Volume 181 Issue 2

GPs are inadequately reinforced and poorly funded — and don’t mention the paperwork “To tell you the truth, I thought of all the damned paperwork this was going to mean in the morning,” said United States General Walter Bedell Smith, recalling the signing of the armistice that ended World War II (New York Times, 8 May 1965). He might have been describing a typical afternoon in general practice. I timed myself one day: a fifth of the 2 hours seeing seven patients had been spent in skirmishes with paperwork. Soldiers fight, surgeons operate, and physicians treat — but GPs? We practise consultatio interruptus (courtesy M Van Der Weyden, MJA Editor). Illustrator: Futcher. First appeared in Australian Doctor, 2002. Paperwork is an occupational hazard for GPs. One GP counted a barrage of 1574 individual communications monthly.1 In cold cash terms, the Productivity Commission found that GPs’ administrative costs from government programs in 2001–02 were an estimated 5% of GPs’ total income in the base case (ie, $13 100 annually for a GP working at least one day a week).2 Putative financial incentives for GPs to provide quality care, such as vocational registration, the Practice Incentives Program (PIP), and Enhanced Primary Care (EPC) Medicare items, accounted for over three-quarters of these costs. The report also acknowledged the stress and frustration experienced by GPs in filling out forms and complying with government programs. In response to the Commission’s report, a GP Red Tape Taskforce has emerged.3 This cross-government group includes staff from the senior ranks of the departments of Health and Ageing and Veterans’ Affairs, Centrelink and the Health Insurance Commission. After consulting GPs, GP groups, consumers and other stakeholders, a draft of possible responses was released in October last year. These included streamlining the government’s information requirements, enhancing GP use of information technology, simplifying programs such as PIP, and minimising administrative costs.3 Discussions with GP groups since then have focused mostly on reworking PIP and EPC items. Predictably, actual reform is yet to materialise. Furthermore, within a year of the Taskforce becoming operational, the government announced its Medicare Plus package, which included tying allied healthcare services access to the EPC program.4 While laudable in its intent, it promised yet another salvo of red tape for GPs. Countermeasures raised since by GP groups will diminish this,5 but it remains an inherently flawed initiative. This war on paper is allied to major themes in the 2004 MJA General Practice issue: general practice funding and workforce pressures. Are fragmented government payments in a fee-for-service system really the way to go? Data furnished by Britt et al (page 100) have implications for current negotiations on restructuring Medicare items. We also asked our Dutch (Van Weel, page 110), British (Weller and Maynard, page 109), Canadian (Martin and Hogg, page 111), American (Green, page 113) and New Zealand (Malcolm, page 106) colleagues to tell us how they fared with funding. The only constant in their replies is that of change, and change can be difficult. Nor is it often well evaluated, say Van Weel and Del Mar (page 98), marshalling the evidence for various payment systems. It is also clear that most of the countries featured in this issue favour deploying capitation (lump sum payment per patient on the GP’s “list”) to pay their GPs. As for workforce pressures, they’re unlikely to improve in the near future (Charles et al, page 85). Some rural communities continue to favour doctors more than other healthcare services (Smith et al, page 91). So find out how a few rural GPs successfully outflanked their workforce problems (Joyner et al, page 96). This issue doesn’t neglect clinical problems — for example: why we shouldn’t panic about avian influenza (Isaacs et al, page 62); what we learnt in the aftermath of Implanon (Wenck and Johnston, page 117; Nisselle, page 64); who should eat which fish (Bambrick and Kjellström, page 61); what dilemmas GPs face in diagnosing and treating heart failure (Phillips et al, page 78); where the luxury of on-site psychologists seemed to benefit patients (Vines et al, page 74); how chronically ill patients like their GPs and their practices (Infante et al, page 74); how GPs can realistically tackle respiratory disease (Beilby et al, page 67) and childhood obesity (Wake and McCallum, page 82). In this issue, we have attempted to enter the fray of real general practice. The campaign against red tape aims to free GPs for what most of us really want to work at — patient care. The battle against red tape is part of the healthcare war.

Mabel Chew MB BS(Hons), FRACGP, FAChPM

Risks to the fetus make it imperative that revised guidelines for fish consumption are clear and reach those most likely to be affected Headlines such as “Mercury warning for children, pregnant women” and “Danger of too much fish” appeared in March throughout Australian newspapers. The media blitz was triggered by the release of revised advice from Food Standards Australia New Zealand (FSANZ) on health risks associated with consuming fish with high methylmercury (MeHg) content (Box).1 The warnings come after a Food and Agriculture Organisation of the United Nations/World Health Organization Expert Committee halved the “provisional tolerable weekly intake” of MeHg in pregnancy from 3.3 µg to 1.6 µg per kilogram bodyweight to protect fetal development.2 Fetal neurotoxicity of MeHg was discovered in the 1960s in Japan. It was named “fetal Minamata disease” after 25 cases of cerebral palsy were found in newborns whose mothers had high levels of MeHg exposure from eating fish contaminated by industrial pollution,3 while the expected number of cases in that population was less than one. Subsequent cohort studies following children from birth to 14 years in New Zealand4 and in the Faeroe Islands5 reported associations between maternal MeHg exposure from fish consumed during pregnancy and deficits in psychological performance or in neurophysiological testing. One prospective study in the Seychelles did not find such effects.6 The Minamata case and subsequent studies indicate that there may be a shift to the left in IQ distribution as a result of excessive MeHg exposure from fish, even at levels too low to produce overt mental retardation. However, a robust debate is continuing about the toxic level of exposure and the “safety margin” required to protect the fetus. The potential risk to children in Australia needs to be carefully considered. The new advice from FSANZ is welcome, as some commonly consumed ocean fish (such as shark) often have natural MeHg concentrations sufficient to cause high weekly exposures. Interestingly, no recommendation was made for tuna. Although canned tuna is usually sourced from smaller, younger fish and is relatively low in mercury, some tuna (albacore, bluefin) has higher concentrations. The United States Environmental Protection Agency advises vulnerable groups against consuming any fish with high mercury content.7 Fish is well established as a “healthy” food. Evidence for cardiovascular benefits from regular fish consumption emerged in the 1990s, as low rates of cardiovascular disease were found in populations with high levels of fish consumption. A number of studies indicate that omega-3 fatty acids reduce cardiovascular risk by improving lipid profiles, inhibiting atherosclerotic plaque, improving arrhythmia, improving vascular function, and reducing damage from ischaemia.8 Curiously, one study reported that high levels of MeHg exposure from fish increased the incidence of myocardial infarction.9 We are therefore faced with the difficult public health challenge of avoiding the health risks from MeHg intake in fish in vulnerable groups while taking advantage of the health benefits of fish consumption. The National Heart Foundation recommends fish be consumed at least twice a week, consistent with advice from FSANZ for most kinds of fish, but this is two to four times the latest recommendations for consumption of fish containing high levels of mercury. While some species of fish have high levels of MeHg, others, such as salmon and hake, have relatively low levels. Expecting consumers to change their understanding that “fish is good” to “some fish are good, sometimes”, and “some fish are not so good, sometimes” introduces a level of complexity into consumer health education that has rarely been seen. Parallels might be drawn with fats and oils, with important shifts in understandings from “all fats are bad” to “some fats are good”, or with alcohol consumption, where some patterns of moderate drinking might be more beneficial to health than abstinence.10 Patterns of fish consumption are highly variable, so ensuring advice reaches those most at risk is essential. For example, shark is frequently unintentional “by-catch”, often used in cheaper meals such as fish and chips and fishcakes, which are consumed fairly regularly by some groups. People more likely to rely on these products may also be less aware of, and less able to respond to, the health advice from FSANZ. While some relatively expensive fish are also high in mercury (swordfish, orange roughy), these are perhaps less likely to form a regular part of the diet. Mercury has a half-life of about 9 weeks, so that women who stop all consumption of fish on becoming pregnant may still be exposing their fetuses to high levels of mercury well into pregnancy. Therefore, we suggest that all healthcare professionals make women of child-bearing age aware of the revised FSANZ recommendations and the potential risks to the developing fetus associated with even moderate consumption of some types of fish during pregnancy. Standards of fish nomenclature should also be developed and enforced to reduce confusion and to ensure consumers are getting what they expect. Further, epidemiological research on actual levels of exposure and the efficacy of the FSANZ health advice is much needed. Revised Australian recommendations for fish consumption* One serve per week (no other fish that week)* One serve per fortnight (no other fish that fortnight)* Two or three serves per week Pregnant women, women intending to become pregnant, and children (up to 6 years) Orange roughy (sea perch), catfish OR Shark (flake), billfish (swordfish, broadbill, marlin) OR Any fish or seafood not listed to the left Rest of population Shark (flake), billfish (swordfish, broadbill, marlin) OR OR Any fish or seafood not listed to the left * Serving size = 150 g for adults and older children, 75 g for children aged up to 6 years.1

Hilary J Bambrick PhD · Tord E Kjellström MEng (Stockholm), MedDr (Stockholm)

