Australia State of the Environment Report 2001 (Theme Report)
Lead Author: Professor Peter W. Newton, CSIRO Building, Construction and Engineering, Authors
Published by CSIRO on behalf of the Department of the Environment and Heritage, 2001
ISBN 0 643 06747 7
Liveability: human well-being (continued)
Environmental health (continued)
The previous sections have described the prevalence of illness and death in the population. Differences in rates of illness and death are treated largely as consequences of variation in exposure to physical and psychosocial environments, including behavioural risk factors such as smoking, alcohol consumption, physical activity, diet and levels of stress.
This section describes society's response to illness, in the process creating environmental settings with direct consequences for health outcomes. This response generally takes the form of health care through preventive and curative services, mostly provided by medical practitioners, nurses and allied health workers. Access to health care facilities and health care professionals is critical to reducing the differences in health outcomes between people living in different regions.
Much of the action taken to prevent illness and injury is in the form of non-medical services such as better roads, safer cars, more rigorous traffic policing (deterring drink driving, speeding etc.), better sanitation, safer farm machinery, and education about risks such as smoking, fatty foods and lack of exercise.
The provision of and access to health care resources such as GPs, pharmacists, nurses and hospital facilities is another major aspect of the society's response to illness. For example, those living in rural and remote zones of Australia are considered to have lower access to health care compared to those living in the metropolitan zone (AIHW 1998a). Access difficulties caused by distance, time, cost and transport availability in rural and remote zones can be compounded by shortages and uneven distributions of health facilities and health professionals.
Australia has higher numbers of clinicians per capita compared with countries such as Canada and New Zealand, whose health systems are comparable and medical workforces are structured as in Australia. In 1998 there were 2.4 clinicians per 1000 population in Australia, 2.1 in Canada and 2.2 in New Zealand. However, while most of the OECD countries for which data is available show a continuing growth in the number of practising doctors per capita, Australia has shown slight decreases since the peak in 1996 (AIHW 2000c).
In Australia the medical workforce is unevenly distributed geographically. There is a higher number of GPs in metropolitan areas (AMWAC and AIHW 1996), and a pattern of undersupply of the health labour force in rural and remote areas (AIHW 1998a). In 1998 there was almost double the per capita number of primary care medical practitioners providing services in capital cities compared with remote areas (Table 47).
|Characteristic||Metropolitan zone||Rural zone||Remote zone||Total|
|Number per 1000 population||1.2||1.1||1.1||0.9||0.8||0.7||1.1|
|Female practitioners (%)||35.7||27.9||32.7||24.5||24.7||30.4||33.2|
|Being on call (%)||28.9||38.8||53.3||63.6||63.8||64.0||36.6|
|Bulk billing rate (%)||85.6||79.6||60.2||59.4||58.7||66.0||79.6|
APrimary care medical practitioners include vocationally registered general practitioners, other medical practitioners, and GP trainees in general practice.
Source: AIHW (2000c), AIHW (unublished data).
There have been consistent efforts lately to bridge this gap. For example, between 1994 and 1997 the number of clinicians per 1000 population increased by 0.7% in metropolitan areas and by 4.5% in rural areas. It is expected that an increase in the proportion of medical students with a rural background will result in an increase in the proportion of Australian medical graduates willing to practice in rural areas in the long run.
In Australia, a general practitioner is usually the first point of contact for any health problem. The importance people place on access to a GP is illustrated by the fact that in 1998-99, on average, Australians visited their GPs 6.3 times per year (Table 48).
|GP consultations||Metropolitan zone||Rural zone||Remote zone||Total|
|Number (in millions)||81.9||9.4||6.9||7.3||11.5||0.8||0.9||118.8|
|Average (per person)||6.9||6.6||6.2||6.0||4.7||3.8||2.8||6.3|
AExcludes medical care provided by Aboriginal health services or defence force medical services, or not billed to Medicare.
People living in rural and remote zones have lower rates of GP consultation than those living in metropolitan areas. In remote areas the rates fall below 50% of rates in metropolitan areas (an average of 2.8 visits per year in 'other remote areas' compared to 6.9 in 'capital cities'). One of the major reasons for lower GP consultation rates in remote areas is limited access to GPs (Humphreys et al. 1997).
