Perspectives

Effective clinical practice is predicated on valid and relevant clinical science — a commodity in increasingly short supply. The pre-eminent place of clinical research has become tainted by methodological shortcomings, commercial influences and neglect of the needs of patients and clinicians. Researchers need to be more proactive in evaluating clinical interventions in terms of patient-important benefit, wide applicability and comparative effectiveness, and in adopting study designs and reporting standards that ensure accurate and transparent research outputs. Funders of research need to be more supportive of applied clinical research that rigorously evaluates effectiveness of new treatments and synthesises existing knowledge into clinically useful systematic reviews. Several strategies for improving the state of the science are possible but their implementation requires collective action of all those undertaking and reporting clinical research.

Ian A Scott FRACP, MHA, MEd · Paul P Glasziou FRACGP, PhD

Donor countries withdraw HIV funding just when compelling evidence on prevention emerges The global epidemic of HIV and AIDS started in sub-Saharan Africa, and there are now 23 million people in the region living with HIV, representing 68% of the world total. In December 2011, I participated in the 16th International Conference on HIV/AIDS and Sexually Transmitted Infections in Africa (ICASA), held in Addis Ababa, Ethiopia. The conference was full of good news about progress against HIV over the past few years, but there was also a great deal of concern about the ability to sustain the momentum. The 2011 Global HIV/AIDS Response progress report, released on 30 November, showed that the number of new HIV infections in sub-Saharan Africa declined from 2.2 million in 2001 to 1.9 million in 2010, and the number of AIDS-related deaths declined from 1.7 million in 2005 (the peak) to 1.2 million in 2010.1 The decline in AIDS deaths is mainly due to the increased availability of antiretroviral therapy (ART), and the main reason for the availability of ART in Africa is the United States President’s Emergency Plan for AIDS Relief (PEPFAR). President George W Bush established PEPFAR in 2003, and he was guest of honour at ICASA. The 5000 delegates gave him a standing ovation as he approached the podium to deliver his address. A major cause for optimism at ICASA was the recently published evidence that ART can effectively prevent transmission of HIV, a concept called “treatment as prevention”. Results from a randomised trial published in August 2011 showed that early initiation of ART for the HIV-positive partner in a serodiscordant couple reduced HIV transmission to the HIV-negative partner by 96%.2 Other studies published in 2011 have shown that use of ART by the HIV-negative partner reduces risk of HIV infection.3 This all bodes well for control of HIV in Africa — but only if there is adequate funding. Overshadowing ICASA was the spectre of cuts to foreign aid to Africa as a result of the global financial crisis. Just before ICASA, the Global Fund to Fight AIDS, Tuberculosis and Malaria announced that it was cancelling Round 11 of its funding. One of ICASA’s keynote speakers, Canada’s Stephen Lewis, was particularly scathing in his criticism of the Global Fund and its donor countries. Like previous speakers, he warned that a reduction in funding meant that people would die because of lack of access to ART. But Lewis went further. He said: “The decision on the part of the donor countries is unforgiveable ... It’s unconscionable, indefensible, outrageous. It’s murder, that’s what it is: murder.”4 While the Global Fund’s decision to cancel Round 11 was unexpected and shocking, there was, nevertheless, general recognition at ICASA that African countries need to become less dependent on donors in their efforts to control HIV and AIDS. Indeed, the theme of the conference was “Own, scale-up and sustain”. One of the advocacy groups at ICASA — these conferences tend to involve a nice mixture of scientists and activists — was lobbying hard for African governments to spend 15% of their budgets on health, as they had agreed to do in the Abuja Declaration as long ago as 2001.5 Led by its Minister of Health, Dr Tedros Adhanom Ghebreyesus, Ethiopia is one country that is taking a comprehensive approach to improving the health of its population. Dr Tedros has often been called the “world’s best health minister”. His major achievements include training and deployment of 38 000 health extension workers and an increase in medical school admissions from 250 students in 2005 to 2500 in 2012. At ICASA, he spoke of how he has used donor funding for HIV programs as a platform for strengthening the entire Ethiopian health system. There was only a handful of Australians at ICASA. I worked with HelpAge International, the World Health Organization and UNAIDS (the Joint United Nations Programme on HIV/AIDS) to convene a workshop on HIV in people aged 50 years and older, and Dr Daniel O’Brien from Geelong presented data from his work with Médecins sans Frontières on false positive results from rapid diagnostic tests for HIV. It’s a pity there weren’t more of us. Ethiopia holds a special place in Australia’s relationship with Africa. It is the site of the fistula hospital established by Australian Dr Catherine Hamlin and her husband, and also a new Australian Embassy that will soon start allocating significant funding for maternal and child health. ICASA shows that the next few years will be crucial to health in Africa. Australian doctors should contribute more to the continent with the highest burden of disease.

Robert G Cumming MB BS, MPH, PhD

Increased research in the area of complementary and alternative medicine (CAM) is urgently required, in addition to a balanced appraisal and communication of the state of evidence in the field. Current challenges for clinicians and the public in accepting purported CAM evidence concern potential selective publication of results, marked differences in product quality ...

Jerome Sarris PhD, MHSc

Ray Moynihan explores dilemmas over public access to records on professional misdemeanours These days, it seems technology starts to answer the questions it raises, even before we’ve had time to properly formulate them. As social media and sophisticated software force previously unimagined forms of transparency deep into the fabric of our lives, asking where to draw the line between professional privacy and the public right to know feels somehow old-fashioned. Yet, the answers will affect the future of health care, its massive workforce and the population at large. Australia’s new national register of over half a million health professionals now offers the possibility of searching someone’s entire track record with one click. The extent to which we embrace this new opportunity is the subject of an emerging debate that’s likely to generate a lot more attention. A powerful piece of investigative journalism from the new Global Mail outlet has laid out some of the groundwork for this debate, citing examples of past egregious conduct which fails to appear on practitioners’ current registration records.1 One case involved a nurse being repeatedly violent to nursing home residents; another featured a pharmacist moving large amounts of flunitrazepam, popularly known as a “date rape” drug; a third involved a doctor using cocaine with, and making sexual advances to, a receptionist and being convicted of criminal charges. As the Global Mail made clear, there is no legal requirement for past suspensions or reprimands — even for serious misdemeanours — to be part of the current registration record of a practitioner. What the new law does require is transparency about ongoing restrictions on a provider’s registration — which is, of itself, a major improvement on the old situation where many adverse findings were effectively secret. “The level of trust in regulators needs to be high”, says Joanna Flynn, chair of the Medical Board, one of the 14 boards that sit within the new Australian Health Practitioner Regulation Agency, in an interview. “If it looks as if we’re hiding anything it could diminish that trust.” She points out that the new register’s site also has links to external legal databases with previous decisions of courts and tribunals, though these can be difficult to track down. As to the question of whether everything in a practitioner’s track record should be easily available at the push of one button, “that’s for a wider debate”, Flynn told me. The new agency’s chief executive officer, Martin Fletcher, agrees. “I think there’s an important debate to have about transparency. There’s no right or wrong answer”, he said when I interviewed him, adding that the register is in place to protect the public, not punish practitioners. The clear tension here is between professionals wanting to protect their reputations and move on from past problems, and the public wanting to make the best decisions about who they want to care for them. “The debate is live, fraught and controversial”, said Ian Freckelton SC, a barrister and law professor at Monash University with long experience on health tribunals, in my interview with him. He says community expectations have changed significantly in the past decade, and there is a need to balance complex issues of privacy, rehabilitation, access to information and informed decision making by patients — which can be more complex still when involving a practitioner’s individual health condition. “This is something we’re just forming our views on.” There does seem to be an informal consensus about the need for a formal public consultation on the extent of transparency on the new national register. Should there be full one-click transparency of the entire track record, or should practitioners’ entries be cleared of problems they have demonstrably overcome? “We believe in rehabilitation”, said Merrilyn Walton, when I interviewed her. Her default position is full transparency, but with the opportunity for material to come off the registration record on a case-by-case basis. A former consumer watchdog and now board member for the new registration agency, she told me in her capacity as professor of patient safety at the University of Sydney that she’d like to see widespread public consultation: “We need to talk about this”. There seems little doubt we’ll soon be doing a lot more talking about the merits and limits of one-click transparency.

Ray N Moynihan BA

A window of opportunity for change The current health care reform process is remarkable for its lack of attention to private non-general practice (non-GP) specialist services. About 23 million ambulatory visits are made to non-GP specialists each year, and $1.6 billion of the Medicare budget flows to these services. For the patient, effective collaboration between his or her various health care providers is essential for safe, high-quality care. This is particularly so when the patient is consulting more than one non-GP specialist. An individual with type 2 diabetes, for example, might be seeing an endocrinologist, a nephrologist, a cardiologist and perhaps others, in addition to his or her general practitioner and allied health providers.1 The final report of the National Health and Hospitals Reform Commission (NHHRC) noted the key role of non-GP specialists in the shared management of care for patients with complex and chronic health needs, and recommended improving access to a more comprehensive and multidisciplinary range of primary health care and specialist services in the community through the establishment of Comprehensive Primary Health Care Centres and Services, available for extended hours.2 However, the current reforms are concerned almost exclusively with public hospital, general practice, community and primary care services. While GP Super Clinics may provide consulting facilities for visiting medical specialists, there are currently only 64 implemented or planned across Australia, and there is no formal requirement or policy incentive for functional integration between non-GP specialists and members of the primary health care team working in the same GP Super Clinic.3 So is there a problem? Potentially, yes. The vast majority of non-GP specialists in private practice are highly skilled, committed practitioners. Nevertheless, the lack of a comprehensive policy framework means that access to private specialist services is determined largely by market forces. This is most apparent in the geographical maldistribution of the medical workforce, with relatively few non-GP specialists choosing to work outside metropolitan areas. Moreover, almost no improvement in specialist–population ratios in remote and rural areas is expected over at least the next 8 years.4 Even in metropolitan areas, there is a tendency for private specialists to practice in affluent areas, limiting the choice available to patients in more deprived areas, whose mobility may be reduced by poverty or disability. And yet it is in socioeconomically deprived areas that patients are more likely to suffer multiple chronic diseases.5 It is striking that about 80% of general practice consultations but only 27% of non-GP specialist appointments for ambulatory care are bulk billed.6 The average gap between the fee charged by a non-GP specialist and the Medicare benefit received by a patient who is not bulk billed is $46.12. A recent Australian Bureau of Statistics (ABS) survey found that about 10% of Australians referred to a non-GP specialist delayed or did not keep the specialist appointment because of cost.7 Unlike in general practice, there are no Medicare incentives for non-GP specialists to bulk bill for most consultations. The Medicare Safety Net helps, but it is clear from the ABS data quoted above that up-front billing can exceed the cash reserves of many patients. A further potential problem with the lack of a policy framework for private non-GP specialist services is the risk of lapses in quality and safety. All medical practitioners in Australia are required to provide evidence of participation in continuing professional development at the time of annual registration but, unlike the accreditation process for general practices, there is no requirement for the quality review of non-GP private specialist practices, with the exception of imaging providers and laboratories. Lapses in the quality of non-GP specialist care are likely to be rare, although few rigorous data exist, but when they occur the implications can be disastrous.8 A more common threat to quality and safety may be lack of timely communication with the patient’s general practitioner following every consultation by another specialist.9 This can have major ramifications for a patient with complex care needs. There is very little point in a doctor seeing and advising a patient without communicating with the other health practitioners involved in his or her care. Radiologists, pathologists and non-medical health practitioners who provide Medicare-rebateable services following referral are required to supply a report to the referring doctor, and it seems reasonable for such reporting to be universally expected of all referred services. No systematic data exist, but general practitioners report frequent frustration at the lack of timely communication from other medical colleagues.10 These difficulties are further compounded by failure to implement the NHHRC’s recommendation of strategies to assist patients living with complex health problems to adopt a single general practice as their “health care home” responsible for continuity and coordination of care.2 So what is required to address these problems? Medicare Locals are currently being rolled out across Australia, replacing Divisions of General Practice, and will be required to work with local clinicians — including Lead Clinician Groups and presumably individual specialists — “to identify and remedy service gaps and breakdowns in service integration and coordination”.11 However, their ability to bring about change at regional level will be limited without a national policy framework that includes provisions relating to non-GP private specialist practice. General practitioners receive incentive payments for bulk-billing concession card holders and children. For reasons that are not clear, other specialists only receive bulk-billing incentives for telehealth consultations. A Medicare incentive for non-GP specialists to bulk bill consultations and other services for concession card holders and children would help to address the financial barrier faced by many patients. Such an incentive would also help redress the potential differential in revenue for specialist practices between affluent and deprived communities. A bulk-billing incentive would be more socially just than the current Extended Medicare Safety Net (EMSN) which, on the ABS evidence cited above, fails 10% of referred patients. A review published in 2011 found that some 53% of EMSN benefits were distributed to the 20% of the population living in Australia’s most socioeconomically advantaged areas, whereas the 20% living in the most disadvantaged areas received only 3.7% of benefits.12 Medicare rebates should be contingent on a report being provided for all referred medical services, not only pathology and imaging services. It will become easier to ensure that such reports are accessible to all treating health professionals once the impediments to a national personally controlled electronic health record are overcome. Incentives are required for all health practices, not just general practices, imaging providers and laboratories, to undergo regular accreditation. The present Australian health reform process provides a window of opportunity to develop and implement policy changes relating to private non-GP specialist practice, ensuring that the considerable public funding flowing to this sector of the health system achieves the most effective and equitable contribution to the nation’s health.

