Volume 164 Issue 4

Heroin-related deaths in New South Wales, 1992: toxicological findings and circumstances Deborah Zador, Sandra Sunjic and Shane Darke For editorial comment see Hall Readers may print a single copy for personal use. No further reproduction or distribution of the articles should proceed without the permission of the publisher. For permission, contact the Australasian Medical Publishing Company Journalists are welcome to write news stories based on what they read here, but should acknowledge their source as "an article published on the Internet by The Medical Journal of Australia <http://www.mja.com.au/>". Abstract - Introduction - Methods - Results - Discussion - Acknowledgements - References - Authors' details - - ©MJA1997 Abstract Objective: To describe the circumstances of death and toxicological findings in all heroin-related deaths in New South Wales in 1992. Design: Coronial files of all cases of heroin-related deaths were reviewed. A standardised form was used to collect information on sociodemographics, history of drug use, circumstances of death, and results of toxicological analysis for each case. Results: 152 heroin-related deaths were identified. Subjects had a mean age of 29.7 years, 82% were male, and 98% were not enrolled in a methadone treatment program at the time of their deaths. Deaths occurred in the home environment in 68% of cases and in the company of at least one other person in 58%. There was intervention before the subject's death in only 21% of cases. Two or more drug classes were detected in 71% of subjects; alcohol was detected in 45%, with a mean blood alcohol concentration of 0.14 g/100mL. Conclusions: Fatal heroin overdose is potentially preventable. Educating users about the risks of co-administering alcohol and other depressant drugs with heroin, the comparative safety of injecting heroin in the company of others and the need to call for intervention sooner may reduce the frequency of heroin-related deaths. MJA 1996; 164: 204 Introduction Over the decade to 1990, mortality from opiate drugs increased by 170% while that from other drugs declined by 8%.1 There is little information available on the circumstances or characteristics of Australian heroin-related deaths. Swensen reviewed 108 opioid drug-caused deaths in Western Australia from 1974 to 1984 and found that propoxyphene was the most common cause, accounting for 36 deaths (33%), followed by methadone in 19 cases (18%), heroin in 12 cases (11%), and morphine in another 12 cases (which may include deaths from heroin).2 Walsh analysed 23 accidental opioid drug deaths in the Newcastle area of New South Wales from 1970 to 1987 and found that most (83%) were caused by heroin/morphine.3 Police reports of cases in this study indicated that in 61% help or intervention by observers was delayed. Both studies found a higher proportion of deaths at weekends, leading both authors to suggest that these deaths involved recreational users rather than "hard-core" addicts. The findings of these two studies cannot be generalised to heroin deaths in Australia because of their relatively small numbers of subjects studied over prolonged periods, the inclusion of all opioid (not just heroin) drug deaths, and the absence of data for Sydney (where most heroin deaths in this country occur). If interventions to reduce the rising mortality rate from opioid drug use are to be developed, then more needs to be known about the circumstances of fatal heroin overdose. Hence, the major aims of this study were to describe the sociodemographic characteristics, circumstances of death and the toxicological findings at autopsy of all cases of fatal heroin overdose in NSW for the year for which the most recent data on drug-caused mortality were available. Methods The approval of the South Western Sydney Area Health Service's Research Ethics Committee was obtained. Permission of the NSW Registry of Births, Deaths and Marriages was obtained to enable the Australian Bureau of Statistics (ABS) to release a list of all heroin-caused deaths in NSW from 1 January to 31 December 1992. ABS records were searched according to the following International Classification of Diseases version 9 (ICD-9) codes: 304.0/304.7 (opiate dependence), E850.0 (accidental opiate poisoning) and E950.0 (opiate-caused suicide).4 Permission was obtained from the Department of Courts Administration to inspect coronial files. A case was identified as a heroin-related death based on the coroner's conclusion alone or in conjunction with results of toxicological analysis. Deaths due to other opiates were excluded from the study. Coronial files contained police reports, ambulance officers' statements, other witnesses' statements, autopsy reports, and results of toxicological analysis. A standardised data collection form