To the Editor: Your otherwise excellent issue on chronic illness (1 September 2003) was timely and appreciated. However, the article by Zajac on the future of public hospitals1 left me pondering how frequently he patrolled the wards and the emergency department.

Most public hospitals have undergone the very revolution he adumbrates.

• Patients now arrive with automated medication records and problem lists from their general practitioner;

• GP liaison doctors from the Divisions attend discharge planning committees;

• discharge summaries are delivered by fax on discharge;

• multidisciplinary clinics abound for complex and chronic illness, but invited GPs claim that time commitments and insufficient payment often preclude attendance;

• there are target waiting times for clinic appointments;

• often there is a quality assurance unit, with a complaints or grievance procedure;

• day surgery and day of admission surgery is now the norm (and strict guidelines help control the morbidity Zajac bemoans), with vastly improved throughput;

• endoscopy and emergency cardiac catheterisation or angioplasty on demand are commonplace;

• we now acknowledge, document and rectify system errors with alacrity, without the rancour and recrimination of years ago; and

• evidence has replaced the wise maxims of the physician.

Admittedly, all is not rosy and funding remains a perennial problem, but within available resources the public hospital is a completely different place from 15 years ago.

A major issue, and Zajac agrees, is the place of general medicine in the public hospital, being rapidly subsumed by sub(super)-specialists together with emergency physicians, as they are available round the clock, skilled and equipped to perform the assessment and early management of most medical patients, while the physicians are in rooms or at home.

We welcome the presence of general physicians in the emergency department, and encourage twice-daily rounds on admitting day with shared care, but so far the rhetoric of general medicine has rarely been matched by attendance.

The real challenge for public hospitals at present is to effectively manage and discharge frail elderly patients, and those with cognitive impairment, thus keeping beds free to reduce access block; otherwise general medicine may suffer the fate Zajac reserves for public hospitals and become “a thing of the past”.

In reply: Walpole and I agree that public hospitals have changed significantly. Where we seem to disagree is that he suggests that we have got to where we are going and all the problems have been solved.

Walpole clearly works in a different world from me. Even a short visit to the wards and emergency department reveals that, despite good will, planning and many of the changes Walpole lists, things are far from perfect. System errors, major and minor, occur far more commonly than they should, elderly patients spend more time as inpatients than they should, and stresses in the system continue to impair quality and efficiency. I think we need to keep working on these issues, and not pretend that they are fixed.

I note with dismay the description of general physicians occasionally visiting Walpole’s emergency department, while other specialists work diligently, 24 hours a day, to heal the sick. These comments demonstrate one of the main problems with doctors in public hospitals, namely, the territorial imperative in full flight. We should be finding ways to work together.