Tim P Usherwood MD, FRACGP, FRCP

“When you have seen one AHSC, you have seen just one AHSC” — Academic Health Sciences Centre, National Task Force Final Report1 Australia’s health system is struggling to meet demand and expectations. Demand is driven by an increasing burden of chronic non-infectious disease associated with ageing.2 Expectations of cutting-edge care for all are set by the public and by government.3 Meeting these demands and expectations will be possible only with substantial effort in research and education as part of health service delivery. Separation of funding for research and education from the delivery of patient care diminishes the opportunity for mutually enhancing integration, and for expenditure efficiencies.4,5 Recognising the importance of evidence-based clinical practice in quality and efficiency of health care delivery has been a driver for the creation of academic health sciences centres (AHSCs) in the United Kingdom6 and Canada.1 Australian commentary on AHSCs7 has emphasised an absence of government leadership in establishing AHSCs in Australia. It is critical to the success of AHSCs as a tool for optimal health care delivery that they are inclusive, and that they set performance benchmarks in service delivery, education and research, while neither aspiring to elitism, nor separating their activities from the provision of health care itself. In early 2010 and 2011, a group of Brisbane hospital, university and community health care practitioners, administrators, educators and researchers had several meetings to consider the feasibility of establishing an AHSC. They recognised that some integration of education and research with service delivery was already occurring. A successful example of this was a hospital-based research program that had led to the development of cervical cancer vaccines,8 which had led to development of research facilities. This and other similarly successful programs were facilitated by leadership from individuals; however, an environment that encouraged activity by all practitioners was seen as likely to result in better outcomes in education, research and service. The meetings concluded that providing such universal support would improve health care, and further noted that failure to combine the three domains could be wasteful. Several barriers to integration of education and research with service delivery were identified, which could be resolved by using a partnership model between local research institutions, public and private health care providers and educational facilities. Emphasising a partnership meant moving from a workplace focus to integrated management and service delivery structures across boundaries between primary and tertiary health care, and between education and research. The partnership model was chosen because governance was identified as key to realigning the purposes of hospital and academic institutions.9 Although it was hoped that merging many of the partners’ processes would occur with time, it was agreed that incremental changes in leadership and management structure could usefully start the process. These changes would be prioritised in terms of their potential to have a positive effect on health outcomes and resource efficiency. Developments in health and hospital reform and the release of a National Health and Medical Research Council position paper on designation of Advanced Health Research Centres in 2010, to which the group provided comments, helped launch the Diamantina Health Partners (DHP) in mid 2011 as an AHSC. This partnership brought together the University of Queensland (UQ) PA-Southside Clinical School, UQ Diamantina Institute, UQ general practitioner partners, research and teaching components of the Queensland University of Technology (QUT), the newly created Translational Research Institute (TRI), and health service delivery units from the Princess Alexandra and Mater Hospitals. The partnership is a functional (not legal) one, with relationships and governance determined by a signed memorandum of understanding (MOU). The MOU covers the following issues relating to governance: The DHP board is entrusted to explore options for the best organisational vehicle for the DHP (which in time may become a separate legal entity). Sufficient internal resources will be committed by the partners as appropriate to achieve outcomes, with each (except the TRI) making an initial financial contribution for the development of the DHP. Financial contributions may be varied by mutual agreement of the board. The initial financial commitments of the DHP are the costs of a senior administrative consultant and workshops for strategic developments. All income remains with the participating entities. The board is to formulate and control administrative and strategic development. Mission and visionThe major aim of the DHP is to integrate research, teaching and training with clinical service delivery, to enable internationally benchmarked, quality health care to be delivered in a timely and cost-effective manner. We recognise that complete integration is not realistic, but believe that mutually beneficial strategic decisions at university and hospital levels will facilitate achievement of the vision. Initially, we will align the strategic goals and plans of DHP stakeholders with expectations of patients using DHP services, for which we established six principles of development (Box 1). Planning coordination is pivotal to the success of the DHP, and we believe education of clinical staff in research will encourage critical evaluation and application of new ideas and therapies in clinical care — skills to improve hospital performance in key performance indicators relating to efficient use of health care infrastructure (Box 2). Staff discussions about conjoint appointments facilitating teaching, research and clinical services are underway between the partners. Current situationOne of our most pressing problems is engagement and representation in the DHP, which we are using our committee structure, reporting system, discussion groups and user groups to address. Early success in engagement is evident in collaboration on draft proposals and in facilitation of clinical research (by building clinical trial enrolments into performance indicators of service providers and departments). Engagement success is also seen in the teaching of medical, allied health and nursing students about clinical research methods, and by facilitating encounters between clinicians and basic researchers. Engagement is important from the strategic and survival perspectives of the DHP, and various strategies to benefit health and working environments are being planned. The ability to address new barriers is also crucial to success. Another issue is that although the DHP board needs to have strategies in the best interests of the DHP, some partner representations on the board will be necessary, at least initially. The long-term aim is to have the right mix of people and skills acting in the interests of the DHP. An appropriate policy for membership of the board and its committees is being developed, as is a structure for successful implementation of DHP strategy into practice. Clear governance lines between the board and the partners will be necessary. Lastly, board diversity needs to be considered. The increasing number of women who are clinical academic leaders in Queensland will help achieve a balance of sexes. Care must be taken not to change organisational structure unless changes are clearly linked to improving health outcomes. Areas under consideration include harmonisation of job descriptions and salaries between employment agencies, transparency of data and information technology services, and standardisation of intellectual property and commercialisation management. Setting research and policy priorities is underway. An evident failure to deliver the vision espoused in the original 2010 proposal for health reforms threatens the existence of AHSCs, as federal funding for research, education and health remain separated. It is expected that the DHP will be politically independent and the board will be accountable for policy delivery and efficient use of public funds. The outstanding issues to be resolved by the DHP board are engagement; structural and policy “levers” it can use to influence institutional strategies; and ensuring strong alignment between the DHP and its individual components. SummaryMany have asked “what is the benefit of the DHP over the current situation?” We believe that the responsiveness of research to community health needs and the balance of research and teaching outcomes in academic institutions can be improved, and stronger incentives to integrate research outcomes into clinical practice can be provided. The DHP is thus set up differently to a clinical research centre. The aim of our DHP is to improve health outcomes by means of coordinated excellence in teaching, research and clinical care. Technical efficiencies and excellence in care mean that financial efficiencies will occur. Joint clinical, research and teaching initiatives are underway, and plans are being developed to teach future clinical staff the science of clinician-directed, rational use of medical resources. These include pathology, imaging services, pharmaceuticals and patient referrals, assisted by published expert guidelines. There are significant administrative and personnel issues to surmount, but planning for integration has begun, and plans for turning research outcomes into clinical care plans are already emerging. 1 Six principles of development The Diamantina Health Partners (DHP) will work towards: 1. A joint governance structure promoting a coordinated effort towards better health care. The DHP governance structure is based on a partnership — a non-incorporated joint venture. This structure enables partners to honour obligations to other entities. Functional integration is supported through joint appointments and creation of joint activity streams. 2. Jointly determined key performance indicators (KPIs) in patient care, education and research. Traditional measures of research focused on publications and of teaching based on student assessment were felt not to provide an ability to measure relevant contributions to health outcomes or “quality”. 3. A jointly agreed strategy for improving health care, focused on health and wellbeing. 4. Administrative processes aimed at accelerating dissemination of research-based evidence into clinical practice. 5. Collaborative use of public resources with public accountability. Cost-effectiveness is part of DHP strategy. Collaborations that ensure the best use of public resources and public accountability are encouraged. Reporting towards KPIs that relate to measurable health improvements will be introduced. 6. Common drivers encouraging development and improvement of clinical innovation, training and health policy. Proven strengths on the DHP campuses will be used as exemplars for setting aims and employment standards at an international level. 2 Clinical issues that could be improved with better linked education and research Role of emergency department for multiple attenders and for people with chronic conditions Bottlenecks in internal medicine discharges and the primary–secondary health care interface Providing health care for areas of high medical need, such as bariatric surgery versus a proliferation of obesity clinics in tertiary hospitals Use of expensive pharmacotherapies that have not been proven to meet clinically relevant end points, and which may cause high rates of adverse drug events New research tools such as genomics for predictive management of disease or response to drug therapies, streamlined by information gained from health services research in a particular health district

Jennifer H Martin FRACP, PhD · David E Theile MB BS, FRACS · Ken K Y Ho MD, FRACP, FRCP(UK) · Ian H Frazer FRCPE, FRCPA, FAA

The challenge of removing what’s useless, harmful or cost-ineffective It’s easy to forget that the evidence-based approach to medicine is still relatively new, and that a substantial part of health care is not supported by gold-standard evaluation. New procedures, until very recently, have had no requirement for rigorous testing, unlike new drugs. Of the more than 5000 items on the Medicare Benefits Schedule (MBS) today, most “have never been comprehensively assessed for their safety, effectiveness and/or cost-effectiveness”.1 But now many more interventions will be exposed to the chill winds of evaluation. And those that don’t shape up could become targets for “disinvestment” — withdrawal of funding from existing treatments. Although not explicitly mentioned, disinvestment is part of the thinking behind recent developments in Canberra. Announced in the current Budget, a “comprehensive management framework” for Medicare strengthens assessment of new treatments, and introduces “rolling reviews” of existing interventions, to assess quality, safety and fee levels.2 Systematic methods will be developed to inform “appropriate amendment or removal of existing MBS items”. Judging by the progress of several “demonstration reviews”, clinicians nervous about threats to their livelihoods needn’t worry too much. Sensitive about perceptions of taking something away, the federal government is treading warily — using maximum engagement with affected specialties. For example, despite finding colonoscopy use had jumped an extraordinary 84% in just a decade, the review of this procedure gave it a big thumbs up.3 The most comprehensive review is the ongoing whole-of-specialty review of ophthalmology. A report has been produced by Adelaide Health Technology Assessment, at the University of Adelaide, advised by a clinical working group from the Royal Australian and New Zealand College of Ophthalmologists (RANZCO) — in close collaboration with the health department.4 The report suggests a number of minor changes, including tightening the patient pool for a handful of Medicare items, but little in it is controversial. Importantly, assessing costs was strictly excluded. A key challenge in reviewing the evidence behind all the tests and treatments used by ophthalmologists was actually finding the evidence. Sometimes there was little published literature, so reviewers relied on guidelines built on consensus rather than on solid evidence. And existing procedures tended to be treated more leniently in the review than new procedures seeking funding today. Alex Hunyor, a representative of RANZCO who is intimately involved in the review, says some treatments, particularly medicines, lend themselves to randomised controlled trials, whereas with surgery often “the evidence is not necessarily of the type we’d like it to be”. He adds that, in cases where technology is evolving quickly, “we can’t necessarily say, ‘here’s the hard evidence’”. A high-profile example of a procedure without hard evidence from another specialty area is vertebroplasty. After a long battle between proponents and critics, trials showing no meaningful benefit, and an independent review, the government’s Medical Services Advisory Committee recommended dropping the procedure — a powerful example of disinvestment.5 Three clinical advisers disagreed with the recommendation, but it was accepted. The procedure no longer carries a Medicare rebate. In the United States, the failure to similarly disinvest in vertebroplasty has become a case study in the difficulty of withdrawing support from well established procedures unsupported by good evidence.6 Even in the United Kingdom, where debate is well advanced, decisions to disinvest are often not implemented in practice. Not surprisingly, the term “disinvestment” is little loved, rather than being seen as a positive attempt to bring scientific accountability to health care funding. “We’re trying to work together to get better value for money” is how the process is described by Ian Larmour from the Southern Health network of hospitals in Victoria, which has generated considerable savings using “therapeutic equivalence” to seek lower-cost medicines.7 It’s vitally important that Medicare’s rolling reviews are as rigorous and independent as they can be, to bring much needed scientific scrutiny to medicine’s vast back catalogue. Outcomes would be more credible if the influence of vested interests in the process was diluted, and the effectiveness, safety and cost of existing treatments was assessed with the same rigour applied to new ones. A healthy dose of disinvestment — no matter how unpleasant the term — may be required for those treatments where the balance of benefits, costs and harms is unfavourable. It’s not unhealthy rationing, it’s rational health policy.

