committee highlights the strongly held perception among GPs that

their incomes have fallen relative to both specialists and other professionals.

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4.37 The Committee was advised that practice costs have increased in recent years but

was given no evidence that the rate of increase was faster than that in the CPI. In rural

areas, higher practice costs appeared to be balanced by higher incomes. Doctors

emphasised the high compliance costs of administering blended payments such as the

Practice Incentive Payments and the EPC schemes.

Recommendation 6 : That the State and Commonwealth Governments

examine the opportunity for microeconomic reforms in the health

sector to reduce General Practitioners surgery costs, allowing doctors

to set a lower price while satisfying their target incomes.

Conclusion 4.38 Because of its centrality in the national health insurance system any decline in

bulk billing rates provokes a significant amount of interest. While the AMA maintains

that the decline has been caused by a failure to increase the Schedule fee, other features of

the Australian health system may also be contributing, including compliance costs and

pressures resulting from the corporatisation of general practice. The Federal government

has placed emphasis for the decline on the supply and distribution of the medical

workforce and has concentrated its policy efforts on encouraging doctors to work in areas

where there is an under supply.

4.39 Outcomes of the decline in bulk billing include an increase in the direct cost of

health care for patients and possible cost shifting to the States. There is also a possibility

that some of the recent gains in primary care will be eroded.

The Decline in After hours General Practitioners 4.40 Commonly stated reasons for the existing lack of out of hours GP services are:

• A shortage of General Practitioners

• Changes in workforce composition

• Reduced Access to General Practitioners

• Lifestyle changes within General Practice

• Financial viability of out of hours practice

• Issues around security and isolation for GPs working out of hours.

4.41 Despite extensive debate and analysis of these issues at the national level in the

course of consideration of the A Fairer Medicare/MedicarePlus (most recently labelled as

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Strengthening Medicare) packages by the Senate Select Committee on Medicare, the

relative contribution of these different factors to the trends remains unclear.48

4.42 Although the causes of the decline in these services are difficult to isolate, it can

be inferred from evidence to the Committee that in general the changing attitude of

practitioners to working long hours would be a significant factor.49 Long hours (including

time spent after hours) are frequently cited as a disincentive to undertake general practice,

and the Department of Health and Ageing has recorded a decline in the average number

of hours worked by doctors from 48.2 to 45.5 hours per week.50 4.43 It is further

argued, in the context of home and nursing home visits, that the rebate does not cover the

costs of taking time away from normal practice, and that unless this is remedied, GPs will

have increasing difficulty in providing out of hours bulk-billed services.51

Workforce Size and Composition 4.44 It has been widely acknowledged that there is a shortage in the supply of GPs in

regions of Australia.52 It has been argued that a primary reason for this shortage53 were

the government policies of the mid 1990’s designed to limit GP numbers. These included

measures to restrict the number of publicly funded university medical school places and

training places, in addition to tight restrictions on the entry of overseas trained doctors,

and the requirement that GPs and newly qualified doctors undertake additional training to

become Vocationally Registered (VRGP) to receive Medicare Rebates.54 These policies,

coupled with the growing inadequacy of the Rebate have served to “discourage

participation in general practice by both new graduates and existing practitioners”. 55

4.45 Compounding this is the observation that there are “too few graduates from

medical schools in Australia”56 and the fact that the incumbent GP population is ageing

and shrinking due to natural attrition. Access Economics attempted to quantify the

shortage in 2001 stating that the number of GPs in Australia was suboptimal by 1,200 to

2,000 and has contributed largely to the observed fall in their accessibility.57

4.46 The table and graph below illustrate the growing paucity of GPs in Victoria. The

total number of GPs billing Medicare fell by 177 or 2.91% from 1996-97 to 2001-02.

This reflects and magnifies the overall downward trend in Australia over the same period

(0.89%). Whilst Full Time Workload Equivalent (FEW)58 GPs increased over the

timeframe (indicating that the remaining GPs were working longer hours), both the total

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amount of GPs per 100,000 population and the FWE per 100,000 population fell (8.49%)

and (4.39%) respectively, again reflecting the Australian trend (6.80% and 3.52%).

Senate Committee p31 (taken from: Report on Government Services 2003, Productivity Commission, February 2002, Table 10A.9, www.pc.gov.au/gsp/2003

Source: Ronald Henderson Research Foundation

Australian Institute for Primary Care (APIC) also noted that whilst there is an overall

decline in the numbers of practicing doctors there is also significant geographic variation

in their supply.59 They note that there exists a “relatively high availability of GP services

per capita in metropolitan capital city centres”, whilst there is a “relatively more limited


161

http://www.pc.gov.au/gsp/2003


availability in rural and remote areas”. This finding, substantiated by the relative average

bulk billing rates of the metropolitan (approx 76%) compared to non metropolitan areas

(approx 55%).60


4.47 The table above illustrates the geographical disparity in GP supplies, showing the

relative undersupply in non capital city areas compared with the relative oversupply in

capital cities. For instance, despite the fact that around 37% of the population live in non

capital cities, only 30% of all General Practitioners are located there, the converse is true

for capital cities with 70% of GPs servicing only 64% of the population.

The number of practising GPs in Victoria has been in steady decline since the mid 1990s,

as shown in following table.

Number FWE* per 100,000 persons

Annual % change

1996-97 6,064 88.8

1997-98 5,952 86.7 -2.4

1998-99 5,917 86.4 -0.3

1999-00 5,906 86.5 0.1

2000-01 5,881 85.0 -1.7

2001-02 5,887 84.9 -0.1

2002-03 5,878 83.7 -1.4 Number of GPs, Victoria, 1996-97 – 2002-03

Source: DHS Submission

4.48 The main characteristics of Victoria’s primary care practitioner (PCP) workforce

and recent trends are shown in the table below (this table is based on a different data

source from that used for the previous table, and the figures for primary care practitioners

from the AIHW data collection are different from those for GPs in the Medicare statistics

data collection by Department of Health and Ageing).

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1996 2001

Male Female Male Female

Number 3,259 1,542 3,628 1,984

Proportion (%) 67.9% 32.1% 64.6% 35.4%

Mean age (years) 47.8 40.7 50.9 44.6

Mean hours worked 49.1 34.2 45.3 33.1

Selected Characteristics of primary care practitioners, Victoria, 1996 and 2001

Source: AIHW, Medical Labour Force Survey, 1996 and 2001

4.49 About one third of the workforce is female, and that proportion is increasing. The

availability of female GPs is an important element in overall access to GP services, so

that the rising trend is a welcome development in that it enhances the accessibility of

primary care for women.

4.50 The workforce is ageing, although the mean age of female PCPs is lower than that

of male PCPs, reflecting the relatively recent (dating from the mid 1980s) strong increase

in female undergraduate enrolments in medical schools. However, the mean hours

worked by female PCPs are significantly lower than those worked by male doctors,

suggesting that many female PCPs work part-time, and mean hours worked for both male

and female PCPs are declining.

Areas of workforce shortage 4.51 The Department of Health and Ageing defines areas of workforce shortage as

follows:

Districts of workforce shortage are those in which communities are considered to have

less access to medical professional services than that experienced by the population in

general, either because of lack of the remote nature of the community or because of

lack of supply of services or a combination of the two factors. Districts are determined

by reference to geographic areas (metropolitan or rural) immediately surrounding

specific practice locations. Areas considered will vary depending on the type of

practice to be engage in……….For example, a ’district’ considered in relation to

…….work as a general practitioner, would be the surrounding postcodes that make up a

shire or local district or a division of general practice. To determine whether workforce

shortage exist in districts, a delegate will examine material relevant to the population

need for professional services….To assist in the understanding of the population needs

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of the particular district, the decision-maker may seek specific information from

authorities such as State Health Departments and Rural Workforce Agencies, examine

Medicare statistics and other relevant health workforce data…..examine the numbers of

other medical practitioners in the district with the same or similar skills.61

4.52 Of particular interest in the context of GP shortages is one factor contributing to

the increasing drift of primary care type patients away from GPs and to public hospital

EDs in outer metropolitan Melbourne is the delineation by Department of Health and

Ageing of areas of workforce shortage in Melbourne, as shown in the following chart.

Areas of workforce shortage, Melbourne

Source: Department of Health and Ageing (http://www.health.gov.au/workforce/new/new/files/maps/melbourne.pdf) accessed February 2004

4.53 While there appears to be a broad relationship between shortages of GPs and the

decline in access to after hours service the relationship is not straightforward, and local

factors are often of significance.

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http://www.health.gov.au/workforce/new/new/files/maps/melbourne.pdf


The causes of reduced access In addition to the reasons stated previously the Senate Select Committee on Medicare

identified a number of other causes for reduced access to General Practitioners.

The falling participation rate and the changing GP demographic 4.54 It can be inferred that the declining trend in the number of medical graduates

choosing to enter general practice is contributing to the overall shortage of GPs. From the

evidence put before the Senate Committee, the causes of this reduced popularity include a

decrease in recruitment to general practice at one end, and a departure of established

practitioners at the other.62

4.55 There are approximately 24,000 GPs in Australia, equating to around 16,700 full-

time equivalent (FTE) practitioners. The number of FTE providers is falling63 in line with

the retirement of older male GPs who tend on average to work more hours than younger

entrants to the profession, particularly women. It is in the context of the average GP

working fewer hours that the workforce shortage is said to have arisen.64

4.56 It has also been reported that one in six GPs (about 16 percent) in Australia were

actually employed in non-medical activities, exerting major downward pressure on the

participation rate. 65 According to evidence put to the Senate Committee the dominant

reason expressed for choosing to abandon general practice is the falling real value of the

sheduled fee.66 However, Australian Institute of Health and Welfare data indicates that

the participation rate is at a relatively high level, with about 92.5 percent of registered

medical practitioners in Australia part of the medical labour force, and about 60 percent

of the remainder being retired.67

4.57 The Senate Committee heard evidence from a number of respondents commenting

on the desirability of a balance between the personal and professional. This has also been

influenced by the growth in the proportion of women in the GP workforce, and the impact

of that change in profile on the supply of GP services.68

4.58 It is expected that the trend towards a higher number of female doctors will

continue as a predominantly male cohort of older doctors is replaced by a cohort of

younger doctors that is at least 50 percent female in any one year. A supply projection

analysis of the GP workforce has assumed that there will be an increase in the proportion

of female GPs from 35 percent to around 41 percent by 2010 and a decline in absolute

numbers of the male workforce.69

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4.59 There is also a difference in the type and number of patients treated between male

and female GPs:

Most notably [men and women] have different levels and types of being less

likely to work in rural and remote areas, and being more likely to choose primary care

over another type of specialist practice.70

4.60 This combination of factors inevitably results in the average doctor working fewer

hours, and it was pointed out to the Senate Committee that, for every GP who drops their

working hours by two hours per week, the equivalent of 1,000 FTE GPs is taken offline.71

4.61 Pending an increased output from medical schools to bolster the participation rate,

it has been submitted that more overseas-trained doctors need to be brought online.72

4.62 There were also reports of overseas-trained doctors residing in Australia who were

yet to interact with the Australian medical sector. It has been suggested that this may be

the result of a system of assessing immigration visa applications which looks less

favourably on those professing medical training. 73 This is discussed further, later in the

chapter

The variation in the number of practitioners between regions 4.63 As stated previously in this chapter, there is a significant variation in the number

of practitioners between regions. The GP Workforce report of 2001 provides the

following summary of issues affecting workforce supply in rural and remote areas:

• Work intensity. The survey revealed that GPs in rural and remote areas perceive

huge disadvantages in country practice through long hours, being on-call, lack of

holidays (due to a scarcity of locums), and after-hours work. They also report a

higher level of diversity and skills challenge in these practices, as well as severely

limited hospital, specialist, allied health, technological, professional and personal

support. 74

• Family conflicts and costs. The difficulties in managing a partner’s career,

children’s schooling, and a lack of family support all feature prominently.

Separation from extended family and friends can be a particular problem for

young or single practitioners. 75

• Business difficulties. The difficulty in securing business partners, running a small

business, the cost of travelling for training, and higher practice costs in some

cases, all auger poorly for retention of contented practitioners in rural areas. 76

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• Lifestyle and other factors. Social isolation, a lack of diversity, and a lack of

anonymity (particularly for minorities) are all perceived as part of rural practice

for many of those surveyed. There are also widespread concerns around

availability of childcare, higher community expectations, and the difficulty of

working part-time.77

4.64 It should also be noted that this misdistribution has a particular effect on

Indigenous Australians, who comprise 13 percent of the rural population, and 26 percent

of the remote population, despite comprising only 2.1 percent of the overall

population.78

4.65 An adequate response to the misdistribution involves more than simply moving

doctors to areas of need. It is clear that any solution must incorporate strategies for both

short- and long-term sustainability of a suitably sized medical workforce.

The increase in GP attendances 4.66 Despite the doctor shortage, there has been an ongoing increase in the number of

GP consultations either partly or fully charged to Medicare over recent decades.

The number of GP attendances rose from 64.8 million in 1984/85 to 99.9 million in

2001/02. The growth in GP services slowed in recent years, and in 2002/03 fell to 96.9

million, in line with the increasing shortage of GPs and increase in out-of-pocket patient

contributions.79

4.67 It should be noted that total services partly or fully charged to Medicare rose from

113 million to 221.4 million from 1984/85 to 2002/03,80 indicating that while GP services

account for the single largest block of MBS claims, there has been a steadier and more

sustained increase in MBS claiming for the broad range of items contained within the

Schedule. On a per capita basis, in 1984/85, an average of 7.2 Medicare services were

dispensed, compared with 11.1 in 2002/03.

An increase in consumer expectations 4.68 Consumer expectation of health professionals is higher than ever before.81

Previously, injuries or disease as a result of the ageing process were largely accepted and

managed. The trend now is to seek treatments or procedures to heal ailments and

illnesses that were previously not detectable or not treatable. This inevitably has an effect

on utilisation of diagnostic services, as well as procedures and medications.

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4.69 There are also changes in patients. expectations of ease and convenience in their

access to medical services. Against a background of ease and speed in accessing services

in other areas of their lives, patients expect that access to medical services and advice will

be equally simple and convenient.

More chronic disease and a move into community-based care 4.70 With an ageing population, Australia now faces a recognisable increase in chronic

disease prevalence. Since 1984, the number of people who are living to the age of 85 or

older has more than doubled bringing with it a larger burden on health systems. 82 Much

of this treatment happens outside the hospital setting, adding particular stress to the

primary care sector.83

4.71 In addition to chronic-care management, other services provided outside the

hospital setting have also increased in the last two decades, driven somewhat by technical

innovation. These services have been funded by a combination of patient and MBS

contributions. They tend to be supplied by practitioners in private practice, who can set

their own fees, and whose patients face an increased possibility of incurring gap charges.

It should be noted that it is not simply GP services which are growing. Non-GP services

are also contributing to out-of-pocket expenses. These changes in how and where people

tend to be treated are placing a growing burden on community GP capacity.