There is currently no need to panic At a recent forum of the Australian Health Policy Institute in Sydney, the Editor of the Journal expressed concerns about Australia’s ability to cope with avian flu, and asked whether he could sleep soundly in his bed. We attempt to answer his concerns. Influenza is justifiably feared. In 1918–1919, 40 to 50 million people (2%–3% of the world’s population) died in the “Spanish” influenza pandemic.1 Subsequent influenza pandemics occurred in 1957 and 1968. Although the mortality of the later pandemics was far less, the potential for another major pandemic is ever present. Annual influenza outbreaks have caused more deaths overall than pandemics, but gentle antigenic “drift”, caused by minor mutations in the viral genome, allows the annual development of a new influenza vaccine, matched as closely as possible with predicted circulating strains. Pandemic strains caused by antigenic “shift” are, by definition, unpredictable, and unlikely to be prevented in the short term by vaccines. In 1999, stimulated by human infections caused by avian influenza in Hong Kong, the World Health Organization (WHO) published a pandemic preparedness plan, and urged countries to make their own plans.2 How well prepared is Australia? The origin of pandemics: The segmented genome of the influenza A virus favours genetic reassortment, which can lead to antigenic shift to a new, potentially pandemic, strain. Pandemic strains arise when a new type of haemagglutinin is introduced into humans. Pigs may act as a mixing vessel for reassortment by supporting growth of both avian and human viruses, or a human might be co-infected with both avian and human strains. Pandemic influenza spreads rapidly and affects children and young adults, causing enormous social disruption.1 Avian influenza: Birds, particularly aquatic and migratory species, are natural hosts of all 15 haemagglutinin subtypes of influenza A virus, whereas only a few of these viruses have established transmissible infections in humans, pigs and other mammals.1 Avian influenza strains readily infect domestic poultry and are highly pathogenic to birds.3 Since mid-December 2003, there has been a catastrophic outbreak of avian influenza in Asia, caused by a highly pathogenic H5N1 strain. Eight countries have confirmed outbreaks, mostly in commercial poultry, although wild birds have been infected. In 2 months, over 100 million birds in Asia died or were culled.3 There was great alarm when human infections with this avian strain were reported, with high mortality in both adults and children. However, despite the extent of the outbreak in birds, very few human cases have been reported. By 24 March 2004, 57 cases had been notified from Vietnam (37) and Thailand (20), of which 23 (40%) were fatal. All cases followed exposure to infected poultry. The number of unreported human cases is uncertain, but the absence of documented human-to-human spread is reassuring.3 The greatest concern is that there will be reassortment between the current avian H5N1 strain and circulating human or porcine influenza viruses, producing a novel, virulent human strain. Pandemic planning: Australia has been actively planning action to cope with an influenza pandemic since 1997. The framework for a pandemic plan was published in 1999,4 and an action plan was published in 2003.5 A National Influenza Pandemic Action Committee (NIPAC), formed in 2003, continues to plan for future pandemics and has closely monitored the avian influenza situation. Although NIPAC is an anagram of “panic”, the message so far is that there is no need to panic. A major concern of the audience at the health policy forum was the large number of different agencies involved in planning for a pandemic — a veritable “spaghetti junction”. Who should coordinate these agencies? Given the complexity of pandemic planning, we believe it is entirely appropriate that there are many different players, coordinated, as is now the case, by the Australian Department of Health and Ageing.6 Planning for pandemic influenza overlaps to an extent with planning for outbreaks of other viral infections. Australian pandemic planning has benefited from the need to develop plans to cope with a potential epidemic of SARS (severe acute respiratory syndrome)7 and possible bioterrorist attack with smallpox virus.8 NIPAC is addressing many facets of planning, including: Border protection. Although Australia is an island, modern air travel and the high infectivity of influenza preclude total exclusion of a pandemic. Because influenza can be transmitted before symptoms appear, screening incoming passengers for reported symptoms, as was done for SARS, would be less effective, but might delay widespread introduction of influenza. Even weeks of delay could be invaluable for vaccine development and distribution. Immunisation. It would probably take at least 6 months after the onset of a pandemic for significant quantities of vaccines specific to the pandemic strain to become available.9 WHO is currently developing H5N1 viruses suitable for vaccine production as rapidly as possible. Antivirals. The H5N1 virus is resistant to amantadine, but sensitive to the neuraminidase inhibitors oseltamivir and zanamavir, which can be used for both treatment and prophylaxis. It has been suggested that countries should stockpile antivirals.10 There was some evidence of their benefit in humans during the 2003 outbreak of highly pathogenic avian H7N7 influenza A in Dutch poultry farms.1 However, antivirals are very expensive and in short supply, and realistically could only be used as a stop-gap measure to “buy time” by treating early cases and protecting essential staff. Laboratory diagnosis. Influenza is difficult to differentiate clinically from “influenza-like illnesses”, necessitating laboratory testing of appropriate respiratory samples for confirmation. However, testing is not often done routinely (at least in adults). SARS and the threat of avian influenza suggest testing should be more widely available to facilitate decisions about infection control, but few laboratories provide rapid viral diagnosis. The network of WHO influenza and other public-health laboratories in Australia is actively developing rapid tests to detect H5N1 influenza. Infection control measures to limit spread. Children are at high risk of contracting and dying of influenza,1 and are an important source of infection for the elderly.11 In a pandemic, it would almost certainly be necessary to close schools, childcare centres and public gatherings to reduce spread. Respiratory hygiene. Simple respiratory hygiene, such as covering the nose and mouth when sneezing, and disposing of used tissues promptly in “no-touch” receptacles, is as important as the use of masks.12 Communication. The level of public concern and, in many countries, panic during the SARS outbreak vividly illustrates the importance of effective public communication. It is vital that authorities do not leave the dissemination of information about outbreaks to the popular press. There is currently no need to panic about avian influenza, as human cases are extremely rare and have followed close exposure to birds. Human-to-human spread of avian influenza has not been described. While Australia is well prepared to cope if an influenza pandemic started tomorrow, the unpredictability of these pandemics, their rapid spread and high attack rates mean it is impossible to be totally reassuring. Like the rest of us, the Editor of the Journal, if he wants to sleep soundly, will just have to cope with uncertainty.

David Isaacs MD, FRACP, FRCPCH · Dominic E Dwyer MD, FRACP, FRCPA · Alan W Hampson MSc, MASM

To focus solely on reducing error may inadvertently reduce the quality of care In this issue of the Journal, Wenck and Johnston (page 117) describe the response of a medical indemnity insurer to the potential for claims associated with the contraceptive implant Implanon (Organon).1 The article stimulates reflection on whether the recent increased emphasis on risk management has been at the expense of quality assurance. The “quality movement” began in Australia over 30 years ago. The 1970s and 1980s saw the development of hospital accreditation through the Australian Council of Hospital Standards (now the Australian Council of Health Care Standards [ACHS], www.achs.org.au) and drove the system of credentialling medical staff in hospitals and delineating their clinical privileges that has become the norm. Accreditation of general practices resulted largely from the Australian government’s decision in the late 1990s to tie various government general-practice payments to accreditation. The “safety movement” developed more recently, catalysed in part in Australia by the 1995 report in this Journal of the Quality in Australian Health Care Study,2 and internationally by the report of the Bristol Inquiry3 and the US Institute of Medicine’s article To err is human.4 However, the increased momentum of the safety movement brings with it the risk that “risk management” (avoiding error) will overshadow “quality assurance” (enhancing quality). Further, Wenck and Johnston’s report raises the question of whether the prudential risk management outlined simply imposed financial disincentives to the continued use of Implanon, and increased funding for potential future claims. Or did it stimulate reduced error — clinical risk management? Recently, concern at the escalating cost of public liability insurance in general, and medical indemnity insurance in particular, has stimulated: A wave of tort law reform across Australia. An early reform that directly affected medical accident compensation, and hence medical indemnity costs, was the New South Wales Health Care Liability Act (2001). Reform of the medical indemnity industry. This culminated in Federal Parliament passing the Medical Indemnity (Prudential Supervision and Products Standards) Act (2003) and a number of subsequent bills. Over $300 million in federal subsidies for medical indemnity insurance premiums (the “Premium Support Scheme”) and medical negligence claims (the “High Claims” and “Exceptional Claims” schemes). Over $300 million in federal funding for the UMP (United Medical Protection) Support Scheme, which replaced the IBNRs (“Incurred but not reported” liabilities) Levy Scheme announced in 2002; the Commonwealth will now directly subsidise three-quarters of the IBNRs of doctors who were members of UMP at 30 June 2000. Now that medical indemnity is not directly provided by the medical defence organisations (MDOs), but by the subsidiary insurance companies they registered (“captive” insurers), the quid pro quo demanded by Government for the $600 million “rescue” injection of subsidies was: that the parent MDO or its subsidiary medical indemnity insurer provide enhanced programs of clinical risk management for their clients and that those clients participate in the programs offered, and that the medical indemnity insurers practise much higher standards of prudential risk management than did their MDO parents in the past. (Prudential risk management refers to how insurers set premiums and manage their reserves and business risk to ensure they remain solvent and able to meet liabilities as and when they arise.) In this process, the two meanings of the phrase “risk management” — the prudential risk management of the insurer, and the clinical/medicolegal risk-management services they offer those who are insured — became blurred. The article by Wenck and Johnston highlights the similarities and differences between these two forms of risk management. Prudential risk management can have perverse effects on clinical practice. For example, from around 1990, the MDOs moved away from “mutual” subscriptions (all doctors paid the same) to “differential” subscriptions (higher-risk disciplines paid higher rates). One result was that general practitioner and specialist obstetricians who practised low-volume obstetrics found a powerful reason to cease midwifery: the extra cost of obstetric indemnity far exceeded the income they derived from obstetric work. There were other factors as well, but the number of doctors for whose obstetric services rebates were claimed through Medicare dropped by 29% between 1989 and 1995.5 The sudden spate of claims arising from the use of the implantable contraceptive Implanon saw the MDOs respond in different ways. Prudentially, they needed to ensure that Implanon claims were properly funded. Clinically, they wanted to reduce the number of such claims by encouraging safe use. Some MDOs chose to maintain the status quo — perhaps relying on media reports either to deter doctors from using Implanon or to ensure they reviewed their clinical techniques. Other MDOs, such as MDA National and UMP, moved coverage for matters arising from Implanon use into the more costly “procedural general practice” category of insurance. The latter approach would predictably lead to most non-procedural GPs stopping use of Implanon in their clinical practice. Who would pay up to $10 000 more per year for insurance to cover a procedure they might perform 20–30 times a year for a fee of less than $30 per service? A third approach was adopted by the Medical Defence Association of Victoria (MDAV) in July 2003,6 demonstrating that risk management by an MDO can be vigorous without perversely affecting clinical services. GPs who used Implanon were advised that they might be asked to pay an excess of $5000 if they were unable to demonstrate adequate training and technique should an Implanon claim be brought against them. There was no fixed economic deterrent to using Implanon, but there was an incentive to “risk manage” clinically to avoid the $5000 excess. After monitoring claims in the ensuing period, MDAV announced in May 2004 that the excess would no longer be applied.7 Similarly, United Medical Protection announced on 21 May 2004 that Implanon insertion would revert to being covered in the non-procedural general practice category of insurance, but with ongoing conditions. To quote from UMP’s media release: It will be a condition of cover that members agree to adhere to risk management guidelines based upon the RACGP’s [Royal Australian College of General Practitioners’] guidelines . . . Members using Implanon will be required to undergo a training session in patient selection and counseling and Implanon insertion and removal techniques arranged by the manufacturer Organon. In addition, members will need to perform the first six insertions under the supervision of a medical practitioner experienced in Implanon insertion.8 MDA National had earlier announced, on 25 February 2004, that, with effect from the insurance year commencing 1 July 2004, Implanon cover would be available again in the non-procedural category — subject to adherence to risk-management guidelines.9 Some MDOs now offer premium discounts to members who satisfy specified standards for risk management in their practices or attend risk-management educational seminars and similar activities. I recently reviewed well over a thousand of the applications for MDAV’s RISQ (Risk Identification for Sustaining Quality) program. Some applicants supported the program strongly, saying the application process stimulated a major review of their practice’s policies. Others thought the discount was not worth the time required to complete the application. In my opinion, this latter group missed the point. The premium discount is a relatively minor immediate incentive when compared with the ameliorative effect that effective risk management may have on claims frequency, and hence the potential impact on their future premiums. Further, one member made another, poignant point: I know this is a very worthwhile exercise, but it’s had the effect of making me view every patient as a potential plaintiff. While his comment strikes an empathic chord, he also missed the point. Medical practice requires quality assurance and risk management. It also requires organisational governance — management of personnel, financial efficiency, systems efficiency, and so on — as much as clinical governance. All the various components of practice governance need to be managed. Focusing on any one component to the detriment of the others leads to a mismanaged practice. It is not a choice between risk management or quality assurance, we need both — less error is part of better quality. Saxe’s poem about the blind men and the elephant is apposite.10 Six blind men argue vigorously about the nature of the beast of which each is holding one part — the tusk, the trunk, an ear, a leg, and so on. The poem concludes: So oft in theologic wars, The disputants, I ween, Rail on in utter ignorance Of what each other mean, And prate about an Elephant Not one of them has seen! The elephant is clinical governance (continuous quality improvement). It has many parts. All must be subject to equal focus.