Ray N Moynihan BA

Despite significant recent public investment in mental health, do we really know what Australia is getting for its money? In response to repeated inquiries revealing a profound crisis in the provision of mental health care services,1 Australia has committed to spending around $8 billion of new money on mental health since 2006. Few would argue that this investment was long overdue, given the significant gap between the funding mental health receives ($5.8 billion2 out of $113 billion of total health expenditure in the 2008–09 financial year3) and the contribution of mental illness to the burden of disease (13%).4 However, proper accountability for this expenditure is crucial. Health care consumers, carers, service providers, funders and taxpayers all have a right to know that funding for mental health is being spent judiciously, is targeted at the areas of greatest need, and is delivering better outcomes for people with mental illness. Establishing this accountability is not easy. The complexity of state and federal Budget announcements (and re-announcements) are the modus operandi of governments and perpetuate an environment characterised by opacity rather than transparency. After decades of underfunding for mental health services, new funding is often simply welcomed without query as to provenance or policy. In this article, we review the recent wave of mental health funding decisions in Australia. While we want to see the level of funding increase, such increases must be evidence-based, effectively delivered and transparently monitored. Recent mental health fundingThe major contribution to recent funding for mental health has been through the Council of Australian Governments (COAG) National Action Plan (NAP) on Mental Health 2006–2011.5 This provided $5.5 billion, comprising $2.2 billion from the Australian Government and $3.3 billion from the states and territories. However, analysis of Medicare Benefits Schedule (MBS) item reports shows that the uncapped growth in the Better Access to Psychiatrists, Psychologists and General Practitioners through the MBS (Better Access) initiative alone accounted for $2.1 billion by September 2011. It is concerning that, for such a sizeable investment, there have only been two NAP progress reports published, the most recent being released in September 2009.6 A subsequent COAG agreement in 2010 included $1.6 billion to be spent on subacute care, with an unspecified proportion to be allocated to mental health. Lastly, there is the federal government’s 2011 Budget announcement of a “record” $2.2 billion investment in mental health, partly funded through changes made to curb government payments under the Better Access initiative. A large proportion of this package was to enable continued funding of existing programs like Better Access, but the Budget also continued the government’s extensive investment in largely untested semi- or non-professional coordination of services (the Personal Helpers and Mentors Program) and “flexible” packages of care. There are as yet no data to assess how this new funding is progressing. In total, this new spending represents a significant public investment in mental health and, as such, deserves scrutiny. COAG National Action Plan fundingThe $5.5 billion committed in the 2006–2011 COAG NAP was allocated across four agreed action areas. However, there were no agreed definitions as to what activities could or should occur within each action area, and jurisdictions had complete autonomy over how money would be spent and reported. Consequently, there were significant variations in the funding allocations between jurisdictions (Box).6 Fully two-thirds of all NAP funding was allocated to Action Area 2 — “integrating and improving the care system” — while only 5% was allocated to Action Area 4 — “increasing workforce capacity”.6 The bulk of Action Area 2 funds went to the Better Access initiative. Supported housing options, community participation and employment (Action Area 3) remained secondary elements of the NAP, accounting for 17% of total funding allocations. In New South Wales, more than half the spending in this area ($58 million) was on one program — the Housing and Accommodation Support Initiative. Victoria pledged to spend about $44 million on growing its psychosocial rehabilitation sector, but over a 5-year period (2006–2011) this would barely cover anticipated price pressures and wage increases, let alone service expansion. Increasing access to mental health care was clearly a key goal of the NAP, but the evidence for progress is equivocal. The second NAP progress report certainly shows substantial service growth over the period 1997–2007, largely accounted for by the growth in Medicare-funded (Better Access) services.7 It reported that the proportion of the Australian population receiving clinical care for mental illness under Medicare rose from 3.1% in 2006–07 to 4.8% in 2007–08.6 However, the same progress report also shows that the proportion of the population accessing state-run mental health services dropped from 1.6% to 1.5%. Further, the National Survey of Mental Health and Wellbeing conducted by the Australian Bureau of Statistics in 2007 showed that treatment rates for people with a mental illness were unchanged since 1997.8 If the spending effort in Action Area 2 has not led to a discernible increase in treatment rates, then what substantive impact is this increased investment in traditional services having on mental health care in Australia? One explanation might be that new funds and new services are struggling to reach new clients. The data for state-run mental health services in the second NAP progress report indicate that this is the case for state and territory services. The current debate regarding the effectiveness and reach of the Better Access initiative is significant in this regard.9,10 There is evidence suggesting that groups who were missing out on care before Better Access are still missing out. In 2008, 68% of people using the Better Access program were using it for the first time. In 2009, this figure had dropped to 57%.11 The NAP progress report does not provide reasons for the variation in spending priorities between jurisdictions. There is no context to explain why Western Australia should allocate nearly a quarter of its funding to Action Area 1, while Queensland spent almost nothing (Box). Similarly, WA spent four times as much as South Australia on Action Area 3, and the Australian Capital Territory allocated 20% of its effort to workforce development, to which Victoria committed less than 1%. It is conceivable that these jurisdictional variations may be based on local service deficiencies and are therefore warranted. However, if this is the case, it is not clear how such deficiencies were identified. The NAP progress report shows a patchwork of jurisdictional investments rather than a coordinated national effort to address the agreed priorities. In the absence of nationally consistent definitions and accounting processes, it is impossible to verify whether jurisdictions really did spend what they reported. 2010 COAG agreement funding for subacute careThe 2010 COAG agreement to spend $1.6 billion on creating 1300 subacute beds, some of which are to be allocated to mental health, is also without transparency and agreed guidelines. In making this commitment to subacute care, COAG echoed the 2009 final report of the National Health and Hospitals Reform Commission, which stated: We recommend that every hospital-based mental health service should be linked with a multi-disciplinary community-based sub-acute service that supports “stepped” prevention and recovery care.12 There has been no progress report on the implementation of the mental health aspect of this agreement, but from public announcements it is possible to once again discern major variations in jurisdictional approaches. Queensland is building community care units, while SA is opting for supported accommodation places with crisis respite support. NSW is allocating all its subacute funding to new beds on hospital campuses. This variation between jurisdictions is not surprising, as there is no agreement on what constitutes subacute mental care. The term “subacute” does not appear anywhere in the National Mental Health Policy 2008 and is mentioned only once in passing in the Fourth National Mental Health Plan. Alternatives to hospital admission for mental health care in Australia are few. An unpublished national snapshot survey of acute psychiatric wards across Australia in 2006 indicated that 43% of all acute beds were occupied by people who could be cared for in other settings if suitable services were available. The investment in subacute care offers critical opportunities to build new services nationwide. However, competing priorities and a lack of consistent implementation may mean this opportunity could be lost. ConclusionDespite these increased investments, mental health’s share of overall health spending is shrinking. For the period 2004–05 to 2008–09, total mental health spending in Australia increased by an average of 4.8% per annum,2 while total health spending rose by more than 5%.3 There have been some 44 inquiries into mental health in Australia since the 1890s — about one every 2 and a half years. Despite these inquiries, and dozens of plans and policies, spending between jurisdictions continues to be uncoordinated, lacking both accountability and a focus on patients’ needs. There is little evidence to show that new mental health investments are driving improved health outcomes. For people with mental illness, the spectrum, capacity and quality of services available depends on where they live, and the quality of care goes largely unassessed. For real accountability, the new National Mental Health Commission must begin with a robust plan to identify and close service gaps based on evidence-based models of care. This should be accompanied by a National Report Card that includes nationally validated data of the experience of care, quality of life, and rates of homelessness, education and employment for people with a mental illness. Without this, no one will know if mental health funding is well targeted or just well meant. Council of Australian Governments (COAG) National Action Plan (NAP) on Mental Health 2006–2011 funding allocations, by action area and jurisdiction6 Action area* Jurisdiction 1: Promotion, prevention and early intervention 2: Integrating and improving the care system 3: Participation in the community and employment† 4: Increasing workforce capacity Total NAP ($ million) Australian Government 164.2 (8.2%) 1329.8 (66.7%) 369.5 (18.5%) 129.9 (6.5%) 1993.4 New South Wales 121.7 (12.4%) 721.6 (73.6%) 113.8 (11.6%) 23.3 (2.4%) 980.3 Victoria 97.7 (15.2%) 432.1 (67.0%) 110.6 (17.2%) 4.4 (0.7%) 644.8 Queensland 16.3 (1.7%) 717.5 (73.0%) 168.4 (17.1%) 76.9 (7.8%) 983.3 Western Australia 106.8 (22.1%) 216 (44.6%) 139.6 (28.9%) 21.5 (4.4%) 483.9 South Australia 47.1 (16.3%) 215.1 (74.6%) 22.1 (7.7%) 4.2 (1.5%) 288.5 Tasmania 2.2 (3.8%) 36.6 (62.4%) 11.3 (19.3%) 8.6 (14.7%) 58.7 Australian Capital Territory 5.1 (12.3%) 20.1 (48.3%) 8.1 (19.5%) 8.3 (20.0%) 41.6 Northern Territory 1.3 (8.6%) 13 (86.1%) 0.8 (5.3%) 0 15.1 Total 562.3 (10.2%) 3701.8 (67.4%) 944.2 (17.2%) 277 (5.1%) 5490.1 * Figures shown for each action area are $ million (percentage of total COAG commitment). Percentages may not sum to 100% because of rounding. † Including accommodation.

Sebastian P Rosenberg MPubAdmin · John Mendoza BEd · Lesley Russell PhD

Non-surgical intervention has many benefits. A recent article published in the Journal1 was widely reported in the popular press, with statements such as the following being quoted: public health messages encouraging people to eat healthy food and to exercise are unlikely to have long-term impact on their weight....

Daniel J Green PhD · Andrew J Maiorana PhD

A High Court of Australia ruling has reinstated the need for patients to prove causation of injury. The tort (ie, civil wrong) of medical negligence has recently changed, to the advantage of doctors. By its judgment in the case of Tabet v Gett in 2010....