A move towards prevention 4.72 There has been increasing focus by government and health sectors on the

importance of prevention as a long-term investment in good health care:84 GPs are often

the first port of call for people seeking information about their health and are ideally

placed to offer advice and assist people to achieve a healthy balance in their lifestyles.85

This has resulted in an increased demand for GP services, on an absolute and per capita

basis, over the longer term. Most recently, there has been a marked increase in the

number of long (level C and D) consultations, co-incident with the small decline in level

A and B services. Ithas been argued that while preventive health measures can initially

be expensive in terms of practitioner time, they prove an important and effective

investment in the long term.86

Over-servicing 4.73 While it is argued that over-servicing is a minor and largely insignificant problem,

patient driven over-servicing is an issue for some GPs, and provides an ongoing challenge

in containing visits only to those medically necessary. Any move to reduce unnecessary

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demand carries inherent problems. Demand may include inappropriate consultations and

under and over-utilisation. It is not a simple to define inappropriate. One approach is

medical necessity. There has been a lot of research conducted, for example, seeking to

establish the appropriate frequency of Pap smears for women of various ages.87 It is quite

well documented that men tend to be poor custodians of their own health, under-utilising

GP services and not always admitting to symptoms. Some patients may access GP

services more often than might be predicted on the basis of physical indications, but may

need to do so for mental health reasons.88

Federal Initiatives to address the problems 4.74 The federal government has over the past ten years or more instituted an array of

initiatives aimed at encouraging GPs to provide a broader range of services more closely

integrated with other health services. It has funded the establishment of divisions of

general practice, and practice incentive payments, and introduced new MBS items. Its

most recent initiatives have been packaged under the label of A Fairer Medicare in 2003

and MedicarePlus and Strengthening Medicare in 2004.

A Fairer Medicare/Medicare Plus/Strengthening Medicare 4.75 The package entitled A Fairer Medicare, announced in April 2003, was costed at

$918m over four years, equivalent to the reduction in the amount included in the budget

forward estimates in the 2003-04 federal budget for the Commonwealth’s contribution to

funding of public hospitals under the Australian Health Care Agreement 2003-08.

Following public debate and consideration by a Senate Select Committee on Medicare, an

expanded package entitled Medicare Plus and costed at $2.4b was announced in October

2003, and a further version was announced in March 2004. The main components of the

package (with costings in brackets) are as follows:

MedicarePlus Safety Net ($440.3 million) 4.76 For families receiving the Family Tax Benefit (A) and Commonwealth

Concession Card holders, MedicarePlus will reimburse 80 per cent of co-payments for

services provided outside a hospital, once a $300 threshold has been reached. The

threshold has been set at $700 for all other individuals and families. Services covered

include GP and specialist consultations, blood tests, psychiatry, X-rays, pap smears and

blood tests. Costs incurred from 1 January 2004 will be included in the safety net

calculation. The federal government estimates that 7 per cent of all individuals and

families will benefit annually (450,000 claimants per year).

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Bulk Billing Incentive ($1087.9 million) 4.77 New MBS items were created for GPs in regional, rural and remote Australia and

all of Tasmania. An incentive payment of $7.50 per consultation will be paid for

providing bulk-billed services for concession cardholders and children under 16 years.

Benefits became available from 1 May 2004, and the federal government expects that an

additional 1.8 million services will be bulk billed a year. Some 22 per cent of all GPs

deliver services in regional, rural and remote Australia (within RRMA classifications 3-

7).

Rural, Remote and Metropolitan Areas (RRMA) Classification (within existing funding) 4.78 This initiative is aimed to extend GP workforce programs and the rural locum

scheme to “areas of consideration” which are rural in nature but are in the same Statistical

Local Area (SLA) as a larger town. The areas of consideration will be determined by

assessing regions where the inclusion of parts of a large town in the SLA has over

represented the access to essential services for those in smaller towns caught in the SLA.

In addition to availability of services, doctor/population ratios will also be taken into

account.

Allied Health/Dental Services (new funding $121.2 million) 4.79 A new MBS item is created for allied health professional services delivered for

and on behalf of GPs under a Multidisciplinary Care Plan (MCP). Since 1999, the EPC

Program has allowed GPs to involve at least two allied health professionals in developing

MCPs for patients suffering chronic/complex conditions. The new MBS item will cover

up to five allied health consultations delivered under a MCP, $80 initially and $35

subsequently. The Commonwealth estimates that 460,000 care plans will be covered by

the new item, or 150,000 per year to 2006-07.

4.80 A new MBS item will also be introduced to support access to dental services for

those patients with chronic/complex conditions that relate to their illness and is at risk of

contributing to a further deterioration in health. The Commonwealth estimates that

69,000 dental care plans will be covered. Benefits are available from 1 July 2004.

Overall, the Commonwealth estimates that this initiative will support 680,000 allied

health consultations a year.

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4.81 Victoria is requesting that the allied health and dental rebates for people with

chronic and complex conditions be available where GPs refer clients to (state-funded)

community health services.

Medical School Places ($43.2 million) 4.82 In addition to the 234 medical school places announced in the previous

MedicarePlus proposal of November 2003, 12 additional places will be provided at

Queensland’s James Cook University, bringing the total to 246 places. Places are fully

funded at $21,000 annually. This measure commences in the 2005 academic year. The

extra places in Queensland are to address workforce shortages in servicing small

populations spread over large geographic areas, with high concentrations of aboriginal

people.

Expanding Health Connect/MediConnect ($80 million already in forward estimates) 4.83 Through State Governments, the Commonwealth will commence implementation

of the HealthConnect integrated medical records system in Tasmania and South Australia

from 1 July 2004. An integrated health record system aims to decrease medical mistakes

and reduce duplication.

HIC Online/New Technology Initiative ($29.8 million) 4.84 This is intended to enable Medicare rebates to be deposited into patients’ bank

accounts directly. To fund set up costs, metropolitan practices will receive $750 and rural

practices $1000. Funding will be provided for grants for GPs to commence claiming

through HIC online ($16.0m), improving broadband internet access for practices in

rural/remote areas ($9.2m), and for GP business practice assessment ($4.6m).

Aged Care Initiative ($47.9 million* part of direct costs below) 4.85 New Medicare item created for GPs who provide comprehensive medical

assessments for new and existing aged care residents (rebate of around $140). Up to

$8000 is available to GPs who provides services for aged care residents who do not have

a regular doctor, including after hours and emergency, and participates with the home in

quality improvement.

Workforce related initiatives ($1,035 million, comprising direct costs $615.8 million, and

flow on costs to Medicare $466.9 million)

4.86 Briefly summarised these initiatives include:

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• $139.1 million (including $37.1m flow on costs to Medicare), to enable up to 800

general practices in urban areas of workforce shortage to receive assistance in

employing a nurse to work in their practice, with up to an additional 457 full time

equivalent nurses funded. A new MBS item is created for specified services that

can be provided by a practice nurse without the supervision of a GP.

Commonwealth claims support to be given to 1600 practice nurses by 2007.

• $200.6m to increase the number of GP registrar training places by 150 places each

year from 2004 onwards, with places targeted to areas of workforce shortage.

Additional supervisors and increased payments for the Australian General Practice

Training Program.

• $70.3m (including $16.9m flow on costs to Medicare) for 280 fully funded short

term supervised placements for junior doctors in general practice (equivalent of 70

full time positions per year), for outer metropolitan, regional, rural and remote

areas.

• $432.5m (including $388.8m flow on to Medicare) to enable the recruitment and

support of 725 overseas trained doctors by 2007.

• $101.2m to support rural and remote GPs develop and maintain procedural skills.

Additional funding for GPs who provide a minimum 10 per cent of their total

MBS workload through procedural services.

• $26.8m (including $24.1m flow on to Medicare) to provide refresher training and

mentoring support for GPs and specialists re-entering the workforce. 22 Regional

Training providers to give refresher courses for GPs. An additional 80

GPs/Specialists are expected by 2007.

• $42.1m to fund an additional 234 medical school places each year from January

2004, with all the new places “bonded” to areas of workforce shortage for a

minimum of 6 years. Periods of up to three years postgraduate training

undertaken by doctors in rural areas will count towards meeting the bonding

requirement.

• $22.4m to provide higher rebates for patients of non-vocationally registered GPs

in areas of workforce shortage, who were practising before 1996. After five years

of service in an area of workforce shortage, the GP will continue to attract higher

rebates beyond the five years.

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Nursing in General Practice Program. 4.87 In its 2001-2002 Federal Budget the Commonwealth provided funding of $104.3

million over four years for incentives to encourage general practices in rural areas and

other areas of high workforce needs to employ more nurses.

The Practice Nurse Initiative has three components:

• A Practice Incentive Payment to encourage eligible practices to employ more

nurses,

• Funding for the provision of ongoing training and support for all nurses working

in general practice, and

• A Scholarship Scheme to support nurses who wish to re-enter the workforce, and

to provide funding for nurses currently employed who wish to refresh their skills.

4.88 A National Steering Committee for Nursing in General Practice has been

established to provide national leadership for the future directions in practice nursing. The

Steering Committee reports to the General Practice Partnership Advisory Council

(GPPAC) and provides advice to DoHA.

4.89 The Australian Divisions of General Practice (ADGP) has appointed a Principal

Policy Advisor for Nursing in General Practice. The role of the Principal Policy Advisor

is to provide assistance to Divisions of General Practice to support nursing in general

practice, and to provide input into future policy directions for practice nursing.

4.90 The Principal Policy Advisor also works closely with the National Steering

Committee to advance and promote the projects established by the Committee.

Recommendation 7: That the Commonwealth and State Governments,

in consultation with stakeholders, support the development of flexible

strategies to address issues of medical workforce shortage and the

decline of bulk billing. Such strategies may include:

an increase in the number of General Practitioners practising in

community health centres

the creation of co-located General Practitioner clinics at

hospitals; and

the introduction of localised telephone triage centres.

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Issues with A Fairer Medicare/Medicare Plus/Strengthening Medicare 4.91 It was intended by design that Medicare would provide universal coverage. The

provision of rebates, while maintaining the access of health care card holders, does not

address the problems of access for those who are in financial difficulty, yet are not

entitled to receive a health care card. The Committee believes that the Federal

Government should examine increasing the scheduled fee for GP consultation in line with

the review undertaken by the Australian Medical Association. This would attract more

doctors to bulk bill and would provide health care coverage to a larger section of the

community.

Recommendation 8: That in order for the Commonwealth Government

to meet the objectives of its social contract, it make a global increase in

the Medicare Schedule Fee to attract General Practitioners back to

bulk billing, ensuring all Victorians have access to an affordable

health care system.

4.92 In a number of areas, the Commonwealth has introduced modest programs to

attempt to deal with the most pressing problems in the area of primary health care. The

programs focussed on attracting doctors to rural and remote areas and from inner to outer

metropolitan areas have met with some success. While these incentives to promote

general practice in regional and rural Victoria are to be encouraged, the Committee is

concerned that the essential problem is a lack of GP numbers. Encouraging GPs to move

from one area to another simply shifts the problem without addressing the root cause.

While the net number of practicing GPs remains inadequate, increasing numbers in rural

areas will only create a decrease in suburban areas. Such incentives are also ineffective in

the short term. The Federal Government needs to increase the number of VRGP in the

short term by making practice in all areas more attractive while increasing the number of

medical school places to address the issue in the long term.

4.93 As part of the A Fairer Medicare initiative, the Commonwealth announced 234

extra medical school places, taking the total number of students commencing medical

studies in Australia in 2004 to 1704. Students who take up the new places are bonded for

six years to work in a Commonwealth defined district of workforce shortage upon

completion of basic and postgraduate medical training. The additional bonded places do

174


not attract a scholarship and a HECS fee still applies (the Commonwealth’s existing

Medical Rural Bonded (MRB) places provide 100 scholarships worth $20,000 a year for

new medical students prepared to commit to at least six years of rural practice, once they

complete their basic medical and postgraduate training).

Melbourne and Monash Universities will each receive an extra five places, a total of ten

for Victoria. Although the increase of medical school places represents an additional 16

per cent across Australia, the number of places in Victoria will only increase by less than

3 per cent.

4.94 In addition, universities have been advised by the Commonwealth that each

University will have around 20 per cent of their places bonded made up of 6 per cent

Medical Rural Bonded Scholarship places and 14 per cent being new bonded places

without a scholarship. The University of Melbourne and Monash University will be

required to set aside approximately 27 and 22 places respectively for bonded students (no

scholarship), despite being granted only an additional five places each. This effectively

represents a reduction in HECS-funded non-bonded places of 22 for the University of

Melbourne and 17 for Monash University. In total, Victoria will effectively lose about 40

HECS-funded non-bonded places through conversion to bonded places. This will drain

the supply of doctors who can work anywhere across the state (including outer

metropolitan areas) at the expense of rural areas.

4.95 While the additional places are an important step toward responding to the rapidly

growing requirement for more medical practitioners they impose some particular

disadvantages on Victoria.

4.96 It has also been argued that the small increase in places for Victoria will not

address Victoria’s growing medical workforce shortage or the widening gap between

medical school completions and vocational training intake requirements for the State

(currently 69 places).

4.97 Within the MedicarePlus package the plan to increase the number of overseas

trained doctors (OTD’S)by 725 by 2007 is welcome, there needs to be some incentive to

encourage the number of OTD’s currently not practising back in to the workforce. It has

been estimated that that there are approximately 3,000 overseas-trained doctors who are

permanent residents of Australia, who have yet to apply to have their medical

qualifications recognised in this country. While, many of those doctors will probably

175


never get their qualifications recognised, there is a group of around 1,200 doctors from

overseas who have already passed half of the examinations set by the Australian Medical

Council to determine whether these doctors are able to practice in Australia, and who are

currently preparing for the second half of their examinations. If those doctors can be fast-

tracked through the system to assist them in their preparation for clinical practice, then

they'll get out into the medical workforce quicker.89 The Committee acknowledges that

even with the increases in medical school places, there will be a gap between the places

provided and the numbers required. Although some groups have expressed concern over

the reliance on OTDs, the Committee believes they are essential to filling the gap in the

provision of health care services.

Recommendation 9: That a recruitment program be put in place to

encourage Overseas Trained Doctors currently working in other areas

back into the medical workforce.

4.98 However, to achieve long term sustainability of the health system, greater levels

of national self sufficiency in the medical workforce will need to be achieved. Action to

address the comparative disadvantage facing Victoria will not, however, address the more

serious long term problem. From 2004, Victoria has 353 medical school places

(including the additional 10 allocated through the recent Commonwealth Government

initiative). The number of vocational training places for 2004 in our public hospital

system is 434, leaving a gap of 81 medical school graduates. The Commonwealth’s

decision to allow full fee paying students to complete their internship, gain general

registration and be granted permanent residency will contribute to alleviating some of this

shortfall, but it is clearly not a medium or long term viable solution, given the size of the

shortfall.

Recommendation 10: That the Commonwealth Government re-

examine the distribution of medical school places in Victoria under A

Fairer Medicare Initiative to ensure that the overall number of

General Practitioner Places is increased to meet demand.

4.99 It is important to note that the projected gap is also expected to grow as more

specialist workforce studies are completed by the Australian Medical Workforce

176


Advisory Committee (AMWAC). It is expected that these studies will identify further

need for increases in vocational training positions and specialists. AHMAC is currently

considering AMWAC recommendations for national increases of 100 in pathology and 35

in emergency medicine and all states are currently negotiating with the Royal Australian

College of Surgeons for increases in advanced surgical training places. This also does not

take account of projected needs for general practitioners which AMWAC is investigating.

AMWAC’s general practice workforce review will provide advice on:

• general practice workforce supply and requirements;

• the structure, balance and geographic distribution of the workforce, and

• the number and distribution of vocational training places needed to meet expected

future requirements as suggested by patterns of supply, population health status,

practice developments and changing models of care.

4.100 The findings and recommendations will update those of the 2000 AMWAC

review of the workforce, and the expected completion date is October 2004.

