A comparison of Australian and UK health systems and PSA testing context
| Australia | The UK | |
|---|---|---|
| How is primary healthcare provided? | The Australian Medicare system is predominantly based around private practice and fee-for-service funding, that is, private practitioners in independent businesses are paid for each instance of service, mainly using public funds through the MBS, sometimes supplemented by patient copayments. Some GPs bulk bill, that is, GPs charge the Government (Medicare) directly for any medical service that their patient receives. In these practices, GPs receive the Medicare rebate (a fixed sum for each type of service) as payment, and patients pay nothing. There is considerable geographical variation in bulk billing practice depending on where the GP is based (less in more affluent areas and in rural, regional and remote areas,10–12 where there is a greater shortage of doctors and healthcare services). There are standards but GPs are mostly free to set their own fees for consultations and procedures. Some charge substantially more than the value of the Medicare rebate. Australians can consult any GP they choose, including seeing multiple GPs in multiple practices. | The countries of the UK have centralised health systems—the NHS. General practices mostly operate as independent businesses managed by GPs delivering care under contract to the NHS and free to the patient at point of use. GPs receive some payment on a capitation basis (practices receive a fixed amount to manage a set of potential patients). There is virtually no fee for service element, but some of the money practices receive from the NHS is dependent on them supplying evidence that certain quality standards have been met (eg, that at least n% of people with a diagnosis of x have received intervention y). Almost all residents in the UK are registered to a GP practice near their usual home, and will consult GPs within that practice. |
| Are GPs advised to offer PSA testing? | RACGP advises its members not to raise the issue of PSA testing with patients, but if men ask, to fully inform them about the potential benefits, risks and uncertainties. USANZ advises for men at average risk of prostate cancer, who have been informed of the benefits and harms of testing and who decide to undergo regular testing for prostate cancer, offer PSA testing every 2 years from 50–69 years, and offer further investigation if total PSA is greater than 3.0 ng/mL. | Universal screening for prostate cancer is not recommended; however, PSA testing can be provided at patient request (UK National Screening Committee). EAU advises that informed men requesting an early diagnosis should be given a PSA test and undergo a DRE. A risk-adapted strategy might be considered based on the initial PSA level. |
| How should men be tested (if they choose to be tested)? | GPs advised to discuss the pros and cons of testing with eligible men. 2012 RACGP Red Book guidance advises GPs to perform PSA and DRE when a patient chooses screening, whereas Australian NHMRC guidelines do not recommend DRE for asymptomatic men in the primary care setting. USANZ suggests that GPs confident in performing DRE are still encouraged to do so. | GPs advised to discuss the pros and cons of testing with eligible men. DRE is not recommended as a screening test in asymptomatic men in the UK (NHS PCRMP). Men aged >50 years who request a PSA test can access the NHS PCRMP, an informed choice programme introduced by the Government in 2002 to ensure that men concerned about prostate cancer receive clear and balanced information. The PCRMP provides GPs with information to counsel any man who asks about PSA testing. It is an English initiative, but Wales, Scotland and Northern Ireland have adopted the same approach and use the same materials |
| Is the PSA test funded? | The Australian Government has subsidised PSA tests for men 50 years and over since 1989 through the MBS.13 | PSA testing can be provided free on the NHS for men over 50 years on the condition they have made an ‘informed choice’ following a GP consultation. |
DRE, digital rectal examination; EAU, European Association of Urology; GP, general practitioner; MBS, Medicare Benefits Schedule; NHMRC, National Health and Medical Research Council; NHS, National Health Service; NHS PCRMP, National Health Service Prostate Cancer Risk Management Programme; PSA, prostate-specific antigen (test); RACGP, Royal Australian College of General Practitioners; USANZ, Urological Society of Australia and New Zealand.