Neera Bhatia LLB(Hons), LLM · James Tibballs MD, MHlth&MedLaw, FCICM

Proactive recognition and response, pre-emptive management Despite improvements in medical therapy and improved outcomes, patients admitted to acute care hospitals may suffer clinical deterioration and potentially avoidable morbidity. Recent reports show that patients admitted to hospital suffer cardiac arrests at a rate between 0.66 and 11.2 per 1000 admissions,1,2 and the approximately 80% mortality rate due to in-hospital cardiac arrests has not changed since the description of cardiopulmonary resuscitation more than 50 years ago.3,4 In this article, we review the epidemiology of in-hospital cardiac arrests and the evolution of the medical emergency team (MET) model to prevent them. In addition, we outline lessons learned from the MET model and the development of a national approach for recognising and responding to deteriorating patients. Finally, we contend that another paradigm shift is required to further improve patient outcomes via a more proactive and pre-emptive approach that includes improved detection and recognition of deterioration as well as structured management of patients who are at high risk of deterioration. The old paradigm: cardiac arrestWith introduction of cardiac arrest teams and Code Blue calls around 1970 came the first ubiquitous hospital protocol for escalating the care for deteriorating patients.3 This system is activated when a patient is pulseless and apnoeic, has no recordable blood pressure and is unresponsive. However, several studies published between 1990 and 2002 reported that in-hospital cardiac arrests were not sudden or unexpected, but were preceded by instability that was sub-optimally responded to.5-7 Up to 84% of patients had abnormal vital signs or new problems before cardiac arrest,5-7 and most were in asystole or had pulseless electrical activity.8,9 The current paradigm: METsIn 1995, the first description of the MET as a model for responding to patient deterioration was published.10 METs are composed of an intensive care, general medicine or emergency medicine registrar, and a critical care nurse. The advent of the MET delivered a mechanism for escalation of care earlier in the course of clinical deterioration than cardiac arrest. Criteria for a MET call are based on deranged vital signs and altered conscious state.10,11 A “staff member worried” criterion is often included to empower ward staff to call for assistance and bypass the traditional hierarchical model of escalation. Such criteria provide semi-objective thresholds for when ward staff should escalate care for deteriorating patients, and provide an expected and structured institutional response. The MET call is usually activated using a public announcement and pagers, and the team is expected to arrive within about 5 minutes. This system is the first patient-centred, organisation-wide system to be implemented across hospitals throughout the world. Over the past 16 years,10 METs have been introduced in at least 100 Australian hospitals.12 Although evidence of the effectiveness of METs is controversial,13,14 the MET model is currently the prevailing paradigm for identification of deteriorating ward patients and rapid escalation of care for them. Research into the characteristics and outcomes of MET patients has provided epidemiological data on deteriorating ward patients. In a MET-naive hospital, it was reported that 4.5% of ward patients fulfilled MET criteria on two separate days.15 Studies of mature METs report that 2.6%–5.6% of patients hospitalised for more than 24 hours receive MET review.16 Thus, about one in 25 ward patients will experience clinically significant deterioration. Research into MET patients has also shown that vital sign measurement is inconsistent and often incomplete, deterioration is variably recognised, and staff do not always activate a MET call when patients fulfil the criteria.17 In addition, activation is often delayed, and this is associated with increased mortality.18,19 Two surveys of ward nurses suggest that there is underappreciation of the significance of physiological derangements associated with MET criteria.20,21 A number of studies have reported that patients subject to MET review have a mortality rate of about 25%22-25 — higher than the 11% in-hospital mortality rate of patients admitted to intensive care units (ICUs),26 and much higher than the 2.5% in-hospital mortality rate for overall hospital admissions.27 Finally, about one-third of MET calls involve end-of-life care issues.24,25,28 These often occur out of hours, when parent teams are not in the hospital. As the patients are acutely unwell, they are often unable to participate in discussions regarding their preferences for active treatment, or conservative or palliative care. Accordingly, these decisions are typically left up to covering doctors, the MET and family members, and often need to be made expeditiously. A new paradigm: proactive, pre-emptiveThe MET model has emphasised the tenet that early intervention improves outcome (Box 1). Thus, the mortality of patients subject to MET review (25%) is lower than that of cardiac arrest patients (80%) but higher than that for patients admitted to ICUs. However, the MET model is reactive, as it requires a patient to deteriorate before it can be activated. We contend that a new paradigm is needed to promote a more proactive approach to recognising and responding to deterioration, and to provide a pre-emptive, structured, standardised approach to managing patients who are known to be at risk of deterioration (Box 2). This paradigm shift is supported by the National consensus statement: essential elements for recognising and responding to clinical deterioration,29 which describes the clinical systems necessary to provide appropriate care to deteriorating patients and the organisational supports needed to ensure that these systems operate effectively (Box 3). Predicting risk and preventing deteriorationNot all patients admitted to hospital will suffer a complication, but some will suffer sudden and unexpected deterioration. Increasing evidence suggests that patients can be risk profiled at, or even before, hospital admission. A hospital outcome predictive equation (HOPE) was recently developed using six variables that are associated with increased risk of death: age, sex, diagnosis at admission, emergency admission, aged care resident and inter-hospital transfer.27 In surgical patients, most postoperative complications are medical.30 It remains to be determined whether hospital-wide strategies or models of medical comanagement can improve patient outcomes based on such risk profiling. Similar criticisms were levelled at the MET model of care almost 10 years ago.31 Advance care planningAdvance care planning is particularly important in the context of the ageing Australian population, increasing numbers of comorbidities in hospitalised patients, and increasing complexity and intensity of medical therapies. Patients need to receive therapies that are beneficial to them, and do not cause significant harm or discomfort, and their wishes and choices regarding such care must be considered. Experience with the MET model suggests that many deteriorating patients receive suboptimal end-of-life care planning, and that this planning is done emergently by the MET. Advance care planning should be conducted when a patient is cognitively intact and able to contribute meaningfully to discussions, so that their preferences are known when deterioration is detected. In a recent trial, an advance care planning program improved the rate at which patients received preferred care, improved patient and family satisfaction, and did not increase patient mortality.32 Detecting and recognising early deteriorationImproved detection of deterioration requires tailoring of vital signs measurement to a level commensurate with a patient’s diagnosis, acuity, proposed treatments and change in status with time.29 In some patients, this may include the use of continuous automatic electronic monitoring systems that record observations and alert staff when trigger points are reached.33 Research shows marked variation in the quality and ease of use of vital sign charts.34 Enhanced design of observation charts has been associated with improved documentation of vital sign sets and recognition of deterioration.35 Improving management and follow-up of early deteriorationImproved training in the recognition of and response to early deterioration is needed. A multifaceted approach to this type of intervention — involving a newly designed observation chart, a track-and-trigger system and an education package — has been shown to be associated with increased MET activation, reduced unplanned ICU admission and reduced in-hospital mortality.36 Optimising the outcomes of MET patientsAs delayed MET activation worsens patient outcomes,18,19 research is needed to better understand the decision-making processes of ward staff with regard to escalating care for deteriorating patients. Specifically, it is important to understand the circumstances under which staff call their parent unit, as opposed to requesting external assistance. Auditing the clinical causes of MET calls may assist in the development of strategies to improve the outcomes of patients who fulfil MET criteria. The concept of “MET syndromes” has been raised,37 and it has been shown that sepsis, heart failure, pulmonary oedema and arrhythmias (especially atrial fibrillation) may be associated with about 50% of MET calls.38 Implementing checklists, guidelines or bundles of care for common causes of MET review may help to standardise management and improve outcomes of patients after a MET call has been activated. A simulation-based training course for MET members has been shown to be associated with improved team performance, but the effect of such training on MET patient outcomes has not yet been tested.39 ConclusionIn the 50 years since the components of cardiopulmonary resuscitation were described, outcomes of in-hospital cardiac arrest have changed little. The failure of cardiac arrest teams to substantially improve outcomes, in conjunction with research showing that cardiac arrests are often preceded by signs of deterioration, facilitated a paradigm shift to encourage detection and escalation of care before the onset of circulatory arrest. Although the effectiveness of the MET approach continues to be debated, METs have highlighted the need for even earlier detection and escalation of care for deteriorating patients. Another paradigm shift is now needed to improve prediction, detection and recognition of deterioration, and to optimise subsequent escalation of care. 1 Criteria for escalation of care and rates of mortality at various phases of patient deterioration Hospital inpatient27 Abnormal vital signs15 MET call22-25 Cardiac arrest1-4 Event rates (per 1000 admissions) — 138 10–50 0.66–11.2 Criteria for escalation Heart rate (beats/min) — ≤ 50 or > 120 < 40 or > 130 0 Systolic blood pressure (mmHg) — < 100 < 90 or > 200 0 Respiratory rate (breaths/min) — ≤ 10 or > 28 < 8 or > 35 0 Other — — Fall in conscious state or urine output Unresponsive In-hospital mortality rate 2.5% 14.6% Approx 25% Approx 80% 2 Phases of patient deterioration and strategies that may improve outcomes at each phase MET = medical emergency team. ICU = intensive care unit. 3 Essential elements for the care of deteriorating patients29 Clinical processes Measurement and recording of observations Escalation protocols Rapid response systems Communication processes Organisational prerequisites Organisational supports Education Evaluation and monitoring Use of new technology

Daryl A Jones FRACP, FCICM, MD · Nicola J Dunbar BSc(Hons), PhD, MPS · Rinaldo Bellomo FRACP, FCICM, MD

When “should not” becomes “must not” — how mandatory compliance with guidelines can threaten professional independence There is a proliferation of rules and red tape at all levels of society. In New South Wales, for example, the Department of Health has been generating around 70–100 policy directives a year. Among other things, such directives tell obstetricians when and how to deliver babies — compliance is mandatory, under threat of disciplinary action and loss of indemnity cover. One of the most prominent recent directives, PD2010_045 (Maternity — towards normal birth in NSW), requires a reduction in caesarean section rates to 20% by 2015,1 a target that is illusory and possibly dangerous. Others are worse. Policy directive PD2007_024 (Maternity — timing of elective or pre-labour caesarean section) states: The risk of respiratory morbidity is increased in babies born by caesarean section before labour, but this risk decreases after 39 completed weeks. Therefore elective or pre-labour caesarean section must not routinely be carried out before 39 completed weeks. These findings are supported by recent studies.2 This text is taken almost verbatim from a guideline of the National Institute for Health and Clinical Excellence (NICE) in the United Kingdom3 and, at the time, accorded with the relevant Royal Australian and New Zealand College of Obstetricians and Gynaecologists (RANZCOG) guideline on the timing of elective caesarean section, the wording of which has since been softened slightly.4 However, there is one very substantial difference: the “should not” of NICE and RANZCOG became a “must not”. The NICE guideline was produced by a committee of 16 members, two of whom were obstetricians. Nicholas Fisk, then chairman of the Royal College of Obstetricians and Gynaecologists (RCOG) Scientific Advisory Committee, strongly criticised the outcome and stated that the committee “selectively interpreted” the facts to suit its case.5 Timing of elective caesarean delivery is a complex issue. There are factors (mainly related to pulmonary maturity) suggesting delay until 39 weeks’ gestation, and others (mainly related to unexplained stillbirth6,7) supporting the traditional timing between 38 weeks and 38 weeks and 6 days. A large randomised controlled trial (RCT) or a carefully conducted observational study employing propensity scoring would be required to provide a solid evidence base. For the moment it remains a matter of opinion, and RCOG, NICE and RANZCOG can, and should, express expert opinion and review the available evidence. Guideline committees and their products make an important contribution to improving clinical practice, and the voluntary work of countless individuals in this regard should not be denigrated. However, the situation may be altered completely once bureaucrats become involved. Changing the “should” of a College guideline to a “must” in a NSW Health policy directive has major implications. PD2007_024 effectively forbids doctors in NSW public hospitals to schedule routine elective caesarean section before 39 weeks. Anyone doing so risks disciplinary action and may forfeit their indemnity cover. PD2007_024 is not currently supported by high-level evidence, and even if there were solid data from a large RCT or a meta-analysis, it would be inappropriate to stipulate “mandatory compliance”. Evidence-based medicine has great potential to improve patient care, but it is a tool to inform clinicians, not an excuse to switch off one’s brain. As recently argued in the case of mesh use in pelvic reconstructive surgery,8 guidelines derived from a large RCT (or a valid meta-analysis of appropriate trials) are of limited use as a guide to the care of an individual patient if that patient is far off the trial sample mean in predictors of outcome. The Term Breech Trial9 is an excellent example. If there is a very high likelihood of an uncomplicated birth for an individual woman (eg, fast progress, small baby, previous normal births), a clinician may want to ignore the findings of the Term Breech Trial when deciding how to advise her. The process of starting with some initial information (probabilities of events of interest) and combining it with data related to an individual case or circumstance has been mathematically formalised by statisticians as “Bayesian updating”.10-13 Information from a clinical guideline, prevalence study or meta-analysis provides the “prior probability”, the data related to the individual case at hand are embodied in the “likelihood”, and the application of Bayes’ theorem13,14 gives the updated “posterior probability” on which a decisionmaker can act. This implies that even the best evidence in literature and guidelines can provide only prior probabilities. It is our job to adapt these to the clinical management of the individual patient, generating posterior probabilities that have been updated by the relevant particulars of the patient and processed by clinical intuition and common sense. However, in a trend that is encouraged by guidelines and policy directives, clinicians increasingly omit this updating process. Once a document — a seminal paper, a guideline, a policy directive — is published, it is likely to be interpreted cautiously (ie, as widely as possible) because of the litigious, risk-averse nature of our society. We do not particularise to the individual patient because our work environment strongly discourages doing so. Finally, even if a guideline is produced after an optimally diligent process and published so rapidly that it is up to date at its launch, it still freezes current best practice. Inevitably, today’s best practice will be obsolete tomorrow. Practice guidelines therefore have the potential to slow down progress, and unthinking adherence to such documents is unlikely to deliver the best outcomes to the greatest number of individuals. The expert system of our brains, employed in the assessment and treatment of the individual patient — and using relevant prior information from evidence-based sources — is a potentially superior tool when compared with the replication of a course of action outlined in a document issued by a government agency or professional body. It is time to reassert our professional independence.