Paul Nisselle AM, FRACGP

The IPCRG is fostering international links between primary care clinicians and researchers Over 450 primary care clinicians and researchers from around the world gathered for the second conference of the International Primary Care Respiratory Group (IPCRG) in Melbourne in February 2004. The IPCRG is an international umbrella organisation for national primary care respiratory interest groups.1 It was established as a charitable company in June 2000 by general practitioners (GPs) and other primary care health professionals from several countries, including Australia, at a meeting of the United Kingdom GP asthma group. Australian GPs have been actively involved in all aspects, including the executive, since its inception. The organisation currently has 21 member countries, represented by national organisations. Australia is represented by the National Asthma Council. The aims of the IPCRG are to provide an international network for research in community settings, to guide and disseminate evidence-based guidelines appropriate for primary care professionals (eg, GPs, nurses, pharmacists and healthcare workers), and to provide practical resources for “respiratory professionals” in community settings around the world. Those involved in IPCRG include such diverse groups as GPs, respiratory scientists, asthma educators, pharmacists and physiotherapists. The theme of the 2004 conference was “the way forward” in managing respiratory disease in primary care. Major topics were asthma, allergy and chronic obstructive pulmonary disease (COPD), while tuberculosis, community-acquired pneumonia and quality-of-life measurement also received substantial attention. Topics were covered from the perspectives of clinical care, people and public policy, and practical training, with plenary sessions, workshops and submitted papers and posters. Core issues arisingProactive models of care should be developed and tested. Most primary care respiratory management is reactive, and not organised or systematic. Different models of evidence-based proactive care need to be developed and tested. New models presented at the conference included telephone consultations for asthma review, integrated decision support, nurse-led asthma clinics, practice-based professional development programs linked to patient audits, and community-based pharmacy outreach programs. Guidelines need to be translated into daily practice. Several internationally developed guidelines for asthma, COPD and rhinitis cannot be implemented in primary care (Professor Onno van Schayck, Faculty of Medicine, University of Maastricht and University of Nijmegen, The Netherlands). Several plenary sessions discussed how best to link guidelines to clinical practice in general practice and other forms of primary care, including nurse-run asthma clinics and Aboriginal community-controlled health services. The “consensus” was that a model centred on the respiratory complaints described by the patient at presentation is more sustainable and may be more effective (eg, a model centred on “cough” may be superior to one centred on “COPD”). The link between allergy and asthma must be applied in clinical practice. Evidence is emerging that effective management of allergic rhinitis may ameliorate and prevent asthma (Associate Professor Mini Tang, Head, Department of Immunology, Murdoch Children’s Research Institute, Melbourne, and Dr Jacques Bouchard, St Joseph’s Hospital, La Malbaie, Quebec, Canada). As almost 45% of the Australian population is atopic, and about a third suffer allergic disease (Professor Robyn O’Hehir, Head of Allergy and Respiratory Medicine, Alfred Hospital, and Monash University, Melbourne, and the Cooperative Research Centre for Asthma, Sydney), a number of speakers stressed the need to consider allergy assessment in all patients with asthma. Undiagnosed asthma and chronic obstructive pulmonary disease must be identified more efficiently. Effective management is now available for people with early signs of asthma and COPD and will substantially improve their quality of life (Dr Christine Jenkins, Director, Clinical Trials Unit, Woolcock Institute of Medical Research, Royal Prince Alfred Hospital, Sydney). More precise assessment of disease severity is needed. The severity of asthma and COPD needs to be specified more precisely to maximise the benefits and minimise the risks of interventions. Smoking-cessation programs, appropriate use of inhaled corticosteroids and long-acting bronchodilators, pulmonary rehabilitation, and self-management strategies all have a role, depending on severity of the condition (Dr Christine Jenkins). Major topics discussedAsthma. With the recent release of the report on the global burden of asthma,2 Professor Richard Beasley (Director, Medical Research Institute of New Zealand, Wellington, New Zealand) highlighted the increasing prevalence of asthma, particularly in Asia. He maintained that the explanation is still uncertain, but multifactorial, with environmental factors, increasing urbanisation and the increasing prevalence of allergic disorders all implicated. This suggests that addressing the increase in prevalence will require multifaceted responses by clinicians, public health physicians, consumers, industry and governments (eg, by providing all essential drugs to treat people with asthma in all Asia-Pacific countries). He argued that primary care is a substantial part of the solution and has specific challenges, including development of simple algorithms for patients who present with vague symptoms of cough, shortness of breath and wheezing. Emerging evidence pointed to a need to ensure that the lowest dose of inhaled corticosteroid is used to control symptoms. Some newly recognised side effects include dental and vision problems. Up to 45% of people taking moderate amounts of inhaled corticosteroids report some side effects (Professor Thys Van der Molen, Department of General Practice, University of Groningen, The Netherlands). Van der Molen commented that primary-care clinicians often do not have the time or tools to identify these less well known side effects. Severe acute respiratory syndrome. Associate Professor Cheong Pak Yean (Family Physician, Faculty of Medicine, National University of Singapore) described Singapore’s response to the epidemic of severe acute respiratory syndrome (SARS). The strategy involved detecting, isolating and “ring-fencing” the virus at four levels — the border, hospital, community, and primary care. Border defence involved screening travellers for possible SARS as they entered Singapore. The hospital defence involved managing all people with SARS (or possible SARS) in hospital, with use of personal protective equipment by staff (masks, gloves, gowns, and goggles) plus barrier nursing in single-patient isolation rooms. Community defences included mass education, twice-daily temperature measurement for any suspected cases, and closure of “at-risk” gatherings, such as markets. In primary care, strategies used included GP education campaigns, telephone information hotlines, and “fever and evacuation” rooms in GP surgeries (separate rooms for patients with suspected SARS awaiting evacuation to hospital). Chronic obstructive pulmonary disease. Identifying people with early smoking-related lung damage would seem a major task. The number of people with COPD in Australia will increase significantly over the next 10–15 years; the estimated prevalence may well exceed 300 000 cases (Professor Justin Beilby, Department of General Practice, University of Adelaide, SA), and the total number of COPD sufferers (both diagnosed and undiagnosed) could range from 620 000 to 2.6 million cases.3 A GP-friendly algorithm based on the recently completed COPDX guidelines4 was presented. Fitting on two A4 pages, this has since been refined and released (Box). Symptom-based questionnaires. There was much discussion about GPs identifying specific conditions, such as undiagnosed COPD. Professor David Price (General Practice Airways Group, Professor of Primary Care Respiratory Medicine, University of Aberdeen, UK) reported on a study of the link between symptoms and results of spirometry testing in 417 current or former smokers recruited from primary-care practices in the United Kingdom and the United States. Predictors were identified that may be useful in identifying early COPD, as measured by spirometry, including: Age group (in years). Pack-years smoked (How many cigarettes do you currently smoke each day [if you are an ex-smoker, how many did you smoke each day]? What is the total number of years you have smoked cigarettes?). Recent cough (Have you coughed more in the past few years?). Breathing-related work loss (During the past 3 years, have you had any breathing problems that have kept you off work, indoors, at home, or in bed?). Hospitalisation for breathing problems (Have you ever been admitted to hospital with breathing problems?). Recent breathlessness (Have you been short of breath more often in the past few years?). Cold usually goes to the chest (If you get a cold, does it usually go to your chest?). It was agreed that these questions require validation among other communities before they can be used as predictors in everyday clinical practice. ConclusionThis was the second IPCRG conference, the first being held in Amsterdam in 2002. The developing international IPCRG networks have now begun developing innovative research programs, such as further validation of the symptom-based questionnaires discussed above. These programs will become the platform for the next conference, to be held in Oslo in 2006. The IPCRG research subcommittee has begun developing a strategic plan for the group — a challenge, because of the diversity of the member countries and the variable access to resources and research expertise across the group. However, meeting the challenge through sharing expertise and skills may also be a great opportunity for IPCRG. Main steps of COPDX checklist for diagnosis and management of chronic obstructive pulmonary disease5 C – Confirm diagnosis Presence and history of symptoms Smoking – history and willingness to quit Spirometry – measure FEV1 and FEV1/FVC and assess reversibility of airflow limitation O – Optimise function Including check of smoking status, optimal therapy and exercise status P – Prevent deterioration Essential steps (including pneumococcal and annual influenza vaccination) Risk-factor reduction (including help with smoking cessation) D – Develop self-management plan Including referral for pulmonary rehabilitation or to respiratory physician or hospital, if appropriate X – Manage eXacerbations Including ensuring understanding of importance of early treatment for exacerbations; regular review

Justin J Beilby MD, FRACGP · Nicholas J Glasgow MD, FRACGP, FAChPM · H John Fardy DRCOG, FRACGP

Objectives: To explore the perceptions of patients with chronic conditions about the nature and quality of their care in general practice.Design: Qualitative study using focus group methods conducted 1 June to 30 November 2002.Participants and setting: 76 consumers in 12 focus groups in New South Wales and South Australia.Main outcome measures: Recurring issues and themes on care received in general practice.Results: Three groups of priorities emerged. One centred on the quality of doctors, including technical competence, interpersonal skills, time for the patient in the consultation and continuity of care. A second concerned the role of patients and consumer organisations, with patients wanting (i) recognition of their knowledge about their condition and self-management, and (ii) for GPs to develop closer links with consumer organisations and inform patients about them. The third focused on the practice team and the importance of practice nurses and receptionists.Conclusion: GPs should consider the amount of time they spend with chronically ill patients, and their interpersonal skills and understanding of patients’ needs. They need to be better informed about the benefits of patient self-management and consumer organisations, and to incorporate them into their care. They also need to review how their practice nurses and receptionists can maximise the care of patients.

Fernando A Infante MPH · Judith G Proudfoot PhD, MA, BEd(Hons) · Gawaine Powell Davies MHP · Mark F Harris DRACOG, FRACGP, MD · Tanya K Bubner BSocSc · Chris H Holton GDPH, GDAcc, BA(Acc) · Justin J Beilby MD, MPH

Objective: To evaluate whether a collaborative model of mental healthcare involving general practitioners and clinical psychologists benefits patients with common mental disorders in primary care.Design and participants: Cohort study of 276 general practice patients with mental health problems receiving collaborative treatment from clinical psychologists and GPs compared with a normative sample of 198 patients attending the same general practice surgeries.Setting: Nine general practices in three regional cities (Bathurst, Armidale and Ballarat) and two single-doctor practices in two rural and remote townships (Rylstone and Trundle). Data were collected in Bathurst, Rylstone and Trundle during 2001 and 2002 and in Ballarat and Armidale in 2002.Intervention: Full assessment, case formulation and “focussed psychological interventions” relevant to the patient’s condition.Main outcome measures: Level of psychological dysfunction assessed before and after the intervention, using the DASS (Depression, Anxiety and Stress Scales), GHQ (General Health Questionnaire) and GWBI (General Well Being Index) scales.Results: After the intervention, average scores in the treatment group decreased significantly (P < 0.001) on all DASS and GHQ measures and increased on the GWBI, indicating a positive change in the patients' mental health. The follow-up scores of the treatment and normative groups did not differ significantly on any of these measures.Conclusion: Preliminary findings suggest that collaborative care involving GPs and clinical psychologists provides significant gains in patients’ mental health.

Robyn F Vines MSc, FAPS · Don Thomson PhD, FAPS · Michelle Kluin BLMC · Louise Vesely · Jeffrey C Richards PhD, FAPS · Margaret Brechman-Toussaint PhD

Objective: To explore potential barriers to the optimal diagnosis and management of heart failure in primary care.Design and setting: Qualitative study involving semi-structured focus groups or telephone interviews with general practitioners, in three urban and one rural Division of General Practice with above-average elderly resident populations, conducted between 1 April and 31 July 2002.Participants: 31 self-selected GPs who responded to a general invitation and four GPs who were personally invited to participate in the study.Main outcome measures: Issues identified by GPs as barriers and GPs’ ratings of their importance.Results: GPs reported that most of the difficulties in accurately diagnosing heart failure were associated with masking of the disease by other conditions and the lack of specificity of the symptoms, particularly in the early stages. They felt that echocardiograms can be difficult to access, were of unclear benefit and may not be warranted in obvious cases. Concerns about possible side effects and reliance on other forms of therapy were common reasons for the suboptimal use of angiotensin-converting enzyme inhibitors. Underuse of β-blockers was associated mainly with concerns about side effects, contraindications and comorbidities, and a lack of experience with initiating therapy, particularly in community settings.Conclusions: This study identified specific barriers to GPs implementing evidence-based recommendations in managing heart failure. Tailored strategies that address the practical concerns of GPs about applying research evidence in the primary care setting and that facilitate better linkages between GPs and specialists are needed.

Susan M Phillips DPhil · Geoffrey H Tofler MB BS, MD · Richard L Marton PhD

At least a quarter of primary school children in Australia are overweight or obese; the long-term impacts are likely to include chronic morbidity and loss of life-years. Universal preventive strategies have so far had limited effectiveness, while secondary and tertiary referral services would be overwhelmed if they attempted to systematically manage a problem with such high prevalence. Primary care services could play an important role in secondary prevention of overweight and mild obesity in children. While reports of child obesity research have burgeoned since 1995, effectiveness trials of primary care interventions in primary-school-aged children have been neglected. Randomised controlled trials of a primary care approach, although challenging, are essential to determine whether it does more good than harm.