was developed to record information on sociodemographic characteristics, history of drug use, circumstances of death, and toxicological findings. Subjects were designated "believed to be a frequent user" if their coronial files provided evidence of two or more criteria indicative of regular heroin use (e.g., known history of heroin use, partner or friends known to be heroin users, history of heroin overdose or treatment for dependence, criminal record and/or unemployment). Subjects were designated "believed to be an infrequent user" if they were known to be primarily dependent on another drug (such as alcohol), were not known to be regular heroin users, and were employed full-time. A "novice" was a person who died from using heroin for the first time. Information on history of admission to methadone maintenance treatment was obtained from data at the Pharmaceutical Services Section, NSW Department of Health. Information on history of admission to other treatment programs for opioid dependence (e.g., detoxification units or residential re habilitation programs) could not be obtained for this study. Data for circumstances of death included the day and date, suburb or town, type of location (e.g., hotel room), time of death, time between injection of heroin and death, presence of other persons, and intervention. A death was considered "instant" if photographs showed a needle and syringe still in situ, if the posture of the body was consistent with a sudden collapse (e.g., slumped against toilet cubicle wall), or if witnesses provided evidence of instant death. "Intervention" was treatment received by the subject while still alive, and did not include treatment by ambulance officers or after admission to hospital if the subject was clinically dead. Information on results of toxicological analysis was obtained from reports of laboratory analyses (by the Division of Analytical Laboratories, NSW Department of Health, Lidcombe) of blood, urine and other tissue specimens taken at autopsy. Statistical analysis For continuous variables, t tests were used, except for highly skewed variables, for which the Mann-Whitney U test (a non-parametric analogue of the t test) was used. Categorical variables were analysed with the chi-squared test and corresponding odds ratios (OR) and 95% confidence intervals (CI) were calculated. To determine which factors were independently associated with blood morphine concentration, we performed multiple linear regressions. SYSTAT was used for all analyses.5 Results Sociodemographic characteristics For the 200 opiate-caused deaths identified by ABS in 1992, one file was unable to be located, one subject was noted to have died on 31 December 1991, one case was found not to be a coroner's case, and seven were found to be misclassifications (i.e., death due to drugs other than opiates). These 10 cases were excluded from the study. The study population thus comprised 190 cases. Of these, 152 (80%) were classified as heroin-related deaths, and the demographic characteristics of the people involved are shown in the Table. They were predominantly male (82%), with a mean age of 29.7 years (SD, 6.7; range, 18-59), and most were unemployed (76%). History of drug use Most (90%) were well known to be heroin users. Eighty per cent were judged to have been frequent heroin users, 17% were considered infrequent heroin users, and two were novice users (1%). Both cases involving novice users were classified as suicides by the coroner. In three cases (2%) it was not possible to estimate the frequency of heroin use from the coronial files. Only 2% were enrolled in a methadone maintenance program at the time of their deaths, with 72% never having been enrolled in methadone treatment in NSW. Some subjects may have been previously enrolled in an interstate program, but this information was not available. Circumstances of death Twenty-six per cent of deaths occurred on Saturdays and Sundays, compared with an expected 29%, assuming a uniform distribution ofdeaths over the seven days of the week. There was also no significant variation between seasons -- summer (18%), autumn (25%), winter (31%) and spring (26%). The times of deaths were distributed as follows: midnight-6am, 23%; 6am- midday, 14%; midday-6pm, 28%; and 6pm-midnight, 35%. Eighty-five per cent of deaths occurred in the Sydney metropolitan region. Fatal heroin overdoses occurred throughout the Sydney area, with the highest frequency (19%) in the East Sydney region (including Kings Cross and Darlinghurst), and the second-highest (16%) in South-Western Sydney (including Cabramatta and Liverpool). Fifty-three per cent of deaths occurred in the subject's usual place of residence or home, and a further 16% in the home of a friend or family member. Thus most (69%) occurred in a home environment. Only 