- by Anna Pha
- The Guardian
- Issue #2028
Photo: piqsels.com ID zkbbq
Reports of emergency patients waiting up to thirty-six hours or more to be off-loaded from ambulances at public hospital emergency departments (EDs) are indicative of a public health system in crisis. Australia is well down the path towards an Americanised two-tier health care system – one for the wealthy and the other for the rest of us.
The crisis is multi-faceted affecting paramedics, doctors, nurses, patients, aged care residents, recipients of aged care at home, people with disability, and anyone else using or working in the public health system.
COVID exacerbated the pre-existing failings of a system that had been run down, starved of funding and neglected by successive state and federal governments.
PRIMARY HEALTH CARE
General practice forms the foundation of the health care system. Doctors increasingly report unsustainable workloads, burnout, mounting administrative burdens and inadequate remuneration. It has become increasingly difficult to find a bulkbilling GP and in some parts of Australia, regional and rural in particular, there are none.
Not only is there a shortage of GPs but according to the annual General Practice Health of the Nation 2022 report, almost half of GPs surveyed reported that it was financially unsustainable for them to continue working as a GP. In addition, one quarter of those who responded indicated that they planned to retire within the next five years.
The overheads of medical practices continue to rise. This, compounded by years of frozen Medicare rebates for doctors, has forced many GPs to abandon bulkbilling or reduce consultations to the bare minimum. In July, the Medicare rebate for a standard consultation increased from $39.10 to $39.75 – a mere sixty-five cents or 1.66 per cent! Whereas price inflation running of 6.1 per cent in the same month and headed towards more than eight per cent. This is a huge cut in real terms following successive years of similar cuts or frozen rebates that can only be seen as an attack on bulkbilling – a death by a thousand cuts.
There has been a growth in corporate bulkbilling businesses with patients being churned through in five-minute consultations.
There is a shortage of GPs, with some having closed their books and others with waiting lists as long as two or three weeks to see a bulkbilling doctor. As a result, many people are turning to hospital emergency departments as they cannot afford to see a non-bulkbilling GP.
The real reduction in GP rebates is a false economy. It costs far less to see a GP, compared with an estimated $500 when someone attends a hospital emergency department for a condition that a GP could have treated or referred them to a specialist.
Those who can afford it attend private GP practices that do not bulkbill. The out-of-pocket gap paid by patients after claiming the Medicare rebate could be $60, $100 or more. Impossible for a low- or middle-income family.
The future of general practice looks grim with around fifteen percent of future medical graduates choosing to specialise in general practice. Successive governments have relied on migrant doctors and specialists to keep the public health system afloat instead of investing in the training of more GPs and making general practice affordable.
The mouth and teeth are integral to a person’s health and well-being. Yet oral health is still not included in Medicare. Apart from the suffering and ill-health consequences that individuals experience on waiting lists of over two years for public care, it is also a false economy, resulting in more avoidable hospitalisations. The importance of oral health cannot be over-stated.
One of the problems is that healthcare funding is more focused on treating illnesses rather than prevention. This costs more and in the private sector creates more profits.
PUBLIC HOSPITAL CRISIS
The number of people waiting for in-hospital treatment and the length of time for which they are required to wait are considered to be important health performance indicators, and on this measure Australia fails dismally.
The Health Services Union (HSU) carried out a survey of members to prepare a submission to the NSW parliamentary inquiry into ambulance ramping (queueing) at public hospitals in that state. The submissions it received should raise alarm bells.
Understaffing, excessive workloads, and burnout are endemic within the sector, the consequences of a sector that has long been under-funded.
“I have worked in health for five years and for that entire time the team I work within has never been fully staffed. We are currently at the lowest level of staffing I have ever experienced. We are tired of giving extra time for an employer (State Government) who is unsupportive, is out of touch with what is actually going on and does not realise the financial waste that is occurring.” (HSU quote from a technical officer in Sydney)
The submission cites the NSW Bureau of Health Information’s quarterly report covering April to June 2022:
- Almost one in ten patients leave hospital without, or before completing treatment.
- The percentage of patients who had their treatment start on time was 57.5 per cent in metropolitan hospitals.
- The three key reasons given were lack of available beds in wards, inadequate staffing, and lack of available beds in emergency.