177


178

Endnotes 1 For example Herald Sun 8 June 2004. 2 An issue related to the decline in bulk billing has been a concern over veterans access to free medical

treatment. Under the Repatriation Private Patient Scheme (RPPS), eligible war veterans are issued with a

gold card that is supposed to provide the holder with access to free medical treatment by general

practitioners and a range of specialists. This program is funded by the Department of Veterans Affairs. A

GP, who has a contract as a Local Medical Officer with the Department of Veterans Affairs, is able to claim

100% of the Medicare Scheduled fee as payment for services rendered to veterans. Those GPs who do not

have a contract with the Department of Veterans Affairs can claim 85 per cent of the Medicare Scheduled

fee for an MBS consultation with an additional 60 cents. The AMA has argued that because of inadequate

reimbursement for the extra costs associated with treating veterans, GPs are beginning to refuse to treat

under the scheme. There is currently an inter-departmental committee considering payments under the

RPPS. See Misha Schubert, 'Doctors 'dumping' vets', The Australian, 13 August 2002; Brad Crouch, 'GPs

refuse veterans' health card' Herald Sun, 4 August 2002; Fia Cumming, 'Appeal to PM on veterans' health',

Sun-Herald, 11 August 2002; AMA, 'Government goes AWOL on Veterans' Health', Media Release, 4

September 2002. 3 Mr Hobby Western Melbourne Division of General Practice, 4 Mr Hobby Western Melbourne Division of General Practice, 5 Ronald Henderson Research Foundation (2003) The Accessibility of Bulk Billing Practitioners to People

with a low Socioeconomic Status, A Report for the Royal Distict Nursing Services et al. 6 Ronald Henderson Research Foundation (2003) The Accessibility of Bulk Billing Practitioners to People

with a low Socioeconomic Status, A Report for the Royal Distict Nursing Services et al. 7 The scheduled fee is indexed to the Wage Cost Index 5 (WCI5). Formulated by the Department of Finance

and Administration, the WCI5 is a compilation of the CPI and a safety net adjustment. The WCI5 does not

usually keep pace with the CPI. Indexation to the CPI could create inflationary pressures as there is a

medical services component in the CPI. 8 Kerryn Phelps, GP bulk billing rates dive again, Press Release, 30 August 2002 9 AMA, Government's Intergenerational report on Health and Aged care, 16 April 2002. 10 Health workforce planning, Health Cover, vol. 11, no 6, 2002, pp: 19–20. 11 AMWAC, Australian Medical Workforce Benchmarks, AMWAC, North Sydney, 1996;

Monica Pflaum, The Australian Medical Workforce, Department of Health and Aged Care,Occasional

Paper No. 12, August 2001. 12 ibid, 57, see also AMWAC, op. cit. 13 Access Economics An Analysis of the Widening gap between Community Need and theAvailability of

GP Services, Canberra ACT February 2002. 14 Medicare Action Group, Public Hearings 15 Dr Conos, Inner Eastern Melbourne Division of General Practice, Public Hearings.


179

16 Dr Conos, Inner Eastern Melbourne Division of General Practice, Public Hearings. 17 Jeff Richardson, Duncan Mortimer & Stuart Peacock, 'Does an Increase in the Doctor Supply Reduce

Medical Fees? An Econometric Analysis of Medical Fees across Australia paper presented to the 24th

Australian Conference of Health Economists Sydney, 18–19 July 2002. 18 Jeff Richardson, Stuart Peacock and Duncan Mortimer Does an Increase in the Doctor Supply Reduce

Medical Fees? An Econometric Analysis of Medical Fees across Australia, Paper presented to the 24th

Australian Conference of Health Economists, July 2002.

19 Jeff Richardson, Stuart Peacock and Duncan Mortimer Does an Increase in the Doctor Supply Reduce


Australian Conference of Health Economists, July 2002, p. 1. 20 Editorial, 'Medicare needs own Medicine', Sydney Morning Herald, 06/09/02; Stephen Smith, MP

'Government Can't Escape biggest yearly bulk billing decline, Media Release 2 September 2002. 21 Of course a failure to increase the Medicare Scheduled fee does contain costs by diminishing the real cost

to government of Medicare services. 22 Medicare Statistics, June Quarter 2002, Released 30 August 2002, p. 4. 23 Medicare Statistics, June Quarter 2002, Released 30 August 2002, p. 4. 24 Senate Select Committee on Medicare

http://www.aph.gov.au/senate/committee/medicare_ctte/report/index.htm 25 Jeff Richardson, Stuart Peacock and Duncan Mortimer Does an Increase in the Doctor Supply Reduce


Australian Conference of Health Economists, July 2002, p. 1. 26AMA, The Review of Red Tape in General Practice, August 2002. 27 Cresswell, A, 'A day a week for government forms', Australian Doctor, 12 April 2002, pp. 1–2. 28 The study was commissioned by Treasury and the Department of Health and Ageing and is being

conducted by the Productivity Commission. The Commission is due to report it's findings in February 2003. 29 Parliamentary Library, Current Issues Brief No 3 2002-03, “Decline in Bulk Billing: Explanations and

implications”, www.aph.gov.au/library/pubs/CIB/2002-03/03cib03.pdf 30 Parliamentary Library, Current Issues Brief No 3 2002-03, “Decline in Bulk Billing: Explanations and

implications”, www.aph.gov.au/library/pubs/CIB/2002-03/03cib03.pdf 31 AMA General Practice Department, 'General Practice Corporatisation', September 2000, p. 1. 32 AMA General Practice Department, 'General Practice Corporatisation', September 2000, p. 1. 33 Nicola Ballenden, 'Doctors in the House', Consuming Interest, no. 91, Autumn 2002,pp. 18–19. 34 Sam DiScerni, The ACCC and competition in health, ACCC Journal, no. 35, July/August 2001, pp. 1–7;

Alan Fels Efficiency in delivering health care: The professions, competition and the ACCC, Healthcover,

vol. 11, no. 6, Dec 2001/Jan 2002, pp. 28–33. 35 Parliamentary Library, Current Issues Brief No 3 2002-03, “Decline in Bulk Billing: Explanations and

implications”, www.aph.gov.au/library/pubs/CIB/2002-03/03cib03.pdf 36 Population Health Section, General Practice Branch, Department of Health and Ageing.

http://www.aph.gov.au/senate/committee/medicare_ctte/report/index.htm


180

37 Parliamentary Library, Current Issues Brief No 3 2002-03, “Decline in Bulk Billing: Explanations and

implications”, www.aph.gov.au/library/pubs/CIB/2002-03/03cib03.pdf 38Dr Hall, Otway Division of General Practitioners, Public Hearings 39 Consumer Price Index, the accepted official Treasury measure of inflation in Australia 40 Deeble, J., (1984), “Medicare: It’s Main Features” Australian Health Review, Vol 7, No1, 1984

In 1984-85, the average benefit per GP service was $12.83. In 2002-03 it was $27.45, an increase of119%.

At the same time the CPI increased by only 109%. However, between 1992 and 2001 the CPI roseby 23%

whilst the Medicare Rebate for standard GP consultations rose by 15% (NSW Submission to the Senate

Committee 2003). 41 NSW Minister for Health (2003b), “Media Release – Medical Insurance Rescue Package Unveiled” June

20 2001, http://www.health.nsw.gov.au/news/2001/June/20-6-01.html 42 Ronald Henderson Research Foundation (2003) The Accessibility of Bulk Billing Practitioners to People

with a low Socioeconomic Status, A Report for the Royal Distict Nursing Services et al. 43 Description of the Relative Value Study (www.health.gov.au/rvs/index.htm) 44 Socio-Economic Indexes For Areas 45Access Economics (2002), “An Analysis of the Widening Gap between Community Need and the

Availability of GP Services – A Report to the Australian Medical Association”, Canberra p15 46Access Economics (2002), “An Analysis of the Widening Gap between Community

Need and the Availability of GP Services – A Report to the Australian Medical

Association”, Canberra p16 47 Senate Select Committee on Medicare. “Medicare – healthcare or welfare?”, October 2003 48 The most recent and extensive discussion of various points of view is contained in the hearings of the

Senate Select Committee on Medicare, 2003 and 2004, and its two reports on the Commonwealth

Government’s initiatives, A Fairer Medicare and MedicarePlus. See

www.aph.gov.au/senate/committee/medicare_ctte/index

49 Mr Hobby Western Melbourne Division of General Practice, 50 Primary Health Care for All Australians: An Analysis of the Widening Gap between Community

Need and the Availability of GP Services, a report to the Australian Medical Association from

Access Economics Pty Ltd, February 2002, p.12. See also Department of Health and Ageing,

Submission 138, p. 10 51 Australian Divisions of General Practice, Submission 37, p. 2. Increased practice staff costs are noted as

a particular burden. 52 Senate Select Committee on Medicare

http://www.aph.gov.au/senate/committee/medicare_ctte/report/index.htm p29

Access Economics (2002), “An Analysis of the Widening Gap between Community Need and the

Availability of GP Services – A Report to the Australian Medical Association”, Canberra

Goddard Matryn (2003), “Not Just Bulk Billing”, Consuming Interest, Winter 2003

http://www.parliament.vic.gov.au/fcdc/PDF%20Files/Bulk%20Billing/www.aph.gov.au/senate/committee/medicare_ctte/index



181

53 For several years experts were informing the Government that there existed a substantial oversupply

indoctors wh en in fact there was a growing shortage. It wasn’t until the shortage became critical that the

experts revised their advice and the Government tried – belatedly – to change course

Goddard Matryn (2003), “Not Just Bulk Billing”, Consuming Interest, Winter 2003 54 Senate Select Committee on Medicare

http://www.aph.gov.au/senate/committee/medicare_ctte/report/index.htm p30 55 Senate Select Committee on Medicare

http://www.aph.gov.au/senate/committee/medicare_ctte/report/index.htm p53 56 Birrell, B., et al (2003) The Outlook for Surgical Services in Australasia, Centre for Population and

Urban Re search, Monash University, June 2003 p6) 57 Access Economics (2002), “An Analysis of the Widening Gap between Community Need and the

Availability of GP Services – A Report to the Australian Medical Association”, Canberra p9 58 Full Time Workload Equivalent (FEW) are calculated for each practitioner by dividing the practitioner’s

Medicare billing by the mean billing of the full-time practitioners for that reference period. For example, an

FEW of two indicates that the practitioner’s total billing is twice that of the mean billing of a full time

practitioner. 59 Australian Institute for Primary Care 60 Data taken from APIC 2003, p18 61 Source: www.health.gov.au/workforce/workforce/policy.htm 62 Primary Health Care for All Australians: An Analysis of the Widening Gap between Community

Need and the Availability of GP Services, Access Economics (commissioned by the AMA), February

2002, p. 12 63 Report on Government Services 2003, Productivity Commission February 2003, p. 10.6 64 Senate Select Committee on Medicare http://www.aph.gov.au/senate/committee/medicare_ctte/report/index.htm 65 Senate Select Committee on Medicare

http://www.aph.gov.au/senate/committee/medicare_ctte/report/index.htm 66 Australian Medical Association Submission 67 The Australian Medical Workforce, Occasional Papers: New Series number 12, Department of Health

and Aged Care, August 2001, p 13. It should be noted that this statistic does not account for those with

relevant medical training who are not registered to practice. 68 The Australian Medical Workforce, Occasional Papers: New Series number 12, Department of

Health and Aged Care, August 2001 As a proportion of the GP population, women increased in

proportion from 23% in 1985 to 34% in 2000 Senate Select Committee on Medicar 69 The Australian Medical Workforce, Occasional Papers: New Series number 12, Department of Health and

Aged Care, August 2001, p. 16 70 The Australian Medical Workforce, Occasional Papers: New Series number 12, Department of Health and

Aged Care, August 2001, p. 16






182

71 Senate Select Committee on Medicare

http://www.aph.gov.au/senate/committee/medicare_ctte/report/index.htm 72 Professor Michael Kidd, Royal Australian College of General Practitioners, The World Today , 19

November 2003. www.abc.net.au/world today/content/2003/s992563.htm 73 Senate Select Committee on Medicare

http://www.aph.gov.au/senate/committee/medicare_ctte/report/index.htm 74 Primary Health Care for All Australians: An Analysis of the Widening Gap between Community


Access Economics Pty Ltd, February 2002, p. 14 75 Primary Health Care for All Australians: An Analysis of the Widening Gap between Community








Access Economics Pty Ltd, February 2002, p. 14 79 Department of Health and Ageing, Medicare Statistics 1984/85 to June Quarter 2003. p. 33

(www.health.gov.au/haf/medstats/) 80 Ibid p.33. Total services include GP and special attendances, obstetrics, anaesthetics, pathology,

diagnostic imaging, operations, optometry, and other miscellaneous chargeable items. 81 Senate Select Committee on Medicare


Department of Health and Ageing, Submission 82 In 2002/03, female patients aged over 55 used an average of around 22 Medicare services per capita,

compared with an average of 13 for all age groups. Over the same period, older males consumed around

20 services on average, compared with a male population average of 9.

Department of Health and Ageing, Medicare Statistics 1984/85 to June Quarter 2003. p. 185, 86

(www.health.gov.au/haf/medstats/) 83 Britt H, Miller GC, Charles J, Valenti L, Henderson J et al. 2002, General practice activity in Australia

2001-02, AIHW, Cat. No. GEP 10. Canberra. 84 Senate Select Committee on Medicare


Department of Health and Ageing, Submission






183

85 Senate Select Committee on Medicare


Department of Health and Ageing, Submission 86 Senate Select Committee on Medicare

http://www.aph.gov.au/senate/committee/medicare_ctte/report/index.htm 87 Senate Select Committee on Medicare

http://www.aph.gov.au/senate/committee/medicare_ctte/report/index.htm 88AMA, An Analysis of the Widening Gap between Community Need and the Availability of GP Services,

Access Economics, February 2002, p. 5 89 Professor Michael Kidd, Royal Australian College of General Practitioners, The World Today , 19

November 2003. www.abc.net.au/world today/content/2003/s992563.htm




http://www.abc.net.au/world today/content/2003/s992563.htm


184

Submissions

SUBMISSIONS

Name Position Organisation

1 Bairnsdale Regional Health Service

2 Vicki Hamilton Secretary Gippsland Asbestos Related Diseases Support Inc.

3 Margaret Hordern Workforce Co-ordinator

East Gippsland Division of General Practice

4 Toni Aslett Chief Executive Officer

Latrobe Community Health

5 Barry O'Callaghan AO

Chairman Mercy Health and Aged Care Group

6 Durham Smith

7 Associate Professor

Marcus Kennedy

Director of

Emergency Services

Royal Melbourne

Hospital

8 Michael Gorey Executive Officer, Community & Health Advisory Groups

Alpine Health

9 Rod Wilson Convenor Victorian Medicare Action Group

10 Paul Woodhouse Director, Policy Development

Australian Medical Association (Victoria) Limited

11 Michael Walsh Chief Executive Bayside Health

12 Colin Smeal Senior Policy Officer, Medical Practice Department

Australian Medical Association

13 Sandra Walker Chief Executive Officer

Goulburn Valley Community Health Service

14 Miriam Manintveld Regional Youth Affairs Consultant

Batforce

15 P. M. Faulkner Secretary Department of Human Services

185


186

Witnesses

WITNESSES

14th July 2003 Dr A. McLean, Chair, Victorian Faculty, Australasian College for Emergency Medicine

28th July 2003 Dr S. Devanesen, Chief Executive;

Dr P. Bradford, Executive Director, Medical Services;

Mr D. Anderson, Executive Director, Finance;

Ms E. Wilson, Executive Director, Rosebud;

Mr B. Gardner, Director, Health Information;

Associate Professor J. Wassertheil, Clinical Director, Emergency Medicine; and

Dr S. Sdrinis, Manager, Medical Operations, Peninsula Health.