Hans Peter Dietz MD, PhD, FRANZCOG · Barrie J Stokes BSc, MMath

The formula for reform works, but is the next review already overdue? In 2008, we reported our review of the Sydney University graduate medical program.1,2 When the program was introduced 11 years previously, it was innovative, with emphasis on helping students to solve problems and to think critically about what they were learning rather than to memorise lists of facts. In 2005, the Australian Medical Council (AMC) reviewed the program and awarded the maximum 10-year accreditation. However, the AMC also suggested a number of actions, including reviewing the role of problem-based learning (PBL) in the final 2 years of the course, reviewing some areas of assessment, providing a renewal process that allowed for flexibility and innovation within the defined outcomes, and reviewing the complex system of committee structures. We made 730 recommendations in our 2007 review, incorporating the AMC’s suggestions and covering the provision of an initial scaffolding on which students could build knowledge, increased anatomy teaching and the creation of clear learning objectives. We now report on the impact of that review. The major changes implemented after the review are shown in Box 1. Eighty-five per cent of the recommendations have been implemented. Another 5% are currently being implemented; 2% are no longer relevant; and 8% have not been implemented (Box 2). The implementation of 85% of the changes was due to three main factors: the inclusive nature of the review process; the commitment of the dean; and the team chosen to implement the changes through a newly created Office of Medical Education. The first 9 weeks of the course became a foundation block that provides a scaffolding of basic facts and concepts on which students can build future knowledge. The foundation block provides learning activities and additional tutorial groups specifically for students from non-science backgrounds who initially find the course difficult. An additional Chair of Anatomy with specific responsibility for teaching was created, and the amount of anatomy teaching in the first 2 years of the course was increased from 50 to 170 hours. An additional appointment of an academic surgeon jointly for Surgery and Anatomy has enabled the return of whole-body dissection as a student elective.3 These new appointments have ensured that anatomy is now taught throughout the course. Students now have electronic access to detailed learning objectives and a core curriculum with clear links to the teaching program for each week. They engage more with medical librarians, critically evaluating information sources, developing and refining search strategies and learning database construction. A student guide provides a direct link for quick location of key databases and basic science resource materials. While PBL remains a core component of the medical program, clinical reasoning sessions, which have more clinical emphasis than the traditional PBL tutorial,4 have replaced PBL tutorials in the final 2 years. The artificial distinction that existed between the two clinical years has been removed so they have become fully integrated. The amount and sophistication of assessment has been increased. In formative assessments, students are able to see their progress in relation to that of other students. Grading, which was not in the original graduate program, now occurs in the last 2 years. The criteria for awarding honours on graduation have become more rigorous, with a higher standard and an increased emphasis on academic supervision. Students interested in pursuing a career in research may also do a concurrent Master of Philosophy degree, which requires intensive immersion in research during holidays and the elective term. Heads of disciplines have become more involved in curriculum matters. Academic staff from disciplines that were previously not well integrated into the curriculum now meet regularly, contribute more to teaching and have become more collegiate. This has re-engaged clinicians and reinvigorated some disciplines that previously had less involvement in the curriculum. The introduction of new material has depended on the leadership given by champions who have taken on these new areas. This was particularly applicable with regard to helping students to understand and critically review complementary and alternative medicine, to develop an awareness of the spiritual dimensions of health for some patients and to better understand the problems of people with a disability. Medical humanities has been strengthened; and the creation of the position of Associate Dean, International Health increased students’ exposure to a range of global health issues. Recommendations regarding the importance of Indigenous health throughout the course have resulted in some Aboriginal health care delivery concepts being incorporated into the teaching of communication skills. Students are now encouraged to become more involved with Aboriginal medical services. Student numbers are increasing (Box 3). The total number of students increased from 261 in 2007, to 299 in 2011, with international fee-paying students increasing from 34 to 66. Federal government funding arrangements have created the need for medical schools to take more international fee-paying students. However, a balance has to be struck between this need and the essential requirement to provide a high-quality program with good support and tutorial groups of an effective size. A medical curriculum cannot guarantee effective student learning and satisfaction if numbers increase without a commensurate increase in academic staff, support staff and upgraded facilities on campus and in clinical schools. This issue is not unique to Sydney Medical School. Medical student teaching is intensive, with emphasis on small group tutorials, one-to-one teaching and role modelling. Teaching cannot be separated from research, as research informs much of the teaching. However, adequate resources must be put into teaching so that it is supported just as research is supported. Areas in which changes to the University of Sydney graduate medical program still need to be made are shown in Box 4. Leadership is essential for creating and sustaining changes. Academic leadership has been a key factor in the implementation of the majority of changes recommended in this curriculum review. The leadership of the dean, the academic course coordinators and the associate deans of the clinical schools has been crucial in implementing the changes so far. The dean should be clearly in charge of the curriculum and the curriculum should be one of his or her obvious priorities. While day-to-day curriculum management is delegated, regular meetings between the dean and academic course coordinators to discuss key issues, rather than curriculum detail, are important. Where innovative recommendations have been implemented, there has been a clearly designated and committed leader for the new area. In some cases these leaders were recognised in advance, while in other cases leadership arose spontaneously. In contrast, recommendations that were not successfully implemented did not have a champion identified. Before introducing change to a medical curriculum, there should be wide consultation with students, faculty members, other teachers, professional bodies and community groups.5 In our experience, wide consultation with faculty members, listening to and incorporating their suggestions and giving them some responsibility for implementation effectively re-engaged them and were the crucial factors in successfully changing the curriculum. While the importance of factors such as leadership and wide consultation may seem obvious, we need to acknowledge their essential contribution to effective, sustained change. Attempts to change a medical curriculum without leadership at the highest level, identification of leaders for specific roles and wide, regular and frequent consultation are likely to be doomed to failure. It became clear when reviewing the curriculum in 2007 that 11 years is too long to wait. A medical curriculum is dynamic and needs to respond to changes in medicine, health regulations, educational thinking and society. More frequent review would ensure that the curriculum remains relevant and plays an integral part in shaping the future leaders in medical care. Medical education and health care delivery are not static, which is why curriculum revision must be a continuous process of renewal and response to change. 1 Key changes implemented after the 2007 review Simplified and strengthened governance Revised first 9-week foundation block Developed core curriculum with clear learning outcomes Increased basic science teaching Trebled anatomy teaching hours Increased written and clinical assessments Introduced grading in final 2 years Upgraded honours requirements Created more research opportunities Created optional concurrent MPhil degree Increased use of IT for teaching and assessment Added new areas to curriculum Increased emphasis on critical care and surgery teaching 2 Why some recommendations were not implemented Lack of funding Increased student numbers Difficulty in recruiting teachers Lack of effective collaboration with outside bodies 3 Local and overseas students admitted to Sydney Medical School, 2007–2011 No. of students Year Local International Total 2007 227 34 261 2008 226 36 262 2009 247 46 293 2010 222 53 275 2011 233 66 299 4 Areas of the University of Sydney graduate medical program still in need of change Refugee health Aboriginal health Equipping students for leadership Clinical teaching on ambulant and standardised patients Interprofessional learning Greater ownership by clinical teachers More involvement by recent graduates

Kerry J Goulston MD, FRACP · R Kim Oates MD, DSc, FRACP

Ray Moynihan explores the push for new powers and strong opposition to it If there was ever a case of market forces running ahead of regulators, it is corporatised medicine in Australia. Driven by medical entrepreneurs and merchant banks, the creation of giant health care empires has taken place with little public debate or political interest. While a new private industry is now successfully profiting from publicly funded Medicare, health authorities have so far found no meaningful mechanism to police the sector. “The business of medicine has been altered forever”, argues the former head of Medicare’s watchdog unit, “by the entry of corporatised medicine”.1 Testifying to a recent senate inquiry, Tony Webber, former Director of the Professional Services Review (PSR), said he’d like to see a revamped PSR scheme within Medicare given the power to “investigate scams and unacceptable corporate behaviour, of which I have seen significant examples”. Asked if any executive had been prosecuted, Webber told senators: “Sadly, no, because the legislation makes it very difficult to do so”.1 Responding to his concerns, the committee recommended strengthening the watchdog’s powers and government is currently considering its response. Evidence of corporate “scams”, says Webber, remains largely anecdotal and based on tip-offs which, while appearing credible, are currently unable to be followed-up. According to Webber, the problem is while companies are geared to make money, Medicare was never designed to pay the doctor and a nice corporate dividend as well — a theme he expands on elsewhere.2 One of the industry’s giants is Sonic Healthcare, owner of the Independent Practitioner Network with 140 medical centres and around 1000 GPs who produced “strong revenue growth” last year, contributing to Sonic’s overall profit of $295 million.3 The other giant is Primary Health Care Limited, running almost 90 centres, also contracting 1000 doctors, worth around $1.5 billion, and with profits of $80 million.4 Another player is Healthscope, bought recently by a consortium of global private equity firms. All three are “vertically integrated”, with medical centres, pathology laboratories and imaging facilities. There is no suggestion that these, or other particular corporations, or people associated with them, engage in or encourage any form of inappropriate behaviour. The man known for pioneering corporatisation of health care in Australia is Edmund Bateman, managing director of Primary Health Care Limited. The company describes itself as the “most profitable in this field” with a “formula” offering value to doctors and patients.4 In an extended interview with me recently, Bateman strongly rejected the need for enhanced watchdog powers, saying it was “based on the assumption that the corporation is responsible for the behaviour of the doctor”, which was “out of touch” with the reality. He said there’s also an assumption of “improper pressure” on doctors, but it doesn’t exist. “I can’t tell them what to do”, he told me, “if there is any pressure, it’s to practise better medicine”. While stressing that doctors signing contracts with Primary Health Care Limited retained clinical autonomy, in general, they also “undertake to support our services, where clinically appropriate” he said, adding doctors “tend to support the pathology in the building, out of convenience”. The idea of forcing corporations to contribute to paying the fines of doctors found to have practised inappropriately is also opposed by Bateman: “it’s human nature for people to try and blame other parties”, he says, “professionals in particular are responsible for their own behaviour”. Arguing it’s not “proper process”, he suggests that the entire PSR Scheme should be abandoned and any action against doctors happen via “normal legal process”. Asked about his own use of courts to take action against doctors contracted to his companies, and a newspaper report that there had been dozens of cases against practitioners in the past decade,5 Bateman declined to confirm a figure, saying that of the 1000 contracts with doctors only a “very small minority” ended in litigation, and that he is suing the newspaper involved. Questioned about suggestions that his centres had created and billed for “care plans” for patients who regularly saw doctors outside, he said that “sounds like sour grapes from someone who should have provided one before this”. Other corporate chiefs contacted declined to comment. In my view, one way to independently assess competing claims about corporate medicine might be to compare profiles of doctors working inside and outside corporate structures. While complex, with confounding factors, a sophisticated analysis could cast much-needed light here and build academic expertise in the field. As to recommendations for new powers to “pursue abuse” of the system,1 the government’s response is pending. Perhaps it may also be timely to reassess just how well the private-for-profit corporate structure sits with the spirit of a publicly funded universal health insurance scheme.

Ray Moynihan BA

Yes. Public health adviser David Roder and Cancer Council Australia CEO Ian Olver believe the reduction in breast cancer mortality in Australia reflects both treatment and screening effects All screening programs should be assessed for their benefits and risks, including the extent of overdiagnosis. Recently, Burton and colleagues concluded that almost 60% of the Australian decline in breast cancer mortality since 1991 could not be due to BreastScreen Australia (the free national mammographic program), attributing most of the decline to adjuvant hormonal and chemotherapy.1 Questions around attribution are not new. There has been no formal modelling in Australia, but modelling funded by the National Cancer Institute in the United States suggested that about half the US breast cancer mortality reduction may be due to adjuvant therapy and about half to screening.2 Age-standardised breast cancer mortality rates have decreased by about 29% among Australian women since the 1989–1991 period, when organised mammography screening (now known as BreastScreen) began.3 Compared with a linear projection of mortality increases in the 1980s, the observed rate in 2007 was about 38% lower.3 Observations on women outside the screening age range show that factors other than screening would have contributed to this decline, but there is also evidence for an important BreastScreen effect.3 Three evaluations of mammography screening of Australian women aged 50–69 years, including the formal BreastScreen Australia Evaluation Plan, indicated reductions in breast cancer mortality of between 30% and 47% from screening.3 This range is broadly consistent with trial evidence where a reduction of around 35% was estimated by an expert working group of the International Agency for Research on Cancer (IARC).4 A 25% reduction in breast cancer was estimated by Australian researchers from a meta-analysis of trial data for all ages.5 Collective results of 35 studies in other countries are similar to the IARC’s 35% reduction estimate,3,4 although individual study results varied from little or no benefit to reductions of up to 76%.3 With present participation rates in Australia’s BreastScreen program, a 35% reduction in breast cancer mortality in participants would correspond with an estimated 270 fewer breast cancer deaths a year in all Australian women aged 55–74 years. (Note that this allows for a time lag of 5 years in deaths.) Breast cancer incidence rates rose in Australia following the introduction of BreastScreen.3 The extent to which this reflected lead-time effects of screening, changes in pathology and other diagnostic practices, overdiagnosis, and real increases due to changes in underlying risk factors (eg, reproductive behaviour, body weight, alcohol consumption and use of hormone replacement therapy) is unknown. Increases in incidence were already occurring in the 1980s before BreastScreen introduction,3 but the contributions of increased use of private mammography and changes in risk factors during that period are not known. The increase in breast cancer mortality rates in the 1980s is suggestive of real increases in underlying incidence.3 There is concern that screening may result in detection of cancers that would never have caused symptoms or death in a woman’s lifetime (ie, overdiagnosis).3 There is no consensus on levels of overdiagnosis, with estimates worldwide varying from close to zero to over 30% of diagnosed cancers, irrespective of whether in-situ lesions were included.3 The estimates vary so widely that interpretation is difficult. Research is needed to better define levels of overdiagnosis and, ideally, to develop more effective means of determining at diagnosis the potential for screen-detected and other breast cancers to progress. In summary, it is likely that the reduction in breast cancer mortality in Australia reflects both treatment and screening effects. The relative contribution of each to the overall reduction is not clear, although there is evidence that both would be contributing substantially. Women should be informed of both the risks and the benefits of screening, including the uncertainty around overdiagnosis. However, present screening participation levels of 50–69-year-olds in BreastScreen would be consistent with a significant annual reduction in breast cancer mortality. Levels of overdiagnosis are uncertain and require better definition. Means of better predicting the likelihood of progression of untreated in-situ lesions and early invasive breast cancers to advanced disease are needed, and this need is likely to increase as more sensitive screening and diagnostic technologies are developed.

