HEALTH SERVICES: USE AND PATIENT EXPERIENCE

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INTRODUCTION

Within Australia, all levels of government provide a range of health services which aim to meet a variety of purposes. Some health services may seek to reduce the onset of disease, while others are concerned with managing ill health.

The majority of Australians utilise health services. Despite the billions of dollars that are spent on health services each year by all levels of government and non-government sources, many people report that they are unable to access the care they require. Improving these health services is one of the objectives of the National Healthcare Agreement. (Endnote 1) Central to achieving this objective is improving primary and community health services by ensuring timely and quality care is available.

This article will consider people’s reported use of selected services, including general practitioners, pathology testing, imaging and medication use, and whether people were able to access appropriate services when they were required.

DATA SOURCE AND DEFINITIONS This article is mainly based on data from the ABS 2009 Patient Experience Survey, the main findings of which can be found in Health Services: Patient Experiences in Australia, 2009 (cat. no. 4839.0.55.001), and the ABS 2007-08 National Health Survey, the main findings being available in National Health Survey: Summary of Results, 2007-08 (Reissue) (cat. no. 4364.0). The scope of both surveys was for people living in private dwellings. People living in health establishments such as hospitals or nursing homes, or in other non-private dwellings, were not included. People living in very remote areas were also not included. After hours care is care that is received after the standard business hours of the health service on a public holiday; or a Sunday; or before 8am or after 1pm on a Saturday; or before 8am or after 8pm on any other day. A hospital admission is the formal acceptance by a hospital or other inpatient health care facility where the patients generally reside at least overnight.

FUNDING OF HEALTH SERVICES

Health services provided by all levels of government strive to promote, restore and maintain health. (Endnote 2) Such services involve the detection and treatment of illness and injury, as well as health promotion initiatives that aim to raise awareness of health issues and reduce the onset of disease. In 2008-09, the Commonwealth, state, territory and local governments spent $78.6 billion on health goods and services, amounting to 70% of the $112.8 billion spent on health goods and services from all sources. (Endnote 3)

The Commonwealth Government accounts for the largest proportion of expenditure on health goods and services, having funded 43% in 2008-09. (Endnote 3) The largest components funded by the Commonwealth Government were its own programs, including the Medicare Benefits Schedule (MBS) and the Pharmaceutical Benefits Scheme (PBS), which totalled $29.4 billion of the $48.7 billion spent by the Commonwealth Government. (Endnote 3)

State, territory and local governments contribute funding for, and deliver, a range of health care and services including: public hospital services, public health initiatives, community health services, public dental services, mental health programs, aged care, and health policy research and development. (Endnote 2) In 2008-09, state, territory and local government funding of health goods and services cost $29.9 billion, or 27% of total health expenditure. (Endnote 3)

Non-government sources for funding health goods and services totalled $34.2 billion (30% of total health expenditure) in 2008-09. These sources included costs incurred by individuals ($18.9 billion), private health insurance funds ($8.8 billion) and other non-government sources such as injury compensation insurers. (Endnote 3)


FUNDING OF HEALTH EXPENDITURE

Source of funds		Expenditure
	Type of expenditure	($ billion)	(%)
Commonwealth Government		48.7	43.2
	Department of Veterans Affairs	3.5	3.1
	Private health insurance rebates	3.6	3.2
	Own programs (a)	29.4	26.1
	Grants to states	11.7	10.4
	Medical expenses rebate	0.5	0.4
State, territory and local governments		29.9	26.5
Non-government sources (b)		34.2	30.3
Total health goods and services		112.8	100.0

(a) These include the MBS, PBS, public health, research, the Aboriginal community-controlled health and substance use services, and health-related capital consumption and capital expenditure.
(b) Mostly out-of-pocket payments by individuals, but also includes funding by private health and injury compensation insurers and other private funding.
Source: AIHW, Health Expenditure Australia 2008-09, viewed 28 February 2011 <www.aihw.gov.au>