Melissa A Wake MD, FRACP · Zoë McCallum FRACP

James D Kidd Retired General Practitioner, The Medical Centre, 125 River Road, Emu Plains, NSW 2750. To the Editor: Although I am retired, I wish to make some comment on the controversy about the use of ciprofloxacin in the treatment of chronic suppurative otitis media.1 I still feel uneasy when there is mention of the topical use of an antibiotic that may be used either orally or parenterally. Many years ago, when I had a large practice, including paediatric patients, chronic suppurative otitis media was common, although most cases responded to the classical ear drops. However, some persisted and, not infrequently, a new patient would present with this problem. As mentioned, most were the result of a pseudomonas infection. Pseudomonas was then a common problem in chronic leg ulcer of the elderly, and I had found that treatment with Burrow’s solution (aluminium sulfate [2.25 g], acetic acid [33%], tartaric acid [0.45 g], calcium carbonate [1 g], purified water [7.5 mL]) was very successful and continued to be successful right up to my retirement, even in new cases which had been treated unsuccessfully with ciprofloxacin. Before the advent of ciprofloxacin, I used Burrow’s solution ear drops in many adult cases of chronic suppurative otitis media with great success. As the number of children with this problem grew, I attempted to get advice on the use and any toxicity of Burrow’s solution ear drops in children. I could not find anyone at the Children’s Hospital with any experience, but the consensus was that it was unlikely to be toxic. Although at first I had difficulty in getting the chemist to make up ear drops for adults, by this time there was little problem getting them made for children, and the results were dramatic. There were recurrences, but these responded as well as they did the first time they were treated. Advice on correct aural hygiene after swimming and bathing was important. Burrow’s solution kills pseudomonas. Am I too old fashioned?

James D Kidd

W Ian Cameron Chief Executive Officer, New South Wales Rural Doctors Network, Level 3, 133 King Street, Newcastle, NSW 2300. icameronAT.nswrdn.com.au To the Editor: Bourke is a small rural town in far northwest New South Wales with a population of about 3500. The Bourke Shire Council has recently published a fascinating small book entitled 100 lives of Bourke, which uses Bourke cemetery as a “window to the past”.1 Included in the 100 vignettes based on headstones in the cemetery is one for Dr George Faithfull, Bourke’s third doctor. Dr Faithfull was born in Calcutta, India. He started medical studies in Edinburgh, Scotland, but did not complete them. He travelled to Australia, arriving in Victoria, and worked his way north (Dr Don Faithfull, grandson of George, personal communication). By 1885, he was working as a chemist in Bourke.2 In view of his experience as a “medical man” and his previous medical studies, he later became registered as a medical practitioner under Clause 3 of Act 70, The Medical Practitioners Further Amendment Act of 1900, where it was stated that: It shall be lawful for the Medical Board or its Doctors to place upon a separate register the name of any person who has passed through a course of study as Medical Practitioner in NSW during five years before the passing of this Act. Dr Faithfull was a doctor in Bourke and Goodooga from 1900 to 1908. He must have been one of the very first doctors to have gained what is now termed in NSW “conditional registration in an area of need”. To have become conditionally registered while practising as a chemist in Bourke, he must also be an early example of rural-based distance learning — a cornerstone of our new regionalised general practice training. Dr George Faithfull and his wife, Mary Faithfull (née Whitfield). (Photo, Dr Don Faithfull.) It is sobering to think that the changes made over the last few years by medical boards, and the streamlining of processes outlined in MedicarePlus, had precursors over a hundred years ago. Doctors and their families were not exempt from the morbidity and mortality of the time. Three of Dr Faithfull’s 11 children died young and are buried in Bourke cemetery. Another Bourke doctor, Dr Sides, had three children die in infancy, and Dr Dey lost a six-month-old son. In 1901, a locum doctor died of heat stroke. More recently, in 1992, Bourke cemetery became the final resting place for another overseas-trained doctor, Professor Fred Hollows, who achieved international recognition for his work in ophthalmology in disadvantaged populations, particularly Indigenous Australians.

W Ian Cameron

Robert W Pegram,* Lisa Valenti† *Senior Lecturer, Department of General Practice, University of Adelaide, Adelaide, SA; †Senior Analyst, General Practice Statistics and Classification Unit, University of Sydney, Wentworthville, NSW. robert.pegramATadelaide.edu.au To the Editor: Young and Dobson’s article1 examining the bulk-billing status of services provided to women generated much debate.2,3 To add to that debate we undertook an analysis of 5546 Medicare-claimable general-practice encounters. Data were provided by 200 general practitioners between May and July 2002, using the BEACH (Bettering the Evaluation and Care of Health) methodology.4 We examined which encounter, GP and patient characteristics determine billing status (patient-billed or bulk-billed). From time and day of service we determined which consultations were “after hours”. Over two-thirds of services (69.8%; 95% CI, 65.4%–74.3%) were bulk-billed. One in fourteen services (7.1%; 95% CI, 2.2%–12.1%) were delivered “after hours” as defined by the Australian Government Department of Health and Ageing5 (ie, between 6 pm and 8 am on weekdays or between 1 pm Saturday and 8 am Monday on weekends). The results after simple and multiple logistic regression analysis are shown in the Box. After-hours consultations were significantly more likely to have been bulk-billed than those held during standard office hours (odds ratio [OR], 1.9). Patients aged < 15, 15–24 years and > 75 years were significantly more likely to be bulk-billed than working-age adults (P < 0.0001). Also significantly more likely to be bulk-billed were patients from non-English-speaking backgrounds (OR, 7.3), living in an urban area (OR, 2.6), holding a healthcare card (OR, 3.5) and/or coming from a low socioeconomic status background (OR, 2.3). There was no significant association between the likelihood of being bulk-billed and the age or sex of the GP, the practice size or the number of problems managed at the encounter. Interestingly, the variable with the largest impact on bulk-billing rates was whether patients were from a non-English-speaking background. These patients were over seven times more likely to be bulk-billed than patients from an English-speaking background. This study adds further support to the findings of Young and Dobson1 that patients in urban areas were significantly more likely to be bulk-billed for general practice consultations than their rural counterparts. We can go one step further and say that consultations given after hours were also significantly more likely to be bulk-billed. The conclusion is that bulk-billing decisions by GPs are not uniformly influenced by timing, location and patient characteristics. This has implications for assessing the likely impact of bulk-billing strategies such as MedicarePlus.6 Factors influencing the likelihood of bulk-billing in Australian general practice* Simple logistic regression analysis Multiple logistic regression analysis OR (95% CI) (n = 5546) Adjusted OR (95% CI) (n = 4793) Time of consultation “After hours” status (standard hours : after hours) 1.5 (0.9–2.5) 1.9 (1.1–3.3) Other variables Non-English-speaking background (no : yes) 8.8 (4.8–16.3) 7.3 (3.8–14.0) Aboriginal or Torres Strait Islander descent (no : yes) 2.0 (0.7–6.0) ns Patient new to practice (new : not new) 1.5 (1.0–2.2) ns Rural/urban place of residence (rural : urban) 2.2 (1.3–3.7) 2.6 (1.5–4.7) Having health care card (no : yes) 3.4 (2.4–5.0) 3.5 (2.3–5.2) Socioeconomic status† (higher SES : low SES) 3.2 (1.8–5.7) 2.3 (1.2–4.5) Practice size (5+ GPs : solo GP) 2.4 (1.0–5.8) ns (5+ GPs : 2–4 GPs) 1.4 (0.9–2.3) ns Patient age (years) (25–64 : < 15) 1.5 (1.1–2.0) 1.4 (1.0–1.9) (25–64: 15–24) 1.4 (1.2–1.8) 1.4 (1.1–1.9) (25–64 : 65–74) 1.8 (1.4–2.5) 1.2 (0.8–1.6) (25–64 : ≥ 75) 2.5 (1.7–3.8) 1.7 (1.1–3.8) Patient sex (female : male) 1.1 (0.9–1.3) ns GP age (years) (25–54 : ≥ 55) 1.6 (1.0–2.8) ns GP sex (female : male) 1.1 (0.7–1.8) ns Number of problems managed per encounter‡ 1.0 (0.9–1.2) ns GP = general practitioner. ns = not significant at 5% level. OR = odds ratio. * For each variable, the first-mentioned category is the reference. † Assessed by SEIFA (Socioeconomic Indexes for Areas) categories of the Australian Bureau of Statistics. ‡ The reference point for this variable is the number of problems managed (1, 2, 3 or 4), measured against whether the patient is bulk-billed. The OR here indicates that for each unit increase in problems managed the odds of the encounter being bulk-billed do not change.

Robert W Pegram · Lisa Valenti

Objective: To examine changes between 1991 and 2003 in the characteristics of active recognised general practitioners in Australia.Design: We compared self-reported GP characteristics from the 1990–91 Australian Morbidity and Treatment Survey (AMTS) with those from the 1999 and 2003 Bettering the Evaluation and Care of Health (BEACH) surveys, after standardisation for age and sex to the respective sample frames. AMTS and BEACH are cross-sectional, paper-based, national surveys.Participants: Three random samples of 473 (1990–91), 980 (1998–99) and 1008 (2002–03) GPs who had claimed at least 1500 A1 (ie, general practice) Medicare items in the preceding year (in the AMTS) or 375 general practice Medicare items in the preceding 3 months (in the BEACH surveys).Main outcome measures: Changes in distribution of GP sex, GP age, number of sessions per week, practice size and location, country of graduation, and postgraduate training.Results: Between 1991 and 2003, the proportion of female GPs rose from 19.3% to 35.2%; GPs aged < 35 years dropped from 22.3% to 10.0%, and those aged ≥ 55 years increased from 21.4% to 31.6%. Between 1999 and 2003, the proportion of male GPs working < 6 sessions/week increased from 6.1% to 11.4%, while the proportion working ≥ 11 sessions/week fell from 23.8% to 17.1%. Between 1991 and 2003, the proportion of solo practitioners nearly halved (25.5% v 13.7%); the proportion of GPs in practices of ≥ 4 partners increased from 34.3% to 59.8%; the proportion of Australian graduates fell from 81.4% to 72.2%; and the proportion of graduates from Asia and Africa increased. Over the same period, the proportion of GPs with Fellowship of the Royal Australian College of General Practitioners more than doubled (17.8% v 36.4%). All of these differences were statistically significant (P < 0.001).Conclusion: Changes in characteristics of the practising GP population will affect consultative services and the balance between supply and demand for these services. These changes should be considered in future workforce planning.

Janice Charles BA, MSc(Med) · Helena Britt BA, PhD · Lisa Valenti BEc

Objective: To evaluate whether rural consumer preferences for health services have changed over time or vary across communities with different models of health service delivery.Design: Questionnaire survey replicating a 1989 study, with ranking of seven different healthcare services.Participants and setting: Adult occupants from a 20% sample of private residences, in towns and on farms, in the rural shires of Bogan and Warren in north-west New South Wales. The survey was conducted in September 2002.Main outcome measures: Rank order of preferences for different healthcare services; preference structure intervals showing relative “distance” between preferences.Results: Response rates were 68% (Nyngan town), 78% (Nyngan farms) and 59% (Warren town). The doctor was the most valued health service in rural communities, followed by the hospital. These preferences occurred regardless of age, sex or place of residence, persisted over time, and were similar for residents of towns with different models of healthcare service provision.Conclusions: Rural people, both in towns and on farms, rate acute primary healthcare services provided by the doctor and hospital as the two most important services. These preferences have not changed substantially after a decade of restructuring rural health services and reorienting them towards a primary healthcare approach. The stability of rural consumer preferences may reflect a bias towards the status quo.

