Family and Community Development Committee

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

MEMBERS

Mr Robert Smith, MLC Mrs Jeanette Powell, MLA Chair Deputy Chair Member for Chelsea Province Member for Shepparton

Hon. David Davis, MLC Ms Heather McTaggart, MLA Member for East Yarra Province Member for Evelyn

Ms Lisa Neville, MLA Mrs Helen Shardey, MLA Member for Bellarine Member for Caulfield

Mr Dale Wilson, MLA Member for Narre Warren South

STAFF Mr Paul Bourke Executive Officer

Ms Lara Howe Office Manager

Ms Iona Annett Research Officer

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

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.

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

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

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

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

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

x CHAPTER ONE INTRODUCTION: AN OVERVIEW OF THE AUSTRALIAN HEALTH CARE SYSTEM

¾ Commonwealth and State Responsibilities in Health Care ¾ The Structure of Health Care ¾ Health Service Funding & Delivery ¾ 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

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 Immediately life-threatening Cardiac arrest; respiratory arrest; immediate risk to airway – impending Simultaneous Conditions that are threats to life arrest; respiratory rate <10/min; extreme assessment & (or immediate risk of deterioration) respiratory distress; BP<80 (adult) or treatment and require immediate aggressive severely shocked child/infant; intervention. Benchmark: unresponsive or responds to pain only; ongoing/prolonged seizure; IV overdose 100% and unresponsive or hypoventilation; severe behavioural disorder with immediate threat of dangerous violence. 2 Assessment & Imminently life-threatening Airway risk; severe respiratory distress; treatment circulatory compromise; chest pain of The patient’s condition is serious within 10 min. likely cardiac nature; very severe pain – enough or deteriorating so rapidly any cause; drowsy, decreased (assessment & that there is the potential of threat responsiveness – any cause; acute treatment often to life, or organ system failure, if hemiparesis/dysphasia; fever with signs simultaneous) not treated within ten minutes of of lethargy (any age); acid or alkali arrival. Benchmark: splash to eye – requiring irrigation; 80% Important time-critical treatment major multi trauma (requiring rapid The potential for time-critical organised team response); severe treatment to make a significant localised trauma – major effect on clinical outcome depends fracture/amputation; high-risk history; on treatment commencing within a behavioural/psychiatric disorder – few minutes of the patient’s arrival violent or aggressive, immediate threat in the ED; humane practice to self or others, requires or has required mandates the relief of very severe restraint, severe agitation or aggression. pain or distress within 10 minutes.

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

3 Assessment & Potentially life-threatening Severe hypertension; moderately severe treatment start The patient’s condition may blood loss – any cause; moderate within 30 min. progress to life or limb threatening, shortness of breath; seizure – now alert; Benchmark: or may lead to significant any fever if immunosupressed; 75% morbidity, if assessment and persistent vomiting; dehydration; head treatment are not commenced injury with short LOC, now alert; within 30 min of arrival. moderately severe pain – any cause, requiring analgesia; chest pain – likely Situational urgency non-cardiac; abdominal pain without There is potential for adverse high risk features; moderate limb injury; outcomes if time-critical treatment limb – altered sensation, acutely absent is not commenced within 30 min.; pulse; trauma – high-risk history with humane practice mandates the relief no other high-risk features; stable of severe discomfort or distress neonate; child at risk; within 30 min. behavioural/psychiatric – very distressed, risk of self-harm, acutely psychotic or thought disordered, situational crisis, deliberate self-harm, agitated/withdrawn, potentially aggressive. 4 Assessment & Potentially serious Mild haemorrhage; foreign body treatment start The patient’s condition may aspiration, no respiratory distress; chest within 60 min. deteriorate, or adverse outcome injury without rib pain or respiratory Benchmark: may result, if assessment & distress; difficulty swallowing, no 70% treatment is not commenced within respiratory distress; minor head injury, 60 min of arrival in ED. Symptoms no loss of consciousness; moderate moderate or prolonged. pain, some risk features; vomiting or Situational urgency diarrhoea without dehydration; eye inflammation or foreign body, normal There is potential for adverse vision; minor limb trauma, normal vital outcome if time-critical treatment is signs, low/moderate pain; tight cast, no not commenced within 60 min. neurovascular impairment; swollen Significant complexity or severity ‘hot’ joint; non-specific abdominal Likely to require complex work-up pain; behavioural/psychiatric – semi- and consultation and/or inpatient urgent mental health problem, under management; humane practice observation and/or no immediate risk to mandates the relief of discomfort or self or others. distress within one hour. 5 Assessment & Less urgent Minimal pain with no high-risk treatment start The patient’s condition is chronic features; low-risk history and now within 120 or minor enough that symptoms or asymptomatic; minor symptoms of min. clinical outcome will not be existing stable illness; minor symptoms Benchmark: significantly affected if assessment of low-risk conditions; minor wounds – 70% and treatment are delayed up to 2 not requiring sutures; scheduled revisit hrs from arrival. eg. wound review, complex dressings; Clinico-administrative problems immunisation only; Results review, medical certificates, behavioural/psychiatric – known prescriptions only. patient with chronic symptoms, social crisis – clinically well patient.

An Overview of the Australian Health System

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;

An Overview of the Australian Health System

• 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

An Overview of the Australian Health System 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;

An Overview of the Australian Health System

• 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 1. Information Tier 1 – Providing data to the Australian Government $3.00 Management/ Tier 2 – Use of bona fide electronic prescribing $2.00 Information software to generate the majority of scripts in the Technology practice Tier 3 – The practice has on site and uses a computer(s) $2.00 connected to a modem to send and/or receive clinical information 2. After hours care* Tier 1 – Ensuring patients have access to 24 hour care $2.00 as specified in the application form Tier 2 – On average, the practice covers at least 15 $2.00 hours per week of its after hours care from within the practice Tier 3 – The practice provides 24 hour care from within $2.00 the practice 3. Teaching Teaching of medical students $50 per session (max. 2 sessions per day) 4. Quality Practice participation in quality use of medicines $1.00 Prescribing programs, endorsed by the National Prescribing Service Initiative 5. Diabetes Sign-on Payment: one-off payment for notifying the $1.00 Australian Government that the practice uses a diabetes register and recall/reminder system

Service Incentive Payment: Payment for each annual $40 per diabetic cycle of care for a patient with diabetes, payable once per year per patient

Outcomes Payment: Payment to practices that complete $20 per diabetic an annual program of care for a target proportion of the patients with diabetes 6. Asthma Sign-on Payment: payment to practices that agree to $0.25 provide data to the Australian Government Service Incentive Payment: Payment to practitioners $100 who complete an Asthma 3+ Visit Plan for patients with moderate to severe asthma, payable once per year

An Overview of the Australian Health System

7. Cervical Sign-on Payment: Payment to practices that agree to $0.25 screening provide data to the Australian Government. Service Incentive Payment: Payment to practitioners for $35 screening women between 20 and 69 years who have not had a cervical smear within the last four years. Outcomes Payment: Payment to practices where a $2.00 per female specified proportion of women aged between 20 and 69 WPE aged years have been screened in the last 24 months between 20 and 69 8. Practice Nurses Payment to practices that employ or retain the services RRMAs 1-2: $8 of a practice nurse and are located in the target area per SWPE RRMAs 3-7: $7 per SWPE 9. Mental Health Sign-on Payment: One-off payment to individual GPs $150 who register for the incentive Service Incentive Payment: Payment to GPs on $150 completion of the 3-step mental health process 10. Rurality# Total PIPs are loaded for rurality, increasing with extent 15% to 50% of remoteness, using RRMA classification 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 & Rural loading RRMA number & Rural loading category category 1. Capital city 0% 5. Other rural 40% centre 2. Other metropolitan 0% 6. Remote centre 25% centre 3. Large rural centre 15% 7. Other remote 50% area 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 80% of out-of-pocket costs (non-hospital services) will be met at certain thresholds for certain groups. Families in Subject to legislation receipt of Family Tax Benefit (A) - $300; Commonwealth Concession Card holders (individuals or families) - $300; all other individuals or families - $700. Bulk billing incentives Incentive payment of $5 to GPs who bulk-bill concession card holders, and children under 16; rate increases to Start 1 May 2004 $7.50 for GPs in regional, rural and remote areas and Tasmania. Allied health services and New MBS item that can be claimed by a GP for certain services provided ‘for and on behalf of the GP’ by an dental health care allied health provider (excluding those funded by the State Start 1 July 2004 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 246 additional medical school places, bonded to areas of workforce shortage Start academic year 2005

Areas of consideration ‘Areas of consideration’ will be established to deal with situations where statistical local area boundaries have Start 1 July 2004 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 Establishing an integrated electronic health information network based on electronic health records. Connect/MediConnect

Start 1 July 2004

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

An Overview of the Australian Health System

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 PROJECT 2003/04 PROVIDER FUNDING

Austin Health Community Link Rapid Response Service $679,194 Enhancement

Respecting Patient Choices $318,481

Out of Area Bed Coordination $112,688

Barwon Health Integrated Disease Management of Chronic $179,712 Heart Failure (CHF)

Bayside Health Medication Alert Project $521,147

Bendigo Health Care Group Improved Management of Care for People $144,877 with Congestive Heart Failure

City Of Port Phillip Care Coordination for Mental Health & $463,911 Complex Psychosocial Needs

Darebin Community Health Integrated Chronic Disease Management – $338,851 Service Chronic Obstructive Pulmonary Disease (COPD) & CHF

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

Dianella Community Health A Comprehensive Community Approach to $187,054 Service Asthma Management for Children and Families - Phase 2

