Changes in public perceptions and experiences of the Australian health‐care system: A decade of change

Abstract Background The views and experiences of the Australian public are an important barometer of the health system. This study provides key findings about the changing views held by Australians over time regarding their individual experiences and perceptions of the overall performance of the health system. Methods A population‐based online survey was conducted in 2018 (N = 1024). Participants were recruited through market research panels. The results were compared with previous Australian population survey data sets from 2008 (N = 1146), 2010 (N = 1201) and 2012 (N = 1200), each of which used different population samples. The survey included questions consistent with previous surveys regarding self‐reported health status, and questions about use, opinions and experiences of the health system. Results Overall, there has been a shift in views from 2008 to 2018, with a higher proportion of respondents now viewing the Australian health‐care system more positively (X 2 (2, N = 4543) = 96.59, P < .001). In 2018, areas for attention continued to include the following: the need for more doctors, nurses and other health workers (29.0%); lower costs for care or Orion medicines (27.8%); more access to care (13.1%); and enhancements in residential aged care (17.3% rated these services as ‘bad’ or ‘very bad’). Conclusions This research suggests that Australians’ perceptions of their health‐care system have significantly improved over the last decade; however, concerns have emerged over access to medicines, inadequate workforce capacity and the quality of aged care facilities. Our study highlights the value of periodically conducting public sentiment surveys to identify potential emerging health system problems.


| INTRODUC TI ON
Population growth, ageing populations, longer life expectancy and increases in the prevalence of chronic diseases and long-term medical conditions are creating expanded demand for health-care services and contributing to rising health-care costs worldwide. 1 In Australia, as with other countries, governments are struggling to meet demands for access to new sophisticated and costly diagnostics, long-term treatments and the growing need for more aged and hospital care, 2 with regular claims that the increases in health-care costs are unsustainable. 3 This has led to calls to transform the health system-to improve efficiencies, reduce costs and continue to deliver high-quality performance-based care. 4,5 Surveys of public perceptions and experiences with health-care services are important in identifying how well a country's health system is meeting the needs of its population, 6 and can be used to leverage policy and system change. For example, the Commonwealth Fund regularly surveys public views about the United States (US) health system and health systems in 11 high-income countries, including Australia. 7 Results from Commonwealth Fund surveys in the United States and comparisons with international data such as these have supported significant health system reforms in the United States. 7 Further, health-care has a unique connection to shared national values around risk and citizenship. This is particularly true of systems providing universal coverage. Canada's universal health-care system (Medicare) embodies the 'social citizenship' that distinguishes Canadians from their more market-driven US neighbours. 8 The British National Health Service was from its foundation treated in almost religious tones. 9 In both these cases, health policy debate has been shaped around these enduring values.
In a similar way, the views and experiences of the Australian public have been an important barometer of the health of the Australian health system, with important implications for health-care practice and policy. Repeated public polls on taxation and social service provision in the 1990s and early 2000s showed the high and increasing importance of health to the Australian public, and broad-based support for Medicare's universal coverage, and for increasing expenditure on health. 10 Public election polls have also consistently shown that 'health and Medicare' is a highly important issue to Australian voters in every federal election since the 1970s. 11 However, robust longitudinal studies that use validated questions about perceptions and experiences of health-care among the adult population are rarely reported in Australia. 12 Australia's Medicare, a national, publicly funded universal health-care system, provides access to medical and hospital services for all Australian citizens and permanent residents. 13 Medicare provides free or subsidized treatment by health professionals including general practitioners (GPs) and other medical specialists, and provides free public hospital treatment. Medical practitioners in private practice and private hospitals are free to charge patients what the market will bear, with a fixed subsidy from Medicare, resulting in varying patient co-payments. A parallel Pharmaceutical Benefits Scheme provides subsidized access to most prescription medicines.
Consumers can take up supplementary private health insurance to help manage some of the additional costs, which is currently held by approximately half of all Australians. 13 Of the estimated AU$170 billion health expenditure in 2015-2016 (representing 10% of gross domestic product [GDP]), almost 70% was funded by government sources, with 17% paid by patients through out-of-pocket expenses and 9% by private health insurers. 13 Understanding what the Australian public expects and values from a contemporary health-care system will not only complement existing surveys, such as the Australian Bureau of Statistics Australian Health Survey, 14 but also unpack the meaning of the concerns over health and Medicare that have been a feature of Australian opinion polling. This will add additional insights into the current issues that are important to the Australian public, as well as the direction national health policy could take to address public needs and concerns.
The overarching objective of this study was to analyse a recent

| Survey
The survey was conducted from 29

| Self-reported health status
Based on the previous Menzies-Nous surveys, [15][16][17] participants were asked how they would describe their own health. This item was rated on a 5-point Likert scale (1 = excellent to 5 = poor).

