Issue 41 / 22 October 2012

WE don’t need a list of 50 references to tell us that the health of our Aboriginal and Torres Strait Islander peoples is a blight on Australia’s reputation as a resource-rich nation with a first-rate health system.

The problem of poor Indigenous health outcomes cannot be blamed solely on our health system — geographical, cultural, legal, educational, economic and other social determinants all play a role.

However, as participants within Australia’s health sector, health professionals have a duty to reflect on how matters can be improved.

A good way to approach this is to contemplate a time when we or one of our loved ones has been sick. Even as doctors — replete with knowledge of “the system” and our networks of colleagues — it can take considerable time, phone calls and paperwork to get things done where we want, how we want and when we want.

GPs know better than anyone else that the role of the doctor is becoming less of diagnostician/curer and more of a manager/coordinator/facilitator. It is now just as important to learn about how the health system works as it is about the diseases themselves.

Now, put yourselves in the shoes of the vast majority of Indigenous patients in Australia. Not only would you be confronted with the maze of the health system, but often also with a lack of money, transport, education and experience to deal with being sick in Australia.

Those of us who work in rural and remote areas are confronted with this not just daily, but many times per day.

The result is that many Indigenous patients simply do not access our health system and all it has to offer. When contact is made, it is often sporadic with little or no continuity — often scripts are not filled, referrals are not followed up, children are not vaccinated, etc.

In 2008, the Australian Government endorsed the Closing the Gap (CTG) initiatives. Among the programs and schemes introduced, referrals to allied health services are now much easier and many Indigenous patients now get Pharmaceutical Benefits Scheme (PBS) prescriptions free or significantly cheaper.

Now prescriptions for sick children are much more likely to be filled by mothers who no longer have to wait for “pay day” (pension day). In my practice, the positive effect of the PBS incentive alone has been dramatic.

But as successful as it has been, there is so much more to do …

To register for CTG incentives, there is still a mountain of paperwork for the patient and the practice. There is a requirement to re-register annually. There is still no dental component to the scheme.

As with many other such schemes, the CTG highlights the awkward disconnect between our state-run hospitals and Medicare. For example, a script written in hospital is not eligible for a CTG annotation, so an Aboriginal patient given a script for antibiotics following an admission for pneumonia cannot get the cheaper rate with the hospital discharge script.

A better way forward would be a system that allows unrestricted access to the full range of services available in our health system.

My experience in treating many Indigenous patients over the years has taught me that unrestricted access to all levels of our system would, in fact, save time and money, as well as achieve better outcomes.

If we gave Indigenous patients a special Medicare card — similar to a Department of Veterans’ Affairs Gold Card — this would allow cheaper scripts, full allied health care, an increased range of dental, eye and nursing services, transport assistance, and access to private hospital facilities.

Some would argue that this singles out one group in our society when so many others are also needy. This is valid, but we cannot escape the fact that we need to make a start and that this group is very much in need.

Others may argue that it would be too expensive and unaccountable. I beg to differ. When taking into account the paperwork, costs and inefficiencies of the current schemes, an unrestricted scheme would in fact be cheaper, even if the odd bit of overservicing occurred (and let’s be honest enough to admit it occurs under current schemes anyway; eg, the Chronic Disease Dental Scheme that is set to be replaced in the near future).

If, after 10–20 years, we have sufficiently closed the gap, we could always reassess and scale it back.

Could you imagine being able to refer Indigenous patients wherever we liked, in a timely fashion, knowing that they would get there and have the treatment needed?

Now that would be revolutionary and truly close the gap!

Dr Aniello Iannuzzi is a GP practising in Coonabarabran, NSW.

Posted 22 October 2012

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7 thoughts on “Aniello Iannuzzi: Gap challenge

  1. Rose says:

    The CTG PBS initiative is a good idea, but the CTG registration, and PIP practice accreditation requirements are onerous, time consuming and expensive for doctors, so direct Medicare funding for the full cost would be a start.
    Any Medicare card would be a bonus , as some Indigenous children born in the local public hospital are not even enrolled-I have enrolled 2 recently.
    Ask Indigenous patients if they want an Aboriginal Medicare card-some may fear discrimination and choose not to identify.

  2. Nick Aalders says:

    Why racist? and why is it necessary to say this four times, Anonymous?

    There is no doubt that racist attitudes are alive and well in Australian health systems. I know this as I work in an Aboriginal Medical Service and I know from my patients the attitudes and treatment they can fall foul of.

    But the existence of racist attitudes and behaviours in the health care system and in the wider community should not be a reason to deny the most marginalised and dispossessed members of our community equity of access to health care. I mean, does anyone seriously cry out ‘Veteranist!’ for those members of our community who do posses (for the time being, anyway) a Gold Card?

    My experiences in Indigenous health care echo those of Dr Iannuzzi and I know my patients and would be a whole lot happier and healthier if such a scheme existed.

  3. Anonymous says:

    A Gold Card for Aboriginal people? 4 words to describe such a system: Racist, Racist, Racist, Racist.

  4. Anonymous says:

    Rather than adding another service, we should maximise the use of the services already in place . An enormous and expensive system exists already and is very inefficient. Clinics are provided, staff organised, patients transported to the services and then patients disappear. While it may be culturally insensitive not to accommodate this behaviour, it is certainly very frustrating. I am not sure the system can be made simpler, what is needed is the aboriginal community to “want” the service before they use it rather than having it imposed on them. This implies that “value” is attributed to the service rather than it being seen as a throw away item. Additionally personal responsibility is essential for any system to work.

  5. Alex Wood says:

    For many “lost” groups the suggestion to make the system straight forward and easy for the consumer especially but also the provider seems long overdue. The Gold Card idea sounds a good model to commence. It could easily be modified after 1-2 years as suggested. There will always be smart, unscrupulous operators, but that can be watched and scoundrels outed.
    We have lacked understanding of disadvantage in many areas, especially our indigenous population so Dr Iannuzzi’s thoughtful comments are applauded and need support.

  6. Shane Wilkie says:

    Very interesting reading this article, but yes I totally agree especially with the gold card or something similar. Not only high statistics with many chronic diseases but also the dental issues that I presume are very high in stats. Many cannot afford medicare or similar personal health funds and the community controlled indigenous health centres are very busy with backlogs of patients.

    But thank you for this article it makes a lot of common sense to me.

  7. Dr tilak dissanayake says:

    Dr .Ianuzzi’s comments highlight the need to reduce multi-tier of bureaucracy (bureau-crazy!) eventually costing more to communities.

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