THERE'S a problem in Australia's health system, and many experts think at least a part of it is acute.
But now the calls to change all that are growing more urgent, and one catalyst for the pressure is the current Productivity Commission inquiry into the health workforce. Acute services are gobbling up a disproportionate share of the funding and priorities. In practice, what this means is that a diabetic patient whose foot becomes diseased and then gangrenous - a well-recognised complication of diabetes - may find that an operation to amputate the foot is less difficult to organise than the long-term care that would have stopped their foot getting so bad in the first place.
Acute services are our ambulance crews, hospital emergency rooms and operating theatres; our GP surgeries when these are the first port of call for injuries or sudden, serious illnesses; and parts of our mental health services.
These are the bastions of the medical profession, and for decades, doctors have taken pride in their position at the centre of the health system - a position entrenched by the introduction of Medicare in 1983.
From the outset, Medicare rebates - which subsidise the cost of medical treatment outside the public hospital system - were only available for doctors services.
While that vastly improved the affordability and access to doctors' services, it did nothing to open up access outside public hospitals to allied health professionals - nurses, physiotherapists, midwives, occupational therapists, psychologists, and the various other disciplines of health worker.
As many of the 156 submissions made to the inquiry so far note, the health system is under increasing pressure. There is a shortage of doctors in many specialties - requiring many to be imported from overseas - and nurses too are feeling the strain.
Federal health minister Tony Abbott this week revealed he would consider a suggestion by midwives that they be given access to Medicare rebates. Abbott's office said any proposal would be considered in due course in the normal way and in the context of recent Medicare additions for allied health groups (from which midwives were excluded).
But midwives are by no means the only group seeking such access. Physiotherapists and others too are pushing hard for Medicare rebates. Physios were on the list of 12 allied health workers who were last year given limited access to Medicare - breaking the medical monopoly for the first time.
An estimated 85,000 patients accessed these rebates in the 12 months since their introduction, having an average of about three services per patient - or a total of 248,046 allied health services under Medicare.
But allied health groups say take-up of these new rebates has been unfairly held back by the restrictions that apply to them, which are designed to prevent over-use. For example, patients can only have five of these allied health consultations a year, and they can't just turn up out of the blue for a Medicare-subsidised session with a physio, or any of the others on the list in the same way they could turn up to see a GP. A GP must first agree the allied health consultation is warranted, and refer the patient to the physio or other worker.
In addition, a bit of back pain is not enough: the patient must have a "chronic and complex" condition already being managed by a GP, and the GP must draw up a care plan for the patient in consultation with other health workers that stipulates the need for the particular allied health service as part of a plan involving allied health professionals.
If the GP refers the patient but never gets around to drawing up the plan, no rebate for the allied health consultation will be paid.
As a result, the allied health professions see last year's new rebates as a first foot in the door, rather than the achievement of their goals.
OT Australia, the professional group for occupational therapists, has told the Productivity Commission that the $44.95 Medicare rebate for an allied health consultation "barely covers fuel costs" in cases where therapists have to travel to see patients in their own homes. (This compares to a rebate of $30.85 to see a GP in their surgery for up to 20 minutes, or about $51 for a home visit.)
The Dieticians Association of Australia said in its submission that "for too long there has been an almost exclusive focus on medical and nursing ... with primary and preventative care receiving less focus and limited funding".
The Australasian Podiatry Council has broadened the scope of the debate by arguing podiatrists should also be able to prescribe S4 (prescription-only) drugs, and refer patients direct to specialists for services such as ultrasound scans.
Currently, without a GP referral, a patient would only receive a rebate of $17.85 for a specialist consultation that might cost many times that.
The Australian Medical Association warns that substituting cheaper workers such as nurses for doctors risks creating second-class care, and opposes "sudden or forced role substitution or task substitution".
AMA president Mukesh Haikerwal says Medicare "is a scheme to rebate patients for doctors' consultations and was set up for that purpose".
"In an ideal system, everybody gets everything at no cost, but while it would be nice to have access to all these modalities, I think it's something we really can't afford without some attempt to assign on a needs basis - which is what last year's rebates tried to do," he says. "We'd all like a bit of physio after a game of soccer, but there have to be some limitations."
The claims from the allied health camp are all arguments that might be expected from professional groups intent on maximising their influence, status and remuneration. However, independent experts - some of them doctors - are now increasingly saying the arguments for opening up Medicare make a lot of sense.
Among them is Peter Brooks, a rheumatologist and executive dean of the faculty of health sciences at the University of Queensland, who says opening up Medicare "has got to happen".
Brooks - whose responsibilities include training for a broad range of health workers including doctors, dentists, nurses, pharmacists and allied health workers - wrote in a second submission to the Productivity Commission last month that while doctors' concerns continued to drive the agenda "there will be no real advance".
He has called for "significant and urgent reorganisation of the health workforce", possibly including pharmacists given prescribing rights, radiographers (who are technicians, not doctors) reading X-rays, and nurses being involved in chronic care, limited prescribing and even performing some simple operations.
Instead of specialists seeing patients for routine annual follow-ups, in conditions such as chronic cardiovascular disease, these "could just as easily (and certainly more cheaply) [be] carried out by a general practitioner or even a nurse practitioner".
Brooks says workforce shortages have bolstered the case for expanding Medicare, and gives examples of how allied health workers could help ease pressure on the system. "Studies have shown that about 20 to 30 per cent of people on orthopaedic waiting lists for hip and knee replacement surgery could come off the waiting list if there were physios working with them and building up their muscles, and helping them lose weight," he says.
"It gets them off the waiting list - not forever, they will probably need a replacement at some point, but it will probably be in two years' time, not right now."
The disciplines Brooks thinks should get more of a Medicare look-in include physios, occupational therapists, psychologists, podiatrists, radiographers, and nurse practitioners.
He says it "wouldn't be inappropriate" for midwives to have "some limited Medicare access for the lowest-risk patients. Doing these things through Medicare helps to move it from a professional-focused health system - which is all about maintaining silos, status and income - to one that's focused on patients, which is what I thought the system was supposed to be about," he says.
And despite claims by some doctors' groups that some examples of role substitution are inherently unsafe, he says the evidence often points the other way. "It's not for any doctor to get up on his high horse and say 'I'm a doctor, and I know best - but I haven't got any evidence for it'."
Another advocate of opening up Medicare is Di Lawson, CEO of the Community Services and Health Industry Skills Council, which advises ministers on training and skills development needs.
She says that warnings by the AMA or other doctors' groups that task substitution - for example, using nurses or midwives to carry out some tasks currently done by doctors - may be unsafe falsely suggests the proposals are "wacky and weird".
"In many instances [these roles] are already happening in other countries," she says. "In the UK, large numbers of births are handled by midwives; we know there are lots of nurse practitioner roles in the US and UK, where they are pioneering new roles. "I think we have built a very acute-care-centric health service, and in doing that we have built a lot of power and authority to these groups - medicine and pharmacy. And we now have a time in our life as a nation where we need to think of more primary health care models, and different ways of delivering services.
"We need to think more about preventive care. We need to find new ways of funding."
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