| General opinions regarding the quality of health-care services
Participants were asked to provide their general opinion regarding the quality of a range of health-care providers on a 5-point Likert scale (1 = the service is very bad to 5 = the service is excellent). This question was included in two of the previous Menzies-Nous surveys (2012, 2010), but not in 2008.

| Visits to general practice
To assess the extent of GP use, participants were asked when they go to their GP, do they: 1 = always try to see the same GP; 2 = always go to the same GP practice but see different doctors; or 3 = go to a GP practice and see whichever doctor is available at the time.

| Overall views towards the Australian healthcare system and areas for improvement
Participants were asked to express their overall views of the Australia health-care system on a 3-point scale (1 = on the whole, the system works pretty well and only minor changes are needed to make it work better to 3 = our health-care system has so much wrong with it that we need to completely rebuild it). This question was included in all three previous Menzies-Nous surveys. [15][16][17] Participants were also asked to identify the areas of the health-care system they thought needed the most improvement. Equivalent data to this question were only available from the 2012 Menzies-Nous survey.

| Confidence in the Australian healthcare system
To assess confidence in key areas, participants were asked if they were to become seriously ill, how confident would they be that they would: get quality and safe medical care; receive the most effective medication; receive the best medical technology; and be able Previous raw data from the Menzies-Nous Australian Health Surveys were made accessible to the research team, which we also postweighted by age, sex and state according to the ABS demographic statistics of June of the respective year. [20][21][22] Each of the four surveys was post-weighted through a survey raking technique using the anesrake package in R. 23 Survey data were analysed using IBM SPSS Statistics Version 25.0. 24 Comparisons across the four surveys were only made where questions were identical. Linear regression was used to examine relationships between age groups, gender, location and survey year for each of the dependent variables with five or more levels (i.e., self-reported health status and general opinions regarding the quality of health-care services). 25 Four sets of dummy variables were examined for each of the categorical measures of age and survey year. For brevity, the results for all of these dummy variables are not presented here, but are available on request. Chi-square (χ 2 ) analysis was used to examine categorical dependent variables for which there was less than five levels (i.e., visits to general practice, overall views towards the Australian health-care system and areas for improvement, and confidence in the Australian health-care system).
Due to the large number of tests, a conservative P value of .001 was used for statistical significance.

| Characteristics
In total, 1024 Australians participated in the 2018 Australian sen-  Table 1, along with a comparison of participant demographics from the three previous Menzies-Nous Australian Health Surveys. [15][16][17] As shown, our post-weights were successful in creating four data sets that were appropriate for comparison, taking into account differences in demographics.

| Self-rated health status
In 2018, the majority of Australians rated their own health as either good (n = 337, 37.0%) or better (n = 414, 40.5%). However, health status ratings in 2018 were found to be significantly lower than previous years (P < .001), with an average of 55.9% (n = 1982) of Australian rating their own health as very good or excellent across the previous Menzies-Nous surveys. Across the four surveys, younger Australians (aged 18-44 years) rated their health significantly higher than older Australians (aged 45 to 65+ years; P < .001), and Australians in cities rated their health significantly higher than Australians in rural or remote regions (P < .001). No significant differences were found for gender ( Table 2). The regression results presented in Table 2 summarize the results from key dummy variables showing: age differences between younger participants (aged 18-44 years; coded 0) and older participants (aged 45 to 65+ years;

| General opinions regarding the quality of health-care services provided in Australia
Respondents were asked to provide their opinion on the quality of a range of health-care services (see Figure 1 for comparisons over time).
In 2018, Australians reported greatest approval for the services provided by pharmacists/chemists and GPs, with 74.0% (n = 758) and 69.1% (n = 708) rating their services as good to excellent, respectively.
Residential aged care services were rated the lowest in 2018, with 17.3% (n = 177) of Australians rating the services as bad or very bad.
In 2018, ratings were significantly more favourable than the previous Menzies-Nous surveys for public hospitals (P < .001), GPs (P < .001) and dentists (P < .001). No other significant differences were found based on survey year, age, gender or geographical location (Table 2).

