Module 1 - Topic 1: Delivery of Health Services

Learning outcomes

When you have completed this topic, you should be able to:

1. Describe the structure of the Australian System

In particular, you should be able to:

 Describe health services provided to .  Differentiate private from public health care services.  Identify health care initiatives for special populations, including people in rural and remote areas and .  Explain the role of the Australian and State and Territory Governments with regard to funding and service provision.  Outline how health services are regulated.  Identify other health agencies that support the Australian Health Care System.

About

Australia is a vast continent with a land mass roughly the same size as Western Europe or the United States of America (excluding Alaska). It has a total population of nearly 23 million.1 The majority of whom (over 80%) live within 50km of the coastline. There are large regions of Australia that have only small, scattered settlements or which are unpopulated.

Settlement of Australia began more than 40 thousand years ago by people now known as 'Indigenous Australians' (also known as 'Aboriginal and Torres Strait Islander' peoples). Indigenous Australians are identified as comprising approximately 3% of the total population.1 In June 2011, NSW had the largest Aboriginal and Torres Strait Islander population (208,400 people), followed by (188,900 people) and (88,300 people). These three states combined comprised 72.5% of the total Aboriginal and Torres Strait Islander population of Australia.

Settlement by people from Great Britain and other countries began in 1788 and the cultural and linguistic diversity of Australia's resident population has been reshaped over many years by migration. Historically, more people immigrate to, than emigrate from, Australia. At 30 June 2011, 27% of the estimated resident population was born overseas (6.0 million people). This was an increase from ten years earlier at 23.1% (4.5 million people). Persons born in the United Kingdom continued to be the largest group of overseas-born residents, accounting for 5.3% of Australia's total population at 30 June 2011. This was followed by persons born in New Zealand (2.5%), China (1.8%), India (1.5%) and Vietnam and Italy (0.9% each).2

The Australian population is ageing: over the past two decades the median has increased to just over 37 years of age.1 The proportion of people aged 65 years and over has increased to 13.7%. During the same period, the proportion of the population aged 85 years and over has more than doubled to 1.8%. Over the next several decades, population ageing is projected to have significant implications for Australia in many spheres, including health, labour force participation, housing and demand for skilled labour.3

Australia is a developed country with a generally high standard of living. Overall, Australians have one of the highest life expectancies in the world – 81.7 years.4 The burden of disease (premature mortality in terms of years of life lost) is mostly attributed to chronic conditions, such as cardiovascular disease and cancer.

Indigenous Australians, however, have much poorer health than other Australians, with a higher burden of both infectious and non-infectious disease, including high rates of diabetes. The life expectancy of Indigenous Australians is also considerably lower, with a difference of approximately 11 years.4

Primary health care is typically the first health service in Australia visited by patients with a health concern. It includes most services not provided by and involves a wide range of professions, such as general practitioners (GPs), pharmacists, ambulances, community health workers, Aboriginal health workers, practice nurses and dentists.5

For many people the first point of contact with the is through a GP.

For specialised care, patients can be referred by GPs to specialist medical practitioners, other health professionals, and hospitals or community-based health-care organisations. Community-based services—some of which can also be accessed directly by patients—provide care and treatment for such health concerns as mental health, alcohol and other drug use, family planning and sexual health services. Australians also visit dentists and other private sector health professionals, such as physiotherapists, chiropractors and natural therapists.

General practice

General practice plays an integral role in the provision of primary . GPs diagnose, treat and manage health complaints, provide preventive advice and care, prescribe medicines, and refer patients to other primary, secondary and tertiary care where required, including specialists, hospitals and aged care. GPs often operate out of a dedicated location, known as a general practice. There can be one or more GPs operating out of a single general practice. Some general practices include many GPs, and general practices can be co-located with other health facilities, such as , dental surgeries and physiotherapists. Many GPs work closely with other professionals within a general practice, such as practice nurses, to provide services.5

Other primary health care services and service providers

Non-GP primary health care includes many different service providers and disciplines, such as ambulances, dentists, dieticians, midwives, occupational therapists, optometrists, pharmacists, physiotherapists, psychologists, nurses, nutritionists and speech pathologists. These service providers operate through a diverse range of service models and settings, including:

 small private practices with one or two practitioners specialising in a particular discipline  large multidisciplinary centres with many service providers operating out of a single facility  outreach services where the practitioners work in the community with targeted individuals or groups  research environments at universities and other research facilities.5

Hospitals

A mix of public and private sector providers deliver health services.

