Madeleine’s* GP wanted to refer her to a urologist to review a large cyst on one of her kidneys, along with kidney stones. The out-of-pocket fee would have been $290.
“I just said, no – not on top of everything else.”
In the months before that appointment her husband, Paul*, was diagnosed with prostate cancer and Madeleine needed to see a rheumatologist for joint problems.
As retirees living on their superannuation, Madeleine says their budget is not much more than living on the pension.
The couple, who live in Sydney’s Sutherland shire, realised that cancelling their private health insurance would save them $500 a month, and their policy was not helping them with the appointments they needed.
The saving allows them to cover rheumatology and cancer services, as well as imaging and allied health costs, but she says they cannot afford additional medical expenses such as urology.
The option of being referred to a public clinic was never mentioned, she says.
Health professionals say Madeleine’s experience reflects why public clinics are vital – many Australians struggle to afford private doctors. But access to this system of public specialists is a lottery that can depend on a patient’s location and medical condition, they say, along with GPs knowing where to refer.
‘A postcode lottery’
The vice-president of the Australian Medical Association, Associate Prof Julian Rait, says some states including New South Wales don’t have many public hospital outpatient clinics and rely almost entirely on the private sector for patients who are not in hospital.
The chief executive of the Consumer Health Forum, Dr Elizabeth Deveny, says Madeleine’s experience is common, as many people are unaware they can ask their GP to refer them to the local public hospital, which is free.
But not all services are available in every hospital and it can fall on the patient and GP to navigate the complicated system, Deveny says.
Dr Tim Senior, the chair of the Royal Australian College of General Practitioners’ specific interest group on poverty and health, says: “It’s all a bit hit and miss.”
Access can depend on which area of the state’s health system a patient lives in, and whether there’s a clinic available to treat the patient’s condition, Senior says.
While access to public cancer services is generally good, for some specialties including neurosurgery, ENT (ear, nose and throat), orthopaedics and psychiatry the public system often doesn’t provide a service at all, Senior says.
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A Grattan Institute report published in June calls for greater investment in public clinics, noting: “Specialist care is a postcode lottery: people living in the worst-served areas receive about a third fewer services than the best-served areas.”
The communities needing the biggest increase in public services are remote and regional communities, often in outback Northern Territory, South Australia, Western Australia and Queensland. Other places, including parts of major cities, are also missing out on particular specialties, the report says.
Bureaucratic roadblocks
Where public clinic specialists are available, the waitlist can be long and access can be difficult, Senior says.
Wait times are often far longer than clinical guidelines recommend, with some extending longer than a year in 50 specialties across Sydney, Melbourne, Brisbane and Adelaide, the Grattan report says.
When GPs refer patients, Senior says they are often given a reason why patients aren’t accepted that “feels more like a demand management reason” than a clinical reason.
The actual process of getting people in there is bureaucratic, Senior says, recalling a time that a clinic refused to see a patient because the referring GP hadn’t used an updated form, “which had exactly the same information on it as the previous one”.
Some public clinics do not accept referrals from GPs and require patients to be referred by non-GP private specialists, he says.
The only way patients can access other public clinics, such as fracture clinics, is to be admitted to hospital, which makes them eligible for follow-up appointments.
Dr Tim Jones, the deputy chair of the Tasmanian RACGP branch, says the public health system is “saturated”, leading to “massive” wait times.
This has meant more work for GPs, with about 86% managing complex conditions non-GP specialists typically treat, according to the RACGP’s Health of the Nation 2025 report.
“Every GP I know has just chosen to upskill more and more, delivering care at the very top of their scope,” Jones says.
The public waitlist for a child with developmental concerns to see a paediatrician in Tasmania is three years. It’s often the only option because the private sector’s books are all closed, Jones says. Similarly, public mental health care capacity is “overwhelmed” after the closure of two private facilities.
Public system specialists are also struggling to refer their patients to other specialists within their networks.
Dr Chloe Wong, speaking as a member of the doctor’s union, the Australian Salaried Medical Officers Federation, works as a geriatrician in the public system in western Sydney.
If she has a patient with Parkinson’s disease, she says, it is often necessary to refer them to a private neurologist to ensure timely access to care. Trying to get a patient in to see a public ENT specialist is also “virtually impossible”.
“You would think I would have a backdoor access but that’s not true.”
Public hospital funding ‘in limbo’
Associate Prof Kudzai Kanhutu, the dean of the Royal Australasian College of Physicians, says the number of public clinics has not kept up with the growth of communities.
While hospitals can request additional training positions to meet an immediate workforce need, he says there is no workforce planning that considers the bigger picture.
Rait says as a consequence of the federal government not yet having a national health reform agreement with the states, the funding of public hospitals has been “in limbo for some time” and has made it difficult to properly support specialist outpatient services.
Kanhutu says there is a “rich legacy of community health centres we’ve lost sight of” – where a GP might practice next to specialist teams so that hospital referral is not always necessary.
A spokesperson says NSW Health is the largest provider of outpatient services in Australia, with more than 12,000 outpatient clinics providing more than 15m services each year, including medical consultations, diagnoses and procedures, allied healthcare and nursing.
Both the NSW and Tasmanian departments of health say patients are placed on waitlists for outpatient appointments based on urgency.
But Deveny says patients are being deeply affected by delays.
“What I want, and what everyone wants [is] to know that when I’m sick, I can get access to timely specialist care without being priced out of the market.”
* Names changed for privacy
Do you know more? Contact: natasha.may@theguardian.com