The settlement distribution of other health workers differs considerably from that of GPs. For example:
- The number of specialists per capita in the remote zone is approximately one-tenth that for capital cities, although some 2% of metropolitan specialists also report practicing in rural or remote areas (AIHW 1999a, 2000c).
- Nursing employment in rural areas is well above that of other health professions. In 1996 the number of nurses per 1000 population in large rural centres (17), small rural centres (14) and remote centres (12) exceeded that of capital cities (11). Around 70% of nurses in the remote zone were registered (rather than enrolled), compared with about 80% in the other two zones combined (AIHW 1999b).
- The number of pharmacists decreases with remoteness, from 85 per 100 000 population in capital cities to 28 per 100 000 population in remote areas (AIHC 2000d).
There are more dentists per capita in capital cities (0.5 per 1000 population) compared with other areas (0.3 per 1000 population), although the number of dental therapists was similar between different areas (Szuster and Spencer 1997a, 1997b).
Hospital outpatient visits are another point of contact for primary health care. However, the settlement pattern of these visits is a mirror image of that noted for GP consultations (Table 49). In 1997-98, the average number of occasions on which a person visited hospital outpatient facilities in remote areas was about twice that noted in metropolitan areas.
|Outpatient visits||Metropolitan zone||Rural zone||Remote zone||Total|
|All occasions (in millions)||11.8||0.9||1.2||1.0||1.4||0.3||0.7||17.3|
|Accident and emergency (in millions)||2.7||0.3||0.5||0.6||0.6||0.2||0.3||5.1|
|Other medical and surgical and obstetric care (in millions)||9.1||0.6||0.7||0.4||0.8||0.1||0.4||12.1|
|All occasions (per person)||1.0||0.6||1.1||0.8||0.5||1.5||2.0||0.9|
AAn unknown proportion of hospital outpatient services are provided by accident and emergency specialists and other practitioners who do not provide primary care.
A main cause of a higher rate of outpatient visits is that the hospital outpatient facilities are used for primary care more often in rural and remote areas than in the metropolitan zone. This is likely in view of relatively lower GP accessibility in those areas. In particular, in remote areas a higher proportion of the population obtains primary care services through either hospital outpatient facilities or Aboriginal medical services. Data for the latter are not available, but average patient encounters with public hospital outpatient services in 'remote centres' (1.5) and 'other remote areas' (2.0) are significantly higher than in all other settlement categories (0.5-1.1).
Statistics on people hospitalised, although sometimes referred to as hospital admissions, are technically referred to as hospital separations. This is because data on patients admitted are collated at the end of a period of care. By this time, the actual length of stay and the procedures carried out are known, and the diagnostic information is more accurate (AIHW 2000a).
Over the two-year period (1996-97 to 1997-98) there were approximately 11.1 million hospital separations in Australia, which is a rate of 282 per 1000 population (Table 50).
|Hospital separation statistic||Metropolitan zone||Rural zone||Remote zone||Total|
|Number (in millions)||6.9||0.8||0.7||0.8||1.6||0.2||0.3||11.1|
ANumber of hospital separations per 100 000 persons, age-standardised to the Australian population at 30 June 1991. Rates for all other zones are significantly different from the M1 zone ('capital cities') at the 5% level.
Source: AIHW (200b).
As Table 50 shows, the hospital separation rate increases from metropolitan to remote zones. Factors that could contribute to higher separation rates in rural and remote zones include higher morbidity, and rural patients being more likely to be admitted to hospital than treated as outpatients because of longer travel distances (Harvey and Mathers 1988). People needing more specialist treatments must travel even further to the larger towns or cities or wait longer for these services to come to them on a rotation basis (AIHW 1998a).
Higher hospital separation rates have been reported among Indigenous people - almost twice the rate among non-Indigenous people (Cunningham and Beneforti 2000). In 1997-98, 30% of male and 34% of female hospital separations in remote areas were Indigenous people. Major reasons for Indigenous hospitalisations were dialysis (25% of separations), complications of pregnancy and childbirth (17%) and injuries (8%). Indigenous hospital separation rates were highest among those living in remote areas (641 per 1000 males and 778 per 1000 females) and lowest for those living in metropolitan areas (424 per 1000 males and 505 per 1000 females).