1st August 2003 Mr D. Huxley, Chief Executive Officer; and

Cr V. Knight, Board Member, Mildura Base Hospital.

Dr P. Webster, Chair; and

Mr R. Mutton, Chief Executive Officer, Mallee Division of General Practice.

Cr P. Byrne, Mayor of Rural City of Mildura

6th August 2003 Dr G. Golding, Executive Director, General Practitioners Association of Geelong

Dr J. Pascoe, Acting Director, Emergency Department; and

Dr R. Fawcett, Manager, Medical Resource Unit, Barwon Health.

Ms M. Manintveld, Regional Youth Affairs Consultant, Barwon Adolescent Task Force

Mr J. Cooke, Special Projects Manager; Colac Area Health; and

Mr R. Kennedy, Service Coordination Project Officer; Barwon Primary Care Forum.

7th August 2003 Dr G. O’Brien, Director of Medical Services;

Ms K. Sloan, Nurse Unit Manager of the Emergency Department; and

Dr S. Tsipouras, Director of Emergency Services, Southwest Healthcare.

187


Dr P. Hall; Otway Division of General Practitioners

8th August 2003 Mr A. Rowe, Chief Executive Officer;

Dr J. Cruikshank, Director Emergency Medicine; and

Mr P. Catterson, Unit Manager, Emergency Department, Ballarat Health Services.

Dr C. Millar; and

Mr U. Mantelli, Ballarat and District Division of General Practice

13th August 2003 Dr J. Ferguson, Group Medical Director, Bendigo Health Care Group

Ms N. Patterson; Chief Executive Officer, Bendigo and District Division of General Practice; and

Dr A. McCarthy , Chair, Bendigo Association of General Practitioners

Ms S. Clark, Chief Executive Officer;

Mr M. Kesper, Director; and

Mr G. Thorne, Director, Bendigo Community Health Service

14th August 2003 Dr A. Wolff, Director, Medical Services, Wimmera Health Care Group

Dr J. Jenkinson, Chair;

Dr R. Grenfell, GP Consultant;

Ms J. Measday, Senior Projects Manager; and

Ms A. McGrath, After-Hours Service Manager, West Vic Division of General Practice.

20th August 2003 Mr G. Pullen, Chief Executive Officer; and

Dr. B. Cole, Chief Medical Officer, Goulburn Valley Health.

Dr S. Adad, General Practitioner; and

Mr D. Atkinson, Clinic Coordinator, Rumbalara Aboriginal Cooperative.

Ms G. Webster, Association of Australian Rural Nurses

188

Witnesses

Dr D. Kelly, Executive Director, Goulburn Valley Division of General Practice

21st August 2003 Mr D. Dart, Chief Executive Officer; and

Dr P. Giddings, Member, Board of Management, North East Division of General Practice

Mr. L. Seys, Chief Executive Officer, Alpine Health

4th September 2003 Mr G. Gray, Chief Executive Officer ;

Dr S. Deller, Clinical Team Leader, Rehabilitation and Emergency Department ; and

Ms T. Burke, Nurse Unit Manager, Emergency Department, Bairnsdale Regional Health Service.

13th September 2003 Dr P. Sloan, Director, Care Program 1 — Medical and Allied Health, Latrobe Regional Hospital

Dr N. Steer, General Practitioner, Central West Gippsland Division of General Practice

Dr Sue Clarke, General Practitioner, Central West Gippsland Division of General Practice

Ms T. Aslett, Chief Executive Officer; and

Ms J. Edwards, Director, Primary Care Services, Latrobe Community Health Service.

15th September 2003 Professor S. B. Capp, Chief Executive;

Mr G. J. Young, Acting Director, Primary Care and Mental Health, Monash Medical Centre;

Mr J. Stanway, Director of Operations, Monash Medical Centre;

Dr P. L. Rosengarten, Director of Emergency Services, Monash Medical Centre; and

Ms M. Abbott, Director of Nursing, Dandenong Hospital, Southern Health.

13th October 2003 Mr R. Burnham, General Manager

Dr I. Carson, Executive Medical Director; and

Dr C. Winter, Emergency Department Director, Northern Hospital.

24th November 2003 Assoc. Prof. M. Kennedy, Director Emergency Services, Royal Melbourne Hospital ; and, Ms Koon, Emergency Services, Royal Melbourne Hospital .

189


19th April 2004 Mr R. Wilson, convenor, and

Mr C. Haggerty, project officer, Victorian Medicare Action Group; and

Mr T. McBride, chief executive officer, Health Issues Centre.

Dr I. Kronborg, clinical director, division service development and continuing care;

Dr S. Lew, GP liaison officer;

Dr G. Ayton, assistant director, emergency department, Sunshine Hospital ; and

Ms K. Bentley, manager, outpatient redevelopment and GP strategy, Western Health.

Mr P. Bain, chief executive officer; and

Dr M. Conway, chairman, Northern Division of General Practice.

Mr D. Hobby, executive officer; and

Dr P. W. Rankin, general practitioner, Western Melbourne Division of General Practice.

Professor J. Rasa, chief general manager, acute services;

Dr L. Hamley, chief medical officer; and

Dr D. Leach, director, emergency services, Eastern Health.

Professor. D. Young, head of department, Department of General Practice, University of Melbourne; and

Dr N. Presswell, medical director, Dianella Community Health Service

Dr J. McEncroe, board member;

Dr M.Conos, board member; and;

Dr J. Addis, board member, Inner Eastern Melbourne Division of General Practice

190

Extracts from Proceedings

EXTRACTS FROM THE PROCEEDINGS The following extracts from the Minutes of Proceedings of the Committee show Divisions

that occurred during the consideration of the draft report on Monday 30 August 2004.

Hon. David M. Davis, MLC moved that: “That the Committee take, and the Report include, further evidence as required by the Terms of Reference , on 'innovative and relevant models of care and service delivery in other Australian States and Territories, and overseas” This was seconded by Mrs Helen J. Shardey, MLA. The Committee then divided: Ayes 2 Noes 4 Hon. David M. Davis, MLC Ms Heather McTaggart, MLA

Mrs Helen J. Shardey, MLA Ms Lisa Neville, MLA

Mr Robert Smith, MLC

Mr Dale Wilson, MLA

The motion was defeated.

Hon. David M. Davis, MLC moved that: “That the Committee take, and the Report include, further evidence on the Australian Health Care Agreements (1999-2003, 2003-2008), to ensure the Committee has adequately considered this matter.” This was seconded by Mrs Helen J. Shardey, MLA. The Committee then divided: Ayes 2 Noes 4 Hon. David M. Davis, MLC Ms Heather McTaggart, MLA



Mr Dale Wilson, MLA


191

Inquiry on the Impact on the Victorian Community and Public Hospitals of the Diminishing Access to After Hours and Bulk Billing General Practitioners Hon. David M. Davis, MLC moved that: “That, pursuant to Terms of Reference 5, the Committee take, and the Report include, further evidence; particularly with regard to the review of the Hospital Demand Management Strategy and evaluation of the Hospital Admissions Risk Program.” This was seconded by Mrs Helen J. Shardey, MLA. The Committee then divided: Ayes 2 Noes 4 Hon. David M. Davis, MLC Ms Heather McTaggart, MLA



Mr Dale Wilson, MLA


Hon. David M. Davis, MLC moved that: “That the Committee take, and the Report include, further evidence with regard to Commonwealth and Victorian legislation, including discussion of the Victorian Health Act.” This was seconded by Mrs Helen J. Shardey, MLA. The Committee then divided: Ayes 2 Noes 4 Hon. David M. Davis, MLC Ms Heather McTaggart, MLA



Mr Dale Wilson, MLA


Hon. David M. Davis, MLC moved that: “That the Committee consider the Auditor-General's Report on Emergency Departments and take evidence from the Office of the Auditor-General regarding this Report.” This was seconded by Mrs Helen J. Shardey, MLA.

192


The Committee then divided: Ayes 2 Noes 4 Hon. David M. Davis, MLC Ms Heather McTaggart, MLA



Mr Dale Wilson, MLA


Hon. David M. Davis, MLC moved that: “That the Committee take evidence on the role of the Royal Children's Hospital in managing and meeting the emergency demands of Victorian children.” This was seconded by Mrs Helen J. Shardey, MLA. The Committee then divided: Ayes 2 Noes 4 Hon. David M. Davis, MLC Ms Heather McTaggart, MLA



Mr Dale Wilson, MLA


Hon. David M. Davis, MLC moved that: “That the Report present data by hospital rather than by Health Service Region.” This was seconded by Mrs Helen J. Shardey, MLA. The Committee then divided: Ayes 2 Noes 4 Hon. David M. Davis, MLC Ms Heather McTaggart, MLA



Mr Dale Wilson, MLA

193

Inquiry on the Impact on the Victorian Community and Public Hospitals of the Diminishing Access to After Hours and Bulk Billing General Practitioners The motion was defeated.

Hon. David M. Davis, MLC moved that: “That a section be incorporated into the Report dealing with the impact of the presentation of mental health and drug and alcohol patients to EDs, and the most effective management practices available to these patients.” This was seconded by Mrs Helen J. Shardey, MLA. The Committee then divided: Ayes 2 Noes 4 Hon. David M. Davis, MLC Ms Heather McTaggart, MLA



Mr Dale Wilson, MLA


Ms Lisa Neville MLA moved that: “That consideration of mental health and drug and alcohol patients is outside the Terms of Reference of the Inquiry and is not required.” This was seconded by Ms Heather McTaggart, MLA The Committee then divided: Ayes 4 Noes 2 Ms Heather McTaggart, MLA Hon. David M. Davis, MLC

Ms Lisa Neville, MLA Mrs Helen J. Shardey, MLA


Mr Dale Wilson, MLA

The motion was carried.

Mr Robert Smith MLC (Chairman) moved that: “That the Report be adopted, taking into account changes to be taken in by the staff.” This was seconded by Ms Lisa Neville, MLA

194


The Committee then divided: Ayes 4 Noes 2 Ms Heather McTaggart, MLA Hon. David M. Davis, MLC


Mr Robert Smith, MLA

Mr Dale Wilson, MLA


195


196

Minority Report

Minority Report of Liberal and National Members

of the Family and Community Development Committee

on Emergency Departments and the Relationship with General Practice

Services

September 2004

197

Minority Report

1. The Need for a Minority Report We regret that it has been necessary to write a minority report on this inquiry into emergency departments at Victorian public hospitals and the impact of bulk billing changes. This has been a ‘political inquiry’. By this we mean not simply that politics has intervened in considerations or played a part. That is normal and to be expected, but on this occasion the process of collection, choice of evidence collected and the partisan use of committee procedures were so extreme that they bring, not only this report but the parliamentary committee process itself, into question The truth of the matter is that the terms of reference were never sincere. Instead, they were designed to reflect Labor Party assertions rather than conclusions derived after examining evidence. Labor members of this Committee were driven by a desire to table this report during the current Federal General Election rather than by considerations of the evidence. While this is a convenient target it is disingenuous. Another key driver for this report is the desire of the Bracks Labor Government to evade responsibility for its mismanagement of the Victorian public hospital system. The Bracks Government has broken a key promise made at both the 1999 and 2002 State Elections – namely to fix the State’s health system. Unfortunately, the system has become worse as the current Government’s incompetent management has begun to have a long term impact on the system. Despite spending more money on the system most objective measures of the performance of our public hospitals show longer waiting lists and longer waiting times. This minority report will highlight key evidence ignored by the Labor members in writing the majority report, because that evidence conflicted with their political agenda. The use of the parliamentary committee process simply to attack another level of government, while ignoring key evidence, is an abuse of the parliamentary committee system. We urge the community to see this inquiry as driven by partisan political considerations alone and the minority report as an attempt to broaden the evidence. The reasons it is necessary to write this report are listed below:

a. The terms of reference provided by the Minister for health to the inquiry are clearly partisan and biased. These terms of reference were not framed in a neutral way that sought to dispassionately seek a solution to a problem facing the Victorian community. The selection of 1996 as the base date is incredible in its breathtaking partisanship. Surely any genuine examination would have seen an attempt to place health system

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Minority Report

changes in a longer term context. No explanation has ever been offered for this selection.

b. The process of the inquiry has been overtly party political with the refusal to consider critical evidence. The instances are listed later in this report.

c. The behaviour of the Chairman of the Family and Community Development Committee was not conducive to properly seeking evidence. Below follow a number of examples of Committee Chairman, Mr Bob Smith’s misbehaviour during the inquiry. There is little question that his approach was boorish and embarrassing for the Committee and many of the witnesses. However the impact went beyond merely being unpleasant. In our view it affected the quality of the evidence and blocked the ability of Committee members to obtain key information.

Mr Smith has a history of such behaviour. In a recent inquiry he sought to throw a journalist with a legitimate right to be present out of a public hearing.

Examples of Mr Smith’s unacceptable and undemocratic behaviour include:

• Royal Melbourne - 24 November 2003

Mrs SHARDEY – Are you able to tell us anything about the heart (sic HARP) programs in particular, which we hope will be for out of hospital, not coming back to the ED; what programs are running, because I suspect –?

The CHAIRMAN – I don't think that is relevant to this inquiry, I am sorry. I can't see any relevance to that at all, and I won't allow that question. It is irrelevant to this inquiry. Come on.

Mrs SHARDEY – In terms of the admission to the ED, I think it is relevant. The CHAIRMAN – I am sorry, I don't agree. Mrs SHARDEY – I think it is – The CHAIRMAN – You can go all you like, Helen; I'm sorry, I don't agree. Mrs SHARDEY – So you are stopping me asking that question? The CHAIRMAN – Yes. Mr DAVIS – You are denying her? The CHAIRMAN – God, what do you want? Do you want me to write it down

for you. Why don't you stick to the agenda; stick to what we are on about. Mrs SHARDEY – This is the agenda, and that is a very important element. The CHAIRMAN – We disagree. When you are in the chair, you can make a

decision on it. Mr DAVIS – Excuse us. What an embarrassment! The CHAIRMAN – Well, you should think about that.

• Bendigo - 13 August, 2003

Mr DAVIS — It has been put to me that Bendigo in particular, in terms of alcohol and drug management programs and so forth, is an area in the state that needs a good deal.

The CHAIR — I am not sure we are sticking to the script now. I have been generous in allowing Mr Davis to draw the long bow, but I think we have heard enough of it.

Mr DAVIS — You will gag me? The CHAIR — Yes, if you like.

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Minority Report

d. The complete failure to address key (but inconvenient) parts of the terms of reference means even the limited instruction to the Committee have not been fulfilled Labor members of the Committee refused to allow the taking of critical evidence that was clearly within the terms of reference. One example of this approach was their refusal to examine the Report of the Auditor General on Managing emergency demand in public hospitals that was recently tabled in the Victorian Parliament. The Committee also refused to take evidence that related to term of reference 4 – ‘overseas and interstate examples and models’: instead, ignoring the New South Wales Auditor General’s recent report, Code Red: Hospital Emergency Departments and ignoring evidence from Mackay. Almost no attempt was made to examine the wealth of evidence that is available from overseas, particularly the United States and Canada.

e. The failure of the Committee to call key witnesses to present evidence or to take important evidence has destroyed the credibility of the report

• Auditor General’s Performance Audit on Emergency Departments

In May 2004, the Victorian Auditor General, Wayne Cameron, presented to the Victorian Parliament a key report titled Managing emergency demand in public hospitals. This report is the most comprehensive examination of the problems facing emergency departments in Victoria, and almost certainly in Australia in recent times. The performance audit has set a new benchmark for information and understanding the problems of and responses to, the issues surrounding emergency departments. Unfortunately the Labor members refused to examine this evidence much of which is highly critical of the performance of the Bracks Labor Government. We sought support (both formally and informally) from the Labor majority for the obvious step of inviting the Auditor General’s audit team to present their material to us. Much that is not written in the Auditor’s report, including their methodology could have impacted directly on our understanding of the issues facing emergency departments. In addition the recommendations of the Auditor should have been discussed by the committee in detail. These issues are clearly within the term of reference five. Later in this report we to discuss the implications of the Auditor’s groundbreaking report.

