10	Primary and community health
Editions of this report before 2004 included a chapter on general practice. Since the 2004 Report, the chapter was expanded to include community health, to achieve a more comprehensive coverage of the primary health services supported by government. The primary and community health sector is the part of the healthcare system most frequently used by Australians. It is important in providing preventative care, diagnosis and treatment of illness, and referral to other healthcare services. 
This chapter now covers general practice, primary healthcare services for Indigenous people, drug and alcohol treatment, public dental services, maternal and child health, and a range of other community health services. The scope of this chapter does not extend to: 
•	Home and Community Care program services (see chapter 12, ‘Aged care’)
•	public hospital emergency departments and outpatient services (see chapter 9, ‘Public hospitals’) 
•	community mental health services (see chapter 11, ‘Health management issues’)
•	government funding of pharmacies or the Pharmaceutical Benefits Scheme (PBS).
Indigenous data in the primary and community health chapter
The primary and community health chapter in the Report on Government Services 2005 (2005 Report) contains the following on Indigenous people:
•	descriptive information on specific health programs for Indigenous people
•	ten most common health problems managed for Indigenous peoples encounters with general practitioners (GPs) and other data relating to the use of general practice services by Indigenous people, and
•	a comparison of hospitalisation rates for diabetes for Indigenous and non‑Indigenous people.
Supporting tables
Supporting tables for data within the primary and community health chapter of the compendium are contained in the attachment to the compendium. These tables are identified in references throughout this chapter by an ‘A’ suffix (for example, table 10A.3 is table 3 in the primary and community health attachment to the compendium). As the data are directly sourced from the 2005 Report, the compendium also notes where the original table, figure or text in the 2005 Report can be found. For example, where the compendium refers to ‘2005 Report, p. 10.15’ this is page 15 of chapter 10 of the 2005 Report, and ‘2005 Report, 10A.2’ is attachment table 2 of attachment 10 of the 2005 Report.
Primary and community health services
In Australia, general practices are an important source of primary health care. General practice is the business structure within which one or more general practitioners provide and supervise health care for a group of patients. The services provided in a general practice include: diagnosing and treating illness (both chronic and acute); providing preventative care through to palliative care; referring patients to consultants, allied health professionals, community health services and hospitals; and acting as gatekeepers for other health care services (DHFS 1996). The Royal Australian College of General Practitioners (RACGP) defines a general practitioner (GP) as ‘a medical practitioner who provides primary, comprehensive and continuing care to patients and their families within the community’ (Britt et al. 2004, p. 135).
Community health services usually consist of multidisciplinary teams of salaried health professionals who aim to protect and promote the health of particular communities (Quality Improvement Council 1998). They are either provided directly by governments (including local governments) or funded by government and managed by a local health service or community organisation. State and Territory governments are responsible for most community health services. There is no national strategy for community health, and there is considerable variation in the services provided across jurisdictions. The Australian Government’s main role in the community health services covered in this chapter is in health services for Indigenous people.
Aboriginal Community Controlled Health Services and government provided community health services
Primary healthcare services are delivered to Indigenous people through Aboriginal Community Controlled Health Services (ACCHSs) and government provided community health services. (The use of general practice services by Indigenous people is discussed separately below.) There are ACCHSs in all jurisdictions. These services are planned and governed by local Indigenous communities and aim to deliver holistic and culturally appropriate health and health‑related services. Funding for ACCHSs is provided by Australian, State and Territory governments. 
In addition to the ACCHSs, specific health programs for Indigenous Australians are funded by jurisdictions:
•	NSW provides Indigenous health services, including health information and promotion programs, pre‑ and post‑natal programs, and early childhood nursing programs (table 10A.10).
•	Victoria provides Indigenous‑specific and mainstream community health services funded by the Department of Human Services. They provide medical, alcohol and drug, maternity and early childhood services (table 10A.11).
•	Queensland provides primary and community healthcare services and activities that address prevention and health management/maintenance for Indigenous communities. Services offered include: health prevention and promotion services; men’s and women’s health programs; child and adolescent health services; alcohol, tobacco and other drug services; sexual health services; allied health services; and patient transport provided to increase access to healthcare (table 10A.12). 
•	Western Australia provides community health services that are also available to Indigenous people in various age groups (table 10A.13).
•	South Australia provides Indigenous health services that include: strategies to improve the outcomes for females giving birth, home support, and programs that provide health screenings and diabetes care (table 10A.14).
