FAMILY AND COMMUNITY DEVELOPMENT COMMITTEE Inquiry on the Impact on the Victorian Community and Public Hospitals of the Diminishing Access to After Hours and Bulk Billing General Practitioners September 2004 Ordered to be Printed No. 84 Session 2003-2004 National Library of Australia Family and Community Development Committee (2004) Inquiry on the Impact on the Victorian Community and Public Hospitals of the Diminishing Access to After Hours and Bulk Billing General Practitioners ISBN: 0-9752253-1-6 Cover Design: Lara Howe Office Manager Family and Community Development Committee Level 8, 35 Spring Street Melbourne, Victoria 3000 Phone: (03) 9651 3526 Fax: (03) 9651 3601 Email: [email protected] Website: http://www.parliament.vic.gov.au/fcdc © State of Victoria MEMBERS Mr Robert Smith, MLC 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 i Parliamentary Committees Act 2003 PARLIAMENTARY COMMITTEES ACT 2003 S.11. The functions of the Family and Community Development Committee are, if so required or permitted under this Act, to inquire into, consider and report to the Parliament on– (a) any proposal, matter or thing concerned with- (i) the family or the welfare of the family; (ii) community development or the welfare of the community; (b) the role of the Government in community development and welfare including the welfare of the family. ii Terms of Reference TERMS OF REFERENCE Inquire into, consider and report to Parliament on: 1. The decline in the bulk-billing of general practitioner (GP) services in Victoria since 1996; 2. The increase in patient presentations to public hospital emergency departments in Victoria since 1996, and the extent to which this includes providing types of medical services that normally would be provided by a GP in a primary care setting (GP-type services); 3. The causes in increased presentations to public hospital emergency departments in Victoria since 1996, including difficulties in patients gaining access to bulk-billed and after- hours GP services; 4. The availability of after-hours GP services in metropolitan, regional and rural Victoria; 5. What effective measures can be taken to reduce the number of presentations to public hospital emergency departments consistent with maintaining the principle of universal access of eligible persons to health care free of charge at the point of access; and 6. the extent to which Commonwealth and Victorian legislation may affect Victoria's ability to develop and implement effective and patient-centred solutions to relieve the pressure on public hospital emergency departments to provide GP-type services. In considering this reference, the Committee should examine: 1. Available bulk-billing, patient out-of-pocket expenses and emergency department data at regional and local levels, highlighting where bulk-billing rates are lowest and where emergency department presentations for urgency categories 4 and 5 are highest; 2. the respective roles and responsibilities of the Commonwealth and the Victorian governments; 3. Relevant Victorian and Commonwealth policies and legislation, including the 1999-2003 and 2003-08 Australian Health Care Agreements; and 4. Innovative and relevant models of care and service delivery in other Australian States and Territories, and overseas. The Committee is required to report to Parliament by 30 June 2004. Dated 6 May 2003. iii Inquiry on the Impact on the Victorian Community and Public Hospitals of the Diminishing Access to After Hours and Bulk Billing General Practitioners iv Chairman’s Foreword CHAIRMAN’S FOREWORD I have great pleasure in presenting the Family and Community Development Committee’s Final Report on its Inquiry into the Impact on the Victorian Community and Public Hospitals of the Diminishing Access to After Hours and Bulk Billing General Practitioners. Current media articles have highlighted trends in the current health care system. As can be seen from statistics presented in the second Chapter of this report increases in emergency department presentations have occurred at a time when access to general practitioners, particularly those who bulk bill or provide after hours service, has fallen in some areas. While there has been some intuitive argument that there is a correlation between these effects this Report attempts to identify the existence and strength of this correlation and to examine proposals which seek to address problems associated with hospital emergency departments and primary care. The first Chapter of the report gives a brief summary of the Australian healthcare system and the split between Commonwealth and State responsibilities- the Commonwealth essentially for primary care and the states for the hospital and critical care system. It also plots the evolution of the Medicare system from its inception. The second Chapter presents a range of data on the use of public hospital EDs in Victoria during the period 1996-2004 and the rate of patient attendances at General Practices for the same period. It seeks to present this data in a wider context by including population profiles, medical workforce and Practice Incentives Program data and rates of bulk billing by electorate. In order to examine the possible association between the two sets of data it has been divided according to health service boundaries. The third Chapter examines the link between increases in emergency department presentations and the decline in access to bulk billing and after hours general practitioners, regional differences and factors which may also contribute to increased presentations. The final section of this chapter examines strategies to minimise these increases including co- located GP clinics, management of chronic diseases and other primary health care initiatives, telephone triage, and nurse practitioners. v 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 vi Recommendations RECOMMENDATIONS Recommendation 1: That the Commonwealth Government continue to increase the number of aged care residential places and transition care places to alleviate pressures on hospitals generally. Recommendation 2: That Health Service Regions are assisted in a programme of education