Volume 183 Issue 2

Objective: To compare the rates of adverse reactions and parental approval ratings for three different techniques for anterolateral thigh vaccination in children aged 2, 4, 6 and 18 months.Design: Randomised, observer-blind trial.Participants: 375 children who received pertussis-containing vaccines in a regional New South Wales town between 29 May 2001 and 30 June 2002.Interventions: Children were randomised to receive intramuscular injection with acellular pertussis-containing and Haemophilus influenzae type b vaccines with one of three recognised injection techniques (Australian, World Health Organization or United States).Main outcome measures: Local adverse reactions (bruising and redness/swelling), systemic adverse reactions (irritability, perceived fever, persistent crying/screaming, drowsiness, vomiting/poor feeding) and parental acceptance were assessed 24 hours after injection.Results: 361 children (96%) were evaluated 24 hours after vaccination. The WHO technique resulted in significantly fewer children, than with the other two techniques, with the systemic adverse reaction variable “irritability” (P = 0.0039). There was a significant difference between the technique groups overall for the local adverse reaction “bruising” with acellular pertussis-containing vaccines (P = 0.0418), due to a lower reaction rate in the WHO group compared with the US group (P = 0.0356).Conclusion: The WHO technique appears to be the optimal technique for anterolateral thigh injection in children — it ensures that the injection is intramuscular, results in fewer adverse reactions, and is the easiest technique to perform as it does not require angling of the needle to the long axis of the femur.

Ian F Cook MFamMed, PhD, FACRRM · John Murtagh MD, FRACGP

Aim: The Asthma 3+ Visit Plan is an initiative to promote organised asthma care in general practice. This study aimed to identify factors associated with uptake of the plan by general practitioners, and their views on barriers and facilitators to implementation of the plan.Design: Postal survey sent to a random sample of GPs.Participants and setting: 315 GPs in five Divisions of General Practice in metropolitan Sydney, surveyed sequentially between 1 October 2002 and 31 May 2003.Outcome measures: Awareness and use of the Asthma 3+ Visit Plan; GP and practice factors associated with use of the plan; and GP views on barriers and facilitators to implementing the plan.Results: The response rate was 55.7%, and 72.1% of participants were male; participants’ mean age was 50.5 years. Most GPs (91.2%) were aware of the plan and and 44.9% had used it. GP and practice factors associated with use of the plan were use of the six-step Australian Asthma Management Plan, confidence in aspects of asthma care, practice accreditation, sign-up for asthma incentives, and computerisation. Major barriers to implementing the plan were workload/paperwork and administrative complexities. Patient factors that influenced completion of the plan were their concept of the severity of their asthma, compliance with follow-up, and patient attitudes towards asthma care.Conclusion: The perceived workload and administrative complexity of the asthma incentives are barriers to uptake. Factors relating to the illness rather than social factors are seen as the most important influences on completion of the plan by patients.

Nicholas A Zwar PhD, FRACGP · Iqbal Hasan MB BS, MPH · Elizabeth J Comino PhD, MPH · Mark F Harris PhD, FRACGP

Objective: To measure the independent effect on length of general-practice consultations of a range of characteristics of the general practitioner (GP), practice, patient and consultation, as a basis for considering future GP workforce needs.Design: Secondary analysis of data from the BEACH (Bettering the Evaluation and Care of Health) study.Setting and participants: Data were obtained from 1904 GPs Australia-wide on 70 758 consultations between 1 January 2001 and 31 December 2002; all consultations that were claimable from the Australian Government’s Medicare system as General Practice Attendances and had recorded start and finish times were included.Main outcome variables: Characteristics of the GP, practice, patient and consultation that were significantly related to consultation length, determined by multiple regression analysis.Results: The following variables had an independent positive effect on consultation length: GP female, older, graduated in Australia, FRACGP-qualified, and in rural practice; patient female, older, new to practice, with higher socioeconomic status, no health concession card, more reasons for encounter, and more problems managed; and management of specific problem types (social, psychological and female genital problems), management of chronic disease, and provision of clinical treatments.Conclusion: The independent relationship of some GP, practice, patient and consultation characteristics with length of consultation may affect future GP supply. These factors should be considered in modelling future general practice workforce needs.

Helena C Britt BA, PhD · Lisa Valenti BEc · Graeme C Miller PhD, FRACGP

Giving patients the highest quality of care must remain absolute “Time is an ocean, but it ends at the shore”, sang Bob Dylan. I think this is a good metaphor of how time seems to a freewheeling young person, who both feels that their youth will last forever and knows the truth of their mortality. However, for many clinicians, especially GPs, time is more like a series of small, leaky buckets in a bathhouse. We are the robed attendants whose job it is to clean each patient as best we can before the bucket runs out. They come anticipating a luxurious sunken bath, while we wonder if we can get away with a quick sponge to the armpits and crotch. Managing time effectively is one of the biggest challenges in clinical practice. Like water, it is becoming increasingly precious — our stress levels rise dramatically when we feel we’re spending too much of it. But sometimes we have no choice. Take Gary, a middle-aged man I’ve been seeing for a few months. He’s a health professional and seems a fairly typical bloke. Overweight and a bit grumpy, he’d had a few headaches and just wanted a blood pressure check. Not surprisingly, his blood pressure was elevated, and he had mild dyslipidaemia to go with it. He doesn’t smoke and admitted to only two or three schooners every now and then, but denied any other significant history — he just wanted his blood pressure controlled. There was nothing to suggest a neurological cause for his headaches, so I duly trotted out the lifestyle advice (which he already knew) and started him on an antihypertensive. Over the next 3 months his blood pressure improved a little and he said the headaches had lessened. Then he didn’t show again until it was time for a repeat script. His blood pressure was still suboptimal, and I began talking about adding in another drug. He told me he was thinking of changing jobs. At this point, I finally noted his bleary eyes, haggard face and dull expressionless voice, and realised that this would not be a one-bucket consult. John was deeply depressed and self-medicating with 10 schooners of full-strength beer daily. He was highly anxious at work, to the point of having panic attacks. He was subject to a range of post-traumatic stress symptoms from his recent close involvement with a variety of distressing incidents including violent suicides, horrific burn injuries and serious child abuse. After such events he had been the one organising care for traumatised staff, but had not himself been debriefed. In addition, he had major personal stress from conflicts in his own family. His overall distress was augmented by a deep shame at his inability to cope with situations. If this were an inspirational example for general practice trainees, this three-bucket consultation would result in Gary receiving successful treatment for his post-traumatic stress symptoms, leading to more moderate alcohol use and better control of his hypertension and other vascular risk factors. His workplace would retain an experienced staff member it can ill afford to lose. But reality is somewhat less committed to happy endings and, although I’ll do my best with this new information, I don’t yet know how Gary’s future will pan out. Only time will tell. Some patients do require us to spend time if we’re to have even a small chance of success but, much as we’ve come to disparage “6-minute medicine”, good practice isn’t always about giving more time either. Just as health expenditure if unchecked could expand to swallow the whole state and federal budgets, we all know patients who would gladly guzzle entire sessions for very little benefit. In the end, time management is a zero-sum game. You can try and cheat a bit by drawing on a bucket you’d put aside for yourself or your family, but in the end Gary’s extra buckets mean wet-wipes only for others in the waiting room. You can tell a lot about our professional values from the way we manage this precious resource. As clinicians we tend to be highly focused on our relationship with individuals rather than populations. Our highest loyalty at any particular moment is to the patient in front of us, followed by those in the waiting room, followed by the rest of our regular patients, with the general populace a distant fourth. We all know that tackling Australia’s undiagnosed mental health problems, for instance, would take far more GP hours than are available. Yet, we would strenuously resist any attempt to force a compromise between patient load and quality of care. Einstein may have shown us that time is relative, but our commitment to giving individual patients the highest quality of care remains absolute.