DISADVANTAGE AND REMOTENESS Areas of disadvantage are analysed in this article using one of the Socio-Economic Indexes for Areas (SEIFA) based upon the 2006 Census of Population and Housing. The SEIFA Index of Disadvantage combines a number of variables (such as income, education and unemployment) of people, families and dwellings within an area, and uses this information to rank areas on a scale of relative disadvantage. The first quintile represents the areas of most disadvantage and the fifth quintile represents the areas of least relative disadvantage. Remoteness Area is a structure of the Australian Standard Geographical Classification (ASGC). It classifies areas sharing common characteristics of remoteness into broad geographical regions (Remoteness Areas). In most instances in this article Remoteness Areas are collapsed into three levels: Major Cities; Inner Regional Areas; and Outer Regional/Remote/Very Remote Areas (where available). For further information about Remoteness Areas see Chapter 8 of ABS Australian Standard Geographical Classification (ASGC), July 2010 (cat. no. 1216.0).

USE OF HEALTH SERVICES

General practitioners (GPs)

Primary and community health services are usually a patient’s first contact with the health care system. These service providers, particularly GPs, play an important role in monitoring an individual’s health and managing their health conditions. Advice from doctors has been shown to be most effective in changing unhealthy behaviour, (Endnote 4) and access to primary health care services is a prerequisite for improved management of chronic disease.


According to the ABS 2009 Patient Experience Survey, four out of five people (81%) aged 15 years and over had seen a GP in the 12 months prior to the survey. Women were more likely than men to have seen a GP in the last 12 months (87% and 75% respectively). This gap was most evident during women's childbearing years, as women may have sought care more frequently for reproductive medical services, and as such, have had a higher number of visits to GPs. (Endnote 5)


Of people who had seen a GP, around one in ten (11%) made 12 or more visits in the year prior to the survey. Those aged 65 to 74 years and those aged 75 years and over were the age groups most likely to visit a GP 12 or more times (23% and 24% respectively). In addition, those living in areas of most disadvantage were more likely than those in areas of least disadvantage to visit a GP 12 or more times (17% compared with 5.9%).

While the proportion of people who visited a GP in the last 12 months did not vary greatly across Remoteness Areas (82% in Major Cities, 80% in Inner Regional Areas and 78% in Outer Regional/Remote Areas), there was a difference in the proportion of people who had seen a GP after hours between Major Cities and Outer Regional/Remote Areas (8.6% and 5.8% respectively).

Of those in Major Cities who had seen a GP after hours, 38% did so at a regular practice, 19% did so at an after hours clinic at a hospital and 43% did so at either a late night clinic, other clinic/practice or via a home visit. Of people in Outer Regional/Remote Areas who had seen a GP after hours, almost half (46%) did so at an after hours clinic at a hospital, while 34% did so at a regular general practice.

Hospital admissions

The hospital sector consists of more than 1,300 public and private hospitals, of which people have the ability to move between for different public or private treatment services. The majority of hospital resources are used to provide care to admitted patients. (Endnote 6) In 2009, just over 13% of the population aged 15 years and over were admitted to hospital. Those aged 75 years and over were the most likely to be admitted in this period (25%). Under the age of 55 years, women were more likely than men to have been admitted to hospital. This is particularly true for those aged 15-24 years (6.7% for men and 12% for women), 25-34 years (7.0% for men and 17% for women) and 35-44 years (8.3% for men and 16% for women). Some of these differences may be explained by women in their child bearing years utilising hospital services such as gynaecological and obstetric services more frequently than their male counterparts - in 2008-09, 6.6% of all hospital separations had a principal diagnosis of pregnancy or childbirth, or conditions originating in the perinatal period. (Endnote 6)


There was a difference in the proportion of public and private patient hospital admissions across areas. Almost half (49%) of those living in Major Cities were treated as private patients, compared with 34% of those living in Outer Regional/Remote Areas. Almost three-quarters (71%) of those in the least disadvantaged areas were admitted to hospital as private patients, compared with 24% of those in the most disadvantaged areas.