Public hospitals

Public hospitals include hospitals established by governments and, in some instances, hospitals originally established by religious or charitable bodies, now directly funded by government.

There are a small number of hospitals built and managed by private organisations that provide public services under arrangements with state governments. Most acute beds and emergency outpatient are in public hospitals.

Large urban public hospitals provide the majority of complex types of hospital care such as intensive care, major surgery, organ transplants, renal dialysis and specialist outpatient clinics.6

Private hospitals

Private hospitals are owned by for-profit or not-for-profit organisations such as large corporate operators, religious operators, and private funds.

Private hospitals traditionally provided less complex, non- emergency care, such as simpler elective surgery, but have extended their clinical capacity since the advent of more accessible technology and also new procedures such as minimally invasive surgery. Their increased range of clinical services thus offers an alternative to elective surgery in public hospitals for which there are long waiting lists.7

Separate centres for same-day surgery and other non-inpatient operating room procedures are found mostly in the private sector. Many public hospitals provide such services on the same site as inpatient care.6

Doctors

Many doctors are self-employed. Others are salaried employees of the government (all levels). Salaried specialist doctors in public hospitals often have rights to treat some patients as private patients in the hospital, charging fees to those patients and usually contributing some of their fee income to the hospital.6

Health services

The following health services are provided in Australia

Aged care

Australia's aged care system is structured around two main forms of care delivery:

Residential (accommodation and various levels of nursing and/or personal care). Residential services are mainly provided by the non-government sector, about half of which are operated by religious or charitable organisations. Community care (ranging from delivered meals, home help and transport to intensive coordinated care packages for people who otherwise would need residential care). Both public and non-government sector organisations provide community care services, under the Home and Community Care Program.6

For more information on the broad range of schemes available to in Australia, refer to the Aged Care Australia website via the link below.

Aged Care Australia

Mental health

Mental Health is an issue that affects the lives of many Australians either directly or indirectly. It is estimated that 45% of Australians between the age of 16 and 85 years will experience a common mental-health related condition such as depression, anxiety or a substance use disorder in their lifetime.8 The mental health sector has been radically restructured over the last few decades, so that people with mental health problems are now generally treated while still a part of the community rather than in long-stay psychiatric hospitals.

Mental health-related services are provided in Australia in a variety of ways:

 services provided by general practitioners  services provided in emergency departments  state and territory community mental health services  ambulatory-equivalent admitted patient care  -subsidised specialised mental health services  admitted patient mental health-related care  residential mental health care  supported accommodation assistance  psychiatric disability support services.

The Australian Institute of Health and Welfare (AIHW) website describes the activities and characteristics of the wide range of health care and treatment services provided for people with mental health problems in Australia. Access the website via the link below:

AIHW – Mental Health Services

Disability services

Australian governments fund a range of services under the National Disability Agreement (NDA). More than 314,000 people used disability support services provided under the NDA during 2010-2011. Intellectual (30%), psychiatric (20%) and physical (17%) disabilities were the most common primary disabilities of service users. Most people needed some assistance in the activities of daily living (52%); independent living (60%); and work, education and community living (57%).9

The government provides support to people with disability, and their carers, through various programs and services, and benefits and payments.

For more information refer to the Department of Families, Housing, Community Services and Indigenous Affairs (FaHCSIA) website.

Disability and Carers

Dental health care

There has been a dramatic improvement in dental over the last few decades and this has been attributed to water fluoridation, public health campaigns, and public dental services for school-age children. Most dental and allied health services are provided in private practice.