Simon Cowap MB BS(Hons), FRACP

Combining commercial interests and public good is a broad social, political and ethical challenge Health care, the practice of medicine, provision of medicines and medical information management are big business. There are deep, inherent tensions and potential for conflict between the needs and vulnerabilities of the sick, and the conduct of a large proportion of health care as a commercial activity. Every doctor in private practice spans this ethical tension each working day. Commercial organisations which provide essential health care and health goods, such as pharmaceutical companies, also tread this fine line. Industry is the largest funder of medical research and provides needed medicines and vaccines. The timelines, costs and risks of product development are substantial — around 80% of pharmaceutical and vaccine candidates which enter human clinical trials do not make it to registration, and the road to registration is formidable. An average of around a decade’s preclinical research, up to 9 years’ clinical development, and a highly variable but average cost of around US$500–800 million are involved in bringing on-stream a new product that is a new entity rather than a “me-too” product.1-3 Coupling these realities with the benefits of global reach to access the best knowledge, candidates and processes means that innovative drug and vaccine development needs big, responsive organisations with diverse skills. But marrying the private, commercial sector with equitable and sustainable development and provision of public goods is a much broader social, political and ethical challenge. The promotional dollars the pharmaceutical industry spends can have clear benefits, such as appropriate use of established and new therapies, encouraging best practice and contributing to policy development. However, the many billions of dollars spent each year in promotion dwarfs, by a factor of 2–3, its research and development expenditures4 — an issue not only for the industry but for all of us in terms of distorted priorities and large opportunity costs. Research in this issue of the Journal suggests that there are serious issues regarding the complex relationship between commercial health care organisations and the healing professions, and regulation of this relationship. Harvey and colleagues (page 75) demonstrate potential breaches of compliance with the Medicines Australia Code of Conduct in many pharmaceutical advertisements placed within the most widely used general practice prescribing software.5 This Code is the benchmark for the pharmaceutical industry’s marketing and promotional activities in Australia, including its interactions with health professionals, and adherence to it is solely the responsibility of pharmaceutical companies. Some of the criteria used in the study were subjective (eg, legibility, inadequate time for comprehension) or quite conservative (eg, reference to the Product Information considered present only if contained within the body of an advertisement, not adjacent to it), and analysis was not comprehensive (eg, accuracy of promotional claims was not systematically assessed). Although the proportion of all advertisements noncompliant by at least one criterion is not specified, this was a majority. The pharmaceutical industry’s Code of Conduct was first developed in 1960 and is currently in its 14th edition; newness or lack of familiarity should not apply. The Code contains a section (3.10) on “Advertising in electronic prescribing software packages”.6 However, compliance with the Code is the responsibility of the pharmaceutical companies, not the software developer. Software companies have the Medical Software Industry Association Code of Practice,7 which refers only to the Media Council of Australia Advertising Code of Ethics. The Media Council has been replaced by the Therapeutic Goods Advertising Code Council.8 The thematic analysis by Harvey et al of email postings by a self-selected group of general practitioners indicates that some GPs may be perturbed by pharmaceutical advertising appearing in their clinical software. Nevertheless, the software package referred to by Harvey et al as “the only Australian prescribing software containing pharmaceutical advertisements” continues its market dominance among GPs,9 although other prescribing software packages are available.10 It follows that many GPs, irrespective of their opinion on the promotional material it contains, continue to use the package and tolerate pharmaceutical advertising for a complex variety of reasons. These are likely to include ease of use, cost, lack of knowledge of competitive products, reluctance to change and lack of flexibility in learning new systems, absence of standards for electronic health records, and time limitation. Ultimately, the question posed by Harvey et al as to “whether pharmaceutical advertisements in clinical software should be banned” does not revolve solely around the opinions and behaviour of GPs, already subject to a range of forces. It also turns on the ethical principles and professional standards that guide the relationship between health care professionals and their patients, the genuine willingness of powerful health care organisations to affirm and facilitate the application of these principles, along with legal and other enforcement mechanisms. A number of recommendations flow from the findings of Harvey et al: All codes of conduct and other professional standards require regular review and updating, as well as implementation. As expressed by the Australian Competition and Consumer Commission in its November 2003 authorisation of the 14th edition, concern remains about the enforcement of the Code.11 Sanctions for breaches are generally modest, especially in comparison with the sales revenue of many widely prescribed pharmaceuticals. During 2003–04, 41 complaints were finalised by the Code of Conduct Committee. Fines totalling $205 000 were imposed in 12 cases (an average of $17 083).11 Corrective letters or advertisements were required in only seven cases. Sanctions could appropriately be increased, and perhaps linked to sales revenue for the product in question. Capping advertising expenditures across the industry, as occurs in the United Kingdom, deserves serious consideration.12 The closer to the doctor–patient interface, the less appropriate is the presence of advertising. The doctor–patient relationship should be free of intrusion or interference. Advertising at the doctor–patient interface is at a minimum intrusive, and may cause distraction and delay in the consultation. At worst, it may inappropriately influence prescribing and, as noted by Harvey et al, when visible on the doctor’s desk during a consultation, could function as prohibited direct-to-consumer advertising of prescription products. In our view, Harvey and colleagues’ recommendation that pharmaceutical promotion be eliminated from prescribing software is justified. Appropriate professional interactions with industry and standards for these should be part of undergraduate and postgraduate medical training programs, and Continuing Medical Education. All clinicians should have ready access to authoritative, independent, regularly updated, best-practice prescribing guidelines, such as Therapeutic guidelines,13 the Australian medicines handbook,14 Central Australian Rural Practitioners Association standard treatment manual15 and Australian adverse drug reactions bulletin.16 Such resources should be user-friendly and could appropriately be included in prescribing software. Doctors working in the pharmaceutical industry play a crucial role as ethical and scientific guardians and gatekeepers. They should be trained and supported in this role from inside and outside the companies, with companies unequivocally committed to developing and sustaining organisational cultures that have ethical and scientifically-based conduct and compliance with the Code at their core. All staff — especially sales and marketing staff — involved in the development, review and approval of promotional material should have compliance with the Code as individual objectives subject to performance appraisal, and should face personal sanction, such as forfeiture of bonus, for breaches of the Code for which they bear responsibility. Pharmaceutical companies should make scientific and ethical competence, and demonstrated familiarity with the Code, a condition of selecting agencies and individuals involved in developing promotional materials. Many of these recommendations are also relevant to medical software companies. Deficiencies described in medical software relate not only to advertising, but also to technical content, for example, in relation to quality of travel medicine information17 — more effective implementation of scientific and ethical standards, and regulation, are required. A step towards addressing these deficiencies is the evaluation and accreditation of GP clinical software packages. The work program of the General Practice Computing Group relating to the Review of Software Systems and the feasibility of a Software Supplier Accreditation Scheme18 is timely; the latter should incorporate the ethical standards, codes of practice and legal requirements for the industry.

