The speciality of Geriatric Medicine in Australia is generally considered to have started in 1950 when the Hospital Commission of New South Wales (NSW) requested the Royal Newcastle Hospital to survey the known people with multiple sclerosis in the Hunter Valley, with a view to setting up a hospital clinic for those patients. Dr Richard Gibson and Miss Grace Parbery, a social worker, were appointed to conduct the survey and identified the need for medical, nursing and domestic care at home for the chronic sick in general. It took another five years to institute these outreach services and subsequently hospital rehabilitation services as well. Rudimentary services started soon after in other states but the independent origins led to different patterns of development.

Australia was founded in 1901 as a federation of six states each of which had a slightly different history and health system. Each state government retained control of existing health services, mainly hospitals. Over the years, the growth of national government taxation revenue has resulted in the introduction of new healthcare programmes, mainly non-hospital services. Many of these services were developed in response to genuine healthcare deficiencies but as a result, Australia has a dually administered health system through a partnership of the national and state governments. The Australian National Government generally retains primary control over the newly established healthcare services or programmes. The national government pays for community health, nursing home and visits to doctors’ offices, but the level of control over these programmes varies. The Australian Government pays for visits to doctors under the Medicare scheme of universal health insurance. Medicare is partially funded by a 1.5% levy on income tax and a 1% surcharge from those earning at least AUD $50 000. Additional revenue for the physician may be generated from the patients, who are responsible for paying when the physician decides to charge an extra fee. Medicare reimburses physicians 85% of the established Schedule Fee, an amount derived from a survey of fees in the early 1970s. The schedule fee has been under-adjusted for inflation over time, with a resulting 30% drop in reimbursement rates. This has prompted some physicians to pass on increasing co-payment fees to their patients. At this time, the percentage of GP consultations entirely paid for by Medicare has declined to about 70%.

Most medical care for older people is administered by GPs. Medicare disproportionately rewards GPs for shorter office-based consultations, which favours younger, single problem patients. General practice has also seen a shift toward corporatization, where companies employ GPs in multidoctor practices and generally discourage non-office work. These trends have resulted in a decrease in the number of GPs who perform home or nursing home visits. In 1999 a range of longer, better-remunerated consultations were introduced to encourage adequate consultations with frail, older people, including annual health assessments, multidisciplinary care planning and case conferencing. These have recently been augmented to also cover residential aged care; however, these measures have not been adequately assessed to determine whether they provide any benefit.

The Australian Government under the Pharmaceutical Benefits Scheme (PBS) pays for medications with some co-payments charged to patients. Rapid increases in the cost of the PBS of around 15% per year have led to a variety of measures to decrease costs. One method is to limit the number of new drugs coming onto the PBS. Patients have also been required to pay the full cost of many new drugs. In other situations, drug companies will negotiate to cap payments for a new pharmaceutical agent on the basis of the projected medication expenditures for that agent.

Geriatric Medicine is a relatively new, but growing speciality. A survey of all specialist consultant physicians found that there were 185 practising geriatricians in 2003. One third also practises general medicine. This provides Australia with approximately one geriatrician per 5900 people aged 75 and over.2, 3 Because geriatric medicine attracts a higher proportion of female specialists in Australia, and over a lifetime, females work approximately 75% of the hours of male graduates, access to geriatricians is more limited than what is actually calculated. The demand for geriatricians is increasing, but not currently met by the supply of trainees. In 2007 specific long and comprehensive consultations exclusively for geriatricians were introduced which meant that a geriatrician could be reimbursed by Medicare at a higher rate than any other physician, to appropriately reflect the complexity of consultations with frail older patients.

The profession, healthcare industry and the government continue to grapple with this problem.

Home care services have become increasingly complex in the types of care provided, the funding arrangements, and number of service providers. The healthcare needs of patients are also more complex due to greater functional and physical dependency. Medical care at home has traditionally been provided by GPs for patients who were too acutely or chronically unwell to attend office visits. However, the relatively poor reimbursement by Medicare and the increasing demand for home visits has led many GPs to abandon them altogether. Because many aged care assessment teams (ACATs) now include a geriatrician or other medical officer, they may provide medical home visits as part of an initial assessment, but not as part of routine care.

Government-sponsored community services existed as early as the 1940s, including emergency housekeeper service and meals-on-wheels, delivered by women volunteers on bicycles. The Australian Government began funding home nursing services in 1956. Although the management and structure varies considerably between states, there is general availability of visiting registered nurses to provide nursing services in the home. Most commonly these services are time limited and based on the individual needs of the client and family. There are separate but generally parallel services for war veterans and individuals in the private sector. Home and Community Care (HACC) services expanded in 1969 to support housekeeping or other domestic assistance, senior citizens centres and welfare officers. Home care was further enhanced with the passage of the Home and Community Care Act in 1985 to include personal care such as bathing and dressing. Demand almost perpetually outstrips supply, because of under-funding, lack of gate keeping at entry, and inadequate exit strategies for maintenance services. A common assumption by service providers is that clients will not significantly improve and thus need prolonged enrolment in the programme. Home care recipients assume that services are difficult to access and thus attempt to retain services long term rather than re-request assistance at a later date.

HACC also funds meals-on-wheels, transportation, home maintenance and modification, counselling, social support, centre-based day care, allied health services, provision of aids, respite care and laundry. HACC services are not exclusively for older people, with 23% of their clients being under age 65, but usage rates do increase with age. The most commonly used service is domestic assistance (usually housekeeping). In 2007–2008, 8 million hours of domestic assistance were provided under the HACC programme. The programme was jointly funded by the state (40%) and national government at $1.65 billion in 2007–2008.