14% of deaths appeared to be "instant" events. The presence of other persons at some time during the interval between the injection of heroin and death was noted in 58% of cases, while 41% of subjects died alone. The presence of others was unable to be determined in 1% of cases. In 79% of cases there was no intervention while the subject was still alive. An ambulance was called while the subject was alive in only 10% of cases and cardiopulmonary resuscitation was attempted by an onlooker in 11%. Toxicological findings Two subjects were deleted from toxicological analyses as they had been maintained on life support systems for two or three days in hospital intensive care units. Morphine was detected in 95% of subjects at autopsy. The second most frequently detected drug was alcohol (45%), with benzodiazepines in 26%. Methadone and amphetamines were each detected in 6% of subjects, and cocaine, antidepressant drugs and barbiturates were detected in 5%, 4% and nil, respectively. A single drug was found in only 27% of subjects -- morphine in 39 of 41, ethanol in one and oxazepam in one. In 71%, two or more different drugs were found at autopsy, and in 18% three or more drugs were detected. Men were more likely to have alcohol detected at autopsy than women (OR, 4.07; 95% CI, 1.44-11.47), while women were more likely to have benzodiazepines detected (OR, 2.82; 95% CI, 1.15-6.93). The distribution of blood morphine concentrations is shown in Figure 1. Twelve subjects were deleted from this analysis because no morphine was found in their blood (although in seven morphine was detected elsewhere, e.g., bile, liver or urine). The median blood morphine level was 0.24 mg/L. Alcohol was detected in 68 subjects (45%); Figure 2 shows the distribution of their blood alcohol concentrations (BACs). The mean BAC was 0.14 g/100 mL (SD, 0.08; range, 0.01-0.35 g/100 mL). Eighty-seven per cent had BACs of 0.05 or higher and 22% had BACs of 0.2 or higher. There were no statistically significant differences between men and women in either median blood morphine concentration (0.25 v. 0.19 mg/L; P < 0.4) or BAC (0.14 v. 0.1 g/100mL; P < 0.25). The median blood morphine concentration in the subjects in whom alcohol was detected was significantly lower than in the group without alcohol detected (0.17 v. 0.34 mg/L; U = 3152; P < 0.001). There was also a statistically significant negative correlation between blood morphine and alcohol concentrations (rs = - 0.28; P < 0.01) The presence of benzo diazepines at autopsy did not significantly affect blood morphine concentrations (0.25 v. 0.24 mg/L; U = 1871; P < 0.7). To determine which individual variables were related to blood morphine concentration, a simultaneous multiple linear regression was performed on log morphine level (because of the skewed distribution of blood morphine levels). Variables used were age, sex, the presence of alcohol and the presence of benzodiazepines. The presence of alcohol at autopsy was the only variable independently associated with lower blood morphine levels (b = - 0.28; P < 0.001); age (P < 0.96), sex (P < 0.2) and the presence of benzodiazepines (P < 0.7) did not significantly predict log blood morphine level. Diagnostic tests of the residuals indicated that the assumptions of the model were met. Classification of deaths Fifty-seven per cent of all death certificates completed by the forensic pathologists reported the cause of death as either "narcotism", "acute narcotism" or "acute intravenous narcotism". Although alcohol was detected in 45% of subjects at time of death, it was noted on the death certificate in only 7% of cases. Most deaths (80%) were classified according to ICD-94 coding as cases of "dependence" (code 304.0), 10% as cases of accidental poisoning (E850.0), 9% as suicides (E950.0) and 1% as opiate drug dependence with contributions from other drugs (304.7). Discussion We found that heroin-related deaths occurred overwhelmingly in people who were male, of an average age of 30 years, and frequent users. Few occurred in those considered to be infrequent users. A recent survey has shown that two-thirds of a large sample of heroin users have had at least one non-fatal overdose and that 86% have been present at another person's overdose.6 This suggests that campaigns designed to reduce the rising mortality rate caused by heroin need to target regular users. The finding that only a minority of cases had ever been in methadone treatment is consistent with other evidence that methadone treatment reduces mortality among the heroin-dependent.7,8 Some of our subjects might be alive today if they had entered and remained in methadone treatment. A striking finding from the toxicological data was the relatively small number of subjects in whom morphine only was detected. Most died with more drugs