Tilman A Ruff MB BS(Hons), FRACP · Hadia Haikal-Mukhtar MB BS, LLB(Hons), FRACGP

Objective: To assess pharmaceutical advertisements in prescribing software, their adherence to code standards, and the opinions of general practitioners regarding the advertisements.Design, setting and participants: Content analysis of advertisements displayed by Medical Director version 2.81 (Health Communication Network, Sydney, NSW) in early 2005; thematic analysis of a debate on this topic held on the General Practice Computer Group email forum (GPCG_talk) during December 2004.Outcome measures: Placement, frequency and type of advertisements; their compliance with the Medicines Australia Code of Conduct, and the views of GPs.Results: 24 clinical functions in Medical Director contained advertisements. These included 79 different advertisements for 41 prescription products marketed by 17 companies, including one generic manufacturer. 57 of 60 (95%) advertisements making a promotional claim appeared noncompliant with one or more requirements of the Code. 29 contributors, primarily GPs, posted 174 emails to GPCG_talk; there was little support for these advertisements, but some concern that the price of software would increase if they were removed.Conclusions: We suggest that pharmaceutical promotion in prescribing software should be banned, and inclusion of independent therapeutic information be mandated.

Ken J Harvey MB BS, FRCPA · Agnes I Vitry PharmD, PhD · Elizabeth Roughead BPharm, MAppSc, PhD · Rosalie Aroni PhD · Nicola Ballenden MA, MPH · Ralph Faggotter MB BS

Objectives: To examine the effect of demographic change on employment patterns for general practitioners, medical specialists and nurses since 1986, and to compare their patterns of retirement.Design and setting: Secondary analysis of previously unpublished Australian Bureau of Statistics Census data for the years 1986, 1991, 1996 and 2001.Main outcome measures: Age distribution of GPs, specialists and nursing workforce; attrition rates as GPs, specialists and nurses left the workforce; and hours worked according to age group.Results: The age profile of the GP, specialist and nursing workforce has aged since 1986 (P < 0.001), with the “baby boomer” generation making up more than half the workforce in 2001. A large proportion of GPs continued to work beyond the traditional retirement age of 65 years, with nurses retiring at a younger age than doctors (P < 0.001). All GP cohorts worked fewer hours in 2001 than they did in 1986 (P < 0.001), with “generation X” GPs working fewer hours than the baby boomers did at the same age (P < 0.001).Conclusions: Attrition of baby boomer clinicians will place unprecedented pressure on the medical workforce, and policy makers face a critical challenge to ensure workforce needs are met over the next 20 years. Policies and incentives to encourage ongoing employment among older clinicians, albeit at reduced hours, are crucial if the Australian health workforce is to be adequate to meet the growing community demand of the 21st century.

Deborah J Schofield PhD · John R Beard PhD, FAFPHM

There is a long tradition of some general practitioners developing areas of special interest within their mainstream generalist practice. General practice is now becoming increasingly fragmented, with core components being delivered as separate and standalone services (eg, travel medicine, skin cancer, women’s health). Although this fragmentation seems to meet a need for some patients and doctors, potential problems need careful consideration and response. These include loss of generalist skills among GPs, fewer practitioners working in less well-remunerated areas, such as nursing home visits, and issues related to standards of care and training.

David Wilkinson MB ChB, FRACGP, DSc · Marie-Louise B Dick MB BS, FRACGP, MPH · Deborah A Askew BAppSci, MHlthSci

On a United States submarine, the officer of the watch hands over responsibility at the end of a shift by asking his replacement, “Do you have the conn*?” And the relieving officer replies, “I have the conn.”1 This exchange ensures there is no doubt at all that responsibility has changed hands and no doubt where the responsibility for the submarine now lies. A recent experience has made me realise that we in medicine could learn something from this protocol. My patient was suffering from a life-threatening illness and, after my initial referral to the specialist of my choice, he was jointly managed in hospital by three senior clinicians. After a while, although still far from fully recovered, it was appropriate to discharge him home to the care of his family and general practitioner, but with frequent specialist reviews by all three attending clinicians. This is where the potential problems arose. Neither the patient nor the GP had a clear idea of who was in fact in charge of the patient’s management after leaving hospital. And while the GP was advised by his colleagues as to what had happened, that advice often failed to arrive for several days because of secretarial delays and the vagaries of Australia Post. The lines of responsibility were not clearly defined. Who was responsible for arranging and reviewing any further postdischarge investigations? What ongoing surveillance was necessary, and upon whose instigation? There was a real chance that gaps would appear in this patient’s care, with each of the four people involved in his management believing one of the others had dealt with any particular aspect. In fact, this is what happened, and it was left to the patient to return to me, more by chance than direction, and a serious relapse in his condition was identified. (In fact, I don’t think that the relapse could have been identified any sooner, but the potential for a delayed diagnosis was there.) The patient, too, had nothing but praise for each of the doctors involved, but commented, “You don’t seem to function as a team, but as loosely connected individuals”. Each patient we encounter is different, and it’s not possible to suggest hard and fast guidelines that should be applied to every patient. But somebody has to be in charge of the whole patient, rather than his or her constituent bits and organs. That obligation must be made clear when one clinician feels it appropriate to transfer that responsibility to another. This experience has reminded me of the potential for serious mistakes to occur when talented and skilled colleagues fail to work as a cohesive team. And, in my view, the biggest single error is failing to identify “who has the con”. * Con, (US) conn: direct steering of ship [The Australian Concise Oxford Dictionary].

Bernard S Pearn-Rowe BSc(Hons), MB BS, FAMA

Objective: To evaluate a hospital-based psychiatric consultation service for patients referred by general practitioners (GPs), and the effect on its use of a focused marketing strategy aimed at GPs.Design and setting: Postal survey of GPs in the catchment area (inner north Brisbane, Queensland), September to November 2003; and assessment of referrals, March to August 2003.Main outcome measures: Patient referrals, satisfaction among GPs who had referred, and awareness and opinions of the service among GPs who had not referred, compared with results of a similar survey conducted before marketing.Results: In the 6 months after marketing, 43 patients were referred by 23 GPs, an average of 7.2 patients per month, compared with 2.5 per month in the first 12 months of the service. Survey responses were received from 13 of 36 GPs who had referred patients and 97 of 282 GPs who had not (response rate, 35%). Satisfaction among GPs who had referred remained high, and 12/13 felt the service should continue. Among GPs who had not referred, 76% were aware of the service, up from 26% in the previous survey, and 99% liked the concept of the service.Conclusion: Given the ongoing low utilisation of this service, we question whether this model is accepted by most GPs in our district. Possibly, they prefer more traditional models, where treatment is taken over by psychiatrists in the public or private system. We believe there is a need to increase the capacity and scope of publicly funded services to treat mental health problems.