• The refusal of the Labor majority on the Committee to invite Dr Peter Archer, Director of the Emergency Department of the Maroondah Hospital to give evidence.

In February this year Dr Peter Archer, Director of Emergency Medicine at Maroondah Hospital wrote to the Minster for Health, Bronwyn Pike, regarding the management of mental health patients and their impact on emergency departments. Despite the gravity of Dr Archer’s statement that 13 patients had committed suicide after discharge from

200

Minority Report

the Maroondah Emergency Department within a 13 month period, Labor members of the Committee were determined to block the taking of evidence that was damaging to the Government. In fact the Labor majority defeated a request asking Dr Archer to give evidence. The Chief Executive Officer of Eastern Health, Ms Tracey Batten, was asked directly by one of us to ask Dr Archer to give evidence. Unfortunately, this approach did not make public the extent of the problems of the mismanagement of these vulnerable patients at Maroondah Hospital. This evidence was also blocked by the Labor majority. Later in this report we will consider the Archer letter and the concerns that it raises about the State Government’s provision of appropriate mental health services. There was a large body of evidence taken by the Committee on issues surrounding the impact of mental health patients and drug and alcohol patients on Victorian emergency departments. This evidence is attached in a table. The decision by Labor members to vote against the incorporation of recommendations flowing from this evidence is disappointing.

• The failure to ask Dr Andrew Dent, Director of the St Vincent’s Hospital Emergency

Department to give evidence. Dr Dent is a respected Emergency Department Director who has written a key paper on the management of emergency department demand in one of Melbourne’s major hospitals. He is also the author of many other papers relevant to the understanding of the operation of emergency departments and the pressures they experience. The Labor members of the Committee were determined to prevent this vital evidence being presented to the Committee. The Labor members determined that no evidence would be taken from St Vincent’s Hospital Emergency Department or Dr Dent because the paper he has written does not support the central contention and the political aims of the Labor members of the Committee. The conclusion of the Dent paper was as follows, “The majority of the presentations by the heaviest users of an ED in a city teaching hospital are not suitable for general practice. Attempting diversion of the heaviest repeat ED users to a general practice in this setting may not be successful due to the severity, acuity and nature of casemix of the presentations and would have minimal impact on crowding in similar emergency departments” (Dent AW, et al Emergency Medicine (203) 15, 322-329). A copy of the paper written by Dr Dent was presented to the Committee but there has been no discussion of the research in the majority report. Simply refusing to consider contrary evidence or an ostrich like, sticking of their heads in the sand, by the Labor members will not change the facts or make inconvenient evidence go away. Only a preparedness to listen, examine and understand evidence will lead to a better understanding of the facts. This minority report will discuss this research.

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Minority Report

• The failure of the Labor members to allow the discussion of the Bracks Government’s Review of the Hospital Admission Risk Programs (HARP) undertaken by KPMG. The Bracks Government’s Review of the HARP programs is squarely within the terms of reference of the inquiry and is referred to in the majority report. However Labor members refused to take formal evidence on this matter. It is difficult to understand how Labor members felt they could examine ‘What effective measures can be taken to reduce the number of presentations to public hospital emergency departments’ without being prepared to engage with this fundamental evidence. For this reason there is an entirely inadequate examination of the effectiveness of particular programs that manage hospital demand and readmission in this report.

• Potential Vetting of Evidence by the Department of Premier and Cabinet or the

Department of Human Services. Whilst most witnesses provided information and evidence of great candour the quality of much of the evidence given to the Inquiry is unknown because the Chair of the Committee would not allow Committee members to question witnesses as to the involvement of the Premier’s Department. Specifically the Chairman would not allow questions as to whether the evidence they were giving had been subject to vetting as required for all submissions under Premier Bracks’ new guidelines. The Guidelines for Submissions and Responses to Inquiries were promulgated by the Department of Premier and Cabinet in October 2002 Without this vital check on the veracity of the evidence no Victorian can have confidence the Department of Human Services or the Premier’s Department have not interfered or modified evidence either written or verbal. The Committee, and hence the people of Victoria are not in a position to depend on much of the submitted evidence in reaching their conclusions. In taking evidence from Eastern Health a question was directed to Professor Rasa:

Mr DAVIS — On that matter, as a follow-up, can I ask you whether your submission and your information you are providing today has in any way been discussed or vetted or worked with in terms of the government, under the guidelines of submissions — — The CHAIR — That is a totally inappropriate question to ask. Mr DAVIS — It is not. The CHAIR — I am ruling it out of order. That is outrageous. It is out of order. Mr DAVIS — I have to say that the guidelines of submissions for response to the inquiry dated October — — The CHAIR — I am not arguing with you, Mr Davis. The question is out of order. Mr DAVIS — I am very happy to ask the witnesses directly whether anyone at Eastern Health — — The CHAIR — When you are chairing the committee you may do what you like. Your problem is I am chairing it. Mr DAVIS — That is an outrage.

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Minority Report

The CHAIR — You will stay within the guidelines of our reference and that is it. Mr DAVIS — You have sought to prevent proper evidence coming before this inquiry and I put on the record my extreme disappointment at your behaviour. The CHAIR — So noted. Are there any questions?

We have attached as an appendix key pages from the Premier’s compulsory guidelines for submission to Parliamentary Inquiries. This issue may compromise the quality of future parliamentary inquiries until Premier Bracks rescinds those guidelines that directly interfere with the Parliament’s prerogatives.

2. The Good Faith Attempt by the Minority to Ensure Key Evidence was

Fully Researched and Formed a Part of the Report. The authors of this minority report sought to insert into the report new sections that dealt with key evidence. We also sought a detailed examination of this evidence. The Labor members of the Committee used their numbers to defeat each and every proposal for a full examination of critical evidence in all of these areas. It is our view that Labor members took this course of action to protect the Bracks Government and to further the Labor Party’s federal agenda. There is no doubt that evidence was ignored where it conflicted with the conclusions Labor members sought to draw in the report. The Labor members had an agenda to complete the report and table the report during the Federal Election. These motions and proposals were formally put to the Committee: Mrs J. Powell was an apology for the relevant meeting.

The following extracts from the Minutes of Proceedings of the Committee show Divisions that occurred during the consideration of the draft report on Monday 30 August 2004.

Hon. David M. Davis, MLC moved that: “That the Committee take, and the Report include, further evidence as required by the Terms of Reference , on 'innovative and relevant models of care and service delivery in other Australian States and Territories, and overseas” This was seconded by Mrs Helen J. Shardey, MLA.

203

Minority Report

The Committee then divided: Ayes 2 Noes 4

Hon. David M. Davis, MLC Ms Heather McTaggart, MLA



Mr Dale Wilson, MLA


Hon. David M. Davis, MLC moved that: “That the Committee take, and the Report include, further evidence on the Australian Health Care Agreements (1999-2003, 2003-2008), to ensure the Committee has adequately considered this matter.” This was seconded by Mrs Helen J. Shardey, MLA. The Committee then divided: Ayes 2 Noes 4




Mr Dale Wilson, MLA


Hon. David M. Davis, MLC moved that: “That, pursuant to Terms of Reference 5, the Committee take, and the Report include, further evidence; particularly with regard to the review of the Hospital Demand Management Strategy and evaluation of the Hospital Admissions Risk Program.” This was seconded by Mrs Helen J. Shardey, MLA. The Committee then divided: Ayes 2 Noes 4 Hon. David M. Davis, MLC Ms Heather McTaggart, MLA



Mr Dale Wilson, MLA

204

Minority Report


Hon. David M. Davis, MLC moved that: “That the Committee take, and the Report include, further evidence with regard to Commonwealth and Victorian legislation, including discussion of the Victorian Health Act.” This was seconded by Mrs Helen J. Shardey, MLA. The Committee then divided: Ayes 2 Noes 4 Hon. David M. Davis, MLC Ms Heather McTaggart, MLA



Mr Dale Wilson, MLA


Hon. David M. Davis, MLC moved that: “That the Committee consider the Auditor-General's Report on Emergency Departments and take evidence from the Office of the Auditor-General regarding this Report.” This was seconded by Mrs Helen J. Shardey, MLA. The Committee then divided: Ayes 2 Noes 4




Mr Dale Wilson, MLA


Hon. David M. Davis, MLC moved that: “That the Committee take evidence on the role of the Royal Children's Hospital in managing and meeting the emergency demands of Victorian children.” This was seconded by Mrs Helen J. Shardey, MLA.

205

Minority Report

The Committee then divided: Ayes 2 Noes 4




Mr Dale Wilson, MLA


Hon. David M. Davis, MLC moved that: “That the Report present data by hospital rather than by Health Service Region.” This was seconded by Mrs Helen J. Shardey, MLA. The Committee then divided: Ayes 2 Noes 4




Mr Dale Wilson, MLA


Hon. David M. Davis, MLC moved that: “That a section be incorporated into the Report dealing with the impact of the presentation of mental health and drug and alcohol patients to EDs, and the most effective management practices available to these patients.” This was seconded by Mrs Helen J. Shardey, MLA. The Committee then divided: Ayes 2 Noes 4




Mr Dale Wilson, MLA

206

Minority Report


Ms Lisa Neville MLA moved that: “That consideration of mental health and drug and alcohol patients is outside the Terms of Reference of the Inquiry and is not required.” This was seconded by Ms Heather McTaggart, MLA The Committee then divided: Ayes 4 Noes 2

Ms Heather McTaggart, MLA Hon. David M. Davis, MLC



Mr Dale Wilson, MLA


Mr Robert Smith MLC (Chairman) moved that: “That the Report be adopted, taking into account changes to be taken in by the staff.” This was seconded by Ms Lisa Neville, MLA The Committee then divided: Ayes 4 Noes 2

Ms Heather McTaggart, MLA Hon. David M. Davis, MLC


Mr Robert Smith, MLA

Mr Dale Wilson, MLA


Because of these omissions the integrity of the Report has been irretrievably damaged. There was a genuine need to ensure that the terms of reference, whatever their deficiencies, were adhered to and that each part of the terms was examined. The view of the minority reporters is that the Labor members in their haste to present the report during the Federal Election were prepared to overlook key evidence.

207

Minority Report We are of the view that this misuse of Committee process breaks the spirit of the non-partisan operation of joint parliamentary committees. It is unacceptable that no discussion of the concerns expressed by Dr Archer were properly examined and that the wide evidence on the impact of mental health patients and drug and alcohol patients on emergency departments was not debated fully and incorporated. Attached to this report is a table listing evidence received around Victoria on this issue.

3. The Main Body of Victorian Evidence The central body of evidence presented to the inquiry is material that tracks the presentations to emergency departments around the state over the last few years. This material is concentrated in Chapter Two of the main body of the majority report. It is best summarised in the tables between page 101 and page 121 but of central importance is the data between pages 119 and 121. This data is taken from the Health Services Reports 1996 – 2004 and is based on the Victorian Emergency Minimum Dataset and the Victorian Admitted Minimum Dataset. In essence it is Victoria Health Department data as supplied by Victorian public hospitals. We have some concerns in relation to this data. There may be deficiencies with the data used in the majority report as analysed and discussed by the Auditor General in his recent report on emergency departments. However, the Labor majority chose to ignore this evidence rather than attempt to understand more fully what has occurred in Victoria. However accepting the Committee’s data, it reveals a great deal about changes in patterns in Victoria Emergency Departments. The central claim by Labor and others that hospital emergency departments are being flooded with category 4 and 5 patients, so called ‘GP’ type patients, is shown not to stand up to rigorous analysis. The cause of problems in Victorian EDs is not largely increases in the number of category 4 and 5 patients. The real increases, with some local and regional exceptions, are in categories 1, 2 and 3. These three more acute categories are agreed by all to not include GP style presentations and are agreed universally to be appropriate for ED and hospital based care. Category 1, 2 and 3 patients have taken up a greater percentage and a greater number absolutely of ED presentations in the period between 1997/1998 and 2003/2004. The minority report members have produced further tables from the figures contained majority report that sharply demonstrate the real change in ED presentations over the period.

208

Minority Report

Regional Health Service Regions – Summary (From Majority Report)

ED Admissions & PresentationsRural Health Service Regions: 1996-2004

020,00040,00060,00080,000

100,000120,000140,000160,000180,000

1997-1998

1998-1999

1999-2000

2000-2001

2001-2002

2002-2003

2003-2004

AllCategories 1, 2 & 3Categories 4 &5

ATS Categories as a % of ED Presentations & AdmissionsRegional Health Service Regions: 1997-2004

0%

20%

40%

60%

80%

100%

1997-1998

1998-1999

1999-2000

2000-2001

2001-2002

2002-2003

2003-2004

Categories 1, 2 & 3Categories 4 &5

Additional Analysis by Minority Reporters for Regional Health Regions 1997-1998 1997-1998 2003-2004 2003-2004 Percent Percent All 145,679 100 161,021 100 Categories 1, 2 & 3 35,867 24.6 50,372 31.3 Categories 4 & 5 109,812 75.4 110,649 68.7

209

Minority Report

Metropolitan Health Service Regions – Summary (From Majority Report)


0

100,000

200,000

300,000

400,000

500,000

600,000

1997-1998

1998-1999

1999-2000

2000-2001

2001-2002

2002-2003

2003-2004




0%

20%

40%

60%

80%

100%

1997-1998

1998-1999

1999-2000

2000-2001

2001-2002

2002-2003

2003-2004


Additional Analysis by Minority Reporters for Metropolitan Victoria 1997-1998 1997-1998 2003-2004 2003-2004 Percent Percent All 437,685 100 553,941 100 Categories 1, 2 & 3 159,364 36.4 242,239 43.7 Categories 4 & 5 278,321 63.6 311,702 56.3

210

Minority Report

Victorian Health Service Regions - Summary (From Majority Report)

ED Presentations & Admissions by ATS CategoryVictoria 1997-2004

0100,000200,000300,000400,000500,000600,000700,000800,000

1997-1998

1998-1999

1999-2000

2000-2001

2001-2002

2002-2003

2003-2004


ED Presentations & Admissions by % of ATS CategoryVictoria 1997-2004

0%

20%

40%

60%

80%

100%

1997-1998

1998-1999

1999-2000

2000-2001

2001-2002

2002-2003

2003-2004


Additional Analysis by Minority Reporters Summary for Victoria 1997-1998 1997-1998 2003-2004 2003-2004 Percent Percent All 583,364 100 714,962 100 Categories 1, 2 & 3 195,231 33.5 292,611 40.9 Categories 4 & 5 388,133 66.5 422,351 59.1

211

Minority Report Majority Report:

ED Presentations by ATS Category, 1997-2004Northern Metropolitan Health Region

0

20,000

40,000

60,000

80,000

100,000

120,000

140,000

1997

-1998

1998

-1999

1999

-2000

2000

-2001

2001

-2002

2002

-2003

2003

-2004

All

Categories 1, 2 & 3

Categories 4 & 5

Northern Health Change in ED Presentations 1997-1998 1998-1999 2003-2004 2003-2004 Percent All 91,419 100 127,303 100 Categories 1, 2 & 3 28,767 31.5 50,097 39.4 Categories 4 & 5 62,652 68.5 77,207 60.6