than heroin alone "on board", with alcohol detected in 45% of subjects and benzodiazepines in just over a quarter. Both of these drugs act as central nervous system depressants and can enhance and prolong the depressant effects of heroin. Our finding (and that of other studies9,10 ) of a significantly lower blood morphine level in subjects who tested positive for alcohol suggests that in the presence of alcohol less heroin is required to exert a fatal effect. Alternatively, alcohol-induced liver enzymes may increase the metabolism of heroin. The very low blood levels of morphine we found may also support these hypotheses. Some pathologists have been reluctant to attribute a heroin-caused death to true overdose because of the frequent finding of a low blood morphine concentration, and prefer to report the death as a case of "narcotism" (Johan Duflou, Deputy Director, Insti tute of Forensic Medicine, Sydney, personal communication, 1993). Further, Monforte showed that in 75% of a group of people who had died from fatal heroin "overdoses" blood morphine concentrations were not higher than in a group of heroin addicts who were victims of homicide.11 Bammer and Sengoz have also challenged the assumption that heroin deaths occur as a result of increased purity of heroin. In a recent paper they identified concomitant consumption of other drugs and reduced tolerance as alternative mechanisms for the cause of death in heroin fatalities.12 The disadvantage of continuing to describe heroin-related fatalities as "overdoses" is that it attributes the cause of death solely to heroin and detracts attention from the contribution of other drugs to the cause of death. Heroin users need to be educated about the potentially dangerous practice of concurrent polydrug and heroin use. Our findings that an ambulance was called while the subject was still alive in only 10% of cases, and that a substantial minority of heroin users died alone, strongly suggest that education campaigns should also emphasise that it is safer to inject heroin in the company of others, and important to call for an ambulance early in the event of an overdose. Consideration should also be given to trialling the distribution of the opioid antagonist naloxone to users to reduce mortality from heroin use. In conclusion, fatal heroin overdose is potentially preventable and research should now focus on reducing its occurrence. The introduction or intensification of education campaigns explaining the risk of polydrug use to heroin users may help to reverse the national trend in heroin-related deaths. Acknowledgements This research was funded by South Western Sydney Area Health Service and the National Drug and Alcohol Research Centre. We would like to thank the following organisations for their assistance: Department of Courts Administration, in particular Glebe Coroners Court and Westmead Coroners Court, and the NSW Registry of Births, Deaths and Marriages. We would also like to thank Mr Stephen Bull of the Australian Bureau of Statistics (NSW office), Dr Johan Duflou, Professor Wayne Hall and Dr Alex Wodak. References Drug Caused Deaths in Australia 1990. Drugs of Dependence Branch statistical update. Number 18. Canberra: Commonwealth Department of Health, Housing and Community Services, August 1992. Swensen G. Opioid deaths in Western Australia: 1974-1984. Aust Drug Alcohol Rev 1988; 7: 181-185. Walsh RA. Opioid drug accidental deaths in the Newcastle area of New South Wales, 1970-1987. Drug Alcohol Rev 1991; 10: 79-83. World Health Organization. International statistical classification of diseases, injuries and causes of death. Vol. 1. Geneva: WHO, 1977. Wilkinson L. SYSTAT: the system for statistics [computer program]. Evanston, Il.: SYSTAT Inc, 1990. Darke S, Ross J, Hall W. Overdose among heroin users in Sydney, Australia: I. Prevalence and correlates of non-fatal overdose. Addiction 1996; 91: 405-411. Gronbladh L, Ohland LS, Gunne LM. Mortality in heroin addiction: impact of methadone treatment. Acta Psychiatr Scand 1990; 82: 223-227. Caplehorn JRM, Dalton MSYM, Cluff MC, Petrenas AM. Retention in methadone maintenance and heroin addicts' risk of death. Addiction 1994; 89: 203-207. Ruttenber AJ, Kalter HD, Santinga P. The role of ethanol abuse in the etiology of heroin related deaths. J Forensic Sci 1990; 35: 891-900. Chan L, Prolov T, Verma S. Morphine tissue concentrations in fatal overdoses in New South Wales, 1986-1987. Proceedings of the 10th Australian International Forensic Science Symposium; 1988 May 23-27; Brisbane. Brisbane: Australian Forensic Science Society, 1988. (Abstract No. 2333.) Monforte JR. Some observations concerning blood morphine concentrations in narcotic addicts. J Forensic Sci 1977; 22: 718-724. Bammer G, Sengoz A. How would the controlled availability of heroin affect the