Eastern Health Integrated Response to Complex Needs in $1,113,400 the Community

Respecting Patient Choices $168,530

Goulburn Valley Health Goulburn Valley Admission Risk Program: $213,710 Strengthening Acute and Community Partnerships

Melbourne Health Comprehensive Community Care Service $675,684

Metropolitan Ambulance Medical Deputising Service link with MAS $139,580 Service Referral Service

Northern Division Of An Integrated Holistic Approach to Diabetes $345,302 General Practice Management

Northern Health Integrated Wound Management Services $392,918

Community Client Orientated Medication $313,888 Services (C-COMS)

Respecting Patient Choices $91,615

Peninsula Health Peninsula Residential Outreach Response $214,454 Team

Royal District Nursing Community Nursing Response to $297,384 Service Metropolitan Ambulance Service Referral Service

St Vincent's Health Holding It Together $481,466

Restoring Health $417,314

Treatment, Response & Assessment For $428,580 Aged Care

The COACH Program in the Community $74,241

Respecting Patient Choices $129,223

An Overview of the Australian Health System

Southern Health Care in Context for Mental Health Patients $354,335

Supporting the Improved Management of $244,652 CHF in the Community

Health for Kids in the South East $424,764

Western Health An Integrated System for Managing the Care $1,113,208 of Older People with Complex Needs

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

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 Northern Metropolitan Hume-Moreland Hume, Moreland Banyule-Nillumbik Banyule, Nillumbik North Central Metropolitan Whittlesea, Darebin & Yarra Eastern Metropolitan Booroondara Booroondara Outer East Health & Maroondah, Knox, Yarra Community Support Alliance Ranges Central East Monash, Manningham, Whitehorse Southern Metropolitan Inner South East Partnership Port Phillip, Stonnington, Glen in Community & Health Eira Kingston-Bayside Kingston, Bayside South East Greater Dandenong, Casey, Cardinia Frankston-Mornington Frankston, Mornington Peninsula Peninsula Western Metropolitan Moonee Valley-Melbourne Moonee Valley, Melbourne Westbay Wyndham, Hobson’s Bay, Maribyrnong Brimbank-Melton Brimbank, Melton Barwon South Western Southern Grampians-Glenelg Southern Grampians, Glenelg South West Corangamite, Moyne, Warrnambool Barwon Colac-Otway, Greater Geelong, Surf Coast, Queenscliffe Grampians Wimmera West Wimmera, Hindmarsh, Yarriamback, Horsham Grampians Pyrenees Ararat, Northern Grampians, Pyrenees Central Highlands Ballarat, Golden Plains, Moorabool, Hepburn Loddon Mallee 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 Central Victorian Health Mt Alexander, Central Alliance Goldfields, Macedon Ranges

An Overview of the Australian Health System

Region Primary Care Partnership Local Government Area Gippsland East Gippsland East Gippsland Wellington Wellington Central West Gippsland Latrobe, Baw Baw South Coast Health Services Bass Coast, South Gippsland Consortium Hume Lower Hume Mitchell, Murrindindi Goulburn Valley Moira, Strathbogie, Greater Shepparton Central Hume Alpine, Delatite, Wangaratta 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.

An Overview of the Australian Health System

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.

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

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.

22 CHAPTER TWO PATTERNS OF USE IN THE VICTORIAN HEALTH CARE SYSTEM, 1996-2004

¾ Introduction ¾ Divisions of General Practice – Profiles ¾ Health Service Areas – Profiles ¾ 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;

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

• 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.

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)

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.

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

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 Local Government Areas Public Hospitals with Divisions of General Region EDs Practice Eastern Yarra Ranges, Knox, Maroondah Hospital Inner Eastern Manningham, Monash, Box Hill Hospital Melbourne, North East Maroondah, Whitehorse, Angliss Hospital Valley, Whitehorse, Boroondara Monash Medical Centre Greater South Eastern, Northern Hume, Nillumbik, Northern Hospital Central Highlands, Whittlesea, Moreland, Austin & Repat North East Valley, Darebin, Banyule, Yarra St Vincent’s Melbourne, North Western, Northern Southern Cardinia, Casey, Frankston Hospital Central Bayside, Inner Mornington Peninsula, Dandenong Hospital Eastern, Inner South Frankston, Greater The Alfred East, Greater South Dandenong, Kingston, Eastern, Monash, Bayside, Glen Eira, Central Bayside, Knox, Stonnington, Port Phillip Dandenong, Mornington Peninsula Western Melton, Brimbank, Moonee Royal Melbourne Westgate, Western Valley, Wyndham, Sunshine Hospital Melbourne, Hobson’s Bay, Western Hospital Melbourne, North Maribyrnong, Melbourne West Melbourne RURAL DHS Region Local Government Areas Public Hospitals with Divisions of General EDs Practice Barwon South Glenelg, Southern Barwon Health GP Association of Western Grampians, Moyne, Geelong, Otway, West Warrnambool, Colac Victoria, Ballarat Otway, Corangamite, Surf Coast, Queenscliff, Greater Geelong Gippsland Bass Coast, South Latrobe Regional Central West Gippsland, La Trobe, Baw Hospital Gippsland, East Baw, Wellington, East Gippsland, South Gippsland Gippsland Grampians West Wimmera, Hindmarsh, Ballarat Health Ballarat, Bendigo, Yarriambiack, Horsham, Services, St John of Central Highlands, GP Northern Grampians, God Health Care, Association of Geelong Ararat, Pyrenees, Ballarat, Hepburn, Moorabool, Golden Plains Hume Mitchell, Strathbogie, Goulburn Valley Health Goulburn Valley, Greater Shepparton, Moira, North East Victoria, Benalla, Murrindindi, Border, Eastern Ranges Mansfield, Milawa, Indigo, Alpine, Wodonga, Towong Loddon Mallee Mildura, Swan Hill, Buloke, Bendigo Health Care Mallee, Murray Plains, Gannawarra, Campaspe, Group Bendigo, Goulburn Loddon, Central Goldfields, Valley, West Victoria Greater Bendigo, Macedon Ranges, Mt Alexander

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

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

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

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

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

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

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

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 – 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 Total Persons 1996 106,977 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)

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

General Practitioner Attendances, 1996-2004

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

520,000 500,000 480,000 Emergency AH 460,000 GP Attendances

Services 440,000 420,000 400,000

98 99 00 01 03 1997 19 20 20 20 8/19 2003/04 1996/ 1997/ 199 1999/ 2000/ 2001/20022002/

1996-1997 2003-2004 % Variation GP Attendances 483,862 441,528 -8.75 (not Emergency)

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 Bulk Billing Rate % Variation June 2000 Dec 2003 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

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

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)

General Practitioner Attendances, 1996-2004

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

395,000 390,000 385,000 380,000 Emergency AH 375,000 GP Attendances Services 370,000 365,000 360,000

97 98 99 01 02 03 04 9/00 1996/ 1997/ 1998/ 199 2000/ 2001/ 2002/ 2003/

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

1996-1997 2003-2004 % Variation 1996-2004 GP Attendances 391,383 387,808 -0.91 (not Emergency)

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

Electorate Bulk Billing Rate Bulk Billing Rate % Variation June 2000 Dec 2003 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

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

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)

General Practitioner Attendances, 1996-2004

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

950,000

900,000

850,000 Emergency AH 800,000 GP Attendances Services 750,000

700,000

97 98 99 00 03 04 000/01 001/02 1996/ 1997/ 1998/ 1999/ 2 2 2002/ 2003/

1996-1997 2003-2004 % Variation GP Attendances 928,215 791,713 -14.71 (not Emergency)

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

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

Electorate Bulk Billing Rate Bulk Billing Rate % Variation June 2000 Dec 2003 Goldstein 72.1% 55.7% -16.4% Isaacs 85.3% 65.1% -20.2%

Practice Incentives Program, May 2004 No. of Practices in PIP 46 RRMA Category Capital City – 46 Ensuring patients have access to 24 hr care 46 Provision of at least 15 hours (AH) care from within the practice 31 Provision of all after hours care for practice patients 11 Practice Nurses unknown

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

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%

Medical Workforce Number of General Practices 45 Number of General Practitioners 188 (not FTE) GP: Population 1:9918 (not FTE)

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

General Practitioner Attendances, 1996-2004

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

680,000 660,000 640,000 620,000 Emergency AH 600,000 GP Attendances Services 580,000 560,000 540,000

97 98 99 00 03 04 000/01 001/02 1996/ 1997/ 1998/ 1999/ 2 2 2002/ 2003/

1996-1997 2003-2004 % Variation GP Attendances 592,260 653,727 +10.38 (not Emergency)

Local Government Area Estimated Population Growth, 1996-2004 Hume 26.80% Melton 78.61% Macedon Ranges 22.69% Mitchell 23.20%

Electorate Bulk Billing Rate Bulk Billing Rate % Variation June 2000 Dec 2003 Calwell 87.7% (Dec 2003) 81.5% -6.2% Lalor 91.6% 77.2% -14.4% McEwan 73.6% 60.9% -12.7%

Practice Incentives Program, May 2004 No. of Practices in PIP 30 RRMA Category Capital City – 7 Other Rural – 23 Ensuring patients have access to 24 hr care 28 Provision of at least 15 hours (AH) care from within the practice 27 Provision of all after hours care for practice patients 5 Practice Nurses 21

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

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% Total Persons 2001 103,700 Total Persons 1996 101,064 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)

General Practitioner Attendances, 1996-2004

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

490,000

480,000

470,000 Emergency AH 460,000 GP Attendances Services 450,000

440,000

97 98 99 00 03 04 000/01 001/02 1996/ 1997/ 1998/ 1999/ 2 2 2002/ 2003/

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

1996-1997 2003-2004 % Variation GP Attendances 486,390 478,133 -1.70 (not Emergency)