The States and Territories run services to provide dental care for school-aged children and subsidise some dental services for low income adults. Generally dental care is financed and delivered privately. As a result, dental services account for a considerable proportion of out-of-pocket health care expenditure borne by Australians. According to the Department of Health and Ageing, the key to accessing affordable services has been through private health insurance ancillary cover. Access and equity therefore are an issue for people on lower incomes.5

Preventive services

The health services described in this topic are complemented by a range of public health and preventive services that are integral to the health system. They include:

 immunisation services and other communicable disease control (including biosecurity)  public health education campaigns (including health promotion in the areas of nutrition and physical activity)  activities to monitor food and water quality  injury prevention activities  programs to reduce the use and harmful effects of tobacco, alcohol and illicit drugs  environmental monitoring and control  screening programs for diseases such as breast, cervical and bowel cancer.

Such public health and preventive services are provided in many settings, including schools, workplaces and community health facilities.5 Innovative solutions

There are some innovative solutions to health issues arising from Australia's unique history and needs. Notable among these are:

1. The Royal Flying Doctors Service 2. The Aboriginal Community Controlled Health Services 3. Regional Health Services 4. The Australian Red Cross (receives government funding for its activities).

Royal Flying Doctors Service (RFDS)

Through the use of flight and other transport means, the utilisation of telephone, radio, satellite and web-based communication technologies and the provision of high quality health services the RFDS improves the health and wellbeing of those who live, work and travel in regional, rural and remote Australia.

Emergency and transport services

The RFDS may fly to an isolated property, such as a station, mine site or small community, without medical facilities to evacuate a seriously injured or ill person and evacuates them to the nearest hospital infrastructure. The RFDS provides this service 24 hours a day to over 80% of the Australian continent.

Inter-hospital transfer involves the aeromedical transport of patients between hospital facilities. This usually occurs when patients with serious illness or injury require medical retrieval to a large regional or tertiary centre for definitive care.

Aircraft are staffed with a pilot, flight nurse and doctor (depending on the case).

Remote services

RFDS health staff can be located at an RFDS base or and a patient, their carer or family member or remote area require medical advice from a distance. The RFDS health professional can conduct an assessment or provide treatment advice remotely and then monitor the situation to determine whether an aerial evacuation is required or whether the patient can be followed up at one of its remote clinics.

Clinic Services

RFDS nationally provides primary health care services through regular clinics conducted at a range of locations such as Aboriginal and Torres Strait Islander communities, rural support towns, remote stations, mines and oil fields, national parks and tourist resorts throughout rural and remote Australia.

For more information refer to the RFDS website.

Aboriginal Community Controlled Health Service

An Aboriginal Community Controlled Health Service (ACCHS) is a primary health care service initiated and operated by the local Aboriginal community to deliver holistic, comprehensive, and culturally appropriate health care to the community that controls it, through a locally elected Board of Management.

Aboriginal communities operate over 150 ACCHSs in urban, regional and remote Australia. They range from large multi-functional services employing several medical practitioners and providing a wide range of services, to small services, which rely on Aboriginal Health Workers and/or nurses to provide the bulk of services, often with a preventive, health education focus. The services form a network, but each is autonomous and independent both of one another and of government.

The integrated primary health care model adopted by ACCHSs is in keeping with the philosophy of Aboriginal community control and the holistic view of health. Local Aboriginal community control in health is essential to the definition of Aboriginal holistic health and allows Aboriginal communities to determine their own affairs, protocols and procedures.

For more information refer to the National Aboriginal Community Controlled Health Organisation website.

Australian Red Cross

The Australian Red Cross provides shelter, food and medical help in response to natural disasters or personal crisis in a patient's home. Red Cross works with the most vulnerable people and communities in Australia and internationally. Their work is focused around seven priority areas:

1. emergency services in Australia 2. international programs 3. Aboriginal and Torres Strait Islander strategy 4. social inclusion 5. stronger communities 6. international humanitarian law 7. migration support.