It is no secret that public hospitals are understaffed and underfunded – not just in NSW. It is a national issue. For years hospitals have faced increased demand (growing and ageing population) without a corresponding increase in staffing and resources. Then there was COVID. There are not enough nurses and midwives which puts patient lives at risk. Long and double shifts cause stress and fatigue and result in dangerous working conditions.
Public hospital waiting lists for “elective surgery” were unacceptably long before COVID and have grown since. “Elective surgery” is a deceptive term. There is nothing “elective” about it for most patients. Category 1 examples of urgent “elective” surgery include breast lump removal or biopsy, neonatal surgery, malignant skin lesion removal, limb amputation, cerebral haematoma (collection of blood within the skull). Joint replacement and reconstructions, endometriosis removal, and grommets are Category 3 at the bottom of the waiting list.
The proportion of patients waiting more than 365 days for their elective surgery also increased between 2019–20 and 2020–21. The increase for total knee replacement was from eleven per cent to thirty-two percent.
At the same time as being applauded by governments for their work during COVID, governments cut their real wages. The Australia Nurses and Midwifery Federation has been campaigning under the slogan “Ratios it’s a life saver” for the introduction of nurse-to-patient ratios which they have won in Victoria. Last month saw nurses and midwives, in an act of desperation, take industrial action.
Not only are there waiting lists for admission to hospital there are discharge blockages. Thousands of people who have been cleared as medically ready for discharge languish in hospital because of lack of aged care and disability services. The longer they languish in hospital the greater the risk of becoming infected with other illnesses such as COVID.
Aged care and NDIS services (community housing and home care) have been largely privatised. They are in crisis with serious labour shortages and lack of government funding. The NDIS also suffers from mismanagement and a punitive system of (not) granting packages.
The appalling situation in aged care facilities, where many residents are fed poor diets, receive inadequate care, and do not always have access to a registered nurse or GPs, contributes to avoidable hospitalisations.
It is not acceptable that someone in extreme pain and their mobility restricted requiring knee transplants may have to wait more than a year. But that is the situation for around half the population without private health insurance (PHI).
As an incentive to take out PHI, the Howard Coalition government introduced a rebate on premiums in 1997. Since then, federal governments have subsidised the private hospital system by a total of $100 billion! The present rebate is age-dependent and means tested ranging from zero for those on $280,000 or more per annum to 32.812 per cent for over 70s on less than $180,000. It is a $7 billion per annum subsidy for private hospitals, which otherwise would be unsustainable.
Australian consumers paid almost $25.7 billion in private health insurance premiums in 2020-21.
You can get on the public list and wait six to twelve months for a procedure or, if you have PHI, it might be a few weeks. Increasingly well-off patients are self-funding or using PHI in public hospital as private patients.
The strength and importance of public hospitals was born out during the pandemic with the government taking over some private hospitals.
“We don’t need a band aid. We need system-wide reform,” the HSU concluded in its submission to the NSW parliamentary inquiry.
A multi-faceted approach is required to address the crisis in the public health system. These measures include:
- Prioritisation of preventative health care;
- Training of more GPs;
- Universal access to bulkbilling;
- Increase in Medicare rebates for doctors;
- Inclusion of oral health care under Medicare;
- Nationalising and adequately funding the NDIS, including building community housing;
- Real wage rises for nurses;
- Nurse-patient ratios in hospitals;
- Aged care reforms increasing residential accommodation, home care packages;
- Divert the $7 billion subsidy to private hospitals to the public sector;
- Make medications under the PBS free;
- Increase number of paramedics and specialist staff; and
- Federal government increase its share of spending on health from forty-five to fifty per cent and remove the cap.
Funding is critical. The government will cry poor – the trillion-dollar debt left by the Coalition. But Labor has no justification to do so when it supports $247 billion in tax cuts for the rich, a trillion-dollar (over twenty years) defence budget alongside another $180 billion plus spend on nuclear-powered submarines. Nor can it justify the billions in fossil fuel subsidies.
This expenditure costs lives, destroys the environment. Public health is about saving lives and the well-being of society.
Access to health care is a right – a human right – not a privilege. Ultimately the only guarantee of a public health system that meets needs is a nationalised system which is democratically run, where workers and local communities have a say on where their health facilities are placed and how they are managed, including having a voice on local hospital boards.