Local Government Area Estimated Population Growth, 1996-2004 Baw Baw 14.42% La Trobe 6.82%

Electorate Bulk Billing Rate Bulk Billing Rate % Variation June 2000 Dec 2003 Gippsland 56.8% 46.1% -10.7% McEwan 73.6% 60.9% -12.7%%

Practice Incentives Program, May 2004 No. of Practices in PIP 20 RRMA Category Small Rural – 14 Other Rural – 6 Ensuring patients have access to 24 hr care 19 Provision of at least 15 hours (AH) care from within the practice 18 Provision of all after hours care for practice patients 9 Practice Nurses 14

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

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%

Medical Workforce Number of General Practices 76 Number of General Practitioners 278 (not FTE) GP: Population 1:610 (not FTE)

General Practitioner Attendances, 1996-2004

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

1,580,000 1,560,000 1,540,000 1,520,000 Emergency AH 1,500,000 GP Attendances

Services 1,480,000 1,460,000 1,440,000 1,420,000

97 98 99 00 02 03 04 000/01 1996/ 1997/ 1998/ 1999/ 2 2001/ 2002/ 2003/

1996-1997 2003-2004 % Variation GP Attendances 1,473,315 1,506,158 +2.03 (not Emergency)

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

Local Government Area Estimated Population Growth, 1996-2004 Greater Dandenong 2.63% Casey 41.95%

Electorate Bulk Billing Rate Bulk Billing Rate % Variation June 2000 Dec 2003 Holt 91.4% 76.1% -15.3% Isaacs 85.3% 65.1% -20.2% La Trobe 79.7% 62.5% -17.2%

Practice Incentives Program, May 2004 No. of Practices in PIP 59 RRMA Category Capital City – 59 Ensuring patients have access to 24 hr care 59 Provision of at least 15 hours (AH) care from within the practice 46 Provision of all after hours care for practice patients 12 Practice Nurses 29

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

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% Medical Workforce Number of General Practices 25 Number of General Practitioners 79 (not FTE) GP: Population 1:908 (not FTE) General Practitioner Attendances, 1996-2004

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

300,000 295,000 290,000 285,000 Emergency AH 280,000 GP Attendances 275,000 270,000 265,000

98 99 01 03 04 9/00 001/02 1996/97 1997/ 1998/ 199 2000/ 2 2002/ 2003/

1996-1997 2003-2004 % Variation GP Attendances 295,800 278,750 -5.76 (not Emergency)

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

Local Government Area Estimated Population Growth, 1996-2004 Wellington 3.15% East Gippsland 5.27%

Electorate Bulk Billing Rate Bulk Billing Rate % Variation June 2000 Dec 2003 Gippsland 56.8% 46.1% -10.7%

Practice Incentives Program, May 2004 No. of Practices in PIP 17 RRMA Category Small Rural – 8 Other Rural – 7 Ensuring patients have access to 24 hr care 16 Provision of at least 15 hours (AH) care from within the practice 16 Provision of all after hours care for practice patients 11 Practice Nurses 15

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

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

Population Division State Persons aged 0-4 19,902 7.0% 6.5% Persons aged over 65 31,115 10.9% 12.6% Total Persons 2001 284,266 Various Information Female 50.6% 50.9% Non-English Speaking Background 5.7% 19.8% Aboriginal & Torres Strait Islanders 0.5% 0.5%

Medical Workforce Number of General Practices 68 Number of General Practitioners 205 (not FTE) GP: Population 1:1388 (not FTE)

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

General Practitioner Attendances, 1996-2004

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

850,000

800,000

750,000 Emergency AH 700,000 GP Attendances Services 650,000

600,000

97 98 99 00 03 04 000/01 001/02 1996/ 1997/ 1998/ 1999/ 2 2 2002/ 2003/

1996-1997 2003-2004 % Variation GP Attendances 830,123 701,029 -15.55 (not Emergency)

Local Government Area Estimated Population Growth, 1996-2004 Yarra Ranges 7.67%

Electorate Bulk Billing Rate Bulk Billing Rate % Variation June 2000 Dec 2003 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 Incentives Program, May 2004 No. of Practices in PIP 44 RRMA Category Capital City – 44 Ensuring patients have access to 24 hr care 44 Provision of at least 15 hours (AH) care from within the practice 35 Provision of all after hours care for practice patients 17 Practice Nurses 18

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

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

General Practitioner Attendances, 1996-2004

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

1,020,000 1,000,000 980,000 960,000 Emergency AH 940,000 GP Attendances Services 920,000 900,000 880,000

97 98 99 00 02 03 04 000/01 1996/ 1997/ 1998/ 1999/ 2 2001/ 2002/ 2003/

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

1996-1997 2003-2004 % Variation GP Attendances 991,420 939,180 -5.27 (not Emergency)

Local Government Area Estimated Population Growth, 1996-2004 Greater Geelong 14.37% Surf Coast 32.05%

Electorate Bulk Billing Rate Bulk Billing Rate % Variation June 2000 Dec 2003 Corangamite 56.4% 41.8% -14.6% Corio 68.9% 57.9% -11%

Practice Incentives Program, May 2004 No. of Practices in PIP 46 RRMA Category Other Metropolitan – 33 Small Rural – 7 Other Rural – 6 Ensuring patients have access to 24 hr care 46 Provision of at least 15 hours (AH) care from within the practice 46 Provision of all after hours care for practice patients 24 Practice Nurses 22

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

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.

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

General Practitioner Attendances, 1996-2004

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

380,000 370,000 360,000 350,000 Emergency AH 340,000 GP Attendances Services 330,000 320,000 310,000

97 98 99 00 03 04 000/01 001/02 1996/ 1997/ 1998/ 1999/ 2 2 2002/ 2003/

1996-1997 2003-2004 % Variation GP Attendances 375,083 350,188 -6.64 (not Emergency)

Local Government Area Estimated Population Growth, 1996-2004 Campaspe 12.01% Greater Shepparton 15.72% Moira 11.17% Strathbogie 11.10%

Electorate Bulk Billing Rate Bulk Billing Rate % Variation June 2000 Dec 2003 Murray 42.3% 31.5% -10.8% McEwan 73.6% 60.9% -12.7% Bendigo 52.3% 48.2% -4.1%

Practice Incentives Program, May 2004 No. of Practices in PIP 20 RRMA Category Large Rural – 8 Other Rural – 12 Ensuring patients have access to 24 hr care 20 Provision of at least 15 hours (AH) care from within the practice 17 Provision of all after hours care for practice patients 11 Practice Nurses 14

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

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

Population Division State Persons aged 0-4 10,204 5.2% 6.5% Persons aged over 65 28,032 14.3% 12.6% Total Persons 2001 195,482 Various Information Female 51.1% 50.9% Non-English Speaking Background 30.0% 19.8% Aboriginal & Torres Strait Islanders 0.2% 0.5% Medical Workforce Number of General Practices 111 Number of General Practitioners 255 GP: Population 1:766

General Practitioner Attendances, 1996-2004

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

1,400,000 1,200,000 1,000,000 800,000 Emergency AH 600,000 GP Attendances Services 400,000 200,000 0

97 98 99 00 02 03 04 000/01 1996/ 1997/ 1998/ 1999/ 2 2001/ 2002/ 2003/

1996-1997 2003-2004 % Variation GP Attendances 1,204,074 974,545 -19.06 (not Emergency)

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

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

Electorate Bulk Billing Rate Bulk Billing Rate % Variation June 2000 Dec 2003 Bruce 86.0% 76.0% -10.0% Chisholm 83.6% 72.7% -10.9%

Practice Incentives Program, May 2004 No. of Practices in PIP 51 RRMA Category Capital City – 51 Ensuring patients have access to 24 hr care 51 Provision of at least 15 hours (AH) care from within the practice 31 Provision of all after hours care for practice patients 10 Practice Nurses unknown

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

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

Population Division State Persons aged 0-4 12,701 5.3% 6.5% Persons aged over 65 36,907 15.4% 12.6% Total Persons 2001 239,862 Various Information Female 52.7% 50.9% Non-English Speaking Background 23.0% 19.8% Aboriginal & Torres Strait Islanders 0.1% 0.5% Medical Workforce Number of General Practices 84 Number of General Practitioners 200 (not FTE) GP: Population 1:1199 (not FTE)

General Practitioner Attendances, 1996-2004

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

1,100,000

1,050,000

1,000,000 Emergency AH 950,000 GP Attendances Services 900,000

850,000

97 98 99 00 02 03 04 000/01 1996/ 1997/ 1998/ 1999/ 2 2001/ 2002/ 2003/

1996-1997 2003-2004 % Variation GP Attendances 1,087,571 957,777 -11.93 (not Emergency)

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

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

Electorate Bulk Billing Rate Bulk Billing Rate % Variation June 2000 Dec 2003 Chisholm 83.6% 72.7% -10.9% Higgins 74.0% 60.5% -13.5% Kooyong 70.8% 58.3% -12.5%

Practice Incentives Program, May 2004 No. of Practices in PIP 51 RRMA Category Capital City – 51 Ensuring patients have access to 24 hr care 50 Provision of at least 15 hours (AH) care from within the practice 32 Provision of all after hours care for practice patients 10 Practice Nurses unknown

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

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% Medical Workforce Number of General Practices 171 Number of General Practitioners 432 (not FTE) GP: Population 1:417 (not FTE)

General Practitioner Attendances, 1996-2004

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

1,350,000 1,300,000 1,250,000 1,200,000 Emergency AH 1,150,000 GP Attendances Services 1,100,000 1,050,000 1,000,000