Alex E Simpson MRCGP, DTMH, FRANZCP · W Brett Emmerson MHA, FRANZCP, FRACMA · Aaron D J Frost BBehSc, BPsych(Hons) · Jacinta L Powell MHA, FRANZCP

To the Editor: GP-Psych Support is a national advice service on mental health management that links general practitioners (GPs) with psychiatrists by phone, fax or email within 24 hours. The service is federally funded through the Better Outcomes in Mental Health Care Initiative, and began operating in March 2004. Over the first 6 months of operation of the phone/fax arm, there were 726 case discussions between GPs and psychiatrists. A third of the GPs were rurally located, and 17% used the service twice or more. Most GPs (94%) accessed the service through the 1800 freecall number, rather than by fax. Three-quarters identified no other suitable, accessible source of urgent psychiatric advice. Two-thirds of cases involved female patients, and 80% were aged 19–65 years. In only 14% of cases was another mental health service provider involved (a psychiatrist in 2%). The primary diagnoses are shown in the Box. The most common topic discussed was medication (77%), with less demand for discussions of general management principles (12%) or diagnosis (7%). However, cases were discussed broadly, and referral to another mental-health care provider was recommended in a third of cases, including to a psychiatrist in 8% of cases. An evaluation survey with 450 randomly selected GP service users received 129 replies. Although the survey response was low (29%), the feedback was very positive, with over 99% of respondents indicating that they would consider using the service again. Over 95% of respondents reported satisfaction with the service in terms of ease of use, helpfulness of advice and ease of interaction with the psychiatrist. Compared with other sources of mental-health care advice, over 85% rated GP-Psych Support as better in regard to accessibility, reliability and the appropriateness of the advice given. Over 70% stated that contact with the service had increased their knowledge about the management of mental disorders and their confidence in managing mental health problems, and had improved the quality of care they provided to their patients. Fifty-three per cent of GPs reported an increased willingness to manage more complex mental health problems. From these data, it appears that psychiatrist telephone support has been well received and adds significantly to the resources available to GPs working in mental health care. The 10 most common primary diagnoses among 726 patients discussed in GP-Psych Support Diagnosis Percentage of patients Depression 45.9% Mixed anxiety and depression 12.6% Chronic psychotic disorder 8.8% Anxiety disorder 8.6% Acute psychotic episode 5.2% Bipolar disorder 5.1% Organic or cognitive disorder 3.6% Drug or alcohol use disorder 2.5% Somatoform disorder 1.5% Eating disorder 1.2%

Stephanie E Bradstock FRANZCP · Andrew J Wilson FRANZCP · Matthew J Cullen FRANZCP · Katie L Barwell RN

Max Kamien Max Kamien graduated from the University of Western Australia in 1960. After graduation, he worked until 1965 in developing countries including New Guinea, South Korea and Nepal. After spending the next 4 years in hospitals in the United Kingdom, he worked from 1970 to 1973 as a GP for the Aboriginal community in Bourke, NSW. His academic career began in 1974 as Senior Lecturer in Medicine at the University of Western Australia, where he was appointed Foundation Chair of General Practice in 1977. He retired in 2003 and now spends his time doing much the same as before. Australian academic general practice began in 1975 as a result of the recommendations of the Australian Universities Commission Committee on Medical Schools.1 The new discipline had to struggle against the “torpor and inertia” of most faculties of medicine in providing it with student time and basic resources.2 But we were patient and resilient, and survived to become a necessary counterculture to the accepted orthodoxy of most medical schools. Our achievements have been in reminding medical faculties of their social responsibility for providing the types of doctors needed by Australian taxpayers, who fund medical education. Consequently, we have been pathfinders for the current educational and experiential accent on rural medicine and Aboriginal health and associated policies on affirmative action for admitting disadvantaged students to medical school. In the early years, our emphasis was on teaching. We were, and still are, assisted by several thousand general practitioners, who, for the most part, follow the injunction of the Hippocratic Oath to “teach students without fee or covenant”. We stressed the need to teach neglected communication and consultation skills, and were gratified to see many sceptical academic specialists adopt our techniques. We also helped students to be as knowledgeable about commonly occurring conditions as they were about esoteric ones. We followed up by improving examinations through the use of standardised OSCEs (objective structured clinical examinations) and the direct observation of consultation skills. By inviting specialist colleagues to examine with us, we established the milieu for generic examinations. After all, patients rarely present to doctors and say, “I have an endocrine disorder”. Research. Any discipline worthy of the name needs to continually examine and advance its intellectual and structural base. Much has been said about the need to embed a culture of research into general practice and the increased role that academic departments of general practice will have to play. Although general practice research output has increased fivefold in the past decade, it is still tiny in comparison to the number of GPs in active practice.3 Since 2000, the Australian Government Department of Health and Ageing has put $10 million a year into supporting general practice research through the Primary Health Care Research, Evaluation and Development initiative. Together with other sources, this has provided more opportunities for established and intending researchers. However, we need more clarity about our research endeavour. General practice research conducted by non-GP researchers will not embed a research culture into general practice. To do this requires GPs to become more scientifically oriented and to ask questions of their own and learn how to answer them. Government funders are interested in health services research. GPs are interested in clinical research. The credibility of academic GPs with “bag-carrying” GPs is highly dependent on us being catalysts and resources for this clinical research. Politics. In 2001, I thought the coming of age of Australian academic general practice was dependent on us becoming more politically aware, recapturing the support of the Royal Australian College of General Practitioners (RACGP), and obtaining a fairer allocation of university resources.4 Four years on, I think academic general practice is more politically aware. Our representative organisation, the Australian Association of Academic General Practice, is certainly a more internally communicative and stronger organisation, but one which still needs some external visibility. For the first time in its 47-year history, the RACGP has an academic GP as its president. Relations with academia have never been so productive. Unfortunately, general practice as a whole has not yet learned to build on its strengths and remains divided and divisive. The often mean-spirited or dysfunctional behaviour of various GP groups makes it difficult for academic general practice to play its proper role in advancing Australian general practice. Funding. Small departments of general practice need to be adequately resourced and not disadvantaged by unfair funding formulas that grossly advantage hospital-based clinical departments. However, formula funding has become an easy structure beneath which deans and finance committees can shelter. Furthermore, most specialist academics still look down on GPs and GP academics. Although they have little idea of what we do, in their non-evidence-based hearts they know that they have long done it and done it better. Nevertheless, progress has been made in winning hearts and minds, and four professors of general practice (Justin Beilby, Chris Del Mar, Richard Hays and John Marley) have recently been appointed as deans or pro-vice-chancellors of Australian medical schools — a situation that would have been anathema only a decade ago. So, does academic general practice have a future? I am sure it does, if only to enable medical schools to cope with their increased student numbers. But extra teaching without a concomitant increase in resources also has the potential to “dumb down” academic general practice.5 Academic GPs need serious time for research and scholarship. Without it, “junior faculty will remain junior for their entire careers”.6 One halcyon day, general practice organisations may realise that the stability and intellectual rigour of general practice vocational education and training would benefit from being centred in universities. This would help ensure the core critical mass of teachers and researchers necessary to advance general practice as a whole. It would also enable the setting up of model practices that could demonstrate state-of-the-art general practice and experiment for its future development.