Majority Report:

ED Presentations by ATS Category, 1997-2004Western Metropolitan Health Region

020,00040,00060,00080,000

100,000120,000140,000160,000

1997

-1998

1998

-1999

1999

-2000

2000

-2001

2001

-2002

2002

-2003

2003

-2004

*

All

Categories 1, 2 & 3

Categories 4 & 5

Western Health Change in ED Presentations 1997-1998 1997-1998 2003-2004 2003-2004 Percent Percent All 96,748 100 133,652 100 Categories 1, 2 & 3 35,253 36.4 54,552 40.8 Categories 4 & 5 61,495 63.6 79,100 59.2

212

Minority Report

Majority Report:

ED Presentations by ATS Category, 1997-2004Eastern Metropolitan Health Region

020,00040,00060,00080,000

100,000120,000140,000160,000180,000

1997-1

998

1998-1

999

1999-2

000

2000-2

001

2001-2

002

2002-2

003

2003-2

004*


Eastern Health Change in ED Presentations 1997-1998 1997-1998 2003-2004 2003-2004

Percent Percent All 139,964 100 162,522 100 Categories 1, 2 & 3 47,900 34.2 68,439 42.1 Categories 4 & 5 92,064 65.8 94,083 57.9

Majority Report:

ED Presentations by ATS Category, 1997-2004Southern Metropolitan Health Region

020,00040,00060,00080,000

100,000120,000140,000

1997-1

998

1998-1

999

1999-2

000

2000-2

001

2001-2

002

2002-2

003

2003-2

004*


Southern Health Change in ED Presentations 1997-1998 1997-1998 2003-2004 2003-2004 Percent Percent All 109,554 100 130,464 100 Categories 1, 2 & 3 47,444 43.3 69,151 53.0 Categories 4 & 5 62,110 56.7 61,313 47.0

213


ED Presentations by ATS Category, 1997-2004Barwon Health

05,000

10,00015,00020,00025,00030,00035,00040,00045,000

1997-1

998

1998-1

999

1999-2

000

2000-2

001

2001-2

002

2002-2

003

2003-2

004*


Barwon Health Change in ED Presentations 1997-1998 1997-1998 2003-2004 2003-2004 Percent Percent All 34,849 100 38,463 100 Categories 1, 2 & 3 9,267 26.6 13,927 36.2 Categories 4 & 5 25,582 73.4 24,536 63.8

Majority Report:

ED Presentations by ATS Category, 1997-2004Bendigo Health Care Group

05,000

10,00015,00020,00025,00030,00035,000

1997-1

998

1998-1

999

1999-2

000

2000-2

001

2001-2

002

2002-2

003

2003-2

004*


Bendigo Change in ED Presentations 1997-1998 1997-1998 2003-2004 2003-2004 Percent Percent All 29,316 100 31,964 100 Categories 1, 2 & 3 5,194 17.7 12,369 38.7 Categories 4 & 5 24,122 82.3 19,595 61.3

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Minority Report

Majority Report:

ED Presentations by ATS Category, 1997-2004Goulburn Valley Health

05,000

10,00015,00020,00025,00030,00035,000

1997-1

998

1998-1

999

1999-2

000

2000-2

001

2001-2

002

2002-2

003

2003-2

004*


Goulburn Valley Health Change in ED Presentations 1997-1998 1997-1998 2003-2004 2003-2004 Percent Percent All 21,103 100 28,680 100 Categories 1, 2 & 3 7,450 35.3 8,635 30.1 Categories 4 & 5 13,653 64.7 20,045 69.9

Majority Report:

ED Presentations by ATS Category, 1997-2004Ballarat Health Services

05,000

10,00015,00020,00025,00030,00035,00040,000

1997-1

998

1998-1

999

1999-2

000

2000-2

001

2001-2

002

2002-2

003

2003-2

004*


Ballarat Health Change in ED Presentations 1997-1998 1997-1998 2003-2004 2003-2004 Percent Percent All 29,557 100 36,142 100 Categories 1, 2 & 3 7,729 26.1 7,670 21.2 Categories 4 & 5 21,828 73.9 28,472 78.8

215


ED Presentations by ATS Category, 1997-2004Latrobe Regional Hospital

05,000

10,00015,00020,00025,00030,00035,000

1997-1

998

1998-1

999

1999-2

000

2000-2

001

2001-2

002

2002-2

003

2003-2

004*


Latrobe Change in ED Presentations 1997-1998 1997-1998 2003-2004 2003-2004 Percent Percent All 30,854 100 25,772 100 Categories 1, 2 & 3 6,227 20.2 7,771 30.2 Categories 4 & 5 24,627 79.8 18,001 69.8

Commentary on Tables Almost the entire increase over that period is due to an increase in category 1, 2 and 3 cases. Category 1, 2 and 3 cases increased from around 200,000 cases state-wide to just under 300,000 cases and provided the main driver for the increase, according to Committee data sourced at DHS, in total presentations Victoria wide from just under 600,000 to just over 700,000 cases. The increase in total presentations to EDs needs to be set against a larger Victorian population, which has increased from 4,597,200 in 1997 to 4,917,000 in 2003.

1997 2003 % Increase Regional Population 1,282,619 1,357,746 5.86

Metropolitan Population 3,314,581

3,559,654 7.39

Total 4,597,200

4,917,400 6.97

Even the absolute increase in category 4 and 5 presentations at EDs in the period 1997/98 to 2003/04 of 4.45% regionally, 12% in the metropolitan region and 8.81 % state-wide seem modest when set against the population changes of 5.86 % regionally, 7.39% in the metropolitan area and 6.97% state-wide over a six year. The larger growth in ED presentations in the Northern and Western regions reflects in large measure the population growth in these regions and perhaps in some cases cultural factors.

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Eastern and Southern metropolitan ED numbers of category 4 and 5 presentations have remained stable over the period despite population growth indicating an effective decline in pressure on EDs for category 4 and 5 patients. All in all the figures do not support the more extreme contention of some commentators, the Bracks Government or others that our EDs are being overwhelmed by ‘GP style’ patients. Whatever changes have occurred in bulk billing rates it is clear that the Committee’s figures obtained from the Department of Human Services support the opposite view from the one assumed in the Terms of Reference and by the Bracks Government and the conclusion of the majority report. Further work will need to be done to explain the modest increase in category 1, 2 and 3 patients. This may reflect, in part, some impact from the ageing of the population. 4. Bulk Billing and the Public Hospital System in Australia and Victoria The Labor members of this Committee and some other commentators in the community have argued that a decline in bulk billing has had a negative impact on public hospitals, particularly emergency departments. It is not necessary in this minority report to review the history of bulk billing as this is discussed in the main report or to discuss the history of the Australian health system. The link between General Practice and increased emergency department presentations is not well researched (Victorian Medicare Action Committee – evidence to Committee). The attempt to solely blame declining bulk billing levels for the problems of emergency departments is driven by the need of State Labor Government’s to blame some other party for their mismanagement. It is true that waiting lists have blown out in Victorian public hospitals and that emergency department performance has declined over the period of the Bracks Government. The decline in performance has accelerated over the last twelve months as the Government has progressively lost control of key aspects of what is a large and complex system. The latest figures show significant deterioration since the previous government. Almost 41,000 Victorians were waiting for elective surgery in the March quarter of 2004. The quarterly figures from March 1999 to March 2004 show:

• Urgent waiting lists increased from 667 to 767 • Semi-urgent waiting lists increased from 11,622 to 16,275 patients • Waits for semi-urgent surgery for longer than the ideal time has blown out from 3,180

to 7,015 • Patients waiting on trolleys in emergency departments for more than 12 hours and

were then admitted to a bed in the same hospital increased from 1,614 in the March 1999 Quarter to a staggering 4,784 in the March 2004 quarter – almost 200 per cent.

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Minority Report Some key results are presented below:

No. of patients stay in each hospital emergency department for longer than 12 hours before they

were admitted to a bed in the same hospital

Mar-99 1,614

Mar-04 4,784

-1,0002,0003,0004,0005,0006,000

Mar 04 Quarterly Hospital services Report

No.

ofPa

tient

s

How often are hospital emergency departments going on bypass

Mar-9972

Mar-04106

0

20

40

60

80

100

120

Mar 04 Quarterly Hospital Services report

No.

ofby

pass

es

Patients on Waiting Lists for Elective Surgery (Urgent)

Mar-99667

Mar-04767

600

650

700

750

800

Mar 04 Quarterly Hospital Services Report

No.o

fPat

ient

s

Patients on Waiting Lists for Elective Surgery (Semi-urgent)

Mar-9911,622

Mar-04 16,275

-

5,000

10,000

15,000

20,000


No.o

fPat

ient

s

Patients on Waiting Lists longer than ideal(Semi-urgent)

Mar-99 3,180

Mar-04 7,015

-

2,000

4,000

6,000

8,000

1

Mar 04 Quareterly Hospital Services report

No.

ofPa

tient

s

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The deterioration has also accelerated over the past twelve months and some of these key results are summarised below:

Patients on waiting lists for Elective Surgery

Mar-0337594

Mar-0440643

36000

37000

38000

39000

40000

41000

March 04 Quarterly Hospital Services Report

No.

of P

atie

nts

People on Waiting Lists for Elective Surgery (Urgent)

Mar-03726

Mar-04767

700710720730740750760770780


No.o

fPat

ient

s

Patients on Waiting Lists for Elective Surgery (Semi-urgent)

Mar-0313,916

Mar-04 16,275

12,000

13,000

14,000

15,000

16,000

17,000

Mar 04 Quarterly Hospital Services Report

No.o

fPat

ient

s

Patients on Waiting Lists for Elective Surgery (Non-urgent)

Mar-03 22,952

Mar-04 23,601

22,600

22,800

23,000

23,200

23,400

23,600

23,800


No.o

fPat

ient

s

Patients on Waiting Lists longer than ideal(Semi-urgent)

Mar-03 5,869

Mar-04 7,015

5,000

5,500

6,000

6,500

7,000

7,500


No.o

fPat

ient

s

219

Minority Report The Bracks Government’s constant excuse for its failure to manage public hospitals and the blow out in Victorian public hospital waiting lists – falling levels of bulk billing – has been shown to be a sham by the latest bulk billing figures. Other excuses include, fault of the Kennett Government, or even sometimes the Minister has blamed poor weather for the increased attendances. However there have been recent changes in the Medicare scheme which if declining bulk billing truly was a key cause of the state health systems woes would surely see a directly favourable impact. The fact is Victoria’s hospital waiting lists have blown out massively in the recent period while bulk billing rates have risen significantly under the Federal Government and it’s incentives for GPs to bulk bill. In the period since the 1st January introduction of the Strengthening Medicare GP bulk billing incentives the latest figures show a 3.9 per cent lift in the Victorian GP bulk billing rate. The most up to date Victorian State figures show a 4.7 per cent surge in the number on Victorian hospital waiting lists. 1,838 more sick Victorians have joined the list since December 2003. The 4.7 per cent increase in Victorian waiting lists is in the face of a 3.9 per cent lift in Victorian GP bulk billing. This shows there is no predictable relationship between bulk billing rates and emergency department presentations. The Victorian GP Bulk billing rate lifted to 67.5 per cent at the end of June – a rise of 3.9 per cent. The latest official Victorian figures – for the March Quarter 2004 show 40,643 Victorians waiting for elective surgery as opposed to 38,805 in the December Quarter 2003. This means at least 1,838 Victorians have been forced onto Victorian hospital waiting lists since the January this year despite the lift in the bulk billing rate. The Federal Government’s new programs that have successfully lifted Victorian bulk billing rates but because of the current Victorian Government’s incompetence and mismanagement almost 41,000 Victorians are still waiting, many in severe pain and discomfort. Recent Changes That Make Medicare More Affordable The Prime Minister John Howard announced additional measures to strengthen Medicare in early September 2004. The Prime Minister said in his statement; “From 1 January 2005, the rebate for all GP services will be increased from 85 per cent to 100 per cent of the Medicare Schedule Fee. This will help all Australians, whether or not they are bulk billed by their doctor.

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For a standard 15 minute surgery consultation, this will mean a rebate increase for the patient of $4.50. Where the consultation is bulk-billed, this increase will be paid to the doctor. It will complement our bulk-billing incentives under Strengthening Medicare. Those incentives of $5 and $7.50 will continue to be paid over and above the increased Medicare rebate. This initiative will apply to services provided in GPs’ surgeries, after hours, home and aged care facility visits, and services provided by GPs to their patients in a hospital. GPs providing services as Local Medical Officers to eligible Veterans and war widows will be entitled to payment at 115 per cent of the Medicare fee plus the Veterans’ Access Payment. This will maintain the relativities between Medicare and the Veterans’ Affairs fee scales.” These changes supersede any recommendations for an increase in the Medicare rebate to attract General Practitioners back to bulk billing. By providing an increase in the rebate for all General Practitioner services the increased rebate will be of assistance to all Australians whether or not they are bulk billed by their doctor. A Study ignored by the Majority Report While it is true that there has been insufficient academic study of issues surrounding any link between bulk billing and emergency departments there is some information available. A key Australian case study, the Mackay study, which has been researched, should have been examined by the Committee. This issue went to the heart of the Committee’s terms of reference in seeking any link between after-hours and bulk billing services and pressure on emergency departments. The evidence appears to contradict the direction of the majority report. Mackay Base Hospital Another very important paper has also been overlooked by the Labor majority. This paper: Hanson, DW, Sadlier, HR and Muller, R entitled Bulk Billing GP clinics did not significantly reduce emergency treatment caseload in Mackay, Queensland and a commentary by Ian Knox, President of the Australasian College of Emergency Medicine in the Medical Journal of Australia (Volume 180, 7 June 2004; “provided an opportunity to assess the effect of the increased availability of bulk billing services on ED presentations”. The set up of two bulk billing clinics near the ED (one within 1 kilometre of the Mackay Base Hospital did not have the effect predicted by the bulk billing thesis. In fact, despite an increase in bulk billing of 237 extra per day in the overlapping Federal Electorate of Dawson and an increase in bulk billing rate of 7.3 per cent ED presentations remained stable at 93 per day. The authors concluded “In MacKay the implementation of two GP clinics did not result in a measurable reduction in the absolute number of ED presentations. The results were

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Minority Report consistent with previous studies that suggest that non-emergency, primary care ED presentations are not a major determinant of ED overcrowding” This important paper has been attached to the minority report. The Labor majority chose to ignore the terms of reference that said the Committee should examine, “4. Innovative and relevant models of care and service delivery in other Australian States and Territories, and overseas.” This is clearly an area where the Labor majority did not want to examine evidence that did not support their political aims. There was no significant effort to obtain relevant evidence or experience from overseas. In these respects the Committee did not adhere to its terms of reference. 5. Category 4 and 5 Patients - Are these really ‘GP type’ patients? A central contention advanced by those who believe that changes in bulk billing rates are the key cause of the pressures faced by emergency departments is that most, or a significant percentage, of category 4 and 5 patients found in emergency departments are really GP type patients. The Australasian Triage Scale Category Descriptors are presented in Table 1.1 of the majority report, chapter 1 It is advanced that these category 4 and 5 patients should have been seen by General Practitioners and are responsible for ‘clogging up’ emergency departments. A further contention advanced together with these points is that the ‘decline’ of bulk billing is the cause of a movement of these ‘GP type’ patients into the ED. The evidence presented to this committee casts real doubt on this sequence of contentions. It certainly does not support a simplistic version of the thesis. Where data was presented as the Committee moved around the state it generally did not support this sequence of explanations. In too many places around Victoria the mix of ED patients had changed in more complex ways that defied straightforward explanation. Labor members of the Committee have chosen to ignore the evidence and have simply parroted their politically driven thesis. A large percentage of category 4 patients are in fact hospitalised. This is not the case with GP patients.