illicit market in the Australian Capital Territory? An examination of the structure of the illicit heroin market and methods to measure changes in price, purity, availability, including heroin-related overdoses. Canberra: National Centre for Epidemiology and Public Health, 1994. (Working Paper No. 10.) (Received 13 Jun, accepted 19 Oct 1995) Authors' details Drug and Alcohol Services, Division of Public Health, South Western Sydney Area Health Service, Sydney, NSW. Deborah Zador, MB BS, FAFPHM, Staff Specialist. Currently, Staff Specialist, Drug and Alcohol Services, Central Sydney Area Health Service, NSW. Sandra Sunjic, BAppSc, MA, Clinical Nurse Specialist. National Drug and Alcohol Research Centre, University of New South Wales, Sydney, NSW. Shane Darke, PhD, Lecturer. No reprints will be available. Correspondence: Dr D Zador, Gladstone Hall Health Services, 114 Ewart Street, Dulwich Hill, NSW 2203. ©MJA 1997 <URL: http://www.mja.com.au/> © 1997 Medical Journal of Australia.

Deborah Zador · Sandra Sunjic · Shane Darke

Recent changes in Australian general practice Michael D Bollen General practitioners need to decide whether the recent changes to general practice are acceptable and whether they are willing to initiate and lead the process of change in concert with the communities they serve MJA 1996; 164: 212 Readers may print a single copy for personal use. No further reproduction or distribution of the articles should proceed without the permission of the publisher. For permission, contact the Australasian Medical Publishing Company Journalists are welcome to write news stories based on what they read here, but should acknowledge their source as "an article published on the Internet by The Medical Journal of Australia <http://www.mja.com.au/>". Introduction - Recent developments in Australian general practice - Recognition of general practice - What has occurred as a result of this report and what is the future for GPs and general practice? - GPs being part of change - References - Authors' details - - ©MJA1997 Introduction During 1995, the Council of Australian Governments (COAG) released a discussion paper entitled "Meeting peoples' needs better".1 Subsequently, the Federal Government called for expressions of interest in programs for management of people with chronic illnesses which would apply the principles of coordinated care outlined in the discussion paper. These programs (which involve fundholding and care coordinators, not necessarily general practitioners [GPs]), are the most recent federal initiatives in reshaping community-based health care. "Coordinated care", "managed care" or "integrated care" (all are basically synonymous) have been introduced in other countries to ensure cost and service efficiencies or to maximise profit in the delivery of health care. Health planners in the United States have some difficulty understanding what we are seeking to achieve in Australia with coordinated care, as Australia is perceived as having a potentially very effective care coordinator called a general practitioner, a care coordinator which the United States is seeking to emulate! Given recent experiences (e.g., making private health insurance a more attractive product, or seeking acceptable ways to encourage quality care in general practice) in attempting to work in partnership with governments, it is not surprising that many in our profession, and GPs in particular, have major reservations about this latest proposal. Recent developments in Australian general practice General practice in Australia has changed significantly over the past six years and responses to these changes have varied widely. Recognition of general practice With the introduction of vocational registration in 1989, general practice was recognised as a distinct professional discipline. Entry to general practice now requires specific training, qualifications and commitment to ongoing education; it is no longer a career default option. Moreover, the establishment of departments of general practice in almost all Australian medical schools has signalled the recognition of general practice as an academic discipline. These developments have led to a blossoming of research within Australian general practice involving two distinct areas: the first is in clinical issues, such as hypertension and diabetes, using general practice data and resources; and the second concerns the framework of general practice and how it might function with different structures. In August 1991, the then Federal Health Minister, Mr Brian Howe, announced a number of "reforms" in general practice, which included fundholding (or budget holding) (see Box 1). 