Max Kamien MD, FRACGP, FRACP

David Weller David Weller graduated from the University of Adelaide in 1982 and completed his general practice training in 1989. He has worked as a GP in Adelaide, Derby (UK) and Edinburgh, and undertook postgraduate study in public health and primary care. He was Senior Lecturer in the Department of General Practice, Flinders University, SA, from 1995 to 2000. In January 2000, he took up the post of James Mackenzie Professor of General Practice at the University of Edinburgh. His research interests are in primary care — principally cancer and medically unexplained symptoms. General practice lacks the academic culture of other medical disciplines. The reasons for this are complex, but relate to its applied nature, its community setting, and its practitioners — most of whom seek to focus on the care of their patients. Nevertheless, academic general practice is now well established, and from within the “ivory tower” it’s easy to point to its achievements. Primary care-based research has made important contributions to the management of common conditions such as otitis media and coronary heart disease, and to smoking reduction and vaccination.1 In the United Kingdom, university departments of general practice and their associated networks of general practitioners deliver 10%–15% of the medical curriculum — much of it in basic clinical skills, and underpinned by investment from the National Health Service.2 Arguments in favour of more research in our field seem compelling. If most prevention, diagnosis and treatment of ill health occurs in primary care, then we need an evidence base derived from that same environment.3 Yet this evidence is frequently lacking: for example, in the Quality and Outcomes Framework of the UK GP’s contract (a system of financial rewards for meeting certain quality-related indicators), cancer — an area in which primary care has a critical role at all stages of the illness — has just two measures, relating to follow-up visits and establishing practice registers. So, does academic general practice enjoy widespread support in the United Kingdom and Australia? On most fronts the support seems lukewarm. Governments have helped establish academic departments and chairs, undertaken various capacity-building initiatives (such as Australia’s Primary Health Care Research, Evaluation and Development program) and recognised the need for financial support for GP-based teaching. But the current level of investment still leaves us well behind our secondary-care colleagues, and we remain under close scrutiny and review. Universities want us to take on more of the curriculum, but often “tolerate” our research at best — the money and interest is in new genes and molecules. There is still a sense of ambivalence and mistrust from our non-academic GP colleagues. Research and teaching networks have helped, but we’ve largely failed to inspire trainees and colleagues to undertake academic pursuits. Clinical academic medicine, itself perceived to be in crisis,4 is becoming an increasingly managed exercise. The UK Clinical Research Network, for example, encourages multicentre, trial-focused research, addressing major issues in chronic disease management. Academic general practice is currently at the margin of these new developments. To shore up our future we must: redouble our efforts to become integral to the wider clinical research enterprise and shape its future. Studies based in primary care need to lead the research agenda, not trail behind it. Our rich heritage of social, cultural and behavioural research, which has contributed so much to understanding patients and their illnesses, needs to be preserved. continue to bring a more academic culture to general practice training, and offer portfolio career development (ie, careers that combine clinical activity with other elements, such as academic work or managerial/leadership roles) — there are still few opportunities to combine clinical and academic training. continue to build on the quality of our research, persuade funding agencies to earmark funds for the work we do, and demonstrate to our colleagues in government and policy-making bodies that this work can provide new ways forward in health care. use our strong presence in the undergraduate curriculum to help produce doctors who are enthused about general practice and inclined towards research. engage with our clinical colleagues and their patients, and demonstrate our relevance to their daily activities. Academic general practice has come a long way in a short time. There seems no doubt it has a future; our challenge is to keep delivering outputs of relevance, and to build an academic workforce that can meet the challenges ahead.

David P Weller MPH, PhD, FRACGP

Claire Jackson Claire Jackson graduated from the University of Queensland in 1980. She first started working as a GP in outback western Queensland in 1982, and has since worked in various settings in Australia, the United Kingdom and Canada. Her academic career commenced when she became an academic General Practice Registrar and Lecturer in General Practice at the University of Queensland in 1989. She is now Chair of the Discipline of General Practice at the University of Queensland, and is involved in active clinical practice in southern Brisbane. Her research interests include heath services research, particularly related to health care integration, and primary eye care. One’s mind, once stretched by a new idea, never regains its original dimensions. Oliver Wendell Holmes From modest beginnings little more than 30 years ago, Australian academic general practice has grown and prospered — particularly with the recent introduction of rural clinical departments and additional medical schools. General practice sits naturally at the “front line” for the prevention and management of a multitude of health problems — management that increasingly relies on the best information, gleaned from research in the primary care setting. However, our health system, like others in developed countries worldwide, is failing fast. Productivity Commission reports, parliamentary inquiries and numerous academic papers describe the current waste and lack of focus on outcomes in our health system,1-3 at a time when communities and dedicated health professionals are screaming for the resources to provide acceptable care for their communities. Academic primary care will take a key role in Australia’s health care future — developing and evaluating new care models and therapies for Australian communities, care-givers and health care professionals. New opportunities in integrated care delivery, health information technology and patient engagement in self-care will provide fertile ground for academic general practice, as will the clinical application of new technologies, medication and treatment modalities. It will be crucial to explore and understand changing societal approaches to end-of-life decision-making, personal rights and responsibilities in health, and the rationing and allocation of the shrinking health dollar. Working across sectors — within the health care system and between health, education, local government and community services — will become much more important, and primary care, supported by academic general practice, is likely to provide the crucible for many new initiatives and approaches. What will academic general practice of the future look like? Committed to teaching — the lifeblood of our profession; Increasingly “broad church” — encompassing clinical, health service, multidisciplinary and intersectoral research; Increasingly essential to effective health service delivery in the “real world”; Increasingly networked with consumers, government and professional groups, such as colleges and divisions of general practice. Sharing in creating and evaluating a “Brave New World”? — academic general practice in Australia can’t wait!

Claire L Jackson MB BS, MPH, FRACGP

There are three points of conflict in how general practitioners receive income that are, I believe, at the centre of the internally inconsistent and often confused position in which we find ourselves. The first is between how general practices receive their income and how general practitioners receive theirs. When the world was flat and most practices were the practitioners in them, this did not matter. Today it does, as the many income streams flowing into a practice form a pool from which, after being evaporated by costs, the practitioners receive fiscal sustenance. Provided the pool is sufficiently deep, it matters little — in purely financial terms — how the income stream flows (in ideological terms, this is another matter). I contend that, in the future, there will be a clear distinction between practice revenues and practitioner incomes. If one is determined to continue to drink from a diminishing pool, then so be it. Robert Pegram holding what is about the value of a GP consultation The second point of conflict is that society has chosen for primary care — a public good — to be provided largely through a private business model. Public goods are about accountability, resource rationing and managing public expectation at minimum cost. Private industry is about autonomy, providing what customers want and maximising profits within the constraints of business competition and legislation. Many of the funding incentives around population health and the GP workforce have been necessary to deal with market failures, and the need to support an essential private industry by means of various public subsidy regimens. The third point of conflict is between the individual and society. The most important person for a GP at any given moment is the patient sitting opposite. Funders, on the other hand, are interested in populations. From their point of view, individuals may fare worse, provided not enough of them do so to damage population averages. However, a GP cannot accept that any patient should fare worse. So, who do GPs and practices serve — the patient, the business, or the funder (as the agent of society)? I would like to see: Practices commissioned to provide care for patients at a payment that is based on a true costed model for infrastructure costs plus a margin. This would target high care need groups where simple fee-for-service payments are not viable. Divisions of General Practice managing pools of resources on behalf of general practice for the mutual benefit of those working in those practices and the populations they serve. Less money and fewer resources devoted to managing the funding demilitarised zone between the federal and state governments. Some will recognise that points one and two have already been achieved in some places — witness the Hunter Urban Division of General Practice After Hours Network for the first, and the Access to Psychologists program for the second. The Hunter Urban After Hours scheme provides realistic levels of funding from federal and state governments and Division(s) into a managed pool that allows total flexibility in how services are provided and paid for. The net result is an integrated regional after-hours service (including an after-hours telephone triage and advice service, five GP clinics located in hospitals and the community, patient transport where needed, and a home visit service) that is highly valued by all, yet allows choice.1 The Access to Psychologists program, as part of the Australian Government Better Outcomes in Mental Health Initiative, allows GPs to refer patients to mental health professionals for focused psychological strategies. It allows flexibility in how the service is provided by specifying inputs (grants provided to each Division) and outcomes (patients requiring such interventions). The bit in between is delivered through local variation within an overall program framework.2 As for the third point, well, as Meatloaf once sang, “two out of three ain’t bad”.