David M Roder PhD · Ian N Olver MD, PhD, FRACP

No. Breast cancer researchers Robin Bell and Robert Burton believe that screening can result in overdiagnosis Screening mammography undoubtedly saves lives. Since 1991, when Australia’s free national mammographic screening program (BreastScreen Australia) began, there has been a 29% reduction in breast cancer-specific mortality. However, our analysis of age-stratified data indicates that BreastScreen does not account for most of this mortality reduction.1 Furthermore, it is now recognised that the balance between the benefits and harms of screening has become increasingly unfavourable. Women should be given a balanced explanation of what BreastScreen offers them. Our study analysed age-specific trends in breast cancer incidence, mortality and BreastScreen participation by Australian women aged 40–79 years since 1991.1 We found that the participation rates and relative mortality declines were the opposite of what the randomised controlled trials (RCTs) of mammographic screening had predicted. Women aged 40–49 years, who had the lowest BreastScreen participation (about 20%), had the largest mortality reduction (43.6%; 95% CI, 34.8%–51.2%). Women aged 60–69 years, who had the highest BreastScreen participation (about 60%), had the smallest mortality reduction (19.1%; 95% CI, 10.5%–26.9%). We also analysed the proportions of the declines in absolute breast cancer-specific mortality from 1991 to 2007 in two parts (before and after 1999–2000), to identify periods before and after any effect of BreastScreen on mortality might have been expected. We found that only about a third of the reduction in mortality in the age group invited for screening (50–69 years) occurred after 1999–2000.1 We have calculated the contribution that adjuvant endocrine therapy and chemotherapy could have made to the reduction in breast cancer mortality in Australia since 1991. Australia is unique in having six datasets from population-based breast cancer treatment surveys between 1986 and 1999. These document the stage at diagnosis and adjuvant treatment received for early breast cancer for different samples of Australian women. Based on a 10–15-year follow-up of their overviews of RCTs of adjuvant therapy in early breast cancer between 1985 and 2000, the Early Breast Cancer Trialists Collaborative Group (EBCTCG) concluded that appropriate use of anthracycline-based chemotherapy followed by tamoxifen for oestrogen-receptor-positive disease would result in annual breast cancer mortality reductions of 57% for oestrogen-receptor-positive women < 50 years of age and 45% for those aged 50–69 years.2 Our analysis, using 1999 Victorian survey results and the EBCTCG overview, found that breast cancer mortality reductions in Australian women in 1999 from adjuvant endocrine therapy and chemotherapy could have been up to 38% for women aged 40–49 years, and up to 24% for women aged ≥ 50 years.1 Therefore, adjuvant therapy had the potential to produce most of the 29% reduction in breast cancer mortality in Australia since 1991. In theory, screening for an asymptomatic earlier stage of a disease that is more effectively treated with available therapies than symptomatic disease will produce less morbidity and mortality, but screening can result in overdiagnosis. Overdiagnosed breast cancers are those detected by screening mammography that would not have become symptomatic in the woman’s lifetime. Overdiagnosis by mammographic screening is most accurately estimated from the RCTs by comparing the increased numbers of breast cancers diagnosed in women invited to undergo screening compared with those not invited. A recent Cochrane systematic review of the RCTs puts the estimate at 30%.3 An estimate from incidence trends in New South Wales indicated that 30%–40% of invasive breast cancers were overdiagnosed in 1999–2001.4 The benefits and harms of mammographic screening are measured in terms of the ratio of lives saved to cases overdiagnosed. Using the RCT data, the 2011 Cochrane review determined that, with 30% overdiagnosis and a relative mortality reduction of 15%, “for every 2000 women invited for screening throughout 10 years, one will have her life prolonged. In addition, 10 healthy women, who would not have been diagnosed if there had not been screening, will be diagnosed as breast cancer patients and treated unnecessarily”.3 As the outcome of treatment for both symptomatic and asymptomatic disease improves, the impact of screening diminishes and the balance of benefits to harms will become less favourable. This has serious implications for health policymakers. We believe it is time for women to be presented with a more balanced view about the benefits and harms of breast screening. Screening programs are currently undergoing review in the United Kingdom, and one of the first commitments is to a new process of developing written information for the public that will synthesise information on benefits and harms. There has been an assurance that the leaflet about breast cancer screening will be among the first to be revised.5

Robin J Bell PhD, MPH, FAFPHM · Robert C Burton MD, PhD, FRACS

Lack of audit control and inability to adapt to change leads to massive waste As Director of Professional Services Review (a role established to protect the integrity of Medicare and the Pharmaceutical Benefits Scheme) for over 6 years, I gained an insider’s insight into how dysfunctional the Medicare/Medibank Scheme has become since the Health Insurance Act 1973 (Cwlth) was introduced. The then Minister for Health, the Hon. Bill Hayden, stated in his second reading speech that the purpose of the scheme was to create the “most equitable and efficient means of providing health insurance coverage for all Australians”.1 The universality of medical insurance coverage benefited all Australians, particularly those for whom a doctor’s visit represented a significant proportion of income. From the beginning, there were inadequate safeguards in a scheme based on the honour system. In no other area of public expenditure where recipients have significant control has so little attention been paid to audit. Medicare Australia administers over half a billion transactions every year for the Medicare Benefits Schedule (MBS) and the Pharmaceutical Benefits Scheme (PBS). Medicare is very efficient at its core business — that of distributing benefits. Electronic claiming has addressed criticism of earlier inefficiencies. However, Medicare’s ability to ensure benefits have been paid appropriately has never fully coped with the medical business environment. Extrapolating modestly from the misuse of the MBS, PBS and the Medicare Safety Net (financial assistance for high out-of-pocket costs for out-of-hospital MBS services) that I am directly aware of, I estimate that 2–3 billion dollars are spent inappropriately each year. Unfortunately, there are no attempts to quantify these losses more accurately. The reasons for this leakage are diverse. The MBS is riddled with misdirected incentives for practitioners, contains items that have not been reviewed despite advances in technology, and has many examples of good public policy thwarted by the MBS rules. In general practice, general practice management plans (GPMPs) and team care arrangements (TCAs) have created opportunities for a bonanza for some practices. Several practitioners I have reported on had admitted that their corporate owner had a business plan based on a defined number of these items claimed every week, irrespective of clinical need. Medicare Australia is also aware that a significant proportion of these plans are not carried out by a patient’s usual doctor’s practice.2 Anecdotally, claiming for clinically unnecessary GPMPs is significant throughout Australia. The policy intent of GPMPs was to provide a higher standard of care for patients with complicated chronic disease. While many doctors use these items appropriately for positive patient outcomes, a proportion of claimed items have added nothing materially to patient care. The TCA items are based on a model of care that works well in an inpatient setting, but does not translate to general practice. This item has created a whole industry of allied health practitioners and dentists who, through a TCA, draw on the public purse. Under a TCA, there is incentive for doctors to be pressured to provide the paperwork for “free” podiatry, physiotherapy, psychology, and dental care, facilitated by computer systems that can generate the necessary paperwork in minutes. The MBS rebate for a GPMP is $138.75, and for a TCA is $109.95. The policy intention was to allow patients with chronic or terminal disease to receive previously unaffordable care, but has created perverse incentives for all parties involved. This is bleeding several hundred million dollars per year as the policy intention is buried by inappropriate claims. The approach of the Department of Health and Ageing (DoHA) in not allowing discretion to doctors to refer purely on clinical grounds has led to this situation. The policy intent by government was sound. However, the DoHA developed MBS items that create incentives to easily misuse and work around the MBS requirements, leading to their misuse by a proportion of both medical and allied health practitioners. Some practitioners consciously misuse the MBS occasionally, and some do so regularly. The policy intent could have been achieved by allowing direct referral, without financial incentive to the doctor. This measure alone would have saved the health budget well over a billion dollars over the life of the program. Instead, a monster was created, eroding the integrity of the health budget. Items are added to the MBS after a long and exhaustive process of evaluation. This includes consideration of the skill level involved, the cost of necessary equipment, time taken for a procedure, and the overall cost–benefit to the community. However, once items are on the MBS, as long as they are still being used, they are rarely re-evaluated, and they attract the yearly rise in benefit level. Minister Roxon, in her first term as Minister for Health, bravely tried to reduce ophthalmologists’ fees for cataract surgery by 50%.3 These items were introduced when the procedure was not considered routine, took much longer than today, and required an inpatient stay of more than a week. The benefit reflected this. In the nearly 40 years since, technology has moved on and now this surgery can be performed under local anaesthetic as a day-procedure lasting 20 minutes. Private patients are sometimes charged more than $4000 for this procedure. In the end, the Minister was only able to achieve a 12% reduction on the MBS fee.4 The top providers of this item have performed more than 20 procedures in one day, according to Medicare Australia data. Not bad work if you can get it, but very poor public policy! The same lack of rigour in reviewing items also applies to gastroenterology and cardiology. While most gastroenterologists and cardiologists practise ethically, there are a few practitioners whose repeated use of procedures and investigations is highly questionable in patients whose clinical condition appears not to warrant them. However, there is no one asking the questions. The Medicare Safety Net is one of the most poorly thought-through pieces of health legislation. Despite its laudable policy intent — to help those with severe and chronic disease afford the cost of modern medical care — its implementation has gaping holes. The open-ended nature of the Safety Net offers the minority of unscrupulous and greedy practitioners opportunities to exploit it. After the Safety Net was introduced, a small group of obstetricians raised their fees for antenatal care from around $3000 to nearly $10 000. Such use of the Safety Net was perfectly legal, thanks to sloppily drafted legislation. During my time as Director of Professional Services Review, the Safety Net was used in effect to subsidise cosmetic procedures such as surgery for “designer vaginas” at $5000–$6000 each. I knew that the DoHA was aware of such misuses of the Safety Net. However, there seem to be no politicians with the appetite to face the problem and rein in millions of dollars in potentially inappropriate payments. Another major concern of mine has been the quantity of prescription drugs, particularly narcotics and benzodiazepines, finding their way onto the street. These drugs are well controlled by the manufacturer and the supply chain to the pharmacy. The weak link is the doctor’s prescription pad. Throughout my term as Director of Professional Services Review, I saw extreme examples of drug prescriptions that were clearly being misused or dispensed for resale by patients. In one instance, a doctor was prescribing 100 ampoules of 30 mg of morphine every week to a young patient without an appropriate indication. The state pharmaceutical branches are underresourced to track the prescription of benzodiazepines. Medicare is unable to identify abnormal prescribing patterns because many benzodiazepines are supplied on a private prescription. It is cheaper for a patient on a federal government benefit to pay for one private prescription for 200 diazepam tablets (less than $20) than to pay for four subsidised prescriptions of 50 tablets. I found many instances where a practitioner had supplied a PBS prescription for 50 tablets and a private prescription for 200 tablets.5 It is not only the MBS and the PBS where maladministration occurs. On several occasions I came across significant cost-shifting between the states and the federal government. Medicare was being used to subsidise state health budgets. Private radiology and pathology services were used for public inpatients, Medicare benefits were used to fund staff specialist study tours and to buy essential equipment. This is against the provisions in the Council of Australian Governments National Health Care Agreement. When this was pointed out to officers in the DoHA, I was told not to say anything. There is significant wastage within the Medicare scheme, which is threatening our ability to maintain first world standards in health care delivery. Australians are fortunate that, in the main, we do have a motivated and ethical health workforce. However, many of our colleagues feel let down by a system that so often does not deliver a timely or cost-effective service with proper controls. Many doctors I have spoken to are disillusioned by the inappropriate claiming and practice they are aware of. They feel disempowered to be able to effect change in our current health system.6 It is time for a thorough review of the manner in which health care is delivered in Australia. Piecemeal policy changes and bandaids are no longer adequate. To be of any value, a major review needs bipartisan political support. However, so long as health policy is used to bludgeon the other side of politics, we will never have meaningful change.