1: Federal Government general practice initiatives2 Address supply and distribution of medical practitioners; Introduce accreditation of general practices; Provide practice grants to complement fee-for-service reimbursement; Trial the use of practice budgets; Amalgamate solo and small-group practices into larger, more efficient entities; and Optimise use of information technology in general practice. Both the Australian Medical Association (AMA) and the Royal Australian College of General Practitioners (RACGP) declared that general practice fundholding was unacceptable, not only because of the perceived threat to traditional fee-for-service practice, but also because of the absence of linkage of patients to practices and the lack of effective information management in Australian general practices. Recent information on the experiences of GPs in the United Kingdom, 3 New Zealand (Professor Greg Coster, Chairperson, Royal New Zealand College of General Practitioners, personal communication) and Canada (Dr Reg Perkin, Executive Director, The College of Family Physicians of Canada, personal communication), where fundholding in various forms had been introduced, would appear to support this position. In response to the "reforms" proposed in 1991 and after extensive negotiations between the AMA, the RACGP and the Federal Government, a joint report entitled "The future of general practice: a strategy for the nineties and beyond" 4 was released in July 1992 (Box 2). 2: Key proposals of the report -- the future of general practice Address the oversupply and maldistribution of general practitioners; Provide support and recognition for appropriate postgraduate training for general practice; Establish local "divisions of general practice" under the control of general practitioners; Develop (by the profession) an independent, voluntary system of practice accreditation with links to regional divisions of general practice; and Introduce remuneration strategies designed to: -- reward quality care in general practice more appropriately; and -- enhance and encourage the role of general practitioners beyond the provision of individual patient care. This report was distributed widely to all GPs and to other interested parties, and working groups were formed to develop strategies to implement a number of these proposals. What has occurred as a result of this report and what is the future for GPs and general practice? Addressing the maldistribution of the GP workforce To address this issue credible answers are required to some key questions, which include: How many practising and non-practising GPs are there in Australia? How many identified general practices are there? How many additional GPs are required for rural and remote areas? What are the essential skills required for GPs to practise confidently and safely in the various areas of need? How many GPs are needed in Australia altogether? Is there a limit to the number of GPs Australia can support and afford? How many GPs are enough? Data on the general practice workforce are most unsatisfactory. The Health Insurance Commission reports that around 23 000 individual doctors use non-referred item numbers and could therefore be considered as GPs. There are about 16 500 "recognised general practitioners" who are either Fellows of the RACGP or who are vocationally registered. The increasing numbers of part-time GPs make estimation of the numbers required in the general practice workforce more difficult. The Federal Government has imposed an annual limit of 200 overseas-trained graduates entering the Australian medical workforce (almost all of whom seek to become GPs). 5 Entry to the RACGP Training Program has been restricted to 400 per year, 6 and the argument used by the government for limiting the number of GPs entering the workforce has been the reportedly unsustainable rate of growth in payments for GP services. There are allegedly too many GPs in most metropolitan areas and a very evident lack of GPs in many rural and remote areas throughout Australia. Despite various incentives, most Australian GPs appear reluctant to spend time in rural general practice. Many GPs have reported that, even in the cities, there is a shortage of both doctors willing to work as locums as well as skilled GPs available to fill vacancies resulting from practice growth or GP resignation or retirement. Recognition of appropriate training for general practice Vocational registration and restricting entry to general practice continue to be a source of anger and resentment. Medical students, recently graduated hospital doctors and those unsuccessful in specialist training had, in the past, an expectation of a right to enter general practice, together with those doctors who considered general practice as a retirement option or a retreat when their original career ceased to be satisfying or rewarding. Such doctors often still refuse to recognise that general practice requires any particular