Robert W Pegram BSc, BM BS, MHSM

The increasing prevalence of chronic conditions requires general practitioners to implement structured care with their patients. This care is often multidisciplinary. Our experience through two coordinated care trials has shown that GPs often have a network of private allied health care providers, but have limited knowledge of the complete range of services available in the community and how to gain access to these services. Dr Beres Wenck (GP), Ms Alison Nason (Practice Nurse Milton Clinic) and Ms Jenny Bostock (Community Health Nurse) We suggest that there are three key elements essential for GPs to improve multidisciplinary care systems in their practice: Find the GP champion in your practice with an interest in chronic disease management who can encourage behaviour change. Appoint a member of the practice staff to be the link with your local community nursing agency. These organisations have an enormous knowledge of the breadth and depth of patient services available, and can help you find appropriate services for your patients. Invite community health nurses to your practice, or meet with them at their centre. Learn to use their expertise by forming and building a relationship. The collaboration has to be two-way, with community nurses equally committed to liaison. Such a change is likely to not only benefit GPs, but also enhance community nursing awareness of local general practice issues. Develop team-building and educational strategies for GPs and practice staff, as this will maximise team efficiency and productivity and boost staff morale. Have a meeting with all practice staff (not just the GPs), and encourage all present to contribute. This will result in knowledgeable and resourceful practice staff who will complement patient management. Use the chronic disease modules developed by Brisbane North Division of General Practice1 to set up a structured clinical education program. This can be based either within a single small group practice or within a locality, to provide the opportunity for GPs, staff, and, when appropriate, allied health care providers, to discuss evidence-based medicine and practice-based issues relating to chronic disease management.1 Involve your practice staff in care planning to help improve patient understanding and care. Medicare Benefits Schedule (MBS) item numbers allow access to five allied health private services a year for those with complex, chronic conditions.2 The new MBS Chronic Disease Management item numbers replacing previous Enhanced Primary Care items include a Management Plan and Team Care component, and were developed from our Team Care Health II learnings. They allow practice staff to assist GPs in planning care, and will facilitate service coordination, especially if the practice has established links with community agencies. These elements need to be put in place at the practice level, but Divisions of General Practice should develop collaborative relationships with community stakeholders for linkages at the local level. Furthermore, to recognise the time-consuming nature of implementing the necessary changes within general practices, there should be appropriate innovative financial incentives for GPs and practices to make this approach a viable option. With the increasing prevalence of chronic conditions, we need to move our focus from a reactive health care model to a proactive service delivery model. Get the incentives right, get the support right, and you might be surprised at the difference you make.

Beres CA Wenck MB BS, FAMA · Prue A Lutton MScSt, BScApp(HMS)

Paperwork has been identified by general practitioners as one of the key areas they most want changed, to allow them more time for direct interaction with patients in general practice. John Aloizos is a part-time GP in Brisbane and is currently Chairman of the Australian Pharmaceutical Advisory Council, and a member of the Australian Health Information Council, where he Chairs the Electronic Decision Support Steering Committee. He is a former member of the General Practice Computing Group Management Committee and the General Practice Partnership Advisory Council. He was the inaugural Chairman of Australian Divisions of General Practice and Australian General Practice Accreditation Limited (AGPAL). He continues to serve as a GP advocate in policy areas including diabetes, asthma and practice standards. In 2001–2002, GPs’ administrative costs associated with government programs came to an estimated 5% of their total incomes.1 The GP Red Tape Task Force reported its findings in December 2003,2 and the government has responded with a number of measures to reduce red tape for GPs, which are currently being implemented (eg, clarifying and simplifying the Practice Incentives Program requirements for practice nurses and the reforms to the Enhanced Primary Care [EPC] Medicare items). With the extensive daily demand on GPs to provide acute care and to implement programs for chronic disease management and illness prevention for better health, amid an ageing population with multiple comorbid conditions, will these measures be enough to solve the problem? There is evidence that the shift towards a multdisciplinary team approach to patient care will assist in reducing the GP’s workload.3 However, there is a risk that, with each new initiative to support the changing workplace environment, another layer of administrative complexity is added. The peak body representing general practice to government, the General Practice Representative Group (GPRG, made up of the Royal Australian College of General Practitioners, Australian Medical Association, Australian Divisions of General Practice and Rural Doctors Association of Australia), needs to provide strategic solutions to the paperwork problem that also recognise the costs of implementation and change management for general practice. As the banking industry has demonstrated, the revolution in information and communication technology (ICT) can bring many efficiency gains. Government-funded incentives have driven the rapid uptake of computers in general practice, but the large shortfalls in the capacity of current software programs to deliver the necessary efficiency and productivity gains must be addressed. The GPRG must advocate for better ICT solutions that integrate medical records, clinical audits, information management systems and electronic decision-support systems; we also need solutions that bring practice management efficiency and connectivity along with the rest of the health care system. GPs have embraced software tools that improve the efficiency of their practices internally (appointment systems, billing systems, medical records) and externally (HIC online, Broadband for Health initiative, Australian Childhood Immunisation Register). However, the different components of the ICT solutions need to be brought together. We run the risk of losing the benefits of ICT in the paperwork battle if the GPRG does not address this as a priority. It is vital that the GPRG (i) supports the General Practice Computing Group,4 the peak body for GP informatics in Australia, which is working towards developing standards for integrated GP software, and (ii) negotiates with government and the ICT and medical software industry. As GPs we should not expect that all the solutions will come from government. Certainly government has a legitimate interest and role in working with the profession to find solutions (as it has done with the Red Tape Taskforce). However, we should expect that our own representative organisations remain united in their conviction and not lose sight of the urgent need for solutions for a balance between productivity, efficiency, professional satisfaction for GPs and quality care for our patients and our communities.