•	Tasmania provides population and health priorities programs to prevent and manage chronic conditions, and to promote nutrition, physical activity and injury prevention in identified population groups, including the Indigenous population (table 10A.15).
•	The NT provides primary care for the Indigenous population directly and by funding community controlled Indigenous health services. It also provides remote health services such as 24 hour emergency services, medical and allied health specialist services, and access to essential medications (table 10A.17).
•	The ACT provides funding for a non‑government Aboriginal Health Service and a variety of programs for Aboriginals and Torres Strait Islanders.
The Australian Government also funds Aboriginal and Torres Strait Islander primary healthcare services. Information on these services is collected through service activity reporting (SAR) surveys. Many of the surveyed services receive additional funding from State and Territory governments and other sources. The SAR data reported here represent the health‑related activities, episodes and workforce that are funded from all sources. 
For 2001‑02, SAR data are reported for 128 Indigenous primary healthcare services (table 10A.1). Of these services, 53 (41.4 per cent) were located in remote or very remote areas (table 10A.2). They provided a wide range of primary healthcare services, including the diagnosis and treatment of illness and disease, the management of chronic illness, immunisations and transportation to medical appointments (2005 Report, table 10A.3). 
An episode of healthcare is defined in the SAR data collection as contact between an individual client and a service by one or more staff to provide healthcare. Over 1.4 million episodes of healthcare were provided by participating services in 2001‑02 (table 10.1). Of these, 573 340 (40.8 per cent) were in remote or very remote areas (table 10A.2). 
The services included in the SAR data collection employed approximately 1601 full time equivalent health staff (on 30 June 2002). Of these health staff, 1036 were Indigenous (64.7 per cent). The proportions of doctors and nurses employed by surveyed services who were Indigenous, however, were relatively low (2.3 per cent and 15.1 per cent respectively) (table 10A.4).
Table 10.1	Estimated episodes of healthcare by surveyed servicesa, b 
	NSW and ACT	Vic and Tas	
Qld	
WA	
SA	
NT	
Aust	
	’000	’000	’000	’000	’000	’000	’000	
1998‑99	265.8	143.5	149.3	247.1	131.4	124.2	1 061.3	
1999‑2000	286.8	172.5	176.3	295.0	129.7	163.0	1 223.2	
2000‑01	348.6	143.5	186.9	326.7	147.4	189.4	1 342.5	
2001‑02	356.9	154.3	214.1	313.1	144.3	233.1	1 415.7	
a An episode of healthcare involves contact between an individual client and a service by one or more staff, for the provision of healthcare. Group work is not included. Transport is included only if it involves provision of healthcare/information by staff. Episodes of healthcare provided at outreach locations are included — for example, episodes at outstation visits, park clinics and satellite clinics — as are episodes delivered over the phone. b 2001‑02 data are estimates.
Source: DHA SAR (unpublished), 2005 Report, p. 10.11, table 10.3.
Use of general practice services by Indigenous people
An overview of health factors and outcomes for Indigenous people is provided in the ‘Health preface’. Data on national expenditure on general practice services for Indigenous people in 1998‑99 (the most recent year for which expenditure data are available by Indigenous status) indicate: 
•	expenditure on Medicare and the PBS per Indigenous person was about 39 per cent of expenditure per non‑Indigenous person 
•	Indigenous Australians used secondary/tertiary care (such as hospitals) at a higher rate than they used primary care and at a higher rate than used by non‑Indigenous people (AIHW 2001; see ‘Health preface’).
Data from the annual Bettering the Evaluation And Care of Health (BEACH) survey indicate the nature of encounters between Indigenous people and GPs. This survey relies on the self‑reporting of an individual’s Indigenous status to the GP, so is likely to underestimate the actual number of GP encounters with Indigenous people. In addition, these data need to be treated with care because the BEACH survey was not designed to produce statistically significant results for Indigenous people and may under‑identify them. Further, the Indigenous Australians included in the BEACH survey do not necessarily have the same characteristics as other Indigenous Australians. For these reasons, the 2003 BEACH survey aggregated Indigenous data over a five year period to improve reliability.