Bayside Health said in its submission, “The Department of Human Services has categorised 30 per cent of Alfred emergency department attendances of category 4 and 5 patients as ‘primary care attendances. We have disagreed with this, as many of the patients so classified actually require admission to hospital or require hospital services.” Up to 25 to 30 percent of category 4 patients in EDs are hospitalised in some locations. In many locations the number is over 10 percent (Committee evidence).

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In General Practitioner locations the percentage is much smaller, often closer to one per cent of General Practice patients. In many GP locations the percentage is far less than this. Extract from Warrnambool transcript 7 August 2003:

Mr DAVIS — The other matter of great interest was the way you put out very clearly the issue of category 4 and 5 patients, and the example you gave of meningococcal is obviously topical, but there must be a number of other types of conditions that would present in category 4 and 5. Perhaps you might like to give us some common examples of the sorts of conditions that might present in a category 4 or 5 but that would be better handled in an emergency department than even the apparent GP-style presentation. Ms SLOAN (Unit Manager of the Emergency Department) — ………… Something like a headache, a first headache that might be something very benign but might also be something that turns out to be a critical event like a cerebral haemorrhage, those sorts of things that someone might go to a GP with, is that what you mean? Things like that? Mr DAVIS — Yes. Ms SLOAN — Some sorts of fractures, you mean? Mr DAVIS — Yes. Ms SLOAN — A patient might have a fall and go to a GP, and that fracture might need surgical intervention. If a patient does not have significant pain or dura-vascular deterioration — for example, if their hand is still pink and warm and they can move it — they might well be in category 4, but then that person might subsequently have to go to theatre to have that fixed. Dr TSIPOURAS (Director of Emergency Services, Southwest Healthcare) — My name is Spiro Tsipouras, and I live at 6 Paul Court, Warrnambool. A lot of medicine is taught as ‘the classic example or common presentation is this or that’, and yet you will have people present with a dizzy spell who could have had a large stroke; they appear well, they are not too unwell, and yet if you do not do a proper neurological examination, if you do not obtain a CAT scan, you will miss the haemorrhage into the brain. They may have vague presentations of chest pain, particularly in the elderly. People present a little bit off their food and, ‘Mum is not getting up and walking around the house much’, and that could be a full-on cardiac infarct. I came from another hospital, which I will not mention — not in this country — where a patient was category 3 or 4 in the waiting room for 3 hours and then went to a GP clinic and was found dead the next morning with meningococcal disease. That was a very classical, vague presentation requiring some degree of skill and expertise to discern. In his submission Peter talks about having a primary health care clinic associated with the hospital, an approach I would fully endorse, because there we will build up a relationship, and we know to some degree the skill and expertise of the people involved in that sort of clinic, as opposed to saying, ‘Look, you are category 5, go out to this or that clinic’ and not being fully aware of what sort of interface they are going to have with a medical practitioner. Ms SLOAN — We are looking at still having those people coming through triage. When patients are triaged on presentation they are seen by an experienced nursing staff member — there is a local accreditation process we go through to be able to triage — and that is an objective assessment of the patient’s conditions. We look at things like their vital signs, with a child we look at their activity — whether

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Minority Report

they are roaring or lying on mum’s lap letting you do anything you like — we listen to patients’ descriptions of pain, those sorts of things. Dr O’BRIEN (Director of Medical Services) — It gets to a point where someone presents with a rash or something that is itchy or whatever, it is quite easy to say that is something the GP could deal with, but when someone presents with a headache or they are a bit dizzy or a child has a bit of a fever — — Dr TSIPOURAS — Or nausea. Dr O’BRIEN — Most of the time in retrospect you say a GP could have done that, but at that time when they come to the ED we are very reluctant to send them off because otherwise we end up on the second page of the Age saying that we happened to send off a child — this one child out of all the rest who have a fever — who actually has something more serious.

Extract from Northern Health transcript on 13 October 2003

Dr WINTER (Emergency Department Director ) — As a percentage, each triage category has seen significant rises, so it is not limited to just those triage categories, but there has been about a 20 per cent rise since last year in the number of category 4s, and as a percentage of last year the category 5s have probably increased by closer to 50 per cent. Ms NEVILLE — So what would be the combined total of, say, 4 and 5 out of everyone who presents to you? Dr WINTER — About 30 000 out of the low 50 000 who will be presenting this year. Ms NEVILLE — And the admission rates from the category 4? Dr WINTER — As far as I recall, admission rates from category 5 are in the order of between 5 and 10 per cent, and category 4s are usually around 15 to 20 per cent. That needs to be looked at in perspective. The overall admission rate from the emergency department is not like you would see at the Alfred or the Royal Melbourne, where it might be 50 per cent. Ours are in the low to mid-20s. Mrs SHARDEY — Obviously not for category 1. Dr WINTER — Surprisingly enough, the category 1 admission rate is not 100 per cent, it is more like 70 or 80 per cent, because the category 1 could be someone who has just had a low blood sugar and has become unconscious — give them sugar and they are fine.

What is not properly understood among many uninformed commentators, including some administrators, is that the triage categories relate to acuity not to severity.

Some patients will be correctly categorised as category four because these is ample time to treat them. But this does not mean they do not need complex diagnostic and therapeutic interventions that are best delivered at an ED. In fact many of these patients could not possibly receive the complex work up required at a General Practitioner’s office. This will often involve radiology and pathology testing that is not routinely available at a GP’s office.

Further we are concerned that the uncritical equation of ED category 4 patients with “GP type’ patients may lead to a mismanagement of these patients. There is good reason to believe that many category four patients are in fact very sick indeed.

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Minority Report

Dr Dent and a collaborator have produced concerning evidence of the risks of underestimating the seriousness of category four patients. (This study is attached)

The Dent and Rofe study concluded that the biggest group of hospital deaths occurred in category four patients. The authoritative study was prospective in design collecting all hospital admissions and their subsequent destination for the calendar year 1997. The results concluded, “The percentage of deaths per triage category decreases with acuity. However numerically the largest group of all admissions and admissions followed by deaths were those presenting in category 4 (semi-urgent). The conclusions continued, “Triage categories maybe a useful tool for prioritizing acute patients, but patients in low triage categories often have serious and fatal illness. Performance measurements and workload assessments for emergency departments may need to involve category four patients to take account of this factor.”

“In this study most hospital deaths occur in emergency triage category four.”

The College of Emergency Medicine has reinforced similar points saying;

“Less than one patient per1000 is sick enough to require immediate referral to an emergency department. Less than one patient per 100 in general practice needs admission to hospital on the day of presentation.” (Australasian College of Emergency Medicine – Fact Sheet)

6. Children

Some patients require specialist examination. One such case is children whose specialist requirements for diagnosis mean that many GPs don’t wish to deal with complex paediatric emergency cases. The Royal Children’s Hospital is the main centre state-wide that handles specialist paediatric emergencies. It does this along with several other metropolitan and regional centres. The complex diagnostic issues surrounding children mean that to simplistically place all category 4 or 5 cases in the group ‘GP type’ patients is both false and dangerous. Sick children need to be handled very carefully and expertly. The refusal of Labor members to hear relevant evidence in this area concerns us greatly. The refusal to discuss in detail figures from the Royal Children’s Hospital Emergency Department concerns us. The figures in the main report were inserted at the last minute and were not discussed by the Committee. Certain conditions such as chest infections can develop rapidly in children and while a child may be categorised as 4 o 5 this is not the basis for complacency. Many such category 4 children should be at the Royal Children’s Hospital ED.

225

Minority Report The waiting times at the Royal Children’s are longer than at the same time last year despite a massive increase in the bulk billing rate in Victoria.

Royal Children’s Hospital Waiting List Performance

March 2003

March 2004

Increase Percent Increase

People on Waiting lists for Elective Surgery

1664 1858 194 11.7%

How many patients stay in each hospital emergency department for longer than 12 hours before they were admitted to a bed in the same hospital?

13 52 39 300%

People on Waiting Lists for Elective Surgery (Semi-Urgent)

224 275 51 22.8%

People on Waiting Lists for Elective Surgery (Non-Urgent)

1416 1561 145 10.2%

Source: Department of Human Services, Quarterly Hospital Services Report, March 2003, 2004.

Specifically, with the new $5 increase in rebate for bulk billed children there is no doubt that under the Bulk Billing thesis the load at the Children’s Emergency Department should have fallen. This is not reflected in the number of children waiting over twelve hours on a trolley, the number of which has grown by 300 per cent.

Children treated in Emergency Departments Mar-03 Mar-04 % change Royal Children’s Hospital 11741 12113 3.20%

The above figures are powerful evidence casting doubt on any link between the bulk billing rate and the number of people presenting at an emergency department. Hospitals such as the Royal Children’s are the responsibility of the State Government. No amount of support from the federal Government will assist via whatever tenuous link when a State Government such as the Bracks Government so comprehensively mismanages a key hospital such as the Royal Children’s. Labor refused to insert a section into the report dealing with emergency department issues and there impact on Victoria’s children. The Labor Majority also refused to take evidence at the Royal Children’s Hospital.

7. Access Block Access block is defined by the Australian College of Emergency Medicine as “the delay patients who need hospital admission experience in the emergency department when their inpatient bed is unavailable.”

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Similar delays also occur when clinicians attempt to move patients to other key facilities within the hospital but it is the frustrated attempt to admit very sick patients that has become the hallmark of access block In Victoria a specific concern is developing over the shortage of Intensive Care Beds. • Bed Numbers

The most recent Australian Institute of Health and Welfare (AIHW) data show that the Bracks Government has cut the number of hospital beds available in Victoria. The number of beds listed as available in 2000-01 was 12,232 by the most recent figures this had declined by almost three hundred beds to 11,938 in 2002-03. This data does not take into account the temporary closure of beds, an increasingly common practice under the Bracks Government. The closure of 12 beds for a month each is the effective equivalent of closing one bed for twelve months. These closures are not reported as part of the AIHW data. The Bracks Labor Government has refused to answer detailed parliamentary or Public Accounts and Estimates Committee questions about bed numbers.

• The impact of access block The facts are that when it comes to the growing problem of ‘access block’ in Victorian hospitals the number of beds open does matter. In fact there is a mounting body of evidence that shows the high bed occupancy rate in Victoria and the cuts to bed numbers under the Bracks Government have begun to have a devastating impact on Victoria’s public hospitals. This is manifesting in two unacceptable ways. Firstly an increase in the length of elective surgery waiting list and secondly in a high rate of long stayers in Victoria’s emergency departments. We know the elective surgery waiting lists in Victoria are now almost 41,000. The Auditor’s report on managing emergency demand shows in 2002-2003 that over 35,000 Victorians were forced to wait on a trolley for over 12 hours in the emergency department of our metropolitan hospitals. The Health Minister has conceded that more the 43,000 Victorians state-wide have been forced to wait over twelve hours on a trolley in the emergency department. The evidence shows access block in our hospitals is life threatening! Powerful evidence makes it clear that waiting time in emergency is independently a factor in outcome of treatment. The longer patients are forced to wait the poorer the clinical outcome for patients.

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A key paper by Liew, Don, Liew, Danny and Kennedy, M.P “Emergency Department Length of Stay Independently Predicts excess Inpatient Length of Stay” (Attached) in the Medical Journal of Australia (Vol 179 Nov. 2003 P524-526) and associated editorial show this link clearly. The retrospective study reviewed the evidence of three Melbourne Hospitals. It concluded, “ED length of stay correlates strongly with inpatient length of stay, and predicts whether inpatient length of stay exceeds the state benchmark for the relevant diagnosis related group, independently of elderly status, sex and time of presentation to ED. Strategies to reduce ED length of stay (including countering access block) may significantly reduce healthcare expenditure and patient morbidity”

The submission to the Committee by the Australasian College of Emergency Medicine makes it clear that access block in our public hospitals is the major cause of congestion and queuing in the EDs around Australia.

The key points of the College submission are quoted below: 1. Emergency Department overcrowding is a national problem and requires a coordinated

nation-wide approach. 2. Hospital bed closures have resulted in hospital occupancies over 95%. This causes

access block for those emergency patients requiring inpatient admission and is the single most important cause of emergency department overcrowding.

3. The Solution to overcrowding is to reduce hospital occupancy below 85%. This will require determining both the total requirements for acute care beds and best practice for managing those beds.

4. Solutions to emergency department overcrowding will be found at all levels of the health system from pre-hospital to post acute care. Solely targeting increased resources to emergency departments will have the least effect in preventing overcrowding.

5. General practice-type patients attending emergency departments represent the low-end of complexity and cost. Significant reductions in this type of patient, if they are capable of being identified, will have marginal impact on emergency Department workloads.

6. Meaningful clinician involvement will be essential to any prospect of successful resolution to access block and over crowding.

7. As the Australian population ages, the demand for acute hospital beds will increase so that increasing efficiency and continuing practise change must become part of managing and working in acute hospitals.

The submission makes it clear that access block is an Australia wide and world wide issue. Unfortunately the majority of the Committee did not want to discuss the broader national and international issues. The Victorian Auditor General also pointed to access block as key issue. He along with the College of Emergency Medicine and other international evidence points to the issue of hospitals running at 95% and over of their capacity. At this level the Auditor says “available research suggests that if hospitals run at occupancy rates above 85%, then periodic episodes of access block will occur.” He and the College both point to the fact that these access block occasions will occur even if other matters are dealt with.

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Minority Report

Most large Victorian public hospitals run at well over 85% capacity and since the Bracks Government’s cuts to bed number the situation has worsened. Access block is the key cause of the decline in performance of Victoria’s EDs. It is an issue that the Bracks Government is determined not to take responsibility for and did not want examined by this inquiry. The issue was raised at the Royal Melbourne Hospital on 24 November 2003.

Mr DAVIS – You were talking about access block and moving people from the department into the short-stay unit and the two types of beds. The other aspect of that is actually into the general hospital where you have 340 beds open most of the time.

Assoc. Prof. KENNEDY (Director Emergency Services, Royal

Melbourne Hospital) – Yes. Mr DAVIS – And maybe 15, that for one reason or another, are not in

operation, but is there a problem in actually moving them out of the ED into the hospital general list?

Assoc. Prof. KENNEDY – Yes, there is. Access block is the single

biggest issue in my mind from the point of view of efficient running of emergency departments, and this is an international issue. At this campus we have particular issues.

Mr DAVIS – Royal Melbourne used to have many more beds; you used to

have many more beds. You used to have 401 beds, I know. Ms KOON (Emergency Services, Royal Melbourne Hospital) – We

used to have 700. Mr DAVIS – I know, but even 99 – Steve Bracks talked about it – Assoc. Prof. KENNEDY – It is what you choose to do with your beds, not

how many you've got. Mr DAVIS – Both? Assoc. Prof. KENNEDY – Usage of beds, it is how you choose to use

them. One of the choices you may want to make might be financially untenable, so therefore the choice can't be made; but how you manage those beds in terms of emergency patients getting access to hospital beds is a matter of management choice.