John Aloizos AM, MB BS

The Australian Primary Health Care Research Institute undertakes and commissions research with the aim of increasing the links between research and policy “Family, neighborhood, community are apple pie virtues, unassailable and unavoidable in political rhetoric.”1 In primary health care, we have our own rhetoric. The challenges facing the primary health care system are endlessly rehearsed: ageing of the population, management of chronic disease, equity, new technologies and workforce issues are but a few. These challenges are not unique to Australia — they drive reform of primary health care around the world. It is agreed that the goal of this reform is to improve health for individuals and communities, and that public policy on this reform should be in the public good, have clear objectives, be transparently communicated, and be assessable in terms of effectiveness, efficiency and achievements. It should also be informed by research evidence.2,3 Yet, sadly this is no more than comfortable rhetoric if there is no practical outcome. How can we move on? Moving beyond rhetoricBoth researchers and policy makers should move out of their “silos”.4 Research cannot be an isolated activity that never impacts on primary health care. Equally, policy formulation cannot be a secretive bureaucratic activity, viewing research as “naive, jargon-ridden and irresponsible in relationship to practical realities.”2 All players within the primary health care system must be engaged, including policy- and decision-makers in both the Commonwealth and the states and territories, researchers, and providers and users of primary health care services. Yet, lack of engagement is common. For example, the Asthma 3+ Visit Plan was tested as an intervention in a randomised controlled trial of structured asthma care in general practice.5 The design, conduct and reporting of this study were research-driven, and the results could not be disseminated until the peer-reviewed publication process was complete. However, just as the early results of the trial were becoming known to the research team, policy makers were fitting the Plan into Medicare through paid incentives for GPs to adopt and complete the Plan. The policy had to be implemented before the trial was formally published. There was no link between the researchers and the policy makers. Would the policy have been different if there was engagement between these parties across these activities? The players must be engaged at all stages of the policy research “cycle” — from priority setting and question formulation, through the development of research methods and conduct of research, to analysis and interpretation of results. Engagement must be real and may be uncomfortable. The role of research“Research” and “evidence” are value-laden words with different meanings for different players. The goal is valid and reliable knowledge that responds to the real needs of those using and providing health services, along with wisdom in applying this knowledge. If we are to achieve this, then all players must be willing to understand research and evidence from the viewpoints of the others. A range of research traditions will yield helpful insights.6 For example, policies for evidence-based clinical care of Aboriginal and Torres Strait Islander communities will be informed both by evidence-based medicine (EBM) and by a well developed understanding of Indigenous cultures derived from other research traditions, such as sociology. This is not a call for less rigour — it is a call for thinking beyond narrow methodological approaches. The role of research evidence in informing policy is broad.2 It should not be understood solely in terms of the findings of individual studies directly shaping particular policies. At times, the use of research evidence may be more symbolic — to add weight to a particular policy direction. At other times, research evidence may be used for enlightenment. For example, it may prompt participants to think in new ways about issues and potential solutions. The National Service Improvement Framework (NSIF) for Cancer is an example. This government initiative aims to drive improvements in health services through the development of a guide to “best practice”. Policy makers, the research community, clinicians, and other stakeholders have been actively engaged in the process through a consultative committee and a public consultation process. The resulting framework incorporates their different perspectives. Its usefulness is evidenced by its adoption as the model for the other NSIFs.7 Research needs to be undertaken within timeframes that are useful to policy makers. This does not rule out research programs longer than 3 years, but means that researchers should be aware of the timeframes that drive policy, such as 3-year election cycles, and should be willing to contribute to policy discussions despite their research being incomplete. In addition, concepts such as “track record” need to be rethought, as publications and grants received are not relevant measures of the success of policy makers and service providers. Methods need to be developed to appraise the relevance of research to policy making. Primary studies should be funded only when systematic reviews of existing evidence indicate they are required. For example, research to resolve the controversy about the role of nurses in Australian general practice should be built on what is already known from a systematic literature review, which is not yet available. If primary health care reform was easy, this editorial would be unnecessary. Research will not be perfect. Evidence will not be complete. Solutions will not be simple or universally acceptable. Reform will not happen overnight. Well intended innovations might deliver unintended harms. Patience, collaboration, good will and resilience are essential for the challenges to be met. The Australian Primary Health Care Research Institute (APHCRI) is a government initiative to increase the links between evidence and policy. Its brief includes prioritising research topics and questions relevant to national primary health care, and then commissioning and undertaking research to address these priorities. Announced as part of the federal government Primary Health Care Research and Evaluation Development Strategy,8 the Institute began operations in 2003. It is committed to a collaborative model that engages policy makers, researchers, providers and consumers in its activities. It adopts new approaches in setting its research priorities and funding research activities. It will go beyond rehearsing the challenges, and question some of our basic assumptions about how to achieve a more equitable, more efficient primary health care system delivering enhanced health outcomes for all Australians.

Nicholas J Glasgow MD, FRACGP · Beverly M Sibthorpe NZRN, BAHons, PhD · Robert Wells

