The column this week addresses three key reviews examining some of the structures and systems that underpin Medicare, general practice and primary care, and also reports that job satisfaction is significantly higher for GPs working in Aboriginal Community Controlled Health Organisations.
Our columnist also covers the retirement of Chief Medical Officer Professor Paul Kelly, and speculates about whether public health qualifications may become a requirement of the role.
On the commercial determinants of the safety and quality of healthcare, read about a United States study that found “quality of care and patient outcomes change after private equity acquisition of hospitals”.
The quotable?
In other words, private equity’s desire to make a quick return leads to staff reductions, which in turn leads to poorer patient outcomes, including potential deaths.
Australian regulatory authorities should consider this evidence next time a private equity firm seeks approval to acquire hospitals – or any other care services.”
Charles Maskell-Knight writes:
Last week was a big week for announcements about general practice and primary care.
After several weeks of teasers, the Royal Australian College of GPs (RACGP) on 8 October finally released the 2024 Health of the Nation report, based on a self-selected survey of a little over 3,000 GPs as well as various official statistics.
The report showed “job satisfaction for Australia’s GPs has improved (73 percent compared to 66 percent in 2023), and more are recommending general practice as a career (44 percent compared to 38 percent in 2023)”.
In response to the report, the RACGP called for the Government to:
- fund a 20 percent increase to all Medicare rebates for 20-minute and longer consults, with additional increases for rural and remote communities
- fund the RACGP to provide an additional 500 training places through the Australian General Practice Training program to accelerate growth in the GP workforce
- attract more GPs in training by funding incentives and work entitlements including parental and study leave
- establish targets for universities of 50 percent of medical graduates selecting GP training, linked to Commonwealth Supported Places funding
- double the Workforce Incentive Program (WIP) to accelerate the growth of multidisciplinary care in general practice.
The survey also showed that GPs working in Aboriginal Community Controlled Health Organisations (ACCHOs) had the highest job satisfaction (88 percent compared with 73 percent overall), were more likely to recommend general practice as a career (68 percent compared with 44 percent), and had the best work-life balance and lowest rate of burnout.
National Aboriginal Community Controlled Health Organisation CEO Pat Turner said: “The consistently high levels of job satisfaction among GPs working in ACCHOs reflect the strong, culturally grounded care models that are vital to the health and well-being of Aboriginal and Torres Strait Islander peoples.
“This sense of purpose and connection drives the exceptional care delivered by these GPs, underscoring the importance of building and supporting a dedicated workforce for Aboriginal and Torres Strait Islander health, which remains central to our advocacy efforts.”
Health Minister Mark Butler spoke at the launch of the report, saying that general practice had been his clear priority, and that it had also been a priority for recent National Cabinet discussions of health policy.
Butler also released reports from the review of GP incentives, the review of after-hours primary care programs and policy, and the review of workforce distribution measures.
The incentives review conducted by an expert advisory panel had a commendably short list of recommendations:
- the Government should introduce a new opt-in, simplified general practice payment architecture that better supports community and patient needs and encourages high-quality, accessible and multidisciplinary care
- the Government should invest in enabling reforms such as accreditation and a performance framework to support the new general practice blended payments architecture within the context of a cohesive vision for primary care by 2032
- while maintaining the principle that general practices can charge fees for medical services that take into account the practice’s own costs and economic imperatives, the Government should establish an independent primary care pricing authority to provide advice on the design and pricing of Commonwealth payments to general practices and primary care providers
- the Government should facilitate an effective transition to the new payment model to achieve the future vision for general practice.
The review also recommended that the current incentive payment to doctors working in rural and remote areas should be retained and refined in the short term, but that within three years the Government “should consider the evidence and impact of redirecting Workforce Incentive Program funding from providers to practices”, and in the longer term the payments should be rolled up into baseline funding.
The after-hours review was conducted by the Department of Health and Aged Care. Rather than make recommendations it cautiously identified “themes” and “opportunities”.
For example, the first theme is “Improve value-for-money of after-hours primary care”, and the associated opportunity is to “better target incentives for after-hours primary care, to ensure a sustainable after-hours system”. While these are unarguable, they do not constitute an implementable action agenda without considerable further development.