Mr DAVIS – Are there suggestions you have in terms of helping EDs by

managing better within the hospitals? Assoc. Prof. KENNEDY – The fundamental issue that exists in any

system is where access block is the issue of capacity, and when we run systems at 100 per cent capacity, whether it is the freeway or the water supply, there is no room for surge or for variation. And we know that we have a variable input point

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Minority Report

down here, so basically efficiency in patient flow systems comes from running at sub 100 per cent capacity, and there isn't a hospital in Victoria – probably Australia – that runs at less than 100 per cent capacity or significantly under to give them a buffer for the peaks and troughs. If you hit a trough in the emergency department you can subsequently easily fill that with short-stay elective patients on a ward. If you get a peak in the emergency department, the only place that peak goes is into the walls of the emergency department – and that means to bad care and to waste – because it creates inefficiency, long patient stays and poor outcomes.

Mr DAVIS – Optimal people outcomes potentially. Assoc. Prof. KENNEDY – I have just come from another meeting where

I did a presentation on this. To give you an example: SARS started in Canada from one indexed case in Toronto that spent 18 hours in an emergency department. We would say that someone with pneumonia should spend no more than four to six hours in an ED; you want them in a bed, they should be monitored and all the rest. That index case directly killed 17 people and infected 128 and cost $1 billion, or something. Now if that person had gone through in ideal time, 60 per cent of families would be a lot happier and the costs would have been smaller, and people would not have died. We haven't started to think about the quality and safety impacts of access block. I think only in terms of –

Mr DAVIS – Inconvenience. Assoc. Prof. KENNEDY – Inconvenience, whether it causes bypass,

where it subsequently ends up in the newspaper or causing a political headache for one of you guys; but we haven't really looked at it well from the point of view of quality and safety. It is a big step up.

The chair Mr Bob Smith ruled out further questions on this topic:

The CHAIRMAN – Helen, you wanted to ask a question relevant to this inquiry? Anyone else?

Mrs SHARDEY – I was just going to ask about intensive care and the

impact that you were talking about there in the block, if there are any issues in relation to that.

The CHAIRMAN – In what regard? Mrs SHARDEY – Moving patients from the ED? The CHAIRMAN – Again, I don't know whether you've read the

reference at all. It is the impact on the emergency department as a result of less access to GPs, not on how they are actually performing on a day-to-day, in normal –

Mrs SHARDEY – I am not going to have an argument with you. I am

asking a question. The CHAIRMAN – Well, you are not asking that one; it is not relevant.

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The Victorian Auditor General’s Report on “Managing emergency demand in public hospitals” We have referred to the failure of the majority, both in their report, and in examining pertinent evidence to consider properly the powerful performance audit undertaken by the Victorian Auditor General Wayne Cameron. On many occasions members of the minority requested that the Auditor’s evidence be examined. Indeed a formal resolution to invite the Auditor’s relevant Audit Group was put to the Committee by members of the minority and defeated on party lines. This failure to consider crucial local evidence goes to the heart of the political nature of this inquiry. The reason the Committee Chair and the majority did not consider this evidence is because it did not support their pre-determined conclusion that a decline in bulk billing was the cause of the problems faced by public hospital emergency departments. The evidence presented by the Auditor in his report was also very damaging to the Bracks Government and the Labor members may for this reason have wished to suppress this evidence. The Auditor’s report comes as the latest in an important series of performance audits that have examined the functioning and adequacy of major health and community services programs. The Auditor is to be congratulated for his preparedness to bring his systematic analysis and evidence gathering to bear in these areas of major impact on the community and major government expenditure. Key issues raised by the Auditor relate to the Committee’s terms of reference, particularly term of reference five, is relevant. We urge readers to read the Auditor’s report in full. Key issues highlighted include access block, walk outs (patients who did not wait in emergency departments), management of emergency department procedures, long staying patients, issues of data collection, information technology and its appropriate application in emergency departments, links to the primary care sector and links to ambulance and other emergency services among other points. To highlight some key concerns about evidence that should have been examined by the majority we attach some key tables from the Auditor’s report that relates to the Committee’s terms of reference: • Long staying patients - key tables:

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• Patients who did not wait (Walk outs):

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Minority Report David Davis, MLC

Helen Shardey MLC

Jeanette Powell MLC

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235

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FCDC Transcripts – references to Psychiatric patients/illness and Mental Illness Frankston – 28 July 2003

Dr S. Sdrinis, Manager, Medical Operations, Peninsula Health

Dr SDRINIS — The GP division down here, and I am sure many other GP divisions, have taken up disease management initiatives from the commonwealth, particularly with diabetes, asthma, psychiatric illness and chronic cardiac failure. They have told us that more GPs are doing longer consultations. So there is certainly a lot of work being done by GPs in terms of chronic disease management, as we ourselves are doing with the HARP initiative and other initiatives we have in the hospital. But going back to what was said before about whether there are enough GPs to do all that is required, that is another issue. But the ones who are there are working very hard, I think, with some of the chronic disease initiatives.

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Geelong – 6 August 2003

Dr J. Pascoe, Acting Director, Emergency Department

Dr PASCOE — For a start, we have a very cramped waiting room, and it struggles to cope with the number of walk-up presentations to the emergency department. In that waiting room we have the whole mix of patients. They may range from elderly patients to patients who are drug seeking or patients who have psychiatric problems right through to paediatric patients as well. In a new emergency department we would envisage having a larger waiting room and separate paediatric and adult waiting areas, and that would certainly make things much better from the patients’ point of view.

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Warrnambool – 7 August 2003

Dr G. O’Brien, Director of Medical Services

Dr O’BRIEN — ..The largest campus of that organisation is the Warrnambool hospital campus with 155 beds, and I understand that this afternoon you are going to visit the emergency department and any other part you would like to see. At that time the chief executive will be keen to welcome you and say hello. As well as the Warrnambool campus, Southwest Healthcare also manages the largest regional psychiatric service in south-west Victoria with branches at Hamilton, Portland and Camperdown. Southwest Healthcare also has community centres at Lismore, Macarthur and Camperdown. The Camperdown hospital campus is also part of Southwest Healthcare, but Warrnambool hospital is the main and certainly the largest campus.

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Bendigo–13 August, 2003

Dr J. Ferguson, Group Medical Director, Bendigo Health Care Group

Dr FERGUSON —….Again, there is nothing unique there, but there are not well-developed drug and alcohol services in Bendigo. There are some, but they are not well developed. When there is any shortage the hospital always acts as a safety net, so those patients tend to end up in the emergency department. It is the same as psychiatric services. Our psychiatric services have actually undergone significant growth in the last four or five years, and we have been extremely fortunate. But if you look at the ratio or proportion of psychiatrists to the population, it is well, well under what is recommended. The difficulty again is that anyone with behavioural disorders or disturbances to their mood pattern will tend to arrive at the emergency department. That gives us, I guess, the one-stop shop concern, but it also means that our department is not necessarily structured appropriately to deal with all these different pressures.

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Bendigo–13 August, 2003

Ms S. Clark, Chief Executive Officer

Ms CLARK — …We counsel a lot of people with AIDS and other, if you like, blood-borne diseases that do not or will not go to the A and E, and do not or will not go to another doctor. Take it as

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you like, that is the way it is. I do not know whether that is about cost or relationships or personalities. Mr DAVIS — I think it is probably about a few things, is it not? Ms CLARK — Yes. The other key area is mental health, I suppose. The third-top reason people come to see our doctors is for depression and anxiety. The mental health component of our practice is stretched, and the mental health services in this region are extremely stretched, so people tend to end up in A and E, although we have a range of projects to actually stop that happening because they are not necessarily diagnosed as having mental illness. They may well be in an episode of sickness.

Epping–13 October 2003

Mr R. Burnham, General Manager; Dr C. Winter, Emergency Department Director, Northern Hospital.

Dr WINTER — It was the meeting held with directors of emergency departments and the nurses and managers of emergency departments which is held every second month at Epworth. He was there, and he was very clear on that issue, and that is quite different to what our experience is. It has caused much discussion amongst the emergency departments that the chief psychiatrist is saying there is no problem with accessing beds, and yet we are commonly holding a patient because there are no beds. I guess he may be right and he may be wrong at the same time, in that there may be a psychiatry bed available in a rural centre but the ambulance will not transport the psychiatric patient, so even though perhaps technically he is correct, the impact is that we still have a considerable number of patients with us. We do have an inpatient facility that can cope with patients that require restraining, but as often as not there are no beds available there because they are full. Mr DAVIS — This is in hospital? Mr BURNHAM — It is a co-located facility, psychiatric services. We do not manage them; they just happen to be on site.. Dr WINTER — But it is a situation we do not see any solution to. The psychiatric assessment teams, particularly after hours, are reduced to one if not two people. They cannot do anything more than bring people to us or then assess them and then leave, and we are left with disturbed people in the emergency department common room. I do not think we will be closing our locked room. I think it is probably better to have it than not to have it, but it is somewhat of a magnet. There are all sorts of dynamics that go on between the police and the psychiatric assessment people. They may be such that the police will not call the assessment people, they may just bring people to us; or in other areas the police call them and the assessments are done in the cells. We are hoping that changes to the legislation on what police can do with the psychiatrically disturbed will have some improvement on our relationship with the police and how we deal with those people.

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Eastern Health - 19 April 2004

Professor J. Rasa, chief general manager, acute services

Mr DAVIS — I want to take you — and I am sure you are not surprised at this — to the letter from Dr Archer of 15 February 2004 — and for those who may not know Dr Archer is the director of emergency services at Maroondah — so I am not sure who I should direct the question to — perhaps John as the head of that campus. You referred in your initial submission to the issues surrounding psychiatric patients and drug and alcohol patients. I note Dr Archer’s letter here said that Maroondah Hospital ED sees over 1600 psychiatric patients per year and many more drug and alcohol patients.

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The letter says that number has rapidly increased in recent times, but more importantly the length of stay of these patients in the facility has reached 2 and 6 days on 57 occasions in the six months to the end of the year. He talks about the number of psychiatric patients who may be waiting and need complex treatment, and you have certainly referred to the complexity issues. He also talks about the fact that he and others have raised this issue with the chief psychiatrist to find additional beds within the system for those psychiatric patients. I have a number of questions regarding — — The CHAIR — You assume these people come through the ED? Mr DAVIS — These people are in the ED. There are 1600 psychiatric patients per year. Dr Archer made a number of points about the issues surrounding their management. What percentage of those patients, if any, can realistically be handled by a GP in the standard way, and is it not really a fact that it reflects the lack of proper psychiatric support services in and around Maroondah, and that those proper services would actually assist the hospital. The CHAIR — Mr Davis, you are going beyond. I caution you. Mr DAVIS — I do not believe — — The CHAIR — We are not investigating psychiatric services — — Mr DAVIS — Well, we — — The CHAIR — It may be warranted, but it is not in this inquiry. Mr DAVIS — The witness has made a direct point — — The CHAIR — I am just trying to give you some guidance. Mr DAVIS — I am not terribly interested in your guidance — — The CHAIR — You will be interested in my decision! Mr DAVIS — Seriously, this is a very important issue and I wonder if you could tell us how you think those services could be better managed in your hospital, whether it has been a — — The CHAIR — I do not believe that is a relevant matter for this inquiry. We are investigating the impact on emergency services. You know that damn well and now you want to extrapolate that out to every health service in the state. Mr DAVIS — I am certainly not doing that. The CHAIR — I think you are. Prof. RASA — I can certainly comment that there have been — at least in the Box Hill and Maroondah hospitals — increases in attendances in the emergency departments with people perhaps having psychiatric problems as well as physical problems, and possibly presenting with the physical problems but then subsequently requiring other care. We have had discussions with the Department of Human Services about the need for psychiatric services to be improved in the eastern suburbs, and those discussions have been quite fruitful. Very recently we have built two additional beds at Maroondah Hospital — in fact, they were opened last week — and that has been some contribution to trying to fix that problem. We need to have further discussions about the broader access to beds. Berwick hospital coming on line is one of those issues that we have been talking to Southern Health about, and trying to access beds there. Mr WILSON — I understand it is 25 beds.

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Prof. RASA — Twenty-five beds will be built there. I think some of those beds will be available to us; we are having discussions around how that will be done. But generally we have also looked at access to beds at the Alfred hospital and other places as well in the meantime. We have not concluded those discussions, but we have at least started them. Mr DAVIS — Many of these patients are difficult to manage in the ED, where you have support, but would be extremely difficult for a GP to manage. Prof. RASA — Partly some of that attendance at emergency is because while GPs handle depression and a number of illnesses they sometimes find it difficult to manage behavioural problems in particular, and that is why they attend — either as voluntary or involuntary patients — at the emergency department. They need some post-follow-up care, some of which is community-based care, and sometimes they require admission. Mr DAVIS — And the Maroondah psychiatric ward, You say there are a couple of new beds there? Prof. RASA — Two new beds. Mr DAVIS — But the original plan was for 45 adult beds according to Dr Archer, and in fact there are only 28 beds plus perhaps 2 more — there are perhaps 30 beds, so there is still a deficit of about 50 per cent on its original estimated needs. Prof. RASA — That is the purpose of accessing beds that may be available at other sites. We have had discussions with St Vincent’s, the Alfred hospital and the Austin Hospital regarding that. Mr DAVIS — Do you agree with Dr Archer that those beds are geographically inappropriate? Prof RASA — The chief psychiatrist has a planning role in relation to the availability of beds. We try and base people as close to home as possible, but in some cases that is not always possible because demand fluctuates, and sometimes you have to look at facilities elsewhere. So we look right across the state for access to psychiatric beds, not just locally. Mr DAVIS — But if you had additional local — — The CHAIR — Mr Davis, you have had a fair crack here.

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Legislative Council Parliament House Melbourne, VIC., 3002 Telephone: 9651 8911

173 Canterbury Road Canterbury, VIC., 3126 Telephone: 9888 6244 Facsimile: 9888 6529

[email protected] www.daviddavismp.com

The Honourable David M. Davis, M.L.C. Shadow Minister for Health

Member for East Yarra Province Monday, 23 February 2004 Mr Bob Smith, MLC Member for Chelsea 376 Nepean Highway Chelsea, Vic., 3196 Fax 9776 1896 Dear Bob, Re: Letter by Dr Peter Archer to Health Minister Bronwyn Pike reporting serious issues surrounding mental health patients at the Maroondah Hospital Emergency Department including the disclosure of a number of suicides. I write to bring to the attention of Family and Community Development Committee members the important letter by Dr Peter Archer that has direct relevance to our inquiry into Emergency Departments. I attach a copy of Dr Archer’s letter. I also attach a copy of recent newspaper discussions concerning these important matters. I ask that we invite Dr Archer to present evidence to the Committee at our next public hearing. Eastern Health is a major health network that contains Maroondah Hospital – which has yet to present evidence to our Inquiry into Emergency Departments. In addition to Dr Archer, representatives of Eastern Health management, including the Chief Executive, Dr Tracey Batten should be invited to give evidence on the same day. At other hearings of this inquiry we have heard significant evidence about the impact of patients with complex psychiatric illness on the operation of emergency departments in Victoria. In particular the evidence provided at the Northern Hospital made it clear that last year an important meeting occurred between emergency department directors and the Chief Psychiatrist, Associate Professor Amgad Tanaghow. It is clear that there is a significant issue in the appropriateness of the management of psychiatric patients in Emergency departments. I do not pretend to have simple answers to these serious matters, however it is clear to me that these matters should be investigated thoroughly as part of our Inquiry into Emergency Departments.

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David Davis, MP Shadow Minister for Health Cc Family and Community Development Committee members

Dr Peter Archer Chief Psychiatrist, Associate Professor Amgad Tanaghow Mr Paul Bourke

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