97 99 00 01 03 001/02 1996/ 1997/98 1998/ 1999/ 2000/ 2 2002/ 2003/04

1996-1997 2003-2004 % Variation GP Attendances 1,291,097 1,123,956 -12.95 (not Emergency)

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

Local Government Area Estimated Population Growth, 1996-2004 Glen Eira 10.94% Port Phillip 21.13% Stonnington 10.21%

Electorate Bulk Billing Rate Bulk Billing Rate % Variation June 2000 Dec 2003 Higgins 74.0% 60.5% -13.5% Melbourne Ports 83.8% 70.5% -13.3%

Practice Incentives Program, May 2004 No. of Practices in PIP 51 RRMA Category Capital City – 51 Ensuring patients have access to 24 hr care 51 Provision of at least 15 hours (AH) care from within the practice 37 Provision of all after hours care for practice patients 10 Practice Nurses unknown

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

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

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 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 57 Number of General Practitioners 203 (not FTE) GP: Population 1:875 (not FTE)

General Practitioner Attendances, 1996-2004

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

1,050,000

1,000,000

950,000 Emergency AH 900,000 GP Attendances Services 850,000

800,000

97 98 99 00 02 03 04 000/01 1996/ 1997/ 1998/ 1999/ 2 2001/ 2002/ 2003/

1996-1997 2003-2004 % Variation GP Attendances 1,014,122 904,948 -10.77 (not Emergency)

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

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

Electorate Bulk Billing Rate Bulk Billing Rate % Variation June 2000 Dec 2003 Aston 86.2% 71.1% -15.1% Practice Incentives Program, May 2004 No. of Practices in PIP 36 RRMA Category Capital City – 36 Ensuring patients have access to 24 hr care 36 Provision of at least 15 hours (AH) care from within the practice 24 Provision of all after hours care for practice patients 7 Practice Nurses 17

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

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.

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

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

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

340,000 330,000 320,000 Emergency AH 310,000 GP Attendances Services 300,000 290,000 280,000

97 98 99 00 03 04 000/01 001/02 1996/ 1997/ 1998/ 1999/ 2 2 2002/ 2003/

1996-1997 2003-2004 % Variation GP Attendances 322,841 307,327 -4.81 (not Emergency)

Local Government Area Estimated Population Growth, 1996-2004 Mildura 12.04% Swan Hill 6.61%

Electorate Bulk Billing Rate Bulk Billing Rate % Variation June 2000 Dec 2003 Mallee 56.9% 54.1% -2.8%

Practice Incentives Program, May 2004 No. of Practices in PIP 19 RRMA Category Small Rural – 10 Other Rural - 6 Ensuring patients have access to 24 hr care 17 Provision of at least 15 hours (AH) care from within the practice 14 Provision of all after hours care for practice patients 9 Practice Nurses 14

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

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.

Population Division State Persons aged 0-4 8,303 4.4% 6.5% Persons aged over 65 18,551 9.9% 12.6% Total Persons 2001 188,063 Various Information Female 50.3% 50.9% Non-English Speaking Background 29.0% 19.8% Aboriginal & Torres Strait Islanders 0.4% 0.5% Medical Workforce Number of General Practices 207 Number of General Practitioners 500 (not FTE) GP: Population 1:376

The Division has noted that it deals with a transient population of city workers, students and tourists. General Practitioner Attendances, 1996-2004

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

1,600,000 1,550,000 1,500,000 1,450,000 1,400,000 Emergency AH 1,350,000 GP Attendances Services 1,300,000 1,250,000 1,200,000 1,150,000

97 98 99 00 02 03 04 000/01 1996/ 1997/ 1998/ 1999/ 2 2001/ 2002/ 2003/

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

1996-1997 2003-2004 % Variation GP Attendances 1,537,874 1,300,557 -15.43 (not Emergency)

Local Government Area Estimated Population Growth, 1996-2004 Melbourne 29.62% Yarra 7.67%

Electorate Bulk Billing Rate Bulk Billing Rate % Variation June 2000 Dec 2003 Melbourne 89.8% 79.9% -9.9%

Practice Incentives Program, May 2004 No. of Practices in PIP 71 RRMA Category Capital City – 71 Ensuring patients have access to 24 hr care 69 Provision of at least 15 hours (AH) care from within the practice 39 Provision of all after hours care for practice patients 13 Practice Nurses 4

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

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%

Medical Workforce Number of General Practices 63 Number of General Practitioners 129 (not FTE) GP: Population 1:1021

General Practitioner Attendances, 1996-2004

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

1,200,000 1,000,000 800,000 Emergency AH 600,000 GP Attendances Services 400,000 200,000 0

97 98 99 00 02 03 04 000/01 1996/ 1997/ 1998/ 1999/ 2 2001/ 2002/ 2003/

1996-1997 2003-2004 % Variation GP Attendances 947,218 784,691 -17.16 (not Emergency)

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

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

Electorate Bulk Billing Bulk Billing Rate % Variation Rate Dec 2003 June 2000 Hotham 87.4% 76.4% -11.0%

Practice Incentives Program, May 2004 No. of Practices in PIP 37 RRMA Category Capital City – 37 Ensuring patients have access to 24 hr care 36 Provision of at least 15 hours (AH) care from within the practice 26 Provision of all after hours care for practice patients 4 Practice Nurses unknown

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

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

Population Division State Persons aged 0-4 17,191 6.4% 6.5% Persons aged over 65 39,962 15.0% 12.6% Total Persons 2001 266,877 Various Information Female 51.4% 50.9% Non-English Speaking Background 6.5% 19.8% Aboriginal & Torres Strait Islanders 0.5% 0.5% Medical Workforce Number of General Practices 74 Number of General Practitioners 252 (not FTE) GP: Population 1:1059 (not FTE)

General Practitioner Attendances, 1996-2004

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

1,600,000 1,400,000 1,200,000 1,000,000 Emergency AH 800,000 GP Attendances

Services 600,000 400,000 200,000 0

97 98 99 00 02 03 04 000/01 1996/ 1997/ 1998/ 1999/ 2 2001/ 2002/ 2003/

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

1996-1997 2003-2004 % Variation GP Attendances 1,342,451 1,126,198 -16.11 (not Emergency)

Local Government Area Estimated Population Growth, 1996-2004 Frankston 13.32% Mornington Peninsula 26.99%

Electorate Bulk Billing Bulk Billing Rate % Variation Rate Dec 2003 June 2000 Dunkley 79.4% 47.6% -31.8% Flinders 71.5% 44.5% -27.0% Isaacs 85.3% 65.1% -20.2%

Practice Incentives Program, May 2004 No. of Practices in PIP 48 RRMA Category Capital City – 48 Ensuring patients have access to 24 hr care 47 Provision of at least 15 hours (AH) care from within the practice 33 Provision of all after hours care for practice patients 15 Practice Nurses 29

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

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%

Medical Workforce Number of General Practices 12 Number of General Practitioners 41 GP: Population 1:1045

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

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, 1996-2004 Murray Plains Division of General Practice

270,000 260,000 250,000 Emergency AH 240,000 GP Attendances Services 230,000 220,000 210,000

97 98 99 00 03 04 000/01 001/02 1996/ 1997/ 1998/ 1999/ 2 2 2002/ 2003/

1996-1997 2003-2004 % Variation GP Attendances 251,041 231,584 -7.75 (not Emergency)

Local Government Area Estimated Population Growth, 1996-2004 Gannawarra -1.19% Loddon -0.23% Buloke -0.81%

Electorate Bulk Billing Bulk Billing Rate % Variation Rate Dec 2003 June 2000 Mallee 56.9% 54.1% -2.8% Murray 42.3% 31.5% -10.8% Practice Incentives Program, May 2004 No. of Practices in PIP 16 RRMA Category Other Rural – 12 Ensuring patients have access to 24 hr care 14 Provision of at least 15 hours (AH) care from within the practice 14 Provision of all after hours care for practice patients 10 Practice Nurses 15

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

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

Population Division State Persons aged 0-4 19,522 6.9% 6.5% Persons aged over 65 35,550 12.5% 12.6% Total Persons 2001 284,789 Various Information Female 51.1% 50.9% Non-English Speaking Background 36.4% 19.8% Aboriginal & Torres Strait Islanders 0.4% 0.5% Medical Workforce Number of General Practices 96 Number of General Practitioners 337 GP: Population 1:845

General Practitioner Attendances, 1996-2004

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

1,700,000 1,650,000 1,600,000 1,550,000 Emergency AH 1,500,000 GP Attendances Service 1,450,000 1,400,000 1,350,000 1,300,000

97 98 99 00 02 03 04 000/01 1996/ 1997/ 1998/ 1999/ 2 2001/ 2002/ 2003/

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

1996-1997 2003-2004 % Variation GP Attendances 1,638,788 1,429,416 -12.78 (not Emergency)

Local Government Area Estimated Population Growth, 1996-2004 Hume 26.80% Moreland 7.01%

Electorate Bulk Billing Bulk Billing Rate % Variation Rate Dec 2003 June 2000 Calwell 87.7% (Dec 81.5% -6.2% 2003) Maribyrnong 92.4% 82.4% -10.0% Melbourne 89.8% 79.9% -9.9% Wills 90.5% 79.0% 11.5%

Practice Incentives Program, May 2004 No. of Practices in PIP 69 RRMA Category Capital City – 69 Ensuring patients have access to 24 hr care 69 Provision of at least 15 hours (AH) care from within the practice 43 Provision of all after hours care for practice patients 7 Practice Nurses 24

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

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)

General Practitioner Attendances, 1996-2004

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

1,250,000

1,200,000

1,150,000 Emergency AH 1,100,000 GP Attendances Services 1,050,000

1,000,000

97 98 99 00 02 03 04 000/01 1996/ 1997/ 1998/ 1999/ 2 2001/ 2002/ 2003/

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

1996-1997 2003-2004 % Variation GP Attendances 1,218,444 1,105,150 -9.30 (not Emergency)