The working better for Medicare review carried out by Professor Sabina Knight AM and Adjunct Professor Mick Reid AM made 26 detailed recommendations to improve the operation of workforce distribution policy levers.
Butler said that “the three reviews involved extensive consultation with primary care and health workforce stakeholders”. He then went on “the Government will consult with the sector as it considers the recommendations and findings of the three reviews”.
I’m not sure if the Government is suffering from analysis paralysis or consultation prevarication – but either condition seems inimical to actual progress.
A number of health groups reacted to the reports.
The Australian Medical Association (AMA) welcomed the reports as “a positive step forward in modernising general practice funding and primary care workforce programs”.
New president Dr Danielle McMullen said the AMA was glad to see “the government taking these issues seriously, but there is a long way to go to ensure the challenges facing general practice, primary care and the health workforce are addressed – and it will require significant investment”.
The Rural Doctors Association of Australia (RDAA) described the reviews as a “mixed bag”. President RT Lewandowski said “there were some positive recommendations in the reports for the future of rural health care, while others failed to deliver ideas for real-world solutions”.
The RDAA said the after-hours review was “the great disappointment [as it] provided no key recommendations on real action to enhance care for patients in the after-hours period”.
Lewandowski said “GP peak bodies put forward plenty of solutions, but this report does not reflect that”.
“Unless Government moves quickly to develop a working group to look at providing action-based recommendations to actually reform the after-hours [payments], the review will be yet another wasted investment in this area,” he said.
The Australian College of Rural and Remote Medicine (ACCRM) welcomed the incentives review, particularly its decision not to recommend the immediate redirection of WIP payments from doctors to practices.
ACCRM also supported the overall approach of the workforce distribution review, while “stressing the need to recognise the fragility of rural and remote medical services to changes in policy levers” as the recommendations are implemented.
The RACGP also supported continuation of the existing framework for WIP payments. More generally, the College said it looked forward to co-designing the reforms with Government “to get the best result for general practices and our patients”.
The Australian GP Alliance (which describes itself as representing general practice owners) supported the recommendation from the incentives review for an independent body to set Medicare rebates.
In other GP-related news, Bupa launched its Blua program, providing policy holders with “three telehealth bookings per person, per year, as part of their policy and… 24/7 access to doctors for consultations that may include general medical advice, repeat prescriptions or referrals”.
Bupa said that a ten-month trial of the program had shown “most calls occurred outside business hours with 72 percent resolved on the initial call, 15 percent were recommended to visit a GP in person and only one percent advised to go to a hospital emergency department”.
The service will be provided by 150 “Australian-based credentialled doctors”, and following the consultation a care summary will be uploaded to the patient’s My Health Record (subject to their consent).
Ministers and government
Minister Butler announced the retirement of Chief Medical Officer Paul Kelly after four years in the job. Kelly took over from Professor Brendan Murphy after he assumed the position of Secretary of the Department of Health in 2020.
Kelly was the first public health expert to hold the post since Dr Tony Adams left in 1997. Between then and 2020 the job was held by a series of eminent doctors with no particular public health background (three kidney specialists, a gastroenterologist, an oncologist, and an emergency medicine physician – all but one of them male).
If the position is to continue as head of the Centre for Disease Control, public health expertise presumably will become essential.
The Public Health Association of Australia (PHAA) acknowledged Kelly’s contribution, with CEO Adjunct Professor Terry Slevin saying that as “a public health physician and infectious disease epidemiologist, Professor Kelly was the right man to offer leadership to Australia during the COVID-19 pandemic… [he] played a vital role in helping Australia navigate through that crisis”.
The AMA paid tribute to Kelly’s invaluable contribution to Australia’s healthcare system, while the Pharmacy Guild praised his “trademark calmness and pragmatism”. Shadow Health Minister Anne Ruston also thanked Kelly for his “strong leadership and significant contributions to Australia’s public health”.
The Australian Institute of Health and Welfare (AIHW) released the eighth annual report on Eye health measures for Aboriginal and Torres Strait Islander people. The headline news was an 87 percent decline in the prevalence of active trachoma in children aged 5 to 9 in at-risk communities from 14 percent in 2007 to 1.8 percent in 2023.
The AIHW said that the report “also shows notable improvements in other measures of eye health, including eye examinations and annual health assessments, screening for diabetic retinopathy among those tested for diabetes and hospitalisations for cataract surgery”.