training. The terms "vocational registration" and "recognised GP" will remain a mystery to most consumers until we, as a profession, accept what much of the developed world, and the World Health Organization in particular, has already accepted: that general practice is a specific discipline in medicine and not merely the sum of special areas of knowledge from other more restricted disciplines. Only then can we unite to promote the excellence of general practice in Australia. It is ironic that Australia is regarded internationally as having one of the highest standards of general practice in the world, but yet is one of the last developed countries to afford real recognition to the discipline. Formation of divisions of general practice Contrary to popular opinion, the concept of divisions of general practice was not a government initiative but arose from within the profession. Divisions were conceived to provide GPs with a strong voice at a local level in their interaction with other local and regional bodies. Members of other Australian medical disciplines have been able to aggregate and organise in hospital "divisions" or departments. This permitted specialists to provide effective hospital clinical services, to undertake teaching and research collaboratively and to provide a professional interface with other disciplines and hospital administration while still retaining their independence. The RACGP had been keen to address the isolation and problems of fragmentation and marginalisation of Australian general practice. There was agree ment for a means to enable local GPs to work together more closely while still retaining t heir independence. In particular, at a local level GPs needed to not only plan their own futures as GPs but also have an input into the important area of health care planning for their communities. These concepts led to divisions of general practice and their proposed roles (Box 3). 3: Proposed roles for divisions of general practice Maintain and improve the standards of general practice in the region, including coordination of care between general practitioners and other service providers for the benefit of patients; Improve communication between general practice, hospitals, medical specialists and community health services; Encourage involvement of GPs in hospitals and other community health services; Foster cooperation between GPs in providing quality after-hours services; Take an active role in the continuum of education from undergraduate through to postgraduate vocational training in general practice; Undertake research in general practice by establishing local research networks; Involve GPs in health promotion and preventive activities; Ensure appropriate access to primary health services in consultation with consumers by sharing allied health resources; and Assist in the development of appropriate information management in general practice. During 1992, 10 groups of GPs from various parts of Australia obtained Federal Government funding to develop local GP organisations, later called divisions of general practice. By the end of 1995 there were 116 divisions of general practice covering 85% of the Australian community. The divisions, and projects promoted through divisions, have been subject to increasingly rigorous evaluation. Inevitably, some are proving more successful than others. The first ten divisions, formed in 1992, appear to be flourishing. Some more recently formed divisions may need a longer time to demonstrate their potential, and some of the early projects proposed by the divisions were poorly developed and sometimes only partially successful. To ensure that divisions of general practice have a future they will need to demonstrate that they are having a positive effect on community-based health outcomes and that this effect is sustainable. Development of practice accreditation The concept of the accreditation of general practices (i.e., the environment in which GPs work) has proved to be highly controversial. Perceived benefits are outlined in Box 4. To provide a basis for such accreditation required the development of agreed standards. 