With approximately 36% of Australia’s total disease burden in 2024 being preventable or reducible by addressing risk and environmental factors, the Australian Institute of Health and Welfare says coordinated care is more important than ever.
Preventable burden isn’t confined to hospitals – it’s playing out in general practice, too.
One in four of the 18.5 million Australians aged 15 and over delayed seeing a GP in 2024–2025, a pattern consistent with the previous decade, according to this year’s AIHW report card.
But cost is increasingly the reason. Approximately one in 13 people skipped or delayed a GP visit in 2024–2025 due to cost, nearly double the rate of 2015–2016.
Patients in rural and remote areas use chronic condition management services less than city residents, despite having a 1.6 times higher mortality rate and more avoidable deaths – a gap the AIHW said may reflect limited service availability and long travel distances.
AIHW executive director of health insights Louise Gates said cost, service availability and waiting times were all potential barriers to care.
GP bulk billing rates have risen in recent months, reaching 82% between January and March this year. But annual GP attendance bulk billing fell from 85% in 2015-2016 to 78% in 2024-2025.
For the AIHW, closing access, outcomes and equity gaps starts with better data.
And it begins with how data is collected.
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Health, welfare and the policy gap
Inequalities in social circumstances contribute substantially to preventable health conditions, especially for people with disabilities or in lower socioeconomic positions.
Between 2022 and 2024, the AIHW reported that people in the lowest socioeconomic areas were 1.5 times more likely to die than those in the highest areas.
So, what happens when the complexities of multiple factors that lay the bricks for these causal pathways are not sufficiently considered? Policy designs are siloed and poorly formed, the AIHW reported.
While government departments may implement and evaluate individual programs, they rarely have a person-centred, holistic understanding of the recipients’ experiences.
Analysing individual service systems, then, is only an initial step in a larger process. Without tracking health outcomes across services, it remains difficult to attribute changes in health outcomes to a single program.
In the AIHW’s case study – understanding deaths among people receiving specialist homelessness services (SHS) and drug and alcohol (AODTS) support – more than a decade of administrative data from the MBS, PBS and the National Death Index were analysed.
The longitudinal dataset (NACS) found AODTS clients were 3.3 times more likely to die than those who hadn’t received treatment, and SHS clients were 1.6 times more likely to die than non-recipients – with the risk higher among men in both groups from 2022 to 2023.
While these results may seem counterintuitive, they reflect the complex health conditions and life circumstances of people needing these supports.
The most common underlying causes of death among these groups between 2012 and 2023 were accidental poisoning, suicide and liver disease.
Combining the data showed higher mortality for those receiving both AODTS and SHS support, with a median age of death of 46; 14 years younger than SHS-only recipients and eight years younger than AODTS-only recipients.
More than half (65%) of deaths among those receiving both services, and 57% of deaths among those receiving only one, were potentially avoidable through personalised care or effective treatment in primary or hospital care settings.
With mental health conditions and substance use disorders among the top five disease groups causing the greatest burden in 2024, the AIHW report said the findings indicate further opportunities in suicide prevention, chronic disease management, overdose prevention, and specialist care access.
“This example points to opportunities for better-designed, cross-portfolio policy responses that account for the complex and overlapping experiences of people using multiple services,” the report read.
Dr Sayan Mitra, a research affiliate in the faculty of medicine at The University of Sydney, said that while digital health plays an important role in data collection, its information must be implemented earlier to reduce avoidable disease burden.
“More Australians are living with chronic conditions and mental health conditions, and the health system is still too often built around late intervention,” he said.
“My argument is that Australia’s next major health gain will depend on shifting digital health from passive data collection to active prevention infrastructure, using individual-level signals at population scale to identify risk earlier,” Dr Mitra said.
Breaking silos of silence: interconnected data as key to policy, research, and patient care
General practice and community primary care services constitute most Australian healthcare encounters but are often absent from national data sets, the AIHW reported.
Developing a National Primary Health Care Data Collection (NHDH) is one example of harmonising data recorded in clinical systems, the AIHW said, from patient characteristics and reasons for encounter to diagnoses.
The AIHW reported that early pilots and projects have demonstrated feasibility, partnering with 17 PHNs to understand dementia diagnosis in general practice.
Alongside PHNs, three additional projects are underway: analysing mental health outcomes in primary care, studying disease prevalence and burden of health conditions, and improving data quality and identifying gaps in general practice data.
The next major focus is to integrate existing datasets to understand how patients move through the health system over time, how services interact, and how subsequent programs and policy changes influence outcomes.
The AIHW said this will enable comparisons of illness management and effectiveness across clinical care sectors such as hospitals, disability, aged care, and primary care, where data have become increasingly fragmented.
There have been 47 completed projects, with a further 57 active projects using the NHDH – one being in Focus Area 1 of the report.
The Australian Centre for Disease Control (CDC) is building a Public Health Data Network to connect notifiable diseases data with other public health, administrative, and welfare datasets. Consultations closed in October 2024.
Its purpose, the AIHW said, is to strengthen national coordination and speed up Australia’s detection and response to national public health threats.
But mending these data gaps will depend on national coordination – not complete uniformity, but agreed technical foundations and clear, interoperable documentation, such as CSIRO’s Sparked program and the development of the Australian Clinical Data for Interoperability (AUCDI), the AIHW said.
It will also require laser focus on improving patient outcomes and equity through strong governance, privacy and ethical safeguards.
“These developments can reduce duplication, improve data quality and usability, and increase the value of existing data – both by supporting comparability across diverse sources and, where appropriate, by encouraging greater standardisation over time,” the report read.
While the gap between Indigenous and non-Indigenous health has narrowed since 2011, First Nations people still experience a disease burden 2.1 times that of non-Indigenous people.
The AIHW said improving First Nations data governance required alignment with the principles of Indigenous Data Sovereignty and support for self-determination – meaning Indigenous governance and culturally appropriate interpretation built into data integration from the outset, not retrospectively.
Co-designed with Aboriginal and Torres Strait Islander partners, the National Indigenous Australia Agency released the Framework of Governance of Indigenous Data to place First Nations people at the centre of decision-making throughout the data cycle.
“Doing so supports better policy decisions, clearer accountability, and progress toward
more equitable health outcomes for First Nations people,” the report read.
Through the latest National Health Reform Agreement, which took effect on 1 July and is amended every five years, the AIHW hopes better data will lead to clearer accountability and, hopefully, more targeted policy responses.
Read the full report here.
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