The AIHW also released some updated data on involuntary mental health treatment and a new report on income and employment support for people suffering from mental illness.
The Australian Commission on Safety and Quality in Health Care (ACSQHC) released resources for use in Infection Prevention and Control week, which runs from 13-19 October.
The Australian Bureau of Statistics (ABS) released causes of death data for 2023. The data showed the leading cause of death was “on the brink of change”, with the proportion of deaths due to ischaemic heart disease falling to 9.2 percent while dementia increased to 9.1 percent. Dementia was the leading cause of death in NSW, SA and the ACT.
COVID-19, which was the third most common cause of death in 2022, fell back to ninth in 2023, as the number of deaths from the disease dropped from 9,862 in 2022 to 5,001 in 2023.
Dementia Australia CEO Professor Tanya Buchanan said that “the ABS data reinforces the urgent need for a public health approach to reducing – or preventing – the risk of developing dementia”.
“It is crucial that we act now to focus on the brain health of the nation as well as provide more targeted, effective support to those impacted by dementia. Taking this dual approach will ensure we are working towards reducing the impact of dementia in the future,” she said.
The Alcohol and Drug Foundation (ADF) noted that the data showed “there were 1,667 alcohol-induced deaths in 2023, down only slightly from the 1,742 recorded in 2022 which marked the highest in over a decade”.
The ADF’s Policy and Engagement Manager, Robert Taylor, said there was a need for “stronger, long-term investments in evidence-based prevention, harm reduction, and treatment services”.
“Action to address alcohol advertising and online sales and delivery is also needed, with stops to targeted, data-driven marketing, a limit on alcohol deliveries to before 10pm, and a minimum two-hour safety pause between ordering and delivery,” he said.
The ABS also released data on autism drawn from the 2022 Survey of Disability, Ageing and Carers. It showed that “in 2022, there were 290,900 (1.1 percent) Autistic Australians, a 41.8 percent increase from the 205,200 (0.8 percent) Autistic Australians in 2018”.
Consumer and public health groups
The Grattan Institute published an analysis of COVID antiviral utilisation for people aged over 70 for the period March 2022 to September 2023.
The study found “there were large disparities in antiviral uptake between different groups in Australia”, with the groups “more likely to miss out on antivirals including Indigenous people, people from disadvantaged areas, and people from culturally and linguistically diverse backgrounds”.
In a summary article in The Conversation, also cross-posted at Croakey, Grattan health program director Peter Breadon wrote that there were large geographic differentials, with people in remote areas 37 percent less likely to get antivirals than people living in major cities, while people in outer regional areas were 25 percent less likely.
There were large disparities by income: in Sydney people living in the “affluent eastern suburbs” such as Vaucluse were almost twice as likely to have had an antiviral as those living in Fairfield in the city’s south-west.
Pointing out that these drugs have so far cost the Government about $1.7 billion, Breadon concluded “such a huge investment shouldn’t be leaving so many people behind. Getting treatment shouldn’t depend on your income, cultural background or where you live. Instead, care should go to those who need it the most”.
Breadon suggested three steps the Government could take to address gaps in preventive care: making Primary Health Networks responsible for addressing gaps by sharing data with GPs and stepping in to boost uptake in communities that are missing out; extending the MyMedicare reforms to all patients; and introducing “team-based pharmacist prescribing” to allow pharmacists to dispense antivirals for patients if they have a prior agreement with the patient’s GP.
Head and Neck Cancer Australia (HANCA) held an event at Parliament House to “call for support from the Government to address the critical gap in recovery for people needing access to facial prosthetics and oral rehabilitation services after treatment for head and neck cancer”.
HANCA founding director Associate Professor Bruce Ashford said “most patients who undergo major head and neck treatment covered by Medicare are left with profound and disfiguring side effects, yet we have no reliable or affordable route for facial prosthetics or oral rehabilitation, so they never access the survivorship care they need”.
HANCA released a pre-election submission seeking funding for a program for facial prosthetics and development work on optimal oral prehabilitation and rehabilitation. (Disclosure: I provided advice on an early iteration of the submission.)
Mental Health Australia (MHA) marked World Mental Health Day with a statement “urging policymakers to recognise that meaningful connections are critical to mental health”.