Tony D Webber MB BS, FRACGP

Lack of transparency and reliance on statistics alone make doctors vulnerable The Professional Services Review (PSR) was established to investigate and manage situations where the Medicare system was being used inappropriately by doctors. Undoubtedly, the PSR’s activities have identified and addressed instances of doctors knowingly exploiting Medicare. However, over the past 5 years, an initial general disquiet about the increased effect of the PSR’s investigative system and processes on general practice grew into widespread concern among broad sections of the medical profession and others. The PSR committees were disbanded because they were not ratified by the Australian Medical Association (AMA), 39 cases under review were dropped, and a senate inquiry into the entire running of the PSR scheme was conducted. The inquiry resulted in the publication of seven recommendations for improvements in the system,1 with a review with all relevant stakeholders planned for 12 months later. A common recurrent complaint was Medicare’s focus on statistics, with less emphasis on other information provided. Medicare targeted the right-hand end of the bell curve, assuming this was where inappropriate practice occurred. The “vanilla GP” who held four standard consultations an hour was the Medicare epitome of a gold standard practitioner and was safe from audit. However, the further GPs steered away from this “standard” practice, the more they were at risk of being investigated by the PSR. There is no substantial evidence that statistical outliers represent a high-risk group, and yet the PSR has intensified its auditing activities among such doctors, increasing auditing from 1% to 4%.2 Surveys of the medical profession have revealed deep concerns with the system and processes of the PSR. The AMA posed the question: “Do you think the Medicare audit process has become too heavy handed?”, to which 88% of respondents (307) voted yes.3 The Medical Observer ran a survey that attracted over 200 replies. It showed that over 80% of respondents felt that Medicare and the PSR had not replied adequately to queries on the Medicare Benefits Schedule and less than 15% felt confident they would pass an audit on the Enhanced Primary Care item numbers.4 The specific concerns held by us and others are numerous. In our view, the operational processes of the PSR and the Medicare audit system appear to be non-transparent, with too much power in the hands of the PSR Director. There is a denial of natural justice, with a high conviction rate and pressure to accept “negotiated agreements”, with no practical appeal process. Fines imposed are large, running to between five and six figures. Preserving patient confidentiality during an audit seems to disadvantage the case of the doctor being audited. The PSR does not appear to respond to concerns raised in these areas, and this undermines community confidence in primary care. A particular problem is that Medicare and the PSR give little or no guidance to GPs on the approved use of item numbers in the Medicare schedule. They have tried to refer complex requests back to the AMA and Royal Australian College of General Practitioners,5 and will not give binding interpretations on the use of Medicare items. Their past rulings do not provide useful guidance. This puts GPs in an extremely vulnerable situation, being unable to reliably check their interpretation of Medicare item numbers, yet able to be severely punished for actions judged to be misdemeanours at a later date. Some of the submissions to the Senate inquiry6 show the heavy-handedness of the PSR, particularly in relation to procedures performed by GPs. Examples include a rural GP being required to pay back a substantial sum because he had not personally documented the wound dressings and vaccinations performed (a nurse had done the documentation), and the rejection of independent assessment that disagreed with the PSR when investigating a rural GP for computed tomography scan orders. The PSR investigated 200 records associated with a procedural rural GP who had been in practice for 26 years because of “statistical anomaly” in the number of pre-anaesthetic checks ordered, even though the local hospital generated all these requests. On this basis, the GP was found guilty of incomplete record keeping and misinterpretations of item numbers 723 and 2713. He decided to accept the settlement after trying to sort through the issue over 2 years, although he did not feel at any stage that he had done anything wrong. Despite his previously clear record and full cooperation, he was subsequently fined a substantial five-figure sum and his patients were banned from claiming item 36 from Medicare. The particular case of Dr Tisdall,7 whose disqualification from Medicare was publicised by the PSR, and who fought for 10 years to clear his name, only to die soon after the federal court granted him the right to have his case reviewed by a new committee, is well known in the medical community and in Kyabram where he worked. The Full Federal Court was highly critical of the way the PSR went about making its findings. They described it as making a “speculative assumption” and decisions “simply based upon inferences drawn from statistics”,7 echoing criticisms from medical groups. The PSR is not only the concern of the various medical organisations that have queried its operation. The Australian community are the losers when government bodies fail. This inquiry has given us all the opportunity to improve a system for the benefit of patients, the government and doctors alike. The PSR needs to work hard with all medical and community groups to regain trust and respect.

C Scott Masters FRACGP, FAFMM, DipMusMed · Malcolm I Watt

Opportunities to examine the relevance of health interventions in actual clinical scenarios need to be created Evidence-based medicine underpins high-quality health care.1 The use of evidence in the practice of medicine informs appropriate decision making, reduces variability in clinical practice and helps ensure improvement of patient outcomes. Most evidence relating to new knowledge is derived from randomised clinical trials.2,3 However, evidence from clinical trials necessarily involves small and very carefully selected populations with particular demographics and disease characteristics. Hence, the results of clinical trials are often not directly relevant to clinical reality. In addition, the scientific basis of “standard therapy” against which new interventions are compared has not necessarily been rigorously tested. Uncertainty about how best to use such new evidence versus the range of alternative options available in the “real world” may create variable practices and impair patient outcomes. Paradoxically, evidence from these trials is used by the Medical Services Advisory Committee and the Pharmaceutical Benefits Advisory Committee to make decisions about approval and reimbursement of health interventions. Furthermore, while there are obvious ways by which governments and health insurance funds can constrain the costs of new technology, new services and new drugs before their reimbursement, their capacity to influence the use of existing, funded services in a manner that improves the quality of care is limited. In this article, I outline why comparative effectiveness research — examining the applicability of marketed and/or approved products, services and technologies to clinical reality — is critical to the future of health care in Australia. Such research should be funded by the existing health portfolio, as it would not only help reduce clinical uncertainty but, in an era of increasing cost constraints, could improve the efficiency of health expenditure within the framework of existing funded services. Proposal for a new funding streamIt might be assumed that funding from the current National Health and Medical Research Council (NHMRC) competitive grants scheme is sufficient for gathering comparative effectiveness evidence. However, this scheme tends to be focused on innovation, track record and scientific merit, but comparative effectiveness research may not be seen to be as novel as research that seeks to redefine the boundaries of new knowledge. In the United States, a focus on comparative effectiveness research has emerged as a high priority of the current administration.4 Given the limited pool of funds available for medical research in Australia, I propose a new funding program that is ring-fenced for comparative effectiveness research but administered by the NHMRC, with applications assessed on the basis of scientific merit, innovation, improved health and patient outcomes, and cost offsets. The new funding stream should encourage research that: rigorously tests scientifically based variations in approved or standard health interventions that are publicly funded directly compares the relative roles of approved, publicly funded components of treatment algorithms. A separate funding stream dedicated to clinical research that tests standard health interventions would benefit the community and the government — it would provide a means of optimising the utility of previously funded and approved clinical programs. A simple example of the type of project that such funding might realise is the comparison of variations to approved chemotherapy regimens, most of which are derived from historical practice patterns. For instance, the Short Course Oncology Therapy (SCOT) trial — comparing 6 months of chemotherapy (standard care)5 to 3 months of chemotherapy6 for the adjuvant treatment of operable bowel cancer (to determine whether less chemotherapy is not only less toxic and costly but also equally efficacious) — is currently underway in Australia and Europe.7 In addition, research that compares the components of treatment algorithms — conducted within or across disciplines in relevant populations — would enable optimisation of existing health practices, many of which required no specific approval process to have been introduced into standard treatment algorithms. (Modifications to treatment algorithms are often funded by being absorbed into the Medicare Benefits Schedule [MBS] and/or health insurance funds or by state-based programs.) For example, postoperative radiotherapy as adjuvant treatment for locally advanced gastric cancer is considered one standard of care in Australia and the US.8 Implementation of this modality required no formal approval process and the costs of adding radiotherapy to treatment algorithms were subsumed into the costs of standard care. However, because other studies suggest that perioperative chemotherapy (without radiotherapy) may suffice,9 a comparative effectiveness trial would result in considerable insights into the relative utility of the two approaches, with initial trial-related cost-savings providing substantial offset to the cost of the research. Furthermore, such research can do more than determine the role of radiotherapy in the treatment of operable gastric cancer. For example, in the Trial of Preoperative Therapy for Gastric and Esophagogastric Junction Adenocarcinoma (TOPGEAR), the study design process required agreement on evidence-based surgical standards, standardised pathology examination and reporting, and standard chemotherapy regimens for this disease — none of which relate specifically to the experimental intervention.10 Hence, the research process resulted in clinician engagement in a change process that directly affected quality of care. By reducing variability in clinical practice outside the remit of the clinical trial, the research methodology will help ensure high-quality standards for patients, regardless of whether they are enrolled in the study. Similarly, the process of identifying and prioritising a potential question would help facilitate a change process inside and outside the specific research endeavour. The importance of such downstream effects is fundamental to understanding the potential impact of clinical research on the quality of the health system. Other types of more sophisticated research initiatives that test the interface between imaging, surgery and other techniques or practices, as well as the roles of pharmaceuticals, would undoubtedly emerge if the proposed funding stream were created. In so doing, such funding would enhance the capacity of Australian clinicians to promote the health care quality agenda in a cost-effective manner and across various components of the health system, such as the MBS and the Pharmaceutical Benefits Scheme (PBS). It would ensure that comparative effectiveness research initiatives do not have to compete against projects designed to develop new knowledge. A funding stream for comparative effectiveness research would invite research applications which are primarily designed to promote research into existing, funded health practices. Key criteria in funding decisions could include the likelihood of the research resulting in substantial impacts on the quality of patient care, in large numbers of patients, and the potential of the research to engage the broader health care community in a change process. The funding would not only help establish the relative roles of individual PBS- and MBS-funded interventions, but, from a broader viewpoint, would also show the government how clinical research represents a critical component of health care delivery. It would bring a quality focus to funding agencies concerned with the cost-effective delivery of medical services to the Australian community. Getting the new funding stream startedFunds from the existing health portfolio (MBS, PBS, etc) could be directed to a new NHMRC-administered funding stream of $100 million per annum for comparative effectiveness research. To start the program, the National Institute of Clinical Studies could facilitate development of a list of priority areas in three or more areas of health practice (eg, oncology, gastroenterology and rheumatology) by consultation with professional organisations, government agencies and consumer groups — similar to the list of priorities compiled by the US Institute of Medicine.11 This list could be used to pilot the funding program and could subsequently be extended to cover all areas of health practice. While the priorities within each health area could help inform the peer-review process, the call for applications should not discourage unanticipated ideas. In addition, the program should not be designed to provide a dedicated funding source for health economists — rather, it should encourage collaboration between practising clinicians from various disciplines, including experts in fields such as health economics and health system design. ConclusionA funding stream dedicated to comparative effectiveness research would improve health care quality, foster clinical practice research, and increase efficiency and effectiveness in the health system. It would also highlight the value of clinical research.