Across different geographical areas, the number of available hospital beds per 1,000 population varied to some extent. In 2008-09, the average number of beds available was less in Major Cities and regional areas (Inner and Outer Regional Areas combined) than it was in remote areas (Remote and Very Remote Areas combined). The average number of available beds per 1,000 population resident in an area was 2.5 in Major Cities and 2.9 in regional areas, compared with 4.3 in remote areas. (Endnote 6) The additional beds in remote areas may in part be explained by some hospitals in these areas having the added responsibility of providing primary health and aged care services, whereas in Major Cities these are separate facilities. (Endnote 7)

Emergency departments

Hospitals also provide an abundance of outpatient services, including those provided by emergency departments. Approximately 2.3 million people (13%) aged 15 years and over reported going to a hospital emergency department in the 12 months prior to the ABS 2009 Patient Experience Survey. The main reason that people went to an emergency department was because their condition was serious or life threatening (47%). Almost a quarter (23%) did so because of the time of day/day of week, suggesting health care was required outside of normal business hours when regular general practices may have been closed.

People from areas of most disadvantage were more likely to visit a hospital emergency department more than once a year. In areas of most disadvantage, 32% of people who had visited a hospital emergency department in the last 12 months had two or more visits, compared with 20% of those in areas of least disadvantage.

Visits to hospital emergency departments were similar across different geographical areas. Approximately 13% of those living in Major Cities went to a hospital emergency department in 2009, compared with 14% of those in Inner Regional Areas and 15% of those in Outer Regional/Remote Areas.

Other health services

Almost half of the population (49%) aged 15 years and over had a pathology test in 2009. People aged 65-74 years (73%), and 75 years and over (69%), were most likely to have had such a test, and women were more likely than men (55% and 42% respectively).

Women were also more likely to have had an imaging test (37% compared with 25% of men), received a prescription for medication (84% compared with 78% of men) or have asked a pharmacist for advice (28% compared with 17% of men).


PATIENT EXPERIENCE

Accountability is an important component of the healthcare system. Information on patient perceptions of their health care experiences is important in determining deficiencies in services and improving accountability. The main barriers to accessing services identified in the ABS 2009 Patient Experience Survey were cost, unacceptable waiting times and lack of available services.

Cost

According to the ABS 2009 Patient Experience Survey, approximately 1.1 million Australians aged 15 years and over (6.3%) reported that they had delayed seeing or did not see a GP in the previous year because of the cost. There was no significant difference in the proportions of those who didn't see a GP because of cost between the most disadvantaged areas and the least disadvantaged areas. This may be due to people living in the most disadvantaged areas having access to government health concession cards and veteran concession cards (Endnote 8) or their ability to access community health facilities or Aboriginal Medical Services. In such circumstances, cost may be less of a consideration.

Similar proportions of people living in Major Cities, Inner Regional and Outer Regional/Remote Areas had seen a GP (82%, 80% and 78% respectively). There was little difference in the proportion who had delayed seeing a GP because of the cost (6.1% living in Major Cities, 6.8% living in Inner Regional Areas and 6.6% living in Outer Regional/Remote Areas).

Almost one in ten delayed getting or did not get prescribed medication because of the cost (9.0% or about 1 million people). Additionally, more than twice the proportion of people in the most disadvantaged areas found cost a barrier to receiving prescribed medication compared with those in the least disadvantaged areas (12% and 5.4% respectively).

Unable to access appropriate health services

In 2009, 5.4% of the population (937,800 people) aged 15 years and over reported there had been times that they had been unable to access health services. For 82% of these people, it had not been possible to visit a GP when one was required, while 9.5% of those who were unable to access health services could not see a medical specialist.

The main reasons reported for not being able to access health services were that waiting times were too long or no appointment was available (47%), or there had been no service available in the area at the time it was needed (34%).

Almost a quarter (23%) of people living in Outer Regional/Remote Areas felt they waited longer than was acceptable for an appointment with a GP, compared with 16% of those living in Major Cities. People living in Outer Regional/Remote Areas were also four and a half times as likely as those living in Major Cities to travel more than one hour to see a GP (8.2% compared with 1.8%).

A shortage of GPs may result in hospitals being the first place of call when medical treatment is required. Indeed, a quarter of those who visited an emergency department (556,400) thought at the time of the visit that the care could have been provided by a GP. The proportion of people who thought this was not significantly different between Major Cities, Inner Regional and Outer Regional/Remote Areas. Around one in ten (12%) of those in Outer Regional/Remote Australia went to an emergency department because the waiting time for an appointment with a GP was too long, compared with 2.0% of people living in Major Cities.

Those living in Outer Regional/Remote Areas also experienced problems when trying to secure an appointment with a specialist. Just over a quarter (27%) felt they waited longer than was acceptable, compared with 20% of those living in Major Cities.