MHA held a Mental Health Sector Expo at Parliament House, co-hosted with the Parliamentary Friends of Youth Mental Health and the Parliamentary Friends of Mental Health, attended by over 120 people from 45 member organisations, and addressed by Minister Butler.
In advance of giving evidence to the Senate inquiry into the Aged Care Bill, Palliative Care Australia welcomed the inclusion of a provision “that all people using or seeking Commonwealth-funded aged care services have a right to equitable access to palliative care and end-of-life care when required”.
This is all very well, but the Bill does not include a right to equitable access to aged care generally! And as PCA pointed out, the Bill does not define palliative care.
First Nations health
Gayaa Dhuwi (Proud Spirit) Australia, the national peak body for Aboriginal and Torres Strait Islander social and emotional wellbeing, mental health, and suicide prevention issued a statement stressing the importance of continuing to work to improve mental health and suicide prevention outcomes for First Nations people.
Professor Helen Milroy AM, Australia’s first Aboriginal psychiatrist and Chair of Gayaa Dhuwi, said “widescale changes are needed. Gayaa Dhuwi has worked with government to develop the roadmap for these changes – in the form of the Gayaa Dhuwi Declaration Implementation Plan and the National Aboriginal and Torres Strait Islander Suicide Prevention Strategy”.
Trade unions
The Australian College of Nursing (ACN) released its White Paper: The Nursing Response to the Climate Emergency.
Mark Holmes, Deputy Chair of the ACN Climate and Health Faculty, said “a complete rethink and overhaul of how health services are provided in a climate emergency are required. We must forget traditional models of health service delivery that will not meet surging climate-related healthcare demands”.
ACCRM released its response to the Medical Board of Australia consultation on health checks for late career doctors, arguing it was “imperative that the proposal does not inadvertently worsen patient safety by resulting in the loss of competent doctors in [rural] communities”.
The College did not support the option for regular health assessments undertaken by specialist occupational and environmental physicians, but did not indicate a preference for either of the other options (maintain the status quo, or introduce general health checks with a GP).
The AMA joined with the Justice Reform Initiative and National Children’s Commissioner at the launch of the Human Rights Commission report ‘Help way earlier!’ How Australia can transform child justice to improve safety and wellbeing.
AMA President Dr Danielle McMullen said the report “is an incredibly sobering read, as it contains many uncomfortable truths about youth justice in Australia – egregious human rights violations, the over-incarceration of First Nations children and young people dying in custody… The AMA is calling for the report’s many recommendations to be implemented, especially raising the age of criminal responsibility in all jurisdictions to 14 years”.
The AMA also issued an updated guide to informed financial consent, referring to the Australian Government Medical Costs Finder website and encouraging members to publish indicative fees and any gap arrangements for select services. The guide also encouraged doctors to disclose financial interests in the facility where services will be provided, or any medical devices used in the service.
Private health insurers’ lobby group Private Healthcare Australia welcomed the guide in a post on X.
The RACGP issued several media releases commenting on the Queensland election.
The first welcomed the commitment from both major parties to “abolish the patient tax” (aka exempt general practice from payroll tax); while the second warned of the dangers from making the pilots of an expanded scope of practice for pharmacy permanent “despite numerous cases of misdiagnosis and incorrect treatment and without a clinical evaluation”.
The College also marked World Mental Health Day by urging the national Government to provide more support for Australians needing mental healthcare by “increasing patients’ Medicare rebates for GP mental health and longer consults – to reduce out-of-pocket costs for patients.”
Industry groups
Medicines Australia used the release of a paper by GSK (one of the world’s largest vaccine manufacturers) on the benefits of vaccination to reiterate its support for the health technology assessment review recommendations to restructure the National Immunisation Program listing process, and to introduce proportionate reviews of vaccines based on complexity and the risks and benefits of the vaccine.
CEO Liz de Somer said “Medicines Australia welcomes the Government’s commitment to pushing on with [health technology assessment] reforms through an independent Implementation Group and are looking forward to the establishment of this Group as soon as possible”.
Politicians and parliamentary committees
The Senate inquiry into the Aged Care Bill continued with hearings in Brisbane. As of today, 35 submissions to the inquiry had been posted on the inquiry website.