Local Government Area Estimated Population Growth, 1996-2004 Banyule 5.97% Manningham 13.81% Nillumbik 12.70%

Electorate Bulk Billing Bulk Billing Rate % Variation Rate Dec 2003 June 2000 Batman 92.9% 83.3% -9.6% Jagajaga 78.0% 72.6% -5.4% McEwan 73.6% 60.9% -12.7%

Practice Incentives Program, May 2004 No. of Practices in PIP 57 RRMA Category Capital City – 57 Ensuring patients have access to 24 hr care 57 Provision of at least 15 hours (AH) care from within the practice 32 Provision of all after hours care for practice patients 11 Practice Nurses unknown

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

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)

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

General Practitioner Attendances, 1996-2004

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

430,000 420,000 410,000 Emergency AH 400,000 GP Attendances Services 390,000 380,000 370,000

97 98 99 00 03 04 000/01 001/02 1996/ 1997/ 1998/ 1999/ 2 2 2002/ 2003/

1996-1997 2003-2004 % Variation GP Attendances 422,528 401,735 -4.92 (not Emergency)

Local Government Area Estimated Population Growth, 1996-2004 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%

Electorate Bulk Billing Rate Bulk Billing Rate % Variation June 2000 Dec 2003 Indi 42.3% 29.8% -12.5% McEwan 73.6% 60.9% -12.7%

Practice Incentives Program, May 2004 No. of Practices in PIP 25 RRMA Category Small Rural – 4 Other Rural – 21 Ensuring patients have access to 24 hr care 24 Provision of at least 15 hours (AH) care from within the practice 24 Provision of all after hours care for practice patients 12 Practice Nurses 23

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

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

Population Division State Persons aged 0-4 18,096 6.7% 6.5% Persons aged over 65 34,029 12.5% 12.6% Total Persons 2001 271,653 Various Information Female 50.9% 50.9% Non-English Speaking Background 45.2% 19.8% Aboriginal & Torres Strait Islanders 0.6% 0.5% Medical Workforce Number of General Practices 128 Number of General Practitioners 264 (57% FT; 35% PT) GP: Population 1:1464 (FTE)

General Practitioner Attendances, 1996-2004

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

1,550,000

1,500,000

1,450,000 Emergency AH 1,400,000 GP Attendances Services 1,350,000

1,300,000

97 98 99 00 02 03 04 000/01 1996/ 1997/ 1998/ 1999/ 2 2001/ 2002/ 2003/

1996-1997 2003-2004 % Variation GP Attendances 1,488,274 1,379,508 -7.31 (not Emergency)

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

Local Government Area Estimated Population Growth, 1996-2004 Hume 26.80% Moreland 7.01%

Electorate Bulk Billing Rate Bulk Billing Rate % Variation June 2000 Dec 2003 Scullin 91.0% 84.8% -6.2% Wills 90.5% 79.0% -11.5%

Practice Incentives Program, May 2004 No. of Practices in PIP 63 RRMA Category Capital City – 63 Ensuring patients have access to 24 hr care 63 Provision of at least 15 hours (AH) care from within the practice 35 Provision of all after hours care for practice patients 5 Practice Nurses 7

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

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%

Medical Workforce Number of General Practices 35 Number of General Practitioners 108 (not FTE) GP: Population 1:1097 (not FTE)

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

General Practitioner Attendances, 1996-2004

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

510,000 500,000 490,000 480,000 Emergency AH 470,000 GP Attendances Services 460,000 450,000 440,000

97 98 99 00 03 04 000/01 001/02 1996/ 1997/ 1998/ 1999/ 2 2 2002/ 2003/

1996-1997 2003-2004 % Variation GP Attendances 496,856 466,386 -6.13 (not Emergency)

Local Government Area Estimated Population Growth, 1996-2004 Colac-Otway 7.17% Corangamite 2.21% Moyne -2.71% Glenelg 0.18%

Electorate Bulk Billing Rate Bulk Billing Rate % Variation June 2000 Dec 2003 Corangamite 56.4% 41.8% -14.6% Wannon 55.7% 42.2% -13.5% Practice Incentives Program, May 2004 No. of Practices in PIP 28 RRMA Category Small Rural – 13 Other Rural – 15 Ensuring patients have access to 24 hr care 28 Provision of at least 15 hours (AH) care from within the practice 27 Provision of all after hours care for practice patients 13 Practice Nurses 21

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

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%

Medical Workforce Number of General Practices 12 Number of General Practitioners 74 (not FTE) GP: Population 1:802 (not FTE)

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

General Practitioner Attendances, 1996-2004

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

260,000 250,000 240,000 230,000 Emergency AH 220,000 GP Attendances Services 210,000 200,000 190,000

97 98 99 00 03 04 000/01 001/02 1996/ 1997/ 1998/ 1999/ 2 2 2002/ 2003/

1996-1997 2003-2004 % Variation GP Attendances 225,774 246,330 +9.10 (not Emergency)

Local Government Area Estimated Population Growth, 1996-2004 Cardinia 26.36% South Gippsland 12.71% Bass Coast 36.25%

Electorate Bulk Billing Rate Bulk Billing Rate % Variation June 2000 Dec 2003 McMillan 68.2% (Dec 2002) 67.6% -0.6%

Practice Incentives Program, May 2004 No. of Practices in PIP 9 RRMA Category Other Rural – 8 Ensuring patients have access to 24 hr care 9 Provision of at least 15 hours (AH) care from within the practice 9 Provision of all after hours care for practice patients 7 Practice Nurses 8

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

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)

General Practitioner Attendances, 1996-2004

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

385,000 380,000 375,000 370,000 365,000 Emergency AH 360,000 GP Attendances Services 355,000 350,000 345,000 340,000

97 98 99 00 03 04 000/01 001/02 1996/ 1997/ 1998/ 1999/ 2 2 2002/ 2003/

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

1996-1997 2003-2004 % Variation GP Attendances 381,261 370,386 -2.74 (not Emergency)

Local Government Area Estimated Population Growth, 1996-2004 West Wimmera -5.32% Hindmarsh -0.40% Southern Grampians -1.55% Northern Grampians 0.15% Yarrambiack -5.10% Ararat 4.98% Pyrenees 0.23%

Electorate Bulk Billing Rate Bulk Billing Rate % Variation June 2000 Dec 2003 Mallee 56.9% 54.1% -2.8% Wannon 55.7% 42.2% -13.5%

Practice Incentives Program, May 2004 No. of Practices in PIP 22 RRMA Category Small Rural – 4 Other Rural – 17 Ensuring patients have access to 24 hr care 22 Provision of at least 15 hours (AH) care from within the practice 20 Provision of all after hours care for practice patients 15 Practice Nurses 16

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

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

Population Division State Persons aged 0-4 19,600 7.1% 6.5% Persons aged over 65 26,164 9.5% 12.6% Total Persons 2001 275,832 Various Information Female 50.3% 50.9% Non-English Speaking Background 44.7% 19.8% Aboriginal & Torres Strait Islanders 0.4% 0.5%

Medical Workforce Number of General Practices 107 Number of General Practitioners 269 (not FTE) GP: Population 1:1025 (not FTE)

General Practitioner Attendances, 1996-2004

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

1,700,000 1,650,000 1,600,000 Emergency AH 1,550,000 GP Attendances Services 1,500,000 1,450,000 1,400,000

97 98 99 00 02 03 04 000/01 1996/ 1997/ 1998/ 1999/ 2 2001/ 2002/ 2003/

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

1996-1997 2003-2004 % Variation GP Attendances 1,606,573 1,497,455 -6.79 (not Emergency)

Local Government Area Estimated Population Growth, 1996-2004 Brimbank 17.19% Maribyrnong 8.97% Moonee Valley 6.22%

Electorate Bulk Billing Rate Bulk Billing Rate % Variation June 2000 Dec 2003 Gellibrand 94.5% 85.0% -9.5% Maribyrnong 92.4% 82.4% -10.0%

Practice Incentives Program, May 2004 No. of Practices in PIP 68 RRMA Category Capital City – 68 Ensuring patients have access to 24 hr care 67 Provision of at least 15 hours (AH) care from within the practice 33 Provision of all after hours care for practice patients 10 Practice Nurses 18

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

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

Population Division State Persons aged 0-4 12,496 7.5% 6.5% Persons aged over 65 15,887 9.5% 12.6% Total Persons 2001 167,322 Various Information Female 50.4% 50.9% Non-English Speaking Background 23.4% 19.8% Aboriginal & Torres Strait Islanders 0.5% 0.5% Medical Workforce Number of General Practices 46 Number of General Practitioners 145 (not FTE) GP: Population 1:1218 (not FTE)

General Practitioner Attendances, 1996-2004

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

820,000 800,000 780,000 760,000 Emergency AH 740,000 GP Attendances

Services 720,000 700,000 680,000 660,000

97 98 99 00 03 04 000/01 001/02 1996/ 1997/ 1998/ 1999/ 2 2 2002/ 2003/

1996-1997 2003-2004 % Variation GP Attendances 758,682 717,712 -5.40 (not Emergency)

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

Local Government Area Estimated Population Growth, 1996-2004 Wyndham 34.86% Hobson’s Bay 14.51%

Electorate Bulk Billing Rate Bulk Billing Rate % Variation June 2000 Dec 2003 Gellibrand 94.5% 85.0% -9.5% Lalor 91.6% 77.2% -14.4%

Practice Incentives Program, May 2004 No. of Practices in PIP 31 RRMA Category Capital City – 31 Ensuring patients have access to 24 hr care 31 Provision of at least 15 hours (AH) care from within the practice 12 Provision of all after hours care for practice patients 14 Practice Nurses 11