For more information refer to the Australian Red Cross website. Health funding

Australian Government

Governments fund more than two-thirds of total health expenditure in Australia, with the contributing two-thirds of this, and State, Territory and Local governments the other third. The two levels of government have overlapping responsibilities with regard to the provision of health benefits and services.5

In 2009-10, private health insurance schemes contributed 8% of the funding for the health system, with accident compensation schemes contributing another 5%. Finally, individuals make out-of-pocket contributions to the costs of services, mostly in the private sector, amounting to 18% of total funding in 2009-10.10

Health funding

The Australian Government's major contributions include:

 Medicare Benefits Scheme (MBS)  Pharmaceutical Benefits Scheme (PBS).

These schemes are further subsidised by social welfare arrangements, with larger rebates provided to individuals and families who receive certain income support payments. Special health care arrangements are also in place for members of the defence forces or for war veterans and their dependants. The Australian Government funds most medical services out of hospital, and most health research. The Australian Government also contributes by jointly funding (with State and Territory governments) public hospitals and community care for aged and disabled persons.

Australian Government departments and agencies that are responsible for various aspects of the health care system are provided in the following table:

Departments Function

Department of Health and Ageing Gives substantial grants to the State and Territory Governments who have (DoHA) responsibility for public hospitals. DoHA also subsidises prescribed medicines and provides specific purpose grants to State and Territory Governments and other (http://www.health.gov.au/) organisations.

Department of Human Services The Department of Human Services is responsible for the development of service delivery policy and provides access to social, health and other payments and (http://www.humanservices.gov.au/) services through:

 Medicare which looks after the health of Australians through the efficient delivery of programs such as the Pharmaceutical Benefits Scheme, the Australian Childhood Immunisation Register and the Australian Organ Donor Register.  which delivers a range of payments and services for retirees, the unemployed, families, carers, parents, people with disabilities, Indigenous Australians, and people from culturally and linguistically diverse backgrounds, and provides services at times of major change.  Child Support which provides support to separated parents to provide the financial and emotional support necessary for their children's wellbeing.  CRS Australia which provides disability employment services to help people with a disability, injury or health condition to get or keep a job, and help their employers to keep their workplaces safe.  Australian Hearing is one of the largest hearing service providers in the world and is dedicated to helping people manage their hearing impairment so they have a better quality of life. Australian Hearing provides a full range of hearing services for children and young people up to the age of 26, eligible adults and aged pensioners, and most war veterans.

Department of Social Services The Department of Social Services (DSS) was established in 2013 replacing The Department of Families, Housing, Community Services and Indigenous Affairs (http://dss.gov.au) (FaHCSIA). The DSS exists to support the Government and, through the Ministers and Parliamentary Secretaries, to deliver on a broad range of social policy outcomes. The department works in partnership with other government and non- government organisations, and support and help a range of people in the community including families and children, carers, the aged etc.

The Department of Veterans' The Department of Veterans' Affairs delivers government programs for war veterans, Affairs (DVA) members of the , members of the Australian Federal Police and their dependants. Services include pensions and compensation, health care, (http://www.dva.gov.au/) rehabilitation, counselling services and home care assistance.

State and Territory Governments

The States and Territories are primarily responsible for the delivery and management of public health services. They deliver public, acute and psychiatric hospital services and a wide range of community and public health services, including school health, dental health, maternal and child health, and environmental health programs.

State and Territory health departments represent the interests of the Commonwealth at the State and Territory level. Regulation of health services

Australian Health Practitioner Regulation Agency

The Australian Health Practitioner Regulation Agency (AHPRA) is the organisation responsible for the implementation of the National Registration and Accreditation Scheme across Australia.

AHPRA works with 14 National Boards including:

 Aboriginal and Torres Strait Islander Health Practice Board of Australia  Chinese Medicine Board of Australia  Chiropractic Board of Australia  Dental Board of Australia  Medical Board of Australia  Medical Radiation Practice Board of Australia  Nursing and Midwifery Board of Australia  Occupational Therapy Board of Australia  Optometry Board of Australia  Osteopathy Board of Australia  Board of Australia  Physiotherapy Board of Australia  Podiatry Board of Australia  Psychology Board of Australia.

