When the option was presented to me to undertake an elective placement during summer 2012, I was acutely aware that this posed one of my last chances to dip my toe in the medical system of another country before the reality as life as a junior doctor in Ireland set in. With this in mind, I was lucky enough to be put in contact with a GP in New South Wales, Australia, who was willing to accept me for a month-long placement in his medical centre. 

I had become increasingly interested in general practice over many years and this seemed like a gilt-edged opportunity to further explore this area and to view it from an international perspective. The purpose of this article is to comment on the differences which I, as a student in general practices in both countries, noted between the systems under which GPs operate in Ireland and Australia, and to consider what each could learn from the other. 

When I first arrived in Australia, my expectation was that I would encounter novel and alternative ways to treat and care for patients in a general practice setting from that which I had witnessed during numerous placements at home. However, perhaps my greatest learning point of the entire experience was that, in fact, the principles and knowledge from which GPs operate are identical on both sides of the globe, with treatment options and recommendations varying only slightly. 

That is not to say that the systems in Ireland and Australia are mirror images of each other. In fact, nothing could be further from the truth, but the major divergences arise from the regulatory and financial systems under which the profession operates in each country. As a consequence, the bulk of this article deals with the differences in the structure of general practice between the two jurisdictions and how, in my opinion, this offers Australian citizens a more equitable and accessible healthcare system than that currently available in Ireland.

Financial equality of access issues

I do not intend to reiterate the arguments about the advantages and disadvantages of the primary care system currently in operation in Ireland or to discuss the merits of the proposed universal healthcare plan. However, a brief understanding of the financial help or hindrance experienced by the citizens of Ireland and Australia is needed in order to adequately compare the service provisions. 

The Australian healthcare system is built around a programme called Medicare. In light of my clinical experiences, I feel that Medicare represents a middle ground between the publicly-funded NHS in the UK and the public versus private situation we are currently dealing with in Ireland. Medicare aims to provide accessible and affordable healthcare to all Australians. The system is funded by a 1.5% health tax levy, with an exemption for low income earners and those on higher salaries (over Aus$70,000) being encouraged to take out private insurance by the imposition of a further 1% levy should they fail to do so. It provides free or subsidised treatment by GPs, as well as assisting with the cost of access to public hospitals, dental care or prescription medicine.

There are two main options available to GPs when deciding how to charge their patients for services rendered. Firstly, a practice may opt to allow a group of patients to be ‘bulk-billed’ to Medicare, in which case the practitioner accepts the Medicare rebate as full payment. A benefit schedule exists under which a rebate level for every procedure is set, ranging from a repeat visit to a GP for a prescription to more invasive procedures such as the removal of skin lesions. At the time of writing, the Medicare rebate for a consultation lasting less than 20 minutes is Aus$36.30 (E25.80). In this situation, the GP agrees to treat for the cost of the rebate with the practice then billing the government directly and no patient charge. Typically, most GPs opt to confer this option on the elderly, those with chronic illnesses and often children, but it is entirely at the discretion of each doctor. In 2009, 74% of all medical visits were bulk-billed.  

In theory, this is similar to the situation of old in Ireland whereby services provided to medical card holders could be charged to the State on a per visit basis as opposed to a flat annual fee per patient, as is now the case. However, where the two systems diverge sharply is in relation to the financial benefits conferred on those who fall outside the remit of the bulk-billing or medical card systems. 

In Ireland, as we are only too well aware, no financial assistance is currently available for the cost of attending a primary care physician to those above the medical card income threshold, unless the patient has a health insurance policy offering some reimbursement for GP costs. As a result, we have reached a critical point in Ireland whereby many people are now postponing necessary and sometimes crucial appointments with their GP, and consequently presenting at a later stage in their illness. 

In contrast to this lack of intervention, in Australia the rebates listed in the benefits schedule mentioned above are paid to the GP for all patients, regardless of income status. As in Ireland, doctors’ fees are not regulated in Australia and consequently many practices choose to charge more to patients outside the bulk-billing system for a service than that listed under the benefit schedule, thus creating a gap between what the patient is expected to pay and what will be refunded by the state. This excess will fall as an expense to the patient. The existence of a ‘safety net’ provision whereby once a threshold of expenses has been reached in a calendar year for those outside the bulk-billing system, the State then accepts the entire cost of medical visits, procedures etc. and ensures that the out-of-pocket expenses to the population as a whole are kept as low as possible. 

So, while both systems lack the universal coverage seen in the UK under the NHS, the extent of the financial burden on patients in Australia is much lower than that currently accepted in Ireland. As a citizen on the cusp of becoming a taxpaying member of society, I would welcome a change whereby 1% of my income was specifically diverted to the provision of health services in a manner similar to that in Australia.

Geographical issues

With a land mass the same as that of the US but with a dramatically smaller population, inequality of access to healthcare secondary to geographic disadvantage is an inevitable problem in Australia. A 2001 survey concluded that 78% of indigenous communities were living at least 50km from the nearest hospital setting and 50% were 25km or more from a community health centre,¹ which is greatly at odds with the ready access available in more urban areas. When this is combined with the predisposition of indigenous communities to chronic physical and mental health issues, the complications of the reduced availability of adequate health services becomes apparent. 

An illustration of the problem can be drawn from looking at life expectancy figures within Australia. The Australian population has an average life expectancy on par with the rest of the Western World. However, men and women from Aboriginal communities live for on average almost 20 years less than other groups of society. When one considers the data widely available regarding the incidence of chronic illnesses among these populations, such as diabetes, cancer and cardiovascular diseases, the prognosis of which can be altered with consistent and accurate monitoring, then the corollary of this reduced access to healthcare professionals is evident. 

It is also important to highlight that the detrimental effect of this geographical dilemma is not solely limited to those of Aboriginal descent. Increased early mortality has also been identified in those of Caucasian race who live in more remote areas. Studies have consistently produced data emphasising the urgent need for health professionals in rural areas, in the field of general practice and in specialist areas. This research has indicated that the only way to adequately redress the unequal distribution of healthcare access in such a vast territory is financial compensation for those willing to consider a rural-based career.   

I was lucky enough as part of my elective placement to visit some Aboriginal outreach clinics where doctors and nurses travel regularly to Aboriginal living camps to assess patients and administer medications or medical treatment if necessary. Basic healthcare checks such as blood glucose and blood pressure monitoring are performed in an effort to reverse the shocking differences in life expectancies. This formed one of the most interesting parts of my experience as it granted me the opportunity to experience at first hand the difficulties that the lack of healthcare services causes for these groups. 

An interesting comparison can be drawn with the Travelling Community in Ireland, which also has significantly higher death rates among their younger population than the national average. I attended a Travellers health clinic that was organised by a GP in Ireland to whom I was attached. I was intrigued to notice how similar the issues facing the two population groups were, but the Irish system had the distinct advantage of the patients being within a much closer proximity to health services of all forms than many of the Aboriginal population in rural Australia.

Insight gained

My aim in writing this article was to articulate my experiences as a medical student working in primary healthcare settings on opposite sides of the globe. The training and dedication of the doctors and medical staff are of the highest standard in both settings, with differences in the regulation of the two systems being the contrast that struck me the most. 

The opportunity to experience another health system at this early point in my career is something that I cannot recommend highly enough as it alerts one to the advantages and disadvantages of the system to which we are accustomed. It challenges you to consider what role each of us can play in developing a more equitable system and certainly provided me with the impetus to reassess what we accept as the status quo. 

References

1. Housing and Infrastructure in Aboriginal and Torres Strait Islander Communities, Australia 2001 (ABS 2002)