4: Benefits of general practice accreditation Raise general practice standards and consequently the quality of care provided to patients; Provide professional benefits for general practitioners; and Facilitate change in general practice. During 1993-1994 the RACGP Standards Development Unit developed "Draft entry standards for general practice", 7 with input from a wide variety of individuals and organisations. In 1994 these draft entry standards were tested in 199 practices through the RACGP Field Test of Standards. A further 500 practices, coordinated through divisions of general practice, undertook local demonstration trials to enable further evaluation of the standards and methods of assessment. While there has not been universal acceptance of the concept of accreditation, responses from participating GPs in both the RACGP field tests and the local demonstration trials strongly suggested that the standards were acceptable and appropriate, that the process was found to be professionally satisfying, and that a better understanding of the standards acted as a catalyst for change in the practices surveyed. One reason for Federal Government support of the concept of accreditation was that it might provide a basis for allocation of funding not dependent on number of patient consultations (i.e., rewarding quality care rather than throughput). The debate around accreditation should not revolve around money but around standards: How are the standards established? Are they are accepted by GPs as well as the rest of the profession? How they are applied? Do they have external credibility to consumers and others outside the profession? Remuneration strategies for general practice There was initial agreement that the existing fee-for-service funding for general practice had an inbuilt "perverse incentive" based on "the more you see and the quicker you see them the more you earn". The RACGP, the AMA and the government were not able to reach agreement on a method of remuneration that encouraged and rewarded the provision of high quality care, other than on a time basis. Agreement attempts were not aided by the Government's part-funding of the general practice reforms, including the introduction of the so-called Better Practice Program, from the funding pool for the fee-for-service rebate increases. That action was totally contrary to the agreed position stated in the general practice strategy document that "Funding for these payments would come from a pool of funds set aside by the Government but the establishment of this pool should not interfere with rebates for fee for service items for vocationally registered general practitioners", 4 and has resulted in the return of an atmosphere of mistrust of government by the profession. GPs being part of change Whatever changes are proposed to the provision of health care in Australia, the final and most important test will be whether such changes result in improved health outcomes. In seeking to apply this test there is a need for detailed criteria on which outcomes will be judged. "Coordinated care" and "budget holding" will remain no more than words or ideas unless the resulting health care is accessible and acceptable to the Australian community. With the advent of early discharge programs, whether as the result of improved technology, better therapeutic techniques or financial pragmatism, it is essential that high quality community-based care -- providing continuity of care as well as ongoing management of people with chronic illness -- be readily available. It is important for GPs to recognise that, to remain in a position of providing most of the community-based care, they will need to be not just responsive to change, but take the initiative and lead the changes in concert with the communities they serve. References Department of Human Services and Health. Council of Australian Governments Taskforce on Health and Community Services. Meeting peoples' needs better -- a discussion paper. Canberra: The Department, January 1995. Health Care in Australia -- directions for reform in the 1991-92 Budget. (Circulated by The Hon Brian Howe, Deputy Prime Minister and Minister for Health, Housing and Community Services.) Canberra: AGPS, 1992. (Budget related paper, No. 9.) Miller G, Booth N. General practice budget holding. What can the United Kingdom teach Australia? Med J Aust 1995; 162: 284-285. Department of Human Services and Health/Australian Medical Association/Royal Australian College of General Practitioners. General Practice Consultative Committee. The future of general practice: a strategy for the nineties and beyond. Canberra: Department of Human Services and Health, July 1992. Commonwealth Government Budget 1995-96. Fact Sheets -- Medical Workforce. Canberra: AGPS, 1995. Royal Australian College of General Practitioners. Program of Vocational Training -- Conditions of Grant Schedule 3. Specific outcomes for 1994-95. Canberra: Department of Human Services and Health, 1994. Royal Australian College of General Practitioners. Standards Development Unit. Draft entry standards for general practice. Sydney: The College, 1994. Authors' details Royal Australian College of General Practitioners, Sydney, NSW. Michael D Bollen, DObstRCOG, FRACGP, Secretary General. No reprints will be available. Correspondence: Dr M D Bollen, Royal Australian College of General Practitioners, PO Box 906, Rozelle, NSW 2039. ©MJA 1997 <URL: http://www.mja.com.au/> © 1997 Medical Journal of Australia.

Michael D Bollen