AHPRA's role is to:

 support the National Boards in their primary role of protecting the public  manage the registration processes for health practitioners and students around Australia  accept notifications from the public about a registered health practitioner or student  on behalf of the Boards, manages investigations into the professional conduct, performance or health of registered health practitioners, except in NSW where this is undertaken by the Health Professional Councils Authority and the Health Care Complaints Commission  publish national registers of practitioners so important information about the registration of individual health practitioners is available to the public  work with the Health Complaints Commissions in each State and Territory to make sure the appropriate organisation investigates community concerns about individual, registered health practitioners  support the Boards in the development of registration standards, and codes and guidelines  provide advice to the Ministerial Council about the administration of the national registration and accreditation scheme. Medical Board of Australia (MBA)

The role of the Medical Board of Australia is to:

 register medical practitioners and medical students  develop standards, codes and guidelines for the medical profession  investigate notifications and complaints  where necessary, conduct panel hearings and refer serious matters to Tribunal hearings  assess International Medical Graduates who wish to practise in Australia  approve accreditation standards and accredited courses of study.

The Medical Board of Australia has established State and Territory Boards, responsible for making registration and notification decisions about individual medical practitioners. State and Territory Medical Board members are appointed by the Minister for Health in each jurisdiction, as practitioner or community members.

For more information refer to the MBA website:

Medical Board of Australia

Other key elements

Health agencies

Research and statistical agencies

provide the information needed for disease prevention, detection, diagnosis, treatment, care and associated policy.

Professional associations for health practitioners

set professional standards and clinical guidelines.

Universities, colleges and hospitals

train undergraduate and post graduate medical professionals.

Consumer and advocacy groups

contribute to public discussion and policy development.

Voluntary agencies

contribute in various ways including raising funds for research, running educational and health promotion programs, and co-ordinating voluntary care.

Statistics, health information and research

Australian Bureau of Statistics (ABS) - The ABS is Australia's national statistical service.

Australian Institute of Health and Welfare (AIHW) - The AIHW is Australia's national agency for health and welfare statistics and information. National Health and Medical Research Council (NHMRC) - The NHMRC promotes the development and maintenance of public and individual health standards. They fund research and develop advice on a range of health care issues.

Module 1 - References

References

1. Australian Bureau of Statistics (ABS). (2012). Australian Demographic Statistics, Mar 2012. ABS cat no. 3101.0. Canberra: ABS. 2. Australian Bureau of Statistics (ABS). (2012). Migrations Australia 2010-11. ABS cat. No. 3201.0 Canberra: ABS. 3. Australian Bureau of Statistics (ABS). (2011). Australian Demographic Statistics, June 2011. ABS cat. No. 3101.0 Canberra: ABS. 4. Australian Bureau of Statistics (ABS). (2011). Australian Social Trends March 2011. ABS cat. No. 4102.0 Canberra: ABS 5. Australian Institute of Health and Welfare. (2012). Australia's health 2012. Australia's health series no.13. Cat. no. AUS 156. Canberra: AIHW. 6. Department of Health and Aged Care (DoHA). (2000). The Australian Health Care System. An Outline. Canberra: AusInfo 7. Healy J, Sharman E, Lokuge B. (2006). Australia: Health system review. Health Systems in Transition. 8 (5): 1–158. 8. Australian Bureau of Statistics (ABS). (2008). National Survey of Mental Health and Wellbeing, 2007. ABS cat. No. 4326.0 Canberra: ABS 9. Australian Institute of Health and Welfare 2012. Disability support services: services provided under the National Disability Agreement 2010-11. Disability series. Cat. no. DIS 60. Canberra: AIHW. 10. Australian Institute of Health and Welfare. (2011). Aboriginal and Torres Strait Islander Health Performance Framework 2010: detailed analyses. Cat. no. IHW 53. Canberra: AIHW. 11. Breen, K.J, Cordner, S.M., Thomson, C.J.H and Plueckhahn, V. D. (2010). Good Medical Practice: Professionalism, Ethics and Law. Cambridge: Cambridge University Press.

This learning module is courtesy of Royal Australian College of Physicians.