Over the period 1998‑99 to 2002‑03, 5476 encounters between Indigenous patients and GPs were recorded in the BEACH survey (table 10A.5). This represented 1.1 per cent of GP encounters in the study over this period. By comparison, the proportion of Indigenous people in the Australian population was 2.4 per cent at June 2001 the midpoint of this period (tables A.2 and A.6). Extrapolating these results to all GP/patient encounters across Australia suggests there was an annual average of around 1.1 million encounters between Indigenous patients and GPs over the five years to 2002‑03 (Britt et al. 2003).
The most common health problem managed in GP encounters with Indigenous people over the five years of the BEACH survey was diabetes, which accounted for 7.1 per 100 GP encounters with Indigenous people, compared with 2.8 per 100 GP encounters with all people. Other problems with significantly higher management rates in GP encounters with Indigenous people included acute otitis media/myringitis, asthma, and pre‑ and post‑natal care (table 10.2). Further information about the location, remoteness and management activities of BEACH survey encounters between Indigenous patients and GPs is included in tables 10A.6, 10A.7 and 10A.8.
Table 10.2	Selected health problems in encounters with GPs, by Indigenous status, 1998‑99 to 2002‑03
	Indigenous people’s encounters		All encounters	
Problems managed	Rate (n=5476)	95% LCL	95% UCL		Rate (n=502 100)	95% LCL	95% UCL	
	no./100	no./100	no./100		no./100	no./100	no./100	
Diabetesa	7.1	6.0	8.2		2.8	2.7	2.9	
Hypertensiona	6.7	5.7	7.7		8.8	8.6	9.0	
Upper respiratory tract 	infection	5.7	4.8	6.5		6.0	5.9	6.2	
Asthma	4.3	3.6	5.0		2.9	2.8	3.0	
Acute bronchitis/ 	bronchiolitis	3.8	3.2	4.5		2.8	2.7	2.8	
Depressiona	3.4	2.9	3.9		3.8	3.7	3.9	
Immunisation (all)a	3.3	2.6	3.9		4.8	4.6	5.0	
Acute otitis media/ 	myringitis	3.1	2.5	3.6		1.4	1.4	1.5	
Back complainta	2.2	1.7	2.6		2.6	2.5	2.7	
Pre‑ and post‑natal 	checka	2.1	1.5	2.5		1.0	0.9	1.0	
Subtotal	41.7	..	..		..	..	..	
Total problemsb	147.7	143.7	151.6		148.1	147.3	148.9	
LCL = lower confidence level. UCL = upper confidence level. a Includes multiple primary care classification codes. b Total problems managed is greater than 100, because more than one problem can be managed per encounter. .. Not applicable.
Source: Britt et al. (2003); table 10A.5; 2005 Report, p. 10.12, table 10.4.
Future Directions
Indigenous health
Barriers to accessing primary health services contribute to the poorer health status of Indigenous people compared to other Australians (see the ‘Health preface’). In recognition of this issue, the Steering Committee has identified primary and community health services for Indigenous people as a priority area for future reporting. Accordingly, the Steering Committee will examine options for including indicators of the accessibility of primary and community health services to Indigenous people. The Aboriginal and Torres Strait Islander Health Performance Framework that is being developed by the National Aboriginal and Torres Strait Islander Health Council will help inform the selection of future indicators of primary and community health services to Indigenous people (see the ‘Health preface’).

References
AIHW (Australian Institute of Health and Welfare) 2001, Expenditures on Health Services for Aboriginal and Torres Strait Islander People 1998-99, AIHW Cat. no. 7, Australian Institute of Health and Welfare and Commonwealth Department of Health and Aged Care, Canberra.
Britt, H., Miller, G.C., Knox, S., Charles, J., Valenti, L., Henderson, J., Pan, Y., Bayram, C. and Harrison, C. 2003, General Practice Activity in Australia 2002-03, AIHW Cat. no. GEP 14, Australian Institute of Health and Welfare, Canberra.
Britt, H., Miller, G.C., Knox, S., Charles, J., Valenti, L., Pan, Y., Henderson, J., Bayram, C., O’Halloran, J. and Ng, A. 2004, General Practice Activity in Australia 2003-04, AIHW Cat. no. GEP 16, Australian Institute of Health and Welfare, Canberra.
DHFS (Commonwealth Department of Health and Family Services) 1996, General Practice in Australia: 1996, General Practice Branch, Canberra.
Quality Improvement Council 1998, Australian Health and Community Service Standards: Community and Primary Health Care Services Module, Melbourne.