Karly B Smith BA(Hons) · John S Humphreys BA(Hons), PhD · Yuliya Lenard BEd · Judith A Jones BA(Hons), MSPD · Vanessa Prince B Public Health · Gil Soo Han MA(Soc), MA(Hons), PhD

When I (P J) explained to one of my younger colleagues that I was writing an article about recruitment and retention of doctors to the country, I finished by asking what made her come and stay here. “I want to work and still have a life” was her spontaneous answer — a response that encompasses most of what we have tried to achieve in this medical practice. Mannum Medical Centre In 1976, after working as an urban general practitioner for 5 years, I moved to Mannum, a delightful small town of about 3000 people, situated on the Murray River some 80 km due east of Adelaide. I formed a partnership with Dr Owen Crompton, who was of a similar age and background, and we worked together until 2000, when he decided to move to (literally) greener pastures in Victoria. Mannum has an annual rainfall of 10–11 inches in a good year and goes through a drought every 4–6 years — Owen despaired of ever being able to raise horses or cattle in such an environment. After some 3 years of unsuccessfully advertising for another doctor to join the practice, we realised that we would need to adopt a different approach if I was to be able to remain in practice in Mannum. The world had changed since I graduated from medicine in 1969. Medical graduates were no longer predominantly male, white and anglosaxon, with a wife and family willing to follow the doctor wherever life took him. Making some changesOver the next few years, we made some significant changes, and the practice now has six GPs, working various hours, up to two GP registrars at a time, and a thriving relationship with Flinders University. To summarise the main changes: We moved the surgery from a small house in the main street where it had been for 40 years to a converted area in the hospital. The operating theatre was no longer in use and could be converted into a more than adequate accident and emergency area. We then built on this to give us a total of five consulting rooms, two clinic nurse rooms, and new reception, office and waiting areas. The extra space allowed registrar training for the first time, as a way of exposing the practice to new graduates. In 2000, our first Registrar, Stephen Napoli (Box 1), returned to Mannum after moving around the state to experience work in other areas. We became (and remain) enthusiastically committed to being a high-quality training practice, encouraging both registrars and students to spend time with us. To that end, we were able to access a federal grant to have two residential units built close to the hospital grounds. We work enthusiastically with the Sturt–Fleurieu GP Education and Training and the Flinders University Medical School and have hosted a range of students to give them an insight into the pleasures of rural practice. Doctors are able to join the practice as associates, and are thus free to come and go, not financially bound to the practice. The practice offers maximum flexibility of working hours, which can be tailored to meet changing family and other commitments. We have a philosophy of mutual respect, that in our practice we are all equally valuable (even though I am ancient compared with the younger doctors) and we are a practice of equals. Our flexible workforceAs present, there are several qualified GPs here, besides Stephen and myself (Box 2). We are lucky to have three women in the practice. Kylie Booth was a registrar here, who left saying she would “come back if she had a room with a river view and if we could organise a youth clinic service for her”. Although Kylie is now married and her husband is committed to work in Adelaide, she works here 2 days a week, returning to a youth clinic in Adelaide on other days. Sonia Schutz trained as a registrar in a practice near here, went to work for further experience in Broken Hill with the Royal Flying Doctor Service, and moved back into the area to work with us. Besides working on their newly acquired farm, her husband, Terry, is employed here for 3 days a week as our office manager. The youngest doctor here is Rebecca George, who, after passing her FRACGP exams last year, has increased her working days from three to four. It was she who gave me the quote I have used to introduce this article. Brian Moore, the only doctor here who is older than me, has had vast experience in Alice Springs and, more recently, in the Adelaide Hills area. He helps with the registrar teaching and works Thursday, Friday and Saturday mornings, being a valuable part of our ability to offer 6-day-a-week consulting and 24-hour, 7-day-a-week medical services. We have had up to two registrars at times, plus doctors in their mentor time, which certainly increases the teaching load but is very enjoyable. At this stage, we have Ethan Tieu — another great registrar, enthusiastic, very competent and very keen to learn all he can of rural general practice I contrast our current situation with the 20-odd years when I was the only doctor offering obstetric services here, and so was on call all the time and juggling holidays around the times when no “mids” were due. At that time we had a saying that “if you needed to be seen you would be seen at some time through the day”, even if it was at 10 o’clock at night at the end of a full day’s consulting. This is now neither practical nor sensible, and is certainly not desirable for either patients or doctors. Why Mannum “works”We have developed a firm policy of trying to encourage other doctors to work with us, either full-time or part-time, in ways that are mutually supportive. Working with younger doctors is one of the joys of life, as the combination of questions, answers, learning, teaching, and sharing their enthusiasm for a balanced life has helped me to totally enjoy the past few years here. The practice has changed when the notice in the toilet now reads “How to practise your pelvic floor exercises”! I believe the future of rural practice depends on being totally involved at all levels of medical training (undergraduate students, postgraduate students, registrars, etc), advertising the good points of where you work and live, always looking for ways to change and improve, and being positive and flexible in supporting any doctor who comes your way. Overall, if new doctors feel supported and valued in the practice and have access to a full life out of surgery and on-call hours, then they are more likely to stay and encourage other doctors to come. Younger doctors give us the great example of wanting both to practise high-quality, satisfying medicine, and to enjoy that part of their life that is outside of medicine. 1 Working and staying in the country as a GP depends on a healthy balance between work and personal life Dr Stephen Napoli In 1999, I had my first taste of working in Mannum in my mentor time as a rural GP registrar and locum. I was married with two young children and must admit did not really enjoy my “introduction” to the town. I replaced one of the then two doctors for 2 weeks, and found the hours long, arduous and not conducive to family life. While working as a rural locum in various towns in South Australia, I quickly became aware of certain aspects of rural practice which reinforced my desire to work in the country. Establishing links with a community, developing relationships with patients, and the opportunity to maintain broad clinical skills was both rewarding and stimulating. But I also realised that in some practices it was difficult for a younger GP, with a young family and an approach to life that put family before work, to feel comfortable. Returning to work in Mannum as one of three and a half doctors was a more positive experience. Mannum also offered the opportunity to fulfil my strong desire to practise obstetrics. I was able to reduce hours when needed to complete my GP registrar exams, following the births of our children (now four). In addition, my wife was able to further her career interest in family therapy and rural mental health. Having a strong teaching and training focus involving both students and registrars has obviously brought vibrancy and a dynamic character to the practice, while keeping us up to date with current approaches to medicine. Good relationships with the reception staff and local hospital staff have aided in creating a harmonious and efficient working environment. Staying in Mannum has been very much affected by my particular family needs, but has also been based on a strong working relationship with Peter. I have felt a strong sense of mutual respect, allowing for a flexible approach to our working relationship as associates, while maintaining an equitable approach to our business relationship. Although we are happy in our current practice team, change is paramount in this modern era. Having a positive, proactive approach will, we hope, allow us to accommodate the changing needs of the future. 2 Why do some medical practices keep their registrars? The Mannum team: Left to right; Dr Brian Moore, Dr Peter Joyner, Dr Rebecca George, Dr Sonia Schutz, Dr Kylie Booth, Dr Stephen Napoli, Dr Ethan Tieu (Registrar). Dr Kylie Booth As a medical student at Flinders University, I was a member of the “rural club”, and visited a variety of country practices. When I applied and was accepted into the RACGP training program to start as a basic registrar in January 2001, Mannum was my second choice as a placement. My first choice was a town that I had worked in as a sixth-year medical student, during my rural GP term. I think that practice familiarity is a very important thing for registrars — past students will often return. In 2001, the college gave most applicants their second choices, so I started my basic term as a GP registrar at Mannum. For a registrar, Mannum has a few practical advantages. The town is only 1.5 hours’ drive from Adelaide, and is a popular tourist destination for water skiing. There is a strong community feel to the town. The community respects the medical practice, which, in turn, provides 24-hour emergency care in addition to daily general practice clinics. The Mannum Medical Clinic initially provided me with appropriate orientation to the practice. The reception staff welcomed me and soon adapted my bookings to my growing abilities. I loved the fact that the practice principals had previously decided that “full time” is 4 days a week, as we all work one night and one weekend in three on call. I did not feel — as some registrars do — that I was a “process worker”, just there to bring money into the practice. I have always felt part of a team. The doctors, whether associates or registrars, all share the same vision and are highly supportive of each other. The supervision and support I have received is ultimately the reason I have stayed. The practice as a whole was particularly supportive during the FRACGP examination period. Peter’s diplomatic optimism, even in difficult situations, is a skill I wish all GP supervisors could develop. Rosters, contracts and salary are all important issues for registrars, and I believe that all of these were fair, and negotiated with the registrar’s interest in mind. To all the staff at Mannum Medical Clinic, I say, “Thank you — and congratulations for being such a great place to work”. They have found the right balance.

Peter Joyner MB BS, FACRRM, DRCOG(Obst) · Stephen Napoli MB BS, FRACGP, DRCOG(Obst) · Kylie Booth BMBS, FRACGP

We need evidence that can underpin fundamental change General practice and the rest of the primary care team, rather than specialist or hospital care, deliver the lion’s share (90%) of healthcare.1 They also provide the anticipatory care necessary for early and better management of the chronic diseases that characterise modern industrial societies. A strong, self-reliant primary care workforce increases quality as well as cost-effectiveness.2 Thus, the way a country remunerates its primary care workforce is vital. This is a good time to debate the options in Australia — a federal election year in which healthcare is likely to be a central issue. Changes to the administrative system can have enormous implications for primary care. So far, planned changes in Australia have been tentative, consisting of “add-on” improvements such as payments to general practitioners (GPs) in addition to the traditional fee-for-service arrangements. These include Practice Incentive Payments (PIPs), which pay GPs who can demonstrate using set protocols for managing some chronic diseases (eg, asthma, diabetes), and Service Incentive Payments (SIPs), which are specific payments for certain services such as mental health care and vaccination. The complexity of administering these programs has prompted complaints from GPs, and in response a Red Tape Task Force has been convened.3 Healthcare systems differ hugely from country to country, as we see from the articles that follow. Reimbursement is perhaps its most emotionally highly charged aspect and, however contentious an issue, some system has to be chosen. Strong primary-healthcare-led systems like those in the United Kingdom4 (page 109) and The Netherlands5 (page 110) use capitation systems as the basis of paying GPs: they contract to assume the obligation to provide care for a group of patients, and their financial rewards are independent of the actual service and care delivered. In the former Yugoslavia, with its socialist origins, remuneration took the form of a salary, accompanied by planning (and restriction in the number) of GPs. A more market-driven way of paying GPs is for GPs to “deliver” before payment (fee-for-service), and in competition with each other, as in Australia and the United States (page 113).6 Canada (page 111) has opted for a combination of methods,7 and New Zealand (page 106) is experimenting with a variety of interesting models in quick succession.8 Fee-for-serviceFinancial incentives have a direct influence on GPs’ behaviour. For example, in Belgium, 46% of GP–patient encounters are home visits,9 whereas in The Netherlands this is only a small proportion of GPs’ clinical activities. The population health status and infrastructures of the two countries hardly differ, so the difference can only be explained by incentives: under Belgian fee-for-service, a home visit is chargeable. It also strengthens patient satisfaction with the GP in a competitive environment. On the other hand, the Dutch GP receives a capitation fee irrespective of whether the patient is seen at home or at the practice (or not at all). One problem with fee-for-service payment is that the way GPs are funded is confounded by other innovations that Australia should be considering, such as patient registration. Although theoretically this could be separated from how doctors are paid (capitation, for example), nowhere does this occur. A second problem is that fee-for-service can be inflexible about who is remunerated. This has held back the proper utilisation of nursing in general practice in Australia simply because nearly all services in general practice are ineligible for a Medicare rebate if provided by nurses, even though for many services (eg, preventive10 or protocol-driven chronic care11) nurses may be better suited. A third problem is the need for a business mind with fee-for-service general practice. Many doctors want to practise unencumbered by a “small shopkeeper” role. One consequence was the evolution in the 1980s of “entrepreneurial practices” (those whose owners were more interested in making a profit than serving their communities). These offered greater flexibility for the increasing numbers of doctors who, wanting “just to practise medicine” and happy to abdicate their commercial role, flocked there. “Perverse incentives” reward some clinical activities better than more valuable ones.12 For example, a GP who delivers many short consultations will earn more than one who has fewer and longer consultations — even though longer consultations are associated with better attention to preventive healthcare and psychosocial problems.13 Attempts to address this by providing less reliance on fee-for-service (to the fury of the Australian Medical Association)14 with additional alternative payment systems (so-called blended payments) such as PIPs and SIPs — funded by what might have otherwise gone to increased fees — are probably only partly successful. It is too early to tell if the complexity of administering them is any better than the fee restrictions that arose to discourage entrepreneurial practices. Do we need more fundamental reforms of the GP system? What are the alternatives? CapitationCapitation payment and its associated patient registration (the “list”) feels like clinical freedom for many GPs in the UK and The Netherlands: the GP accepts an obligation to provide care for the patients on the list and do what is in their best interests. It has offered GPs a level platform to counter medicalisation, overdiagnosis, over-referral and spurious prescribing, without the tilt of having to please the patient (something usually miscalculated in any case15). But there are disadvantages. A capitation system can be a haven for laziness, because payment comes irrespective of the quantity (let alone the quality) of care. GP-initiated activities — like anticipatory (chronic disease management) and preventive care — are particularly sensitive to this. Perhaps this is the basis for the reforms currently under way in the UK NHS.16 Disciplinary hearings against GPs in the UK and The Netherlands are, to a large degree, occupied with GP failure to provide enough care — in particular, failure to visit patients in a (perceived) emergency at home. In Australia, the focus of disciplinary hearings is on overservicing. The issue for capitation systems is deciding what is enough care; for fee-for-service, deciding what is too much. The solutionBlended payments (a mixture of fee-for-service and payments for good practice) sound sensible (the best of both worlds), but there is little evidence17 to reassure us we might not get the worst of both: entrepreneurial GPs learning which mix of activities yields the highest earnings, and government reacting by over-regulating the system to avoid this. GPs are at the forefront of evidence-based patient care. It would be good if GPs’ financing systems were established by good evidence, but little exists regarding the effects on service of different payment systems (Box). Thus, we need to trial different systems, not simply enact the latest political ideology. The current flux in the Australian healthcare system is surely an ideal environment for such experiments. Possible alternatives would be payment systems that allow for patient registration, that include the option of salaries for doctors uninterested in running a business, and that encourage doctors to collect and analyse clinical data about the services they provide. There is no doubt that such trials would be hard to conduct politically,17 and perhaps randomised controlled trials would have to give way to the pragmatics of quasi-experiments. But we need changes to the system that are fundamental, rather than the lean-to sheds propping Australia’s current archaic system. The evidence base for different primary care payment systems The best evidence comes from a Cochrane review.18 This is in need of update (last search date was 1997). The review compared four payment systems (fee-for-service, salary, capitation, and mixed), and accepted studies that were randomised controlled trials (RCTs) or controlled before–after (CBA) studies if there were at least two measurements before and two after the intervention (nine studies were excluded for failing this test). Two RCTs (total of 98 doctors) and two CBAs (216 doctors) were included: all had potential biases in their methods. Compared with capitation, fee-for-service was associated with more services, tests and referrals to specialists, but fewer referrals to hospital. Compared with salaried payment, fee-for-service was associated with more services and more continuity of care, but less patient satisfaction with access to care. A more recent narrative review (conducted at an international conference on the subject) reached the same conclusions.19