HEALTH INSURANCE With the advent of Medicare, private health insurance became less essential for many people. In an attempt to improve private health insurance coverage, the Commonwealth Government introduced several policies to encourage its uptake. (Endnote 9) These policies take some of the demand from the public health system by encouraging those who can afford it to use the private hospital system. Figures from the ABS 2007-08 National Health Survey indicate that over half (53%) of the population aged 15 years and over have private health insurance. Those in the age groups 15-24 years, 25-34 years and 75 years and over had the lowest rates of private health insurance (46%, 45% and 45% respectively). After accounting for the effects of age in comparisons between people living in Major Cities and outside Major Cities, people who lived in Major Cities in 2007-08 were 27% more likely than those living outside Major Cities to have private health insurance. Conversely, those living in Major Cities were 23% less likely than those living outside Major Cities to have a government health-related concession card (such as a Health Care Card). In 2007-08, those living in Major Cities were 26% less likely than those living outside Major Cities to have a Health Care Card (including the Low Income Health Care Card). A quarter (25%) of those living outside Major Cities did not have either private health insurance or a government health related concession card, compared with 22% of those living in Major Cities. The most common reason for those who did not have private health insurance in both Major Cities and outside Major Cities was that they could not afford private health insurance or thought that it was too expensive (59% and 58% respectively).

LOOKING AHEAD

The majority of Australians interact with health services each year. However for some, cost and accessibility provide barriers to accessing care when it is required. The National Healthcare Agreement has identified health service accessibility as a priority. It states that providing all Australians with timely access to quality health services when required should not be based on their ability to pay or where they live in the country.

ENDNOTES

1. Steering Committee for the Review of Government Service Provision (SCRGSP), 2009, National Agreement performance information 2008-09: National Healthcare Agreements, Productivity Commission, Canberra.2. Steering Committee for the Review of Government Service Provision (SCRGSP), 2010, Report on Government Services 2010, Productivity Commission, Canberra.3. Australian Institute of Health and Welfare 2010. Health expenditure Australia 2008-09. Health and welfare expenditure series no. 42. cat. no. Canberra: AIHW, p. 22, <www.aihw.gov.au>.4. Jepson RG, Harris FM, Platt S and Tannahill C, The effectiveness of interventions to change six health behaviours: a review of reviews; BMC Public Health 2010, 10:538, <www.biomedcentral.com>.5. Uncommon Insights, 2007, Literature Review on Effective Sex and Gender-Based Systems/Models of care, U.S. Department of Health and Human Services, p. 2, <www.womenshealth.gov>.6. Australian Institute of Health and Welfare 2010, Australian hospital statistics 2008-09, Health services series no. 34. cat. no. HSE 84. Canberra: AIHW, <www.aihw.gov.au>.
7. Productivity Commission, 2009, Public and Private Hospitals, Research Report, Canberra, <www.pc.gov.au>.
8. Australian Bureau of Statistics, 2010, ‘Health and socioeconomic disadvantage’, Australian Social Trends, March 2010, cat. no. 4102.0, ABS, Canberra, <www.abs.gov.au>.
9. These policies are:

i. The Medicare Levy Surcharge. Introduced on 1 July 1997, the surcharge is applied to people who do not have private hospital cover and earn above a specified amount ($77,000 for individuals and $154,000 for families in 2010-11).

ii. The Private Health Insurance Rebate. Introduced on 1 January 1999, this incentive provides a rebate on every dollar an individual contributes to their private health insurance premium, irrespective of income. The Rebate increases depending on age:

• 30% for people aged under 65,
• 35% for people aged 65-69, and
• 40% for people aged 70 and over.

iii. The Lifetime Health Cover scheme. Introduced on 15 July 2000, this scheme provides incentives to people who purchase hospital cover. People who purchase cover before the 1st July following their 31st birthday, and who maintain their membership, pay lower premiums throughout their lifetime relative to people who delay joining.

Australian Bureau of Statistics 2003, Private Health Insurance 2001, cat. no. 4815.0.55.001, <www.abs.gov.au>.

Private Health Insurance Ombudsman, Government surcharges and incentives, viewed 2 March 2011, <www.privatehealth.gov.au>.
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