International organisations
The World Health Organization (WHO) released a report finding that “vaccines against 24 pathogens could reduce the number of antibiotics needed by 22 percent or 2.5 billion defined daily doses globally every year, supporting worldwide efforts to address antimicrobial resistance”.
“While some of these vaccines are already available but underused, others would need to be developed and brought to the market as soon as possible.”
Finally
A LinkedIn post this week alerted me to an article published in JAMA late last year examining how “quality of care and patient outcomes change after private equity acquisition of hospitals”.
The study found that “after private equity acquisition, Medicare beneficiaries admitted to private equity hospitals experienced a 25.4 percent increase in hospital-acquired conditions compared with those treated at control hospitals… driven by a 27.3 percent increase in falls and a 37.7 percent increase in central line–associated bloodstream infections… despite placing 16.2 percent fewer central lines. Surgical site infections doubled from 10.8 to 21.6 per 10 000 hospitalisations at private equity hospitals despite an 8.1 percent reduction in surgical volume”.
In suitably neutral and academic language, the study observes that “hospital-acquired adverse events have been shown to be sensitive to staffing ratios and composition, specifically among nurses”.
“Given that private equity firms have reduced staffing and changed the clinician labour mix at acquired hospitals and clinics, an analogous cost-cutting strategy in our sample may help explain the increase in hospital-acquired conditions. These adverse events themselves can raise the risk of mortality, which highlights the clinical importance of this evidence”.
In other words, private equity’s desire to make a quick return leads to staff reductions, which in turn leads to poorer patient outcomes, including potential deaths. Australian regulatory authorities should consider this evidence next time a private equity firm seeks approval to acquire hospitals – or any other care services.
Consultations and inquiries
Here is our weekly list of requests by government bodies and parliamentary committees for responses to consultations or submissions to inquiries, arranged in order of submission deadlines. Please let us know if there are any to add for next week’s column.
Therapeutic Goods Administration
Proposed changes to the Australian Essential Principles for Safety and Performance of medical devices
16 October
Ahpra Accreditation Committee
Guidance on developing professional capabilities
18 October
Department of Health and Aged Care
Draft 24-hour movement recommendations for adults and older Australians
18 October
Therapeutic Goods Administration
Public consultation on interim decisions to amend the Poisons Standard
18 October
Department of Health and Aged Care
Draft National Nursing Workforce Strategy
20 October
Therapeutic Goods Administration
Proposed amendments to the Poisons Standard
22 October
Australian Commission on Safety and Quality in Health Care
Critical results management of pathology and diagnostic tests and imaging investigations
23 October
Independent Health and Aged Care Pricing Authority
Pricing Approach for the Support at Home Service List
25 October
National Mental Health Commission (National Suicide Prevention Office)
Draft National Suicide Prevention Strategy
27 October
Australian Commission on Safety and Quality in Health Care
Draft Medication Management at Transitions of Care Stewardship Framework
27 October
National Health and Medical Research Council
Draft Procedures and Requirements for Meeting the NHMRC Standards for Clinical Practice Guidelines
27 October
Food Standards Australia and New Zealand
Varying maximum residue limits (MRLs) for residues of specific agricultural and veterinary chemicals that may occur in food commodities
29 October
Department of Health and Aged Care
Proposed amendments to the Gene Technology Act 2000
8 November
Podiatry Board of Australia
Proposed change to the protected title for the specialty of podiatric surgery
8 November
Department of Health and Aged Care
Reforms to strengthen the National Mental Health Commission and National Suicide Prevention Office
11 November
Independent Health and Aged Care Pricing Authority
NDIS pricing reform
15 November
Office of the Gene Technology Regulator
Online Services Portal Survey
22 November
House of Representatives Standing Committee on Health, Aged Care and Sport
Inquiry into the health impacts of alcohol and other drugs in Australia
31 December (extended from 30 September)
Charles Maskell-Knight PSM was a senior public servant in the Commonwealth Department of Health for over 25 years before retiring in 2021. He worked as a senior adviser to the Aged Care Royal Commission in 2019-20. He is a member of Croakey Health Media; we thank and acknowledge him for providing this column as a probono service to our readers. Follow on X/Twitter at @CharlesAndrewMK.
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