Chris Van Weel PhD, FRCGP · Chris B Del Mar MD, FRACGP

Objective: To examine relations between consultation length and content, and general practitioner choice of claiming level B or C when billing consultations > 20 minutes through Medicare.Design and setting: A secondary analysis from a cross-sectional national general practice survey (1 April 2000 to 31 March 2003) of 101 112 consultations with 2811 GPs, comparing level B consultations ≤ 20 minutes with consultations > 20 minutes (claimed as level B or C), and consultations > 20 minutes claimed as level C with those claimed as level B.Main outcome measures: Consultation length, encounter, patient characteristics; number, type of problems managed; type and frequency of treatments provided in relation to consultation level charged.Results: There were 80 476 level B consultations ≤ 20 minutes and 14 893 > 20 minutes claimed as level B or C (5725 [38.4%] level B; 9168 [61.5%] level C). Longer level B+C consultations differed from shorter level B consultations in patient sex, Department of Veterans’ Affairs card status, and new-patient status, and involved more reasons for encounter, problems managed, chronic problems, clinical treatments, therapeutic procedures, referrals and pathology and imaging orders. Longer consultations claimed as level C were significantly longer (0.9 minutes) than those claimed as level B and involved more reasons for encounter, problems managed (particularly new, chronic, psychosocial and gynaecological) and more clinical treatments.Conclusions: Patient characteristics and consultation content differ at longer consultations. Consultations charged as level C are more complex than those charged as level B. GPs use both time and content when choosing item number, rather than relying only on specified time thresholds. This has implications for future restructuring of MBS attendance items.

Helena Britt BA, PhD · Lisa Valenti BEc · Graeme C Miller MB BS, PhD, FRACGP · Jillann Farmer MB BS, FRACGP, GradCertAppLaw

How general practice is funded in New Zealand depends upon an answer to the question “This week or next?”! General practice, and primary healthcare generally, is currently undergoing a revolution greater than anything since the early 1940s, when government funding of general practitioners was introduced. GPs then successfully argued for the “sacred” right to charge a fee commensurate with their services, making them unique compared with similar countries, including Australia. Substantial patient copayments resulted, rising at times to more than 80% of practice income. In the early 1990s, the government introduced a “community services card” (CSC) for people on below-average incomes. Currently, the threshold for this is NZ$21 913 for a single person and NZ$31 225 for a married couple, and rises with number of children. The CSC entitles holders to higher subsidies, including for prescriptions, but the quid pro quo was the removal of all government subsidies for adults on above-average incomes, including the elderly. However, the government proportion of GP funding remained low, averaging about 30% of practice income.1 With this underfunding, many GPs became Robin Hoods, charging minimal or no fees to patients who could not afford to pay, with some compensation from their well-off patients. Many (understandably) located themselves in more affluent areas.1 Hence, central Aucklanders have 800–900 population per GP, whereas more disadvantaged populations have almost twice as many people per GP.2 Of course, the Robin Hood system did not work for practices serving predominantly poorer and disadvantaged (including rural, Mäori and Pacific Islander) populations. Radical organisational reforms in 19933,4 encouraged GP leaders to voluntarily form independent practitioner associations. Similar to Australian Divisions of General Practice, these primary care organisations (PCOs) rapidly expanded to include 85% of GPs by the end of the 1990s. PCOs took on the financial management of pharmaceutical and pathology services to improve quality use.1,3-5 Savings from this were used to promote other services, such as vaccination, smoking-cessation programs, chronic disease management and terminal-care services. They were also used to remunerate GPs and associated services (eg, free nursing and radiology services for community-based alternatives to hospital admission). This was never called fundholding, the term for a scheme implemented, then abandoned, in the United Kingdom. The real revolution began in 2000, with the New Zealand Public Health and Disability Act. This established 21 decentralised and population-based district health boards (DHBs) providing public hospital services and managing government funding of all health and disability services, including primary healthcare. In 2001, a new government primary healthcare strategy launched the evolution of PCOs into broader primary health organisations (PHOs).6 These are needs funded and serve defined populations enrolled in member GP practices. They provide population healthcare as well as treatment services, involve communities in their governance, and are multidisciplinary. GP membership is voluntary. This strategy is supported by the New Zealand Medical Association and the Royal New Zealand College of General Practitioners, but there is ongoing criticism over the implementation process. Two forms of PHOs have been established, the first (Access PHOs) serving disadvantaged populations. The remainder are called Interim PHOs, in the expectation that Access funding will eventually apply to all PHOs. An alternative strategy, Care Plus, is being launched to fund the needs of individual high users. The different levels of funding are shown in Box 1. Disadvantages of the current systemThe additional funding still covers less than half of the cost of running a general practice. More has been promised after 2005 by the Health Minister, “subject to the availability of funding”. A particular issue is the inequity between the two forms of PHOs, with funding being based upon the level of disadvantage of the enrolled population rather than individual need. Hence, poorer patients in Interim PHOs remain disadvantaged. The Care Plus strategy is an attempt to rectify this. From late 2004, PHOs will be required to manage equitably funded budgets for pharmaceutical and pathology services, commonly called “referred services”,7 in a more formal process than PCOs used. There is clear evidence of serious inequities in current referred-services expenditure.2 This will mean significant shifts of expenditure from practices, PHOs and DHBs serving well-off populations to those below equity, but the funding distribution may be vital to improving the health of the disadvantaged. Relevance to AustraliaIs this relevant to the future of Australian general practice? Almost certainly, given the recommendations of the 2003 Review of Divisions.8 A comparison of primary care in both countries (Box 2) suggests that New Zealand is some 10 years ahead,9 with a more integrated and influential primary healthcare service. Although the organisational upheavals and additional paperwork have been traumatic for many GPs, the prospects of improved care and better outcomes for patients and communities, while yet to be proven, appear to be good. 1 General practice funding in New Zealand, by type of organisation to which GPs belong Non-PHO organisation and individual GPs Access PHOs serving high-need patients Interim PHOs serving other populations Current and expected GP membership 20%–25%, diminishing rapidly 20%–25%, increasing 50%–55%, increasing Current government subsidy for GP (includes practice nurse at $1.70 per consultation) Fee-for-service claims $0–$35 Capitation payments for enrolled population Average $13 per consultation Average $24 per consultation Average $15 per consultation ACC subsidy per consultation* $2.00 $2.00 $2.00 Patient copayment† $0–$45 $0–$20 $0–$45, and reducing Special funding groups Extra funding for low-income and high-need patients Aged under 6 years, $35 per consultation; aged 6–17 years and high users, and (from 1 July) aged over 65 years, $26 per consultation Expected subsidy trends over next few years Expected to diminish to insignificance over next year All to be based on Access formula To become equivalent to Access PHOs over time ACC = Accident Compensation Corporation. PHO = primary health organisation. * ACC funding for treatment of injuries is paid as fee for service, averaging $2 per consultation, or $30 for all consultations. † Patient copayment is paid as fee for service. 2 Features of New Zealand primary health organisations contrasted with Australian Divisions of General Practice Feature Australia New Zealand Organisation Divisions of General Practice Variable, but primary care organisations forming into PHOs Roles Largely GP focused Broad primary health/population focus, multidisciplinary, strong community participation Membership of organisation Based on geographic location Chosen by practice from local options Health services funding Fragmented between federal and state levels Fully integrated through district health boards Government payment/subsidy for services Open-ended fee for service. AMA strongly opposes capitation Rapid progress towards universal capitation Patient copayment Small but increasing Large but decreasing Organisational accountability for primary-care-related expenditure (eg pharmaceuticals) No direct financial accountability and resisted by AMA Well accepted. Expenditure to be in PHO budgets Ability to shift resources (including savings) from low- to high-priority services Nil. No referred-services budgets and hence no incentives or ability to make savings Substantial. Expected to increase with global budgets for PHOs Models of service integration, including primary/secondary Limited to selected high-risk diseases and local initiatives Wide-ranging developments (eg, community alternatives to acute hospital admission) Relative power balance between primary and secondary care Hospitals in a much stronger position than primary care Improving balance through government policy and DHB and PHO collaboration Quality improvements in primary care Largely “top down” and through local initiatives Major improvements driven by clinical leadership AMA = Australian Medical Association. DHB = District health board. PHO = Primary health organisation.

