The release of the Strengthening Medicare Taskforce report in early February triggered an avalanche of comment about the challenges facing primary care in Australia and what needs to be done to fix it.
The hard work of implementing change lies ahead, and evidence is mounting that the Government can rely on a strong community licence to do whatever is necessary to rebuild Medicare and restore it to its rightful place as the shining star of the health system.
The Report has confirmed what many health professionals have known for years – general practice, the cornerstone of what was once a world leading health system, is under unbearable strain and is no longer fit for purpose.
Cascading crises
The symptoms of a sick system abound.
Patients are paying up to $90 upfront for a standard consultation which can take several weeks to secure.
Clinics are finding it harder to recruit doctors with just 14% of medical graduates electing to work as GPs.
Too many young doctors are shunning careers in primary care, possibly deterred by the Coalition-era Medicare rebate freeze, which the Australian Medical Association says has ripped $8 billion out of general practice and left doctors underpaid.
The quality of care is being undermined by an outdated funding system, the fee-for-service model, which rewards doctors for seeing lots of patients for short one-off visits when more comprehensive and holistic consultations are often needed.
The cascading crises have contributed to a 4% decline in national bulk billing rates in just the past 3 years, according to an analysis of Health Department data by The Guardian.
The drop is far bigger in some areas such as the central coast of New South Wales, the corridor between Brisbane and the Gold Coast, and the northern suburbs of Perth where the number of people who are fully bulk billed by their GP has crashed by up to 18%.
More people than ever before are paying to see their doctor which is further eroding the principles Medicare was founded on: equity, efficiency, simplicity and universality.
With primary care increasingly unaffordable, some patients are delaying GP visits or bypassing their local clinics altogether and fronting up at overstretched emergency departments which is adding to the growing pressure on public hospitals.
Health Minister Mark Butler was not pulling his punches when he declared that Medicare is in the worst shape of its 40 year history.
The Strengthening Medicare Taskforce Report is the Minister’s roadmap for lasting structural reform – containing many big ideas to strengthen primary care’s capacity to meet current and emerging challenges.
The sector should be encouraged that the Minister has embarked on this critical and complex work so early in his tenure.
His stated approach is to take a long term view to resolve some of the entrenched problems that have been previously identified, but not addressed, by several forerunner reviews conducted by both sides of politics.
The report is only 12 pages long and some health groups are lamenting a missed opportunity saying it contains no proposals that would give Australians immediate access to more affordable and timely care.
But the report is accessible and essential reading for anyone concerned about the future of an affordable and equitable public health system.
A launch pad for enduring reform - key takeouts
Further details will need to be woven into the “roadmap” before it can become a fully implementable plan.
The Report nonetheless gives the Federal Government a much needed launch pad for enduring reform, with several laudable recommendations which are worth pursuing.
Key among them is a team-based approach to primary care involving a whole ecosystem of health professionals – doctors, nurses, pharmacists, midwives, allied health, and Aboriginal and Torres Strait Islander health workers.
This would give busy GPs a lot more support by allowing – and funding – nurses and physiotherapists, for example, to treat straightforward cases.
Another more contentious option would be for chemists to write prescriptions for certain conditions under certain protocols.
Such an initiative will only occur if the states and territories dismantle the barriers which currently stop pharmacy prescribing – a direction that some states and territories are already taking in their own bid to ward off the pressures on emergency departments.
And vested interest groups, such as the AMA and the Pharmacy Guild, would have to end their long-standing turf wars which have plagued the health system for decades.
In a bid to support continuity of care, patients would be encouraged to register with a single practice where they would receive wrap-around services which the Report says would build a stronger relationship between the patient and their entire care team, including allied health professionals.
Another suggested improvement is a new blended funding model for general practice, which would combine the standard fee-for-service with other types of payments such as extra funds for longer consultations and support for other providers which would help patients with more complex chronic diseases.
Incentives would also be paid to encourage clinics to offer after hours services to reduce avoidable hospital presentations.
The regional system of Primary Health Networks could also see themselves take on enhanced roles to fund gaps in services, mobilise workforce, support the sector to drive organisational and cultural change and better enable local innovation.
The consumer voice and role in shaping better services is acknowledged – again, a capability that needs much more investment.
The recommendations have a single overarching objective – to deliver better health outcomes.
A challenging reform path
But the reform path will be challenging and Mark Butler is managing expectations by warning that the biggest overhaul of Medicare in four decades is “not going to be quick, it’s not going to be easy.”
Nor will it be cheap, especially if the Government increases the Medicare rebate to doctors, which the Minister says is “not off the table.”
"Neither the Taskforce nor the Government have put a price tag on the cost of fixing Medicare, but it would run into untold billions of dollars, placing future budgets under enormous strain and easily eclipsing the $750 million the Albanese Government has allocated as a downpayment to support primary care."
But timing may well be on the Government’s side.
One of the enduring outcomes from the COVID-19 pandemic is that it focussed people’s attention on the strength of the health system which underpins their own good health.
This points to a potential appetite in the community to spend what is needed to repair Medicare, regardless of the cost to the budget.
And it would correlate with Labor’s adoption of a wellbeing budget, which included options to measure the impact of budget decisions on community health and wellbeing, not just standard economic indicators like GDP.
Community licence
Research commissioned by 89 Degrees East shows that an overwhelming majority of Australians – 69% – support a wellbeing approach to the budget.
This springs from their concerns about their own health and safety, and a post COVID understanding of what really matters to their quality of life.
"71% of people responded that the Government must prioritise mental and physical health, with more than one third of people reporting that their own health “was just OK”."
Critically, the states are on board – they want the system revamped to take the pressure off their own health budgets.
Victorian Premier Dan Andrews is pushing the fairness and equity argument that the huge sums needed for reform “won’t be a cost, but an investment in being a fair place, a decent place.”
This all means that the time is right for the biggest ever redesign of Medicare to drag it out of the past and restore it to pride of place in a modern and efficient health system, where the patient is at the centre of care.
The heavy lifting must start immediately given the ageing of the population and the rising rates of mental illness and complex chronic diseases.
Labor has long trumpeted the achievements of Medicare as a gold standard health system where the quality of care is determined by your Medicare card and not your credit card.
The Prime Minister has already declared that health reform will be a “first priority issue” this year.
Labor’s legacy as champions of universal health care will now depend on Anthony Albanese and Mark Butler walking in the footsteps of Gough Whitlam and Bob Hawke and reimagining – and implementing – a health system that is fit for all Australians.
Carpe diem.
Leanne Wells is Policy and Advocacy Director at 89 Degrees East.