John R Zalcberg OAM, MB BS, PhD, FRACP

Three features are essential in designing the flexible funding payments and pay-for-performance elements Performance pay for doctors has been introduced in many countries, including the United Kingdom through the Quality and Outcomes Framework (QOF) and the United States through the patient-centred medical home model.1 The effectiveness of these models remains in question, although there is emerging evidence that these schemes can reduce hospital admissions.2-4 In Australia, the Coordinated Care for Diabetes Pilot (CCDP) begins in 2012.5 The key elements of the pilot (Box) are voluntary patient enrolment, a flexible payment for each diabetes patient to cover allied health services (among other things) and a pay-for-performance element. General practitioners will continue to be able to charge fee-for-service payments and claim diabetes-related payments from the Practice Incentives Program (PIP), but will no longer be able to claim the Chronic Disease Management Medicare Benefits Schedule (MBS) items for GP management plans or team care arrangements.5 Doubts about the effectiveness of financial incentives are raised, not only by poor design of evaluations, but also by poor design of funding models. Careful design, based on theory and empirical evidence, is essential in designing interventions to change professional behaviour.6,7 This helps to ensure that the intervention is likely to be effective, and that unintended and undesirable consequences of incentives are minimised. Our aim in this article is to propose three essential features of the flexible payment-per-patient and the pay-for-performance elements of the new CCDP.8,9 Rewarding improvements in quality of careAn objective of the CCDP is that incentive payments will be paid for: . . . the delivery of patient-centred care in accordance with best practice management guidelines for diabetes, and for achieving improvements in patients’ health against specific indicators.5 Payment should be made for improvements in the quality of care, which requires measuring changes in quality over time. Previous schemes have made payments for the achievement of a level of quality, often based on a relatively high threshold, rather than for an improvement in quality. Using thresholds may not lead to changes in behaviour because: (i) doctors in practices with already high levels of quality of care can claim the highest threshold payment without changing their behaviour; (ii) there are no incentives to go beyond the threshold, and (iii) doctors in practices with low levels of quality of care have little incentive to reach a high threshold, as they perceive the costs to be greater than the financial reward.10 One option is to reward improvements in quality between two time points, and set successive thresholds close together, say at 5% intervals.8 This would encourage those with low baseline levels of quality to improve the quality of their care. Furthermore, economic theory would predict that behaviour is only likely to change if the level of the payment is at least equal to the costs of improving the quality of care. These costs will vary across practices depending on their baseline level of quality and the complexity of the health problems of their patients.3 Allowing payments to vary in line with these cost variations would lead to a potentially more effective intervention. The costs of improving quality of care from 10% to 15% are likely to be lower than those of improving from 90% to 95%. Practices that already attain high standards of care find it difficult and costly to improve further and would not be able to claim an improvement payment. Thus, an element of performance pay should recognise the high performance levels already achieved. The “improvement” payment should be higher than the “achievement” payment, or there would be little incentive for practices to improve their quality of care. Avoiding “cream-skimming” and sharing financial riskA fixed payment per patient gives GPs an incentive to minimise costs, as any surplus from the budget can be kept as personal income or reinvested in patient care, and any deficits are borne by the provider.11 This is good for governments, who want to control costs and ensure costs are predictable, because it shifts the financial risk to GPs. However, if this risk is perceived to be too high, GPs may choose not to participate in the scheme or to enrol only “healthy” patients, so a careful balance needs to be struck between risk-sharing and the strength of incentives. The incentives to minimise costs and “cream-skim” are already ameliorated to some extent in the proposed CCDP. GPs can still claim standard MBS items and PIP payments for their patients with diabetes. Total revenue per patient will vary according to the number of visits made per year, and the length of each visit, which partly reflects complexity. However, this may not cover intensity in terms of the use of other resources in the practice, such as practice nurses or the costs of employing allied health professionals. One option is to “risk-adjust” fixed and performance payments, so that higher payments are made to practices with patients with higher needs or more complex health problems than the average. There is much international literature on this subject, including on the use of risk adjustment in the design of the patient-centred medical home pilots in the US.12 Risk adjustment requires data on the primary care costs of diabetes care for all patients and how this varies according to patients’ characteristics. Unfortunately, there are no routinely available data, and very little information on the use of allied health services by patients with diabetes and the associated costs.13,14 Primary care and hospital data would need to be linked to obtain adequate measures of patients’ severity of illness and diabetes complications.14 It is doubtful whether adequate risk adjustment can be developed and implemented in time for the pilot. However, given continued access to MBS and PIP payments, the additional level of risk for practices under the new scheme may not be high, although this will vary across practices. Avoiding exception reportingA further way that cream-skimming can take place for enrolled patients is exception reporting.15,16 Paying for the proportion of patients who achieve a certain target means that payments are based on a ratio, with the numerator equal to the number of patients reaching the target and the denominator equal to the number of patients in the population. Exception reporting occurs when practices exclude patients from the denominator, thus increasing measured performance and earning income, while not improving quality. For example, in the first year of the UK Quality and Outcomes Framework, a median of 5.4% (range, 0–40%) of practices used exception reporting for patients with diabetes. This translated into median gains of between £1700 and £15 000 per practice.15 One way to avoid exception reporting is to make payments based on the numerator only — that is, on the number of patients whose quality of care improves from one period to the next. This would involve a payment for each patient achieving a desired change in performance. Payments can only be increased from one time period to the next if the number of patients achieving a target, or whose quality of care improves, increases. ConclusionThe design of the new payment system in the CCDP should attempt to maximise the impact of the incentives on quality of care while also ensuring an “appropriate” sharing of financial risk with providers, in addition to minimising any unintended consequences, such as exception reporting and cream-skimming. This will partly depend on the validity and reliability of quality indicators, but experience from the Australian Primary Care Collaboratives Program suggests that such data can be extracted from practices. The balance of additional revenue between the flexible payments and performance-pay elements is also crucial, and can influence behaviour as well as costs. Careful design of incentive schemes is essential for their success. Current and new mix of payments for patients with diabetes under the Coordinated Care for Diabetes Pilot (CCDP) Payments Current mix New mix of payments in the CCDP*† 1. Fees for professional attendances For each visit, general practitioners can charge patients what the market will bear, and patients claim (often via their GP) a fixed rebate determined by the MBS. No change‡ 2. Practice Incentives Program Practices can claim payments for patients with diabetes within the PIP (the diabetes sign-on payment, the diabetes service incentive payment for completing a three-visit cycle of care, and the outcomes payment for each diabetes patient if the practice has completed cycles of care for at least 20% of their patients with diabetes). Practices in rural areas (RRMA 3–7) receive a loading on all PIP payments (including diabetes payments) of between 15% and 50%. No change 3. Fees for GP management plans and team care arrangements GPs can claim under MBS items 721 (development of a GPMP), 723 (development of TCA) or 732 (review of a GPMP or TCA). These are fees for each visit (so standard professional attendance fees cannot be claimed), with one GPMP or TCA claim allowed in 12 months (with some exceptions) and one review claim once every 3 months. Patients being managed under the chronic disease management items may be eligible for: allied health services (MBS items 10950–10970); and/or allied health group services (MBS items 81100–81125); and/or dental services (MBS items 85011–87777). There are restrictions on claiming both SIPs and GPMP/TCA/review payments. Practices can no longer claim these fees 4. Flexible funding None A single payment per enrolled patient per year 5. Pay for performance See PIP diabetes outcome payment for completion of cycles of care above. Payments related to improvements in quality of care — to be designed GPMP = GP management plan. MBS = Medicare Benefits Schedule. PIP = Practice Incentives Program. RRMA = Rural, Remote and Metropolitan Areas classification. SIPs = service incentive payments. TCA = team care arrangements. * There are other indirect funding sources for the care of patients with diabetes, including funding for practice nurses, which changed in late 2011 from practice nurse MBS items and payments under the PIP scheme, to fixed subsidies for practice nurse and allied health salaries under the Practice Nurse Incentive Program (http://www.medicareaustralia.gov.au/provider/incentives/pnip.jsp). † The levels of payments are to be determined as part of the implementation of the CCDP. ‡ To the extent that the scheme leads to more visits by patients with diabetes, this will also increase costs to the MBS.

Anthony Scott BA(Hons), MSc, PhD · Mark F Harris MB BS, FRACGP, MD

Australia’s Medicare Locals are in a formative period, and any comparison so far has focused on the United Kingdom The Australian and Canadian health systems share many similarities; one author has described them as “children of a common mother”.1 The fundamentals of the provision of primary care in both countries are the same: the overwhelming majority of “general practitioners” in Australia and “family physicians” in Canada work in independent practices, billing “Medicare” on a fee-for-service basis. The structure of family practice is similar, with a mix of solo and multiphysician practices. In Alberta, patients are not required to register with a single practice, but many family practices are not accepting new patients, and so registration with a practice is universally seen as desirable. There is no financial penalty (on the patient or the practice) for patients seeing a physician outside the practice in which they are registered. There are some differences; most notably that health care in Canada is essentially a provincial responsibility operating within overall parameters set by the Canada Health Act, and that “extra-billing” (billing above the schedule fee) is prohibited. The health systems in both countries face similar challenges in meeting the needs of primary health care: improving access, especially in rural and remote areas; better managing chronic disease; developing more effective links between primary care and hospital practice; and working out how to foster multidisciplinary teams. Alberta’s answer to these challenges has been to develop Primary Care Networks (PCNs), which may provide useful lessons for the establishment of Medicare Locals in Australia. Alberta is one of Canada’s western prairie provinces, with a population of 3.7 million, covering a geographic area about three-quarters the size of New South Wales. In 2009, Alberta had 113 family physicians per 100 000 population (4187 family physicians).2 The first PCN was established as part of the funding agreement between the province and the Alberta Medical Association in 2005. There are currently 39 PCNs in Alberta, and about 75% of family physicians work in practices that are members of PCNs.3 How PCNs functionPCNs are organisations of practices — the PCN itself does not enrol patients and does not run the practices. PCNs are eligible for a capitation payment of $50 per patient (for the purposes of this comparison, the Australian dollar can be assumed to be on a par with the Canadian dollar). PCNs are required to submit a “business plan” to Alberta Health Services (the provincial provider organisation responsible for the flow of funds to the PCNs) about how the capitation funding would be spent. Considerable flexibility is permitted in the structure and content of business plans, which allows for local variation in priority setting. PCNs range in size in terms of both the number of physicians linked to them and the number of patients served. PCNs in rural areas are smaller on both dimensions. PCN governance reflects both physician autonomy and the need for accountability to the funders (Alberta Health Services, and the relevant government department, Alberta Health and Wellness), reflected in two decision-making fora: a physicians’ board (known colloquially as the “Little Board”) and a PCN board (“Big Board”) with representatives of the funding organisations. The Big Board thus provides a direct link between the PCN and senior local Alberta Health Services leaders who are responsible for wider health issues. The PCN budget is derived from the capitation payments used to cover administrative costs of the initiative, which include employing an executive director responsible to the Little Board, employing allied health or mental health staff (often based in individual practices), and providing other support functions (eg, supplying comparative data). Evaluation of PCNsStakeholders see collaboration as the principal benefit of PCNs, and the provision of improved access to allied health care as one of their greatest strengths. “Collaboration” is used broadly here, to refer not simply to relationships between physicians and allied health professionals but also to relationships between physicians and the rest of the health system. In recent interviews with family physicians involved in PCNs in Alberta, conducted by one of us (A S, as part of a medical student placement), one physician stated that, “The PCN initiative has saved primary health care in Alberta”. Another, who holds positions on both the Little and Big Boards of a larger PCN, stated: Of the most important things which the PCN has achieved for our province, the first would be the re-involvement of family physicians with the health system, since, before this, they had been somewhat isolated; and the second [would be] better use of the full extent of capabilities and intelligences on offer from allied health professionals. There are disadvantages of the current PCN arrangements, including a lack of clarity with regard to general PCN direction, which stems from the autonomy in setting priorities granted to PCNs to allow maximum flexibility in responding to local needs. What can PCNs offer Medicare Locals?Strengthening primary care has been a catchcry of health reform efforts around the world for decades. The most recent Australian example is the report of the National Health and Hospitals Reform Commission.3 However, primary care is complex and reform is hard to achieve. One strategy has been to attempt to strengthen primary care by developing a stronger organisational base for it — initially, in Australia, through Divisions of General Practice,4,5 and more recently, through Medicare Locals.6 Divisions have been successful on a number of dimensions,7 although the administrative arrangements at both national8 and local levels9 have not been perfect. Arrangements for Medicare Locals are still evolving, and their evolution could benefit from taking note of similar strategies in other countries. Alberta’s PCNs have something to offer here as they have proven themselves to be a vital part of continued access to primary health care in the province. Although the Canadian and Australian health care systems are similar, they are not identical. Some aspects that may be portable are: Capitation funding — means that PCNs know how much they can expect and can plan accordingly. Depending on their size, PCNs receive up to $15 million per annum to be distributed in line with business plans. A dual board system — provides a compromise between physician autonomy in management of the PCN while allowing delegation of some decisions to the physician group. It has some parallels to the German approach of management and supervisory boards.10 An evolutionary approach — incorporating a slow phase-in means the system is not being imposed on any physician or practice and allows skeptics to evaluate the benefits of local cooperation. The first PCN was established more than 5 years ago, but some practices have not yet linked up to a PCN, despite the financial incentives. Alberta appears to have invented a wheel for primary care that is supported by family physicians. Australia could learn from this example without needing to totally reinvent it.

Andrew Suchowersky BMedSci(Hons) · Oksana Suchowersky MD, FRCPC, FCCMG · Stephen J Duckett PhD, DSc, FASSA