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

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

Population Division State Persons aged 0-4 16,092 6.0% 6.5% Persons aged over 65 39,003 14.4% 12.6% Total Persons 2001 269,929 Various Information Female 51.9% 50.9% Non-English Speaking Background 23.9% 19.8% Aboriginal & Torres Strait Islanders 0.2% 0.5%

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

General Practitioner Attendances, 1996-2004

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

1,450,000 1,400,000 1,350,000 1,300,000 Emergency AH 1,250,000 GP Attendances Services 1,200,000 1,150,000 1,100,000

97 98 99 00 02 03 04 000/01 1996/ 1997/ 1998/ 1999/ 2 2001/ 2002/ 2003/

1996-1997 2003-2004 % Variation GP Attendances 1,413,181 1,228,049 -13.10 (not Emergency)

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

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

Electorate Bulk Billing Rate Bulk Billing Rate % Variation June 2000 Dec 2003 Deakin 80.6% 64.6% -16.0% Menzies 80.7% 70.0% -10.7%

Practice Incentives Program, May 2004 No. of Practices in PIP 57 RRMA Category Capital City – 57 Ensuring patients have access to 24 hr care 57 Provision of at least 15 hours (AH) care from within the practice 39 Provision of all after hours care for practice patients 9 Practice Nurses 5

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

ALL REGIONAL DIVISIONS OF GENERAL PRACTICE General Practitioner Attendances, 1996-2004 Does not include Emergency AH attendances.

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

7,800,000 7,700,000 7,600,000 7,500,000 GP Attendances 7,400,000 Services 7,300,000 7,200,000 7,100,000

97 98 99 01 02 04 9/00 1996/ 1997/ 1998/ 199 2000/ 2001/ 2002/032003/

1996-1997 2003-2004 % Variation GP Attendances 7,765,066 7,359,685 -5.22 (not Emergency)

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).

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

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

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

20,000,000

15,000,000

10,000,000 GP Attendances Services 5,000,000

97 98 99 01 02 03 04 9/00 1996/ 1997/ 1998/ 199 2000/ 2001/ 2002/ 2003/

1996-1997 2003-2004 % Variation GP Attendances 18,949,879 15,719,673 -17.05 (not Emergency)

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).

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

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

26,000,000 25,500,000 25,000,000 24,500,000 24,000,000 GP Attendances 23,500,000

Services 23,000,000 22,500,000 22,000,000 21,500,000

97 98 00 01 02 03 04 8/99 1996/ 1997/ 199 1999/ 2000/ 2001/ 2002/ 2003/

1996-1997 2003-2004 % Variation GP Attendances 25,496,501 23,079,358 -9.48 (not Emergency)

Victoria 1996-1997 2003-2004 % Variation Bulk Billing Rate 78.5% 64.5% -14.00% (Non-referred GP attendances, GP/VRGP)

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

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

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, 1996-2004 Eastern Metropolitan Health Region

180,000 160,000 140,000 120,000 All 100,000 Admitted 80,000 Presentations 60,000 40,000 20,000 0 1996- 1997- 1998- 1999- 2000- 2001- 2002- 2003- 1997 1998 1999 2000 2001 2002 2003 2004

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

180,000 160,000 Angliss 140,000 Box Hill 120,000 100,000 Maroondah 80,000 60,000 Monash Medical 40,000 Centre 20,000 TOTAL 0 1996- 1997- 1998- 1999- 2000- 2001- 2002- 2003- 1997 1998 1999 2000 2001 2002 2003 2004

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

180,000 160,000 140,000 120,000 All 100,000 Categories 1, 2 & 3 80,000 60,000 Categories 4 & 5 40,000 20,000 0

1998 1999 2000 2002 2003 9- 2- 9 0 1997- 1998- 19 2000-20012001- 20 003-2004* 2

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

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%

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

PUBLIC Hospital Town Data included 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

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, 1996-2004 Northern Metropolitan Health Region

140,000 120,000 100,000 All 80,000 Admitted 60,000 40,000 Presentations 20,000 0 7 2 99 003 1 200 2 004* 2 996- 001- 1 1997-19981998-19991999-20002000-20012 2002- 2003-

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

140,000 120,000 100,000 Austin & Repat 80,000 Northern Hospital 60,000 St Vincent's 40,000 TOTAL 20,000 0

9 0 3 9 0 0 9 0 -1 -20 -2 8 9 2 9 0 9 0 1996-19971997-19981 199 2000-20012001-20022 2003-2004

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

140,000 120,000

100,000 All 80,000 Categories 1, 2 & 3 60,000 Categories 4 & 5 40,000

20,000 0

00 02 04 1998 20 2001 0 2003 0 7- 9- 2- 99 99 001-2 00 1 1998-19991 2000- 2 2 2003-2

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

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%

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

PUBLIC Hospital Town Data included 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.

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, 1996-2004 Western Metropolitan Health Region

160,000 140,000 120,000 100,000 All 80,000 Admitted 60,000 Presentations 40,000 20,000 0 0 1 2 3 4 00 00 00 00 00 1997 1998 1999 2 2 2 2 2 6- 7- 8- 9 9 9 999- 000- 001- 002- 003- 19 19 19 1 2 2 2 2

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

160,000 140,000 120,000 Royal Melbourne 100,000 Sunshine 80,000 60,000 Western 40,000 TOTAL 20,000 0 7 999 000 199 1 2 004* 2 996- 1 1997-19981998- 1999- 2000-20012001-20022002-2003 2003-

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

160,000 140,000 120,000 100,000 All 80,000 Categories 1, 2 & 3 60,000 Categories 4 & 5 40,000 20,000 0

* 98 00 02 4 0 0 -19 -20 -2 7 9 1 3-20 99 99 0 1 1998-19991 2000-200120 2002-2003200

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

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

70,000 60,000 50,000 All 40,000 Categories 1, 2 & 3 30,000 20,000 Categories 4 & 5 10,000 0 3 00 2 002- 1997-19981998-19991999-20002000-20012001-20022 2003-2004*

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

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%

Hospital Services with Emergency Departments Unless otherwise stated, EDs are open 24 hours. PUBLIC Hospital Town Data included 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

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

Admissions & Presentations to EDs, 1996-2004

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

140,000 120,000 100,000 All 80,000 Admitted 60,000 Presentations 40,000 20,000 0 1996- 1997- 1998- 1999- 2000- 2001- 2002- 2003- 1997 1998 1999 2000 2001 2002 2003 2004

ED Presenations & Admissions, 1996-2004 Southern Metropolitan Health Region - by Hospital

140,000 120,000 100,000 80,000 60,000 40,000 Dandenong 20,000 0 Frankston 7 9 1 9 9 0 003 The Alfred 19 19 20 - 7-1998 - 9-2000 - 1-2002 -2 3-2004 996 99 998 99 000 00 002 00 1 1 1 1 2 2 2 2 TOTAL

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

140,000 120,000 100,000 All 80,000 Categories 1, 2 & 3 60,000 40,000 Categories 4 & 5 20,000 0 8 1 2 99 00 0 20 004* 7-1 0-2 - 99 0 1 1998-19991999-200020 2001 2002-2003003-2 2

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 & Admissions Metropolitan Victoria: 1996-2004

600,000

500,000

400,000 All 300,000 Admitted 200,000 Presentations

100,000

0 1996- 1997- 1998- 1999- 2000- 2001- 2002- 2003- 1997 1998 1999 2000 2001 2002 2003 2004

ED Presentations by ATS Category Metropolitan Victoria: 1997-2004

600,000

500,000

400,000 All 300,000 Categories 1, 2 & 3

200,000 Categories 4 & 5

100,000

0 1997- 1998- 1999- 2000- 2001- 2002- 2003- 1998 1999 2000 2001 2002 2003 2004

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

100%

80%

60% Categories 4 & 5 40% Categories 1, 2 & 3

20%

0% 1997- 1998- 1999- 2000- 2001- 2002- 2003- 1998 1999 2000 2001 2002 2003 2004

102

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

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%

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

PUBLIC Hospital Town Data included 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

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, 1996-2004 Barwon Health

45,000 40,000 35,000 30,000 25,000 All 20,000 15,000 10,000 5,000 0 1996- 1997- 1998- 1999- 2000- 2001- 2002- 2003- 1997 1998 1999 2000 2001 2002 2003 2004

ED Presentations by ATS Category, 1997-2004 Barwon Health

45,000 40,000 35,000 30,000 All 25,000 Categories 1, 2 & 3 20,000 15,000 Categories 4 & 5 10,000 5,000 0 3 00 2 002- 1997-19981998-19991999-20002000-20012001-20022 2003-2004*

104

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

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%

Hospital Services with Emergency Departments Unless otherwise stated, EDs are open 24 hours. PUBLIC Hospital Town Data included 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, No Donald, Wycheproof 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, 1996-2004 Bendigo Health Care Group

35,000 30,000 25,000 20,000 All 15,000 10,000 5,000 0 1996- 1997- 1998- 1999- 2000- 2001- 2002- 2003- 1997 1998 1999 2000 2001 2002 2003 2004

ED Presentations by ATS Category, 1997-2004 Bendigo Health Care Group

35,000 30,000 25,000 All 20,000 Categories 1, 2 & 3 15,000 10,000 Categories 4 & 5 5,000 0 3 00 2 002- 1997-19981998-19991999-20002000-20012001-20022 2003-2004*

106

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

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. PUBLIC Hospital Town Data included in HSR Bairnsdale Regional Health Service Bairnsdale No Central Gippsland Health Service Sale No Far East Gippsland Health & Support Service Orbost No (AH) 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