Laurence A Malcolm MD, FRCPE, FFPHM

The National Health Service (NHS) has undergone fundamental reform since 1948, but the fabric of UK general practice remains more or less intact. Fundholding was probably the most significant change in financial arrangements (Box). Essentially, this was an experiment for the NHS to contain costs, stimulate competition and bring resource allocation decisions closer to the patient — fundholding general practitioners assumed significant roles in local healthcare economies. Nevertheless, there was much debate over whether it was equitable. Many saw it as a basis for partnerships with the private sector and fragmentation of the healthcare service.1 Others showed that it reduced non-emergency medical admissions.2 Fundholding grew from the Thatcher government’s strongly held belief that markets are the best way to achieve efficiency in healthcare. At the same time, fundholding established general practice as the cornerstone of the NHS.3 Further, it brought a questioning of the “status quo” in the NHS, and the prospect of higher standards of care. These expectations remain in the eyes of the public, government and the profession. Reforms aside, under “standard” contracts, UK general practitioners have been rewarded for increasing patient list size, and for providing specific services to achieve target payments. Unlike in Australia, there is no incentive to overservice, but an incentive to limit the availability of appointments, and pressure to keep appointment times to a minimum. Interestingly, salaried GPs in the personal medical services pilots (Box) have similar productivity without affecting other GP behaviours or quality of care.4 The new contractThe new GP contract, operative from April 2004, brings more funding, fundamental structural change, greater regulation and performance monitoring. There are concerns that many of the quality targets (eg, the incentive to diagnose, investigate and treat hypertension) have not been adequately costed.5 Further, this new environment has a strong emphasis on performance management and holding doctors to account. Some people see this as an erosion of public trust in the medical profession, which could undermine doctor–patient relationships; others see it as an essential mechanism of delivering proven, cost-effective care. For patients, NHS general practice is well integrated with the wider health service, and gives access to a multidisciplinary primary care team, including health visitors and practice nurses. On the downside, a non-competitive system means there are not the same incentives to attract patients as exist in Australia’s fee-for-service environment, and there is a culture of demand management, which often takes precedence over making services attractive and convenient to patients. In many ways, the NHS places GPs at the centre of the healthcare service and gives one a sense of being part of a team, with less of the fragmentation and isolation that often exists in Australian general practice. Whether the new GP contract will improve experiences and outcomes for patients, at a cost the NHS can afford, remains to be seen. On the downside, many GPs believe the wider healthcare service has not been able to accommodate the needs of patients in recent years; this may, despite the best efforts of individual primary care teams, lead to a demoralised workforce. Towards the end of New Labour’s second term, the NHS is being pulled in several directions — involving performance management, quality payments, new contracts, and greater engagement with the private sector, including American managed care organisations. The competition and “constructive dissonance” of these changes is very reminiscent of the Thatcher reforms. How general practice will fare in this turbulent environment is unpredictable, but no doubt being a GP or a patient in the NHS will be a very different experience in 2010. How it works Most UK general practitioners are independent contractors with the National Health Service. They own their own premises, hire their own staff, and supply general medical services. Remuneration is based mainly on capitation (ie, a payment dependent upon list size), supplemented by fees for certain specific services (eg, maternity care) and for achieving certain “target” levels of service (a complex system, although it only involves childhood vaccination and cervical cytology). Payments are also made for seniority and postgraduate education activities. Alternatives: the NHS (Primary Care) Act of 1997 allowed GPs to provide “personal medical services” (PMS) on a salaried basis through local service contracts that are designed to meet the particular needs of the locality. More than 35% of GPs are now salaried. Fundholding was a system of general practice purchasing services from secondary care. It operated between 1991 and 1999. Fundholding practices were given greater autonomy over aspects of practice expenditure such as drugs, diagnostic testing and staffing (within defined budgets), and could “shop around” for the best deal on procedures such as hip replacement. A further initiative, “total purchasing”, allowed practices to purchase a wider range of services from both primary and secondary care — for example, community nursing. Primary care trusts were established in 1997 (they began as primary care groups; in England, these became trusts in 2002, but have taken different forms in Scotland, Wales and Northern Ireland). Individual practices were replaced as purchasers by regional organisations, which could assess and plan for local needs. A new GP contract took effect in April 2004, with GP payments more closely linked to “quality targets” for both clinical and organisational activity. This has been coupled with increased funding and structural change — for example, GPs are no longer obliged to provide out-of-hours services, and the contract is with whole practices rather than individual GPs.

David P Weller FRACGP, MPH, PhD · Alan Maynard DSc, FAMS, MFPHM

The strength of Dutch healthcare is that the general practitioner’s role is enshrined in the primary care structure and the personal listing of patients (Box).1,2 Primary care is delivered through a personal working relationship with the patient over time and the payment system reinforces this to some extent. Capitation fee payment encourages delivery of care that is tailored to individual needs, rewarding powerful primary care strategies such as “watchful waiting” and the follow-up of the natural course of signs and symptoms.3 It takes considerations of financial reward out of the consultation. The profession of general practice considers the capitation fee payment as the prevailing frame of reference on which professional standards of care are based. Healthcare policymakers’ attempts to change capitation payment are usually resisted by the profession. Although private insurance and fee-for-service might theoretically invoke different professional behaviour, in practice there are few differences in the care received by privately insured patients and that received by those who are Sickfund-insured. In general, GPs do not like fee-for-service payment, because it does not acknowledge strategies such as “masterly inactivity”.3 Over the years, Dutch GPs have been jealously protecting capitation payment and tried to exclude any financial biases that might affect their performance. Allowances in the actual money received have been made for the number of elderly and migrants on the practice list, compensating for the extra burden of illness and GP care needed. This has maintained relatively equal status among Dutch practices and helped to strengthen the corporate identity of GPs. The most recent proposal by the Minister of Health to change healthcare financing aims to introduce a form of patient copayment for healthcare received, at 25% of GP costs for consultations, and more for secondary care. The objective is to encourage patients to take more responsibility for their own health and consult less often. This proposal is still in its early stage of political decision making, and it remains to be seen if it will be introduced. If it is, it will be interesting to see whether this financial approach rewards valued primary care approaches such as watchful waiting. An alternative form of payment that has developed in recent years is GPs in the salaried service of colleague GPs. Although there has been a long tradition of locum services by young GPs before selecting a practice of their own, more GPs now seem to prefer salaried employment. This indicates dissatisfaction with the combined role of both practitioner and practice manager. As a consequence, practice has to be reorganised to make it more attractive for younger GPs, and salaried employment may become more prominent. Disadvantages of the systemThe trend towards salaried GPs highlights an obvious disadvantage of capitation fee payment, which covers practice costs and GPs’ income at the same time, without conditions attached. For example, the fee covers a full-time-equivalent practice assistant for a standard practice, irrespective of actual hours of employment. Thus, general practice was poorly prepared for the rapid increase in female GPs, who prefer part-time, salaried positions to full-time, private contractor status. The need for general practice to accommodate this change, together with the additional resources needed to train more part-time GPs, is one of the factors leading to increased GP costs. Another disadvantage is that new developments in medicine have to be included in the package covered by the capitation fee. As a consequence, there are few (financial) incentives for GPs and practices to innovate their care. This has particularly affected proactive aspects of care such as illness prevention and high risk screening, and investment in practice support (such as practice assistants and nurses; providing technical equipment). The package of care that the capitation fee should cover is critical. This should be based on the effectiveness of diagnostic and therapeutic interventions. In reality, the package has to flow with the political and economic tides. For a long time, the level of the capitation fee was fixed, irrespective of the patient’s health status. In recent years, the fee has been increased for certain groups (eg, the elderly), becoming an indirect incentive to provide more proactive services (such as preventive home visits) for these groups. However, this is as far as the system has come in enhancing the capitation principle with financial stimuli. ConclusionGiven the lack of financial incentives, it is surprising how strong general practice care is. For a long time, hospital specialists were paid on an item-for-service basis, in conjunction with GPs’ capitation fee. Yet, although this payment system did reward the transfer of patients to secondary care, rates of GP prescribing and referral in The Netherlands were among the lowest internationally.1,4 Furthermore, more than 80% of Dutch practices are computerised in the absence of direct financial support.5 This may indicate that the payment system is not the sole determinant of GP performance, and that corporate identity and healthcare structure may also play a vital role. How it works General practitioner payment is based on a two-tiered system depending on patients’ income: Capitation fee for Sickfund-insured patients (70% lowest income; in 2004, up to €32 600/year for people younger than 65 years. As the insurance includes the period after retirement (“pensioners”), the cut-off income for people 65 years and older is €20 750/year. Fee-for-service payment by the 30% highest-income privately insured patients, who do not contribute to the Sickfund. Capitation fee is the payment a GP receives from the Sickfund for each patient on the practice list, regardless of whether the patient decides to consult the GP. Sickfunds pay the capitation fee out of the insurance contribution received from their insured members. This fee fully covers all GP services for that patient, including the GP’s income and a proportionate contribution for practice costs. The capitation fee is extended to family members who do not generate income of their own. Employee and employer pay 8% of the income for Sickfund contribution (1.25% by the employee, 6.75% by the employer). There is no direct government involvement. Key to access to general practice care is registration of the patient with the GP or practice, establishing continuity of care over time. For Sickfund-insured patients, registration is obligatory for access to care. For privately insured patients, registration is usually not required, but most patients do list with a practice and obtain care from the same GP or practice over time. Through registration with a GP, primary care remains the foundation of healthcare: patients receive their basic medical care through the GP and the primary care team, and specialist care is only available through referral by the GP.

Chris Van Weel PhD, FRCGP

Family physicians (FPs) in Canada undergo specialised training, often in a Family Medicine Residency, and complete the College of Family Physicians of Canada (CFPC) national certification examination. Their payment is negotiated and administered separately by the 10 provincial governments and three territorial governments, using different funding arrangements in different settings. Under the Canada Health Act, provinces will be financially penalised if they permit private billing by physicians or copayments by provincially insured patients other than for certain services funded by third parties, such as insurance medical examinations, reports and travel services. In 2001, FPs reported practising in private offices/clinics (73.1%), community health centres (7.1%), emergency departments (6.7%), hospital in-patient units (3.3%), walk-in clinics (3.1%), and family medicine teaching units (2.5%).1 National surveys confirm that fee-for-service continues to be the main form of remuneration for physician services (Box), with little apparent change between 1997 and 2001.1 The drive towards alternative payment methodsUnder the current healthcare system, 12% of Canadians (with considerable geographical variation) report having unmet healthcare needs.2 Millions do not have access to an FP, and emergency department waiting times are long. FPs have identified high levels of dissatisfaction with current workloads and working conditions.1 Governments appear to believe that alternative funding arrangements will address these problems and are the key to involving FPs in primary healthcare reforms.2,3 Alternative payment approaches combine fee-for-service, capitation (lump sum payment per patient managed over a given period), salary, sessional and other funding arrangements.4 Other, less common funding arrangements include block funding and service agreements. In block funding, annual budgets are negotiated for a group of physicians, usually associated with an academic medical centre. Service agreements are often used to recruit and retain physicians in rural areas and take the form of: funding to regional boards for clinical services under arrangements by which boards have discretion regarding specific uses of the funds; contractual payments; and payment arrangements that incorporate both alternative remuneration and fee-for-service. Both the Canadian Medical Association and the CFPC advocate that all FPs should be able to choose the practice model that best meets their patients’, their co-workers’ and their own needs.5 In Canada’s largest province, Ontario, both the Ontario College of Family Physicians and the Ontario Medical Association (OMA) support FPs working in practice networks (Family Health Networks) funded through a blended payment model (which combines different methods), but recommend physicians have a choice. The remuneration model for Family Health Networks (FHN) preferred by the Ontario Ministry of Health is based on: a capitated rate for all registered patients; fee-for-service payments at a rate of 10% of the provincial schedule for most services; bonuses for targeted preventive care (theoretically up to C$8800/FP); payment for taking new patients; continuing medical education allowances; practice management fees; and some access to nurse practitioners paid by the government. This model encompasses on-call arrangements 24 hours a day, 7 days a week, and evening and weekend clinic access. Working in such networks with blended capitation payment is thought to provide incentives for promoting preventive healthcare and chronic disease management, and to improve professional satisfaction.1 However, uptake of the FHN model has been slow, prompting the Ontario government, in conjunction with the OMA, to introduce a simpler model, the Family Health Group. This model, based on virtual patient populations (either from the ministry health insurance database or patient registration), is paid on a fee-for-service model, with requirements to provide on-call arrangements 24 hours a day, 7 days a week, and after-hours clinic access. The Primary Health Care Transition Fund3 policy to shift physicians to a blended capitation model aims to improve access to care, quality, integration, health outcomes and cost-effectiveness. There is a strong desire that the most appropriate (least expensive) person deliver the service to the patient, invoking passionate debate about whether this means substituting for or supplementing FPs. The current policy position is that a collaboration of FPs with nurse practitioners, pharmacists and other professionals is more feasible with blended and capitation models than with the current fee-for-service arrangements. However, it is yet to be seen if blended payments and new models, with their additional administrative burdens on the FP and the practice, will add costs to the healthcare payer or improve health outcomes. Remuneration* among Canadian family physicians, 20011 Physicians receiving remuneration type† Mean (SD) proportion of total income accounted for by remuneration type Fee-for-service 23 070 (90.8%) 85.4% (24.9) Salary 3 775 (15.0%) 50.5% (37.4) Sessional 8 171 (32.5%) 35.0% (33.7) Capitation 469 (1.9%) 69.9% (31.0) Other 4 567 (18.2%) 14.1% (20.9) * Remuneration for clinical services other than on-call services. Based on a census survey of Canadian family doctors (n = 13 088) weighted to estimate the total population of Canadian family doctors. † The combined percentage may exceed 100% as some respondents checked off more than one answer.