Australia needs a coherent long-term strategy for implementing these systems Electronic Decision Support Systems (EDSS) have been defined as “access to knowledge stored electronically to aid patients, carers and service providers in making decisions on health care”.1 These systems provide relevant evidence-based information to both patients and health care providers at the time of making a decision about clinical management. More sophisticated systems provide a clinical decision based on information from a range of knowledge bases. EDSS are currently espoused as one of the keys to good quality and safe health care.2 With the current explosion of medical knowledge, most of which is stored electronically, both clinicians and consumers will increasingly require EDSS to assimilate and summarise information. Yet for most clinicians, there is a gulf between this ideal (see Box 1) and reality. Here, we look specifically at general practice, and we argue for the creation of a guiding body — a deus ex machina — to provide a comprehensive framework to remove all the constraints on achieving the full potential of EDSS. General practice cannot be considered in isolation, and EDSS will be used across the whole health care system. For this to happen, certain “clinical knowledge processes”, as identified by the National Electronic Decision Support Taskforce (NEDST), need to occur (Box 2).1 The NEDST was established under the ministerial National Health Information Management Advisory Council (NHIMAC) to address significant issues in the health sector’s information requirements for implementing electronic decision support . Australia has already done much to foster the uptake of EDSS (Box 3). In particular, the development of a vocabulary, data model and core data set for general practice within the Standards Work Plan by the General Practice Computing Group (Box 3) would allow seamless communication between different clinical software packages. These are important steps that should not be stalled because of political imperatives. While this progress has been important, significant developmental gaps still exist, and the entire “clinical knowledge process” must be embraced in a coordinated manner. Generating and integrating knowledgeDevelopment of computer-interpretable guidelines is not limited by clinical content, but by the clinical systems that exist today. To incorporate clinical concepts for use within an EDSS requires gathering specific clinical information and then incorporating it within the EDSS tool. The ideal EDSS knowledge base would seamlessly link these clinical concepts with standardised patient clinical records. Yet, it is unclear how this crucial linkage will be achieved when clinical computerised systems are presently imposed on general practice in an ad hoc and proprietary manner. Currently, there is no apparent active engagement between software developers, government, clinicians and funding bodies to establish a transparent and sustainable program of EDSS development in Australia. It is crucial that national bodies generate knowledge bases by developing clinical practice guidelines. Evidence points to the need for research on how guidelines may be implemented within EDSS to increase their acceptability in day-to-day practice.6 Each national body that develops guidelines should be working within a framework that explicitly states the eventual role of EDSS in their implementation. Clinical applicationWe currently lack a generic standards-based “middleware” that would sit outside all clinical desktop software systems and support the exchange of information with other clinical systems and clinical knowledge repositories. In Australia, no such standards exist, leaving EDSS development dependent on the whims of the software vendors. In the United Kingdom, although the National Health Service (NHS) has just agreed to allow greater choice among clinical desktop software packages, all clinical software must conform to minimum standards of interoperability within the NHS.7 Evaluation of efficacyA recent systematic review of 100 randomised and non-randomised trials of EDSS that aimed to improve clinical performance and patient outcomes found that, of the 97 studies that measured practitioner performance, 62 (64%) showed improvement — four in diagnosis; 16 in reminder systems; 23 in disease management systems, and 19 in prescribing.8 Of 51 studies examining patient outcomes, only 7 (13%) showed improvement (in blood pressure control, rates of urinary incontinence, outcomes with acute respiratory distress syndrome, asthma, anticoagulation management, and the care of people with acute myocardial infarction). The EDSS research agenda must begin to look more systematically at the influence of EDSS on patient outcomes and quality of care. One report argues that more multidisciplinary research is required to map and understand the “complex system” of day-to-day general practice, “in which technologies, people and organisational routines dynamically interact”.2 Other studies have identified similar concerns.9 Multidisciplinary research teams involving psychologists, fulltime GPs, practice staff and qualitative researchers must be adequately funded and supported over a number of years to realise this goal.10 NEDST has called for rigorous evaluation of EDSS programs, but only after programs were well established within a workplace.3 ConclusionThere is clearly much to be done and, at the moment, there is no obvious coherent long-term strategy in Australia to drive the EDSS agenda forward. The solution may be to establish a national EDSS coordinating centre with substantial funding and expertise. A multidisciplinary framework will be required, which includes appropriate long-term funding and meaningful intellectual property arrangements with software vendors to promote open standards. This would be an excellent first step to move this agenda forward in a balanced, integrated and evidence-based framework linked to appropriate policies, legislation and standards development. 1 Electronic decision support systems (EDSS) case study: the ideal A 44-year-old man presents to his general practitoner with newly diagnosed hypertension. The GP reviews his blood pressure and prepares to assess his cardiovascular risk using the EDSS. The EDSS directly integrates all his electronic medical record information (lipid levels, smoking status, family history, age, sex, and weight) to calculate his risk score. This provides a comprehensive profile that contains all relevant information which can be quickly updated on subsequent visits. The GP opens the software, selects the patient from the practice database and begins to work through the tool, entering the clinical information directly into the EDSS. As he goes, he shows the patient how he calculates his risk of cardiovascular disease and how the patient can alter the level of risk. This visual demonstration helps the patient realise that he must change his behaviours. They discuss the options available. To educate the patient on how to moderate his risk and adopt healthy behaviours, the doctor shows him the embedded resources and video on hypertension, exercise and salt intake. The GP chooses the best evidence-based management plan and prescribes new medication. The management plan is instantly updated in his notes. The EDSS automatically places the patient on the practice-based cardiovascular disease register. The patient feels reassured and informed. Details of his clinical management will now form part of the GP’s quality improvement audit. 2 The “clinical knowledge process”, from building the evidence to implementing a decision support “product” Identified by the National Electronic Decision Support Taskforce.1 3 Achievements in implementing Electronic Decision Support Systems (EDSS) in the Australian health sector to date Identification of six key areas for improvement by the National Electronic Decision Support Taskforce: (i) fostering research; (ii) development and best practice in the implementation of EDSS; (iii) enhancing the safety and quality of EDSS; (iv) establishing a national standards framework; (v) encouraging an evaluation culture; (vi) encouraging the use of EDSS and establishing a national governance model.1 Creation of an evaluation framework for EDSS by the Australian Health Information Council.3 Establishment of the National e-Health Transition Authority to accelerate the adoption of e-health by such measures as developing standards for the exchange of clinical information; enabling the unique identification of patients, providers, products and services; and integrating infrastructure.4 Initiation of the Standards Work Plan by the General Practice Computing Group to develop a vocabulary, data model and core data set for general practice.5

Justin J Beilby MD, MPH, FRACGP · Andre J Duszynski BSc · Anne Wilson PhD, BN, MN · Deborah A Turnbull MPsych(Clin), PhD

“Advanced access” is a set of change principles for improved scheduling in office-based health care, widely applied in the United States and in the United Kingdom. Examination of advanced access in two Australian general practices indicates it is feasible in this country and may offer improvements in patient access to care, practice income and workplace conditions. Rigorous evaluations of advanced access are lacking, but in the Australian National Primary Care Collaborative, 300 practices will implement advanced access, providing an opportunity for a rigorous evaluation of these principles.

Andrew W Knight MB BS, MMedSci(ClinEpid), FRACGP · John Padgett MB BS, DRANZCOG, FRACGP · Barbara George · M R Datoo MB ChB, FACCRM

Australia has begun to encourage and financially reward general practitioners for implementing preventive activities. While an expanding preventive agenda for general practice remains attractive, there is a real potential for opportunity costs, especially in the absence of realistic practice-based support for preventive care. These costs may include a shift from the needs of individual patients to those of the community. It is crucial not to neglect the concept of relationship-centred primary care (which may actually enhance preventive activities), as well as enhancing the preventive environment of the practice, when considering strategies to improve preventive uptake.

Grant M Russell FRACGP, DRANZCOG, MFM

Primary health care (PHC) reforms focus on improving access to and effectiveness of general practice services, with greater emphasis on health promotion, prevention and chronic disease management, and integration with population health approaches. Currently, reforms are often based on scant evidence from the most accessible and easily known PHC domains and activities, yet most PHC is complex and poorly understood. Complexity theory is based on understanding patterns that are not predictable by traditional evidence and social knowledge, within a complex adaptive system. Complexity knowledge provides a way of understanding the general practitioner’s role in PHC in self-organising local networks, with a capacity to generate new solutions integrated through historical and social connections. Complex systems provide a framework for an expanded knowledge base, debate and discussion of reforms and development of PHC goals and strategies.

Carmel M Martin PhD, MSc · Joachim P Sturmberg PhD, MFM, FRACGP

Primary care research has been described as a “lost cause”, and, although this claim has been strongly refuted, general practitioners publish less research than their colleagues in surgery, medicine and public health. Despite a fivefold increase in Australian general practice research papers from the 1980s to the 1990s, fewer than half of these focused on clinical topics. Trying to establish a global figure for expenditure on general practice and primary care research is difficult, but data show that public expenditure for primary care research is minimal in Australia, New Zealand, the Netherlands and the United Kingdom — fewer than $1.50 per capita in 2002–2003. Compared with hospital- and laboratory-based research, primary care receives significantly fewer resources, ranging from 3.2% of total public expenditure on health and medical research in the Netherlands to 6.8% in New Zealand. Government-led investment in interventions such as strengthening primary care departments and colleges and supporting primary care academics, establishing practice-based networks, fostering international initiatives for cross-national efforts, and engaging individual primary care practitioners in research projects, are all required to build research capacity in primary care.

Brian R McAvoy MD, FRACGP, FRCP