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, 1996-2004 Latrobe Regional Hospital

35,000 30,000 25,000 20,000 All 15,000 10,000 5,000 0 1996- 1997- 1998- 1999- 2000- 2001- 2002- 2003- 1997 1998 1999 2000 2001 2002 2003 2004

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

35,000 30,000 25,000 All 20,000 Categories 1, 2 & 3 15,000 Categories 4 & 5 10,000 5,000 0 3 999 1 200 004* 2 002- 1997-19981998- 1999-20002000-20012001-20022 2003-

108

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

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%

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

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

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, 1996-2004

ED Presentations & Admissions, 1996-2004 Ballarat Health Services

40,000 35,000 30,000 25,000 20,000 All 15,000 10,000 5,000 0 1996- 1997- 1998- 1999- 2000- 2001- 2002- 2003- 1997 1998 1999 2000 2001 2002 2003 2004

ED Presentations by ATS Category, 1997-2004 Ballarat Health Services

40,000 35,000 30,000 25,000 All 20,000 Categories 1, 2 & 3 15,000 Categories 4 & 5 10,000 5,000 0 3 00 2 002- 1997-19981998-19991999-20002000-20012001-20022 2003-2004*

110

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

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. PUBLIC Hospital Town Data included in HSR Alpine Health (limited AH) Bright, Mount Beauty, No Myrtleford 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

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ED Presentations & Admissions, 1996-2004

ED Presentations & Admissions, 1996-2004 Goulburn Valley Health

35,000 30,000 25,000 20,000 All 15,000 10,000 5,000 0 1996- 1997- 1998- 1999- 2000- 2001- 2002- 2003- 1997 1998 1999 2000 2001 2002 2003 2004

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

35,000 30,000 25,000 All 20,000 Categories 1, 2 & 3 15,000 Categories 4 & 5 10,000 5,000 0 3 00 2 002- 1997-19981998-19991999-20002000-20012001-20022 2003-2004*

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REGIONAL HEALTH SERVICE REGIONS – SUMMARY

ED Admissions & Presentations Rural Health Service Regions: 1996-2004

180,000 160,000 140,000 120,000 All 100,000 Categories 1, 2 & 3 80,000 60,000 Categories 4 &5 40,000 20,000 0 1997- 1998- 1999- 2000- 2001- 2002- 2003- 1998 1999 2000 2001 2002 2003 2004

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

100%

80%

60% Categories 1, 2 & 3 40% Categories 4 &5

20%

0% 1997- 1998- 1999- 2000- 2001- 2002- 2003- 1998 1999 2000 2001 2002 2003 2004

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%

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METROPOLITAN HEALTH SERVICE REGIONS – SUMMARY

ED Presentations by ATS Category Metropolitan Victoria: 1997-2004

600,000

500,000

400,000 All 300,000 Categories 1, 2 & 3

200,000 Categories 4 & 5

100,000

0 1997- 1998- 1999- 2000- 2001- 2002- 2003- 1998 1999 2000 2001 2002 2003 2004

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

100%

80%

60% Categories 1, 2 & 3 40% Categories 4 & 5

20%

0% 1997- 1998- 1999- 2000- 2001- 2002- 2003- 1998 1999 2000 2001 2002 2003 2004

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.

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VICTORIAN HEALTH SERVICE REGIONS - SUMMARY

ED Presentations & Admissions by ATS Category Victoria 1997-2004

800,000 700,000 600,000 500,000 All 400,000 Categories 1, 2 & 3 300,000 Categories 4 & 5 200,000 100,000 0 1997- 1998- 1999- 2000- 2001- 2002- 2003- 1998 1999 2000 2001 2002 2003 2004

ED Presentations & Admissions by % of ATS Category Victoria 1997-2004

100%

80%

60% Categories 1, 2 & 3 40% Categories 4 & 5

20%

0% 1997- 1998- 1999- 2000- 2001- 2002- 2003- 1998 1999 2000 2001 2002 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.

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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/medicar e.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

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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/

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118 CHAPTER THREE DEALING WITH INCREASED EMERGENCY PRESENTATIONS: ISSUES, STRATEGIES AND SOLUTIONS

¾ Introduction ¾ The Link between General Practice and Increased Emergency Presentations ¾ Other Causes of Increased Presentations ¾ State, Federal and Joint Initiatives ¾ Telephone Triage ¾ 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

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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

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

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

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

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 Annual % change 2000/01 - 2001/02 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 6.8% 4.5% reason within 28 days Source: DHS, Victorian Admitted Episodes Dataset and Victorian Emergency Minimum Dataset

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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 coordinated 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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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,

133 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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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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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

139 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

141 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 • ICU liaison • Haematology • Custodial nursing • Diabetes (3) • Homeless persons • Community midwifery • Primary health care • Palliative care (2) (3) • Youth (2) • Women's health • Paediatrics (2) • Aged care (3) • Wound management • Neonatal nursing • Maternal and Child Health. • Cystic Fibrosis • Aboriginal health (midwifery & women's • Mental health (3) health) • Men's health • Haematology • Dialysis • Peri-operative

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

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Dealing with Increased Emergency Presentations: Issues, Strategies and Solutions 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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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.

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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

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148 CHAPTER FOUR EXPLAINING AND RESOLVING THE DECLINE IN BULK BILLING AND AFTER HOURS GENERAL PRACTITIONERS

¾ Introduction ¾ The Decline in Bulk Billing ¾ The Decline in After Hours Services ¾ Federal Initiatives to address the problems ¾ 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.

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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

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

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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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Explaining and resolving the decline in bulk billing and after hours general practitioners 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

Source: Ronald Henderson Research Foundation

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

Source: Ronald Henderson Research Foundation 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 Annual % persons 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 3,259 1,542 3,628 1,984 Number

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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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).

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

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:

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

• $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.

y an increase in the number of General Practitioners practising in community health centres

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

y the introduction of localised telephone triage centres.

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

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.

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

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Explaining and resolving the decline in bulk billing and after hours general practitioners 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 Inquiry on the Impact on the Victorian Community and Public Hospitals of the Diminishing Access to After Hours and Bulk Billing General Practitioners

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

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

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.

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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 Medical Fees? An Econometric Analysis of Medical Fees across Australia, Paper presented to the 24th 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 Medical Fees? An Econometric Analysis of Medical Fees across Australia, Paper presented to the 24th 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.

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

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

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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

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

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 Need and the Availability of GP Services, a report to the Australian Medical Association from Access Economics Pty Ltd, February 2002, p. 14 75 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. 14 76 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. 14 77 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. 14 78 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. 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 http://www.aph.gov.au/senate/committee/medicare_ctte/report/index.htm

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 http://www.aph.gov.au/senate/committee/medicare_ctte/report/index.htm

Department of Health and Ageing, Submission

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85 Senate Select Committee on Medicare http://www.aph.gov.au/senate/committee/medicare_ctte/report/index.htm

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

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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- East Gippsland ordinator Division of General Practice 4 Toni Aslett Chief Executive Latrobe Community Officer Health 5 Barry O'Callaghan Chairman Mercy Health and AO Aged Care Group 6 Durham Smith

7 Associate Professor Director of Royal Melbourne Marcus Kennedy Emergency Services Hospital

8 Michael Gorey Executive Officer, Alpine Health Community & Health Advisory Groups 9 Rod Wilson Convenor Victorian Medicare Action Group 10 Paul Woodhouse Director, Policy Australian Medical Development Association (Victoria) Limited 11 Michael Walsh Chief Executive Bayside Health

12 Colin Smeal Senior Policy Officer, Australian Medical Medical Practice Association Department 13 Sandra Walker Chief Executive Goulburn Valley Officer Community Health Service 14 Miriam Manintveld Regional Youth Batforce Affairs Consultant 15 P. M. Faulkner Secretary Department of Human Services

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

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

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

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

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 Mrs Helen J. Shardey, MLA Ms Lisa Neville, MLA Mr Robert Smith, MLC Mr Dale Wilson, MLA

The motion was defeated.

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 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 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 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 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.

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Extracts from Proceedings

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 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 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 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 Mrs Helen J. Shardey, MLA Ms Lisa Neville, MLA Mr Robert Smith, MLC 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 Mrs Helen J. Shardey, MLA Ms Lisa Neville, MLA Mr Robert Smith, MLC Mr Dale Wilson, MLA

The motion was defeated.

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 Robert Smith, MLC 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

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Extracts from Proceedings

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 Robert Smith, MLA Mr Dale Wilson, MLA

The motion was carried.

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

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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

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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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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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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

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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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• 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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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:

This was seconded by Mrs Helen J. Shardey, MLA.

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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

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:

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

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The motion was defeated.

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

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 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 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 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.

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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 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 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:

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

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The motion was defeated.

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 Robert Smith, MLC 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

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 Robert Smith, MLA Mr Dale Wilson, MLA

The motion was carried.

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.

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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.