Carmel M Martin PhD, MSc, FRACGP · William E Hogg MD, MClSc, FCFP

Underperformance of the healthcare system at great expense is the situation in the United States. The results are great inequity, problems with access, missed opportunities for prevention, fragmented rather than integrated care, relatively poor chronic disease care, and high expenses without commensurate improvements in health as compared with what would be expected from a well-functioning primary care system.1 Indeed, “. . . the need to manage escalating health care costs while maintaining reasonable access to care is becoming the salient challenge in US health care policy”.2 The diversity of healthcare arrangements in the US precludes a single, reliable answer as to how family physicians are paid. However, using national reports,3 including surveys done by the American Academy of Family Physicians,4 a generally accurate idea of “how it works” in the United States can be derived (Box). It is stunning how much is spent to accomplish occasionally spectacular results for some, but overall so little, for so few. Family physicians are not satisfied with the results of current payment arrangements in the US, as they undervalue family medicine and primary care in general; too often family physicians are unable to provide the care they think their patients need.5 Through research and deliberations by their national organisations, family physicians have concluded that, without significant changes in both the way they practise and the way family medicine is financed, family medicine in the US will probably become untenable in 10–20 years.6 In aggregate, the current payment systems are believed to contribute to a deterioration of primary care, with market forces rewarding commodity production and use of technology, while punishing sustaining relationships, listening to people, and sorting out and responding to troubles that may or may not be amenable to technological medical care. The solutionsFee-for-service payments alone are not sufficient, as this approach rewards doing more, not necessarily doing best. Capitation is no panacea, because it is subject to rewarding underservicing and may deter care for the sickest patients unless payments are adjusted for greater need. Paying for performance (outcomes) is intuitively attractive, but subject to factors well beyond the control of individual clinicians, or even, in many instances, an entire practice. A system of payment that blends these different approaches to capture their respective strengths while minimising their weaknesses is conceptually attractive, but difficult to define and implement. Such a blended system would presumably be based on capitation adjusted for population characteristics, additional premium payments based on services provided, and incentives based on achieving particular policy objectives.6 Currently, in the US, calls for a new model of family medicine, with a robust “basket” of services and the intelligence and performance attainable through information technology, have created an urgent sense that payment reform is necessary. A classic “chicken-and-egg” problem exists — the new model is not feasible until there is payment reform, and payment reform is not realistic without demonstrated improvements inherent in the fully implemented new model. Fortunately, both public and private payers recognise that steps need to be taken to assure entry to timely healthcare, health promotion, disease prevention, and care of chronic conditions.7-13 As a spokesperson for the US Medicare program (which provides health insurance for people aged 65 and older) noted at a recent policy forum in Washington, DC: “With very little friction, we will probably approve expenditures in the billions of dollars for biventricular pacing, yet we still don’t know how to pay for someone to have their own doctor.”14 A task force chartered by the Future of Family Medicine collaborative project is now at work, estimating the full cost of the proposed new model of family medicine and the amount and sources of revenues necessary to cover its cost and leave a margin sufficient to pay family physicians fairly and competitively. As concluded at the Keystone III Conference in 2000, family medicine in the US needs to spend less time justifying itself and more time acquiring the practical means to achieve its objectives.15 Indeed, another time to revise family medicine in the US is at hand — this begs for reform in how family physicians are paid. How it works (or not!) * Based on 35 965 respondents to American Academy of Family Physicians Survey.4 † Medicare is a federally funded national insurance program for people ≥ 65 years. ‡ Medicaid is a state-based insurance program (with federal and state funding) for people on low incomes. § Based on 32 321 respondents to American Academy of Family Physicians Survey.4

Larry A Green MD

H Stuart Patterson’s life was one of extraordinary achievement. He had a distinguished record of service to medicine, in war and peacetime, and to the community. Stuart was born on 17 September 1911 in Aramac, central western Queensland, where his father was the Medical Superintendent. He was educated at Ipswich Grammar School, where he described his academic achievements as “pretty undistinguished”. He did, however, excel at sport, playing cricket in the First Eleven and representing the school in tennis. Stuart began his medical studies at the University of Sydney in 1931, but in 1933 went to Scotland and enrolled at the University of Edinburgh, where he graduated in 1937. He also captained the Edinburgh University cricket First Eleven. He completed an internship at the Edinburgh Royal Infirmary and the Hospital for Sick Children. On his return to Australia just before the outbreak of World War II, he worked for a short period at the Brisbane General Hospital. Then, in 1940, he joined his father in general practice in Ipswich, where he remained for 35 years (apart from a period of war service as a Captain in the Royal Australian Army Medical Corps). In 1975, he moved to the Sunshine Coast, where he practised for a further 11 years. Stuart was a Foundation Member of the Royal College of General Practitioners (1953) and co-founder of the Royal Australian College of General Practitioners (RACGP) (1954), and served on their councils for 5 years and 20 years, respectively. He was elected to Fellowship and Life Membership of each college, and was awarded the prestigious Rose–Hunt Medal by the RACGP in 1981 for outstanding service in promoting the objectives of the College. He was President of the RACGP from 1961 to 1963. Stuart served as a Councillor on the Queensland Branch Council of the British Medical Association (later the Australian Medical Association [AMA]) from 1948 to 1968, and was President of the Branch from 1954 to 1955. He was elected to Fellowship of the AMA in 1970 (and later awarded an honorary life membership), and received the Citation of the Queensland Branch in 1990. Stuart was also a Foundation Member of the Paediatric Association of Queensland (1949) and worked as a Visiting Paediatrician at Brisbane’s Mater Children’s Hospital (1949–1961) and the Ipswich General Hospital (1961–1975). He served as a member of the Order of St John of Jerusalem for 22 years, and was an active Rotarian. He was named Paul Harris Fellow in 1986 for exceptional services to the Rotary Foundation and was made a Member of the Order of Australia in 1994 for outstanding and meritorious service to medicine and the community. He was a member of the Queensland Cricket Club, Queensland Rugby Club, Senior Golfers Society, Caledonian Society and the National Trust. Stuart had several papers published and wrote two books: The ordinary doctor (1990) and Friends of the ordinary doctor (1994). Those who knew him will agree with me that his self-appointed description of “the ordinary doctor” does not do justice to this remarkable man. He was no ordinary doctor, nor was he ordinary in any other sense. Stuart died in Ipswich on 15 May 2004, and is survived by two sons and three daughters. John A Comerford

John A Comerford

The contraceptive implant Implanon (Organon) was introduced in Australia in May 2001, and in the next 18 months was associated with an unprecedented number of adverse incident reports to medical indemnity insurers, including almost 100 unintended pregnancies. The medical indemnity insurer, MDA National, responded to this by applying the Australian and New Zealand Standard for Risk Management (AS/NZS 4360: 1999) in two stages. The first stage was to contain potential costs by moving the treatment into the general practice procedural category, resulting in a one-year moratorium on its use for most general practitioner members (prudential risk management). The second stage was to manage the clinical risk by developing strategies to reduce identified risks associated with the procedure. The Royal Australian College of General Practitioners (RACGP) was enlisted to develop guidelines for use of Implanon, with a consent form and checklists for doctors and patients, enabling MDA National to reinstate the treatment to the general practice non-procedural category. This case demonstrates the need for early risk assessment and development of risk-management tools for new treatments and devices, a role that is appropriate for the RACGP.

Beres C A Wenck MBBS, FAMA · Penelope J Johnston

Re: “The Medical Journal of Australia — prospere, procede et regna”, the editorial by Martin B Van Der Weyden in the 1 July 2004 issue of the Journal (Med J Aust 2004; 181: 3-4) cites incorrect references. These should read: 7 Bhasale AL, Miller GC, Reid SE, Britt H. Analysing potential harm in general practice: an incident-monitoring study. Med J Aust 1998; 169: 73-76. 8 Kuhse H, Singer P, Baume P, et al. End-of-life decisions in Australian medical practice. Med J Aust 1997; 166: 191-196. 12 Armstrong R, Van Der Weyden MB. Indigenous health: tell us your story [editorial]. Med J Aust 2004; 180: 492. 14 Stelfox HF, Chua G, O'Rourke K, Detsky AS. Conflict of interest in the debate over calcium channel antagonists. N Engl J Med 1998; 338: 101-106. 18 Laporte RE, Marler E, Akazawa S, et al. The death of the biomedical journal. BMJ 1995; 310: 1387-1390. This error only affected the printed version of the article. The web version was correct when published and has not been changed.

Martin B Van Der Weyden MD, FRACP, FRCPA

The male pill. A biography of a technology in the making. Durham: Duke University Press, 2003 (xi + 306pp). ISBN 0 8223 3195 0. Why haven’t we got a contraceptive pill for men? Nelly Oudshoorn, Professor of Gender and Technology at the University of Twente in the Netherlands, attempts to provide some of the answers in this timely historical account. In 1972, the World Health Organization (WHO) Male Task Force concluded that a long-acting gestagen to suppress pituitary gonadotropin secretion, and hence testicular activity, supplemented by androgen replacement therapy, was the way to develop a male contraceptive. But which gestagen, and which androgen, in what dose, and by what route of administration? These questions still remain, 32 years later, although the latest Australian study,1 has shown that three-monthly injections of 300 mg depot medroxyprogesterone acetate and four-monthly implants of 800 mg testosterone give excellent contraceptive protection for one year. A male contraceptive implant might find a small niche market in the developed world, but in the developing world, where most of the world’s population lives, the logistics and cost of repeated implants or injections would probably make it a non-starter. Another worry is that anabolic steroids (aka androgens) are now internationally banned as performance-enhancing drugs, and hence any athlete taking a hormonal contraceptive would simply not be allowed to compete. The lack of interest shown by the pharmaceutical industry (wisdom in hindsight?) has been a major blow, as has the low profile of andrology as a medical specialty. Nelly Oudshoorn concludes that we have failed to develop a male pill simply because “technological innovation in male contraception thus facilitates a situation in which hegemonic masculinities are destabilized and nonhegemonic masculine identities are articulated and gain momentum”. The truth is somewhat simpler. A male pill is still not in sight, and the pharmaceutical industry will have to invest hundreds of millions of dollars to bring a three-monthly injectable hormone cocktail onto the market. Is it worth the investment? Roger V ShortProfessor of Obstetrics and Gynaecology Royal Women’s HospitalMelbourne, VIC 1. Turner L, Conway AJ, Jimenez M, et al. Contraceptive efficacy of a depot progestin and androgen combination in men. J Clin Endocrinol Metab 2003; 88: 4659-4667.

Roger V Short