| Visits to general practice
In 2018, the majority of participants (n = 761, 74.3%) reported that they always try to see the same GP. This was significantly higher

| Overall views towards the health-care system
In 2018, almost half of Australian participants reported that 'there are some good things in the Australian health-care system, but fundamental changes are needed to make it work better' (n = 502, 49.0%).
However, there has been a shift in views over the past 10 years, with a higher proportion of respondents now viewing the Australian health-care system more positively (X 2 (2, N = 4543) = 96.59, P < .001; Figure 2

| Areas for improvement
In 2018, respondents reported that the greatest improvement needed to the health-care system is: the need for more doctors,

| Confidence in the Australian healthcare system
In 2018, over 80% of respondents reported that they were 'somewhat' or 'very confident' that upon becoming seriously ill, they would receive: quality and safe medical care (n = 898, 87.7%); the most effective medication (n = 879, 85.8%); and the best medical technology (n = 843, 82.4%). However, less than two-thirds of respondents expressed confidence that they would be able to afford the care needed (n = 641, 62.7%).
This was similar to sentiments reported by Australians across the

| D ISCUSS I ON
This study provides unique insights into the views held by Australians about their individual experience and the overall performance of the health system. Overall, there are predominantly positive views towards the Australian health system and these have improved over the past decade. Almost half of Australians view their health-care system positively, and this is a significant improvement from only 30% in 2012. 16 In 2018, public sentiment was significantly more favourable towards public hospitals, GPs, and dental services than previously reported, 15,16 reflecting improved satisfaction with these services.
In 2018, three in four Australians reported that they always try to see the same GP; this is also up significantly from the previous Menzies-Nous surveys and reinforces its findings that Australians are comfortable with a consistent relationship with a single primary care practice. [15][16][17]27 This is a substantial issue in current health pol- In 2012 and 2018, close to 90% of respondents were confident that they would receive quality and safe care on becoming ill, signalling high levels of confidence in the Australian health system. However, less than two-thirds of respondents expressed confidence that they would be able to afford the needed care. The concern among Australians regarding the affordability of health care is consistent with past research, 10 and an area that demands further exploration. Our findings of increasing concerns about affordability across the decade of surveys also concur with recent reports regarding increasing out-of-pocket expenses, 30  Among all health services, residential aged care services were rated most poorly in 2018, with fewer than one in three Australians rating the services as good to very good. This has been a consistent concern raised over the past 10 years, highlighting the on-going need for improvement in the aged care sector. The concerns of the Australian public have continued despite several reforms to improve the aged care system. 35 The Royal Commission into Aged Care Quality and Safety was established in 2018 to investigate the quality and safety of care provided to older people receiving aged care services at home and in residential aged care facilities. 35 Public perceptions expressed in our survey are consistent with the Royal Commission's recent report that described the Australian aged care system as fragmented, poorly managed and underfunded. 36 Furthermore, the recent COVID-19 crisis has highlighted the vulnerability of the sectors with several aged care facilities designated as outbreak hot spots, with one facility reporting over 16 deaths. 37

| Strengths and limitations
A unique strength of this study is that it compares the views of surveys. Finally, we were unable to establish a survey response rate because of the sampling process applied to an established panel. along with rising concern over the quality of residential aged care services.

CO N FLI C T O F I NTE R E S T
None to declare.

DATA AVA I L A B I L I T Y S TAT E M E N T
The data that support the findings of this study are available on request from the corresponding author. The data are not publicly available due to privacy or ethical restrictions. of services How would you rate each of the following? -The service offered by public hospitals -The service offered by private hospitals -Services provided by GPs and GP practices -Services provided by dentists or and the services they offer -Pharmacists or chemists and the services they offer -Services provided by specialist doctors such as a cardiologist, psychiatrist, surgeon outside of hospitals in private practice -Services provided by psychologists or counsellors -Services provided by community care services delivered at home -Residential aged care facilities including nursing homes and the services they provide -Services provided by other allied health providers such as physiotherapists, dieticians and the services they offer Select as many as apply -Can't afford it/ too expensive -High risk category -Lack of value for money/not worth it -Medicare cover sufficient -Don't need medical care/in good health/have no dependants -Won't pay Medicare and private health insurance premium -Disillusioned about having to pay out-of-pocket costs or gap fees -Prepared to pay costs of private treatment from own resources -Pensioner/Veteran's affairs/ health concession card -Not high priority or previously included in parents' cover