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Regional Health Service Regions – Summary (From Majority Report)

ED Admissions & Presentations Rural Health Service Regions: 1996-2004

180,000 160,000 140,000 120,000 All 100,000 Categories 1, 2 & 3 80,000 60,000 Categories 4 &5 40,000 20,000 0 1997- 1998- 1999- 2000- 2001- 2002- 2003- 1998 1999 2000 2001 2002 2003 2004

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

100%

80%

60% Categories 1, 2 & 3 40% Categories 4 &5

20%

0% 1997- 1998- 1999- 2000- 2001- 2002- 2003- 1998 1999 2000 2001 2002 2003 2004

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

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Metropolitan Health Service Regions – Summary (From Majority Report)

ED Presentations by ATS Category Metropolitan Victoria: 1997-2004

600,000

500,000

400,000 All 300,000 Categories 1, 2 & 3

200,000 Categories 4 & 5

100,000

0 1997- 1998- 1999- 2000- 2001- 2002- 2003- 1998 1999 2000 2001 2002 2003 2004

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

100%

80%

60% Categories 1, 2 & 3 40% Categories 4 & 5

20%

0% 1997- 1998- 1999- 2000- 2001- 2002- 2003- 1998 1999 2000 2001 2002 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

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Victorian Health Service Regions - Summary (From Majority Report)

ED Presentations & Admissions by ATS Category Victoria 1997-2004

800,000 700,000 600,000 500,000 All 400,000 Categories 1, 2 & 3 300,000 Categories 4 & 5 200,000 100,000 0 1997- 1998- 1999- 2000- 2001- 2002- 2003- 1998 1999 2000 2001 2002 2003 2004

ED Presentations & Admissions by % of ATS Category Victoria 1997-2004

100%

80%

60% Categories 1, 2 & 3 40% Categories 4 & 5

20%

0% 1997- 1998- 1999- 2000- 2001- 2002- 2003- 1998 1999 2000 2001 2002 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

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Majority Report:

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

140,000 120,000

100,000 All 80,000 Categories 1, 2 & 3 60,000 Categories 4 & 5 40,000

20,000 0

00 02 04 1998 20 2001 0 2003 0 7- 9- 2- 99 99 001-2 00 1 1998-19991 2000- 2 2 2003-2

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, 1997-2004 Western Metropolitan Health Region

160,000 140,000 120,000 100,000 All 80,000 Categories 1, 2 & 3 60,000 Categories 4 & 5 40,000 20,000 0

* 98 00 02 4 0 0 -19 -20 -2 7 9 1 3-20 99 99 0 1 1998-19991 2000-200120 2002-2003200

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

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Majority Report:

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

180,000 160,000 140,000 120,000 All 100,000 Categories 1, 2 & 3 80,000 60,000 Categories 4 & 5 40,000 20,000 0

1998 1999 2000 2002 2003 9- 2- 9 0 1997- 1998- 19 2000-20012001- 20 003-2004* 2

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, 1997-2004 Southern Metropolitan Health Region

140,000 120,000 100,000 All 80,000 Categories 1, 2 & 3 60,000 40,000 Categories 4 & 5 20,000 0 8 1 2 99 00 0 20 004* 7-1 0-2 - 99 0 1 1998-19991999-200020 2001 2002-2003003-2 2

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

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Majority Report:

ED Presentations by ATS Category, 1997-2004 Barwon Health

45,000 40,000 35,000 30,000 All 25,000 Categories 1, 2 & 3 20,000 15,000 Categories 4 & 5 10,000 5,000 0 3 00 2 002- 1997-19981998-19991999-20002000-20012001-20022 2003-2004*

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, 1997-2004 Bendigo Health Care Group

35,000 30,000 25,000 All 20,000 Categories 1, 2 & 3 15,000 10,000 Categories 4 & 5 5,000 0 3 00 2 002- 1997-19981998-19991999-20002000-20012001-20022 2003-2004*

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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Majority Report:

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

35,000 30,000 25,000 All 20,000 Categories 1, 2 & 3 15,000 Categories 4 & 5 10,000 5,000 0 3 00 2 002- 1997-19981998-19991999-20002000-20012001-20022 2003-2004*

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, 1997-2004 Ballarat Health Services

40,000 35,000 30,000 25,000 All 20,000 Categories 1, 2 & 3 15,000 Categories 4 & 5 10,000 5,000 0 3 00 2 002- 1997-19981998-19991999-20002000-20012001-20022 2003-2004*

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

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Majority Report:

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

35,000 30,000 25,000 All 20,000 Categories 1, 2 & 3 15,000 Categories 4 & 5 10,000 5,000 0 8 9 0 1 2 003 199 199 200 200 200 004* 7- 8- 9- 0- 1- 2-2 2 00 199 199 199 200 200 2 2003-

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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Some key results are presented below:

No. of patients stay in each hospital emergency How often are hospital emergency departments department for longer than 12 hours before they going on bypass were admitted to a bed in the same hospital Mar-04 120 106 6,000 Mar-04

s 100 4,784 Mar-99 se s 5,000 t 80 72 n as e

i 4,000 t yp

a 60 Mar-99 b P 3,000 f f o 40 o 2,000 1,614 . . o

N 20 No 1,000 - 0 Mar 04 Quarterly Hospital services Report Mar 04 Quarterly Hospital Services report

Patients on Waiting Lists for Elective Surgery Patients on Waiting Lists for Elective Surgery (Urgent) (Semi-urgent)

Mar-04 800 20,000 Mar-04 767 16,275 s s Mar-99 t 750 t 15,000 n n e e 11,622 i i t t a Mar-99 a P 700 P 10,000 f 667 f o o . . 650 5,000 No No

600 - Mar 04 Quarterly Hospital Services Report Mar 04 Quarterly Hospital Services report

Patients on Waiting Lists longer than ideal (Semi-urgent) Mar-04 8,000 7,015 s t

n 6,000 e

i Mar-99 t a

P 4,000 3,180 f o . 2,000 No - 1 Mar 04 Quareterly Hospital Services report

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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-04 41000 40643

40000

39000 Mar-03 38000 37594

No. of Patients 37000

36000 March 04 Quarterly Hospital Services Report

People on Waiting Lists for Elective Surgery Patients on Waiting Lists for Elective Surgery (Urgent) (Semi-urgent)

Mar-04 Mar-04 780 17,000 767 16,275 770 s s 16,000 t 760 t n n e e i 750 i t t 15,000 Mar-03 a Mar-03 a P 740 P 13,916 f 726 f o 730 o 14,000 . . 720 No No 13,000 710 700 12,000 Mar 04 Quarterly Hospital Services report Mar 04 Quarterly Hospital Services Report

Patients on Waiting Lists for Elective Surgery Patients on Waiting Lists longer than ideal (Non-urgent) (Semi-urgent)

Mar-04 23,800 7,500 Mar-04 23,601 7,015 23,600 s s 7,000 t t n n e 23,400 e i i t t 6,500 a a Mar-03 P 23,200 Mar-03 P f f 5,869 o 22,952 o 6,000 . 23,000 . No 22,800 No 5,500 22,600 5,000 Mar 04 Quarterly Hospital Services report Mar 04 Quarterly Hospital Services report

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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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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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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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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.

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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 March Increase Percent 2003 2004 Increase

People on Waiting lists for Elective 1664 1858 194 11.7% Surgery

How many patients stay in each 13 52 39 300% hospital emergency department for longer than 12 hours before they were admitted to a bed in the same hospital?

People on Waiting Lists for Elective 224 275 51 22.8% Surgery (Semi-Urgent)

People on Waiting Lists for Elective 1416 1561 145 10.2% Surgery (Non-Urgent) 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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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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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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David Davis, MLC

Helen Shardey MLC

Jeanette Powell MLC

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Frankston – 28 July Dr S. Sdrinis, Manager, Dr SDRINIS — The GP division down here, and I am sure many other GP divisions, have taken up Page 14 2003 Medical Operations, disease management initiatives from the commonwealth, particularly with diabetes, asthma, Peninsula Health 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. Geelong – 6 August Dr J. Pascoe, Acting Dr PASCOE — For a start, we have a very cramped waiting room, and it struggles to cope with the Page 59 2003 Director, Emergency number of walk-up presentations to the emergency department. In that waiting room we have the Department 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. Warrnambool – Dr G. O’Brien, Dr O’BRIEN — ..The largest campus of that organisation is the Warrnambool hospital campus with Page 74 7 August 2003 Director of Medical 155 beds, and I understand that this afternoon you are going to visit the emergency department and any Services 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. Bendigo–13 August, Dr J. Ferguson, Group Dr FERGUSON —….Again, there is nothing unique there, but there are not well-developed drug and Page 117 2003 Medical Director, alcohol services in Bendigo. There are some, but they are not well developed. When there is any Bendigo Health Care shortage the hospital always acts as a safety net, so those patients tend to end up in the emergency Group 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. Bendigo–13 August, Ms S. Clark, Chief Ms CLARK — …We counsel a lot of people with AIDS and other, if you like, blood-borne Page 137 2003 Executive Officer 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 Mr R. Burnham, Dr WINTER — It was the meeting held with directors of emergency departments and the nurses and Page 268 2003 General Manager; managers of emergency departments which is held every second month at Epworth. He was there, and Dr C. Winter, he was very clear on that issue, and that is quite different to what our experience is. It has caused much Emergency Department discussion amongst the emergency departments that the chief psychiatrist is saying there is no problem Director, Northern with accessing beds, and yet we are commonly holding a patient because there are no beds. I guess he Hospital. 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. Eastern Health - 19 Professor J. Rasa, chief Mr DAVIS — I want to take you — and I am sure you are not surprised at this — to the letter Page 19-21 April 2004 general manager, acute from Dr Archer of 15 February 2004 — and for those who may not know Dr Archer is the director of services 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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Minority Report 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 173 Canterbury Road Parliament House Canterbury, VIC., 3126 Melbourne, VIC., 3002 Telephone: 9888 6244 Telephone: 9651 8911 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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It is critical that the Chief Psychiatrist should be invited to give evidence as a witness under oath. It is also critical, given the last page of Dr Archer’s letter that Dr Ruth Vine, Director, Mental Health Branch, Victoria be invited to give evidence to the Inquiry.

I look forward to further discussing these important matters in the hope that through the recommendations of our inquiry, Victoria can develop a better system of caring for psychiatric patients in its emergency departments and have in place appropriate management and referral protocols.

I will contact you about this matter shortly.

Yours sincerely,

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