General medicine

Inappropriate intravenous fluid therapy is a significant cause of patient morbidity and mortality and may result from either incorrect volume (too much or too little) or incorrect type of fluid. Fluid overload has no precise definition, but complications usually arise in the context of pre-existing cardiorespiratory disease and severe acute illness. Insufficient fluid administration is readily identified by signs and symptoms of inadequate circulation and decreased organ perfusion. Administration of the wrong type of fluid results in derangement of serum sodium concentration, which, if severe enough, leads to changes in cell volume and function, and may result in serious neurological injury. In patients whose condition is uncomplicated, we recommend a restrictive approach to perioperative intravenous fluid replacement, with initial avoidance of hypotonic fluids, and regular measurement of serum concentration of electrolytes, especially sodium.

Andrew K Hilton FANZCA, FJFICM · Vincent A Pellegrino FRACP, FJFICM · Carlos D Scheinkestel FRACP, FJFICM, DipDHM

Men surviving cancer. Barry Leigh. Sydney: Jane Curry Publications, 2007 (viii + 255 pp). ISBN 978 1 920727 31 4. This account of men’s stories provides a lesson in the power of interaction and how what we say as health professionals can change people’s perceptions. A single “throw away” statement or sentence can be etched into a patient’s mind forever. It can shape the way a person diagnosed with a life-threatening illness views both their prognosis and their future. Most of the accounts in Men surviving cancer are about Australian men who have had above average difficulties. It could be confronting for those who have been recently diagnosed, as the path ahead may seem horrendous. Those in the course of challenging treatment, however, may be encouraged by the ultimate success of such treatment. The accounts in this book, as well as those in numerous other books on the cancer journey, suggest that men experience the same physical, emotional and sociological problems as do women. Men cry too. Men feel isolated too. Men change their priorities too: focusing on the importance of family, of friends and of nature. This account of men’s experiences may help others in a similar situation recognise that emotions are normal in the abnormal situation of having cancer. These individual inspiring stories help us recognise that fear of death is at the heart of much of our day-to-day anxiety when faced with a cancer diagnosis. Perhaps the title will attract men who would not normally consider reading a book about cancer, and the upbeat nature of the accounts will help them cope better. As health providers, we can be inspired to communicate more deeply with our patients and appreciate more keenly their willingness to appreciate the power of the spoken word.

Dawn Hooper · Mark Tweeddale

To the Editor: Learning in the clinical setting remains central to the development of well trained health care professionals. The issue is whether that learning should occur through formal or informal learning opportunities. Westbrook and colleagues define “supervision or education” in a way that focuses mainly on formal experiences,1 possibly because trained observers could accurately classify such experiences. As noted by Brown and Arnold, much learning in the hospital setting is largely informal in nature.2 Although learning is likely to be occurring during the many discussions that junior doctors have with consultants or during the procedures they perform in an emergency department,3 it can be difficult to describe, and may not be recognised as learning by the individuals involved.4 There is a divide between the perceptions of teachers and trainees about how much learning is occurring, whether teaching has occurred and feedback has been given. Consultants believe they are providing a great deal, but junior doctors do not recognise it. Although junior doctors perceive they have adequate informal contact with registrars, and some (but not enough) with consultants, what they want is more teaching in “formal” sessions.5 Additionally, supervisors think they give detailed feedback, but junior doctors view it as less than adequate.6 The answer might lie in upskilling both junior doctors and teachers to make teaching and learning more effective, in part by making it more explicit to all involved. At Sir Charles Gairdner Hospital in Perth, an innovation has been to create new positions known as “medical education registrars” who, as supernumerary staff at a senior registrar level, have time to advise on patient management, supervise and teach skills.7 Much of this is provided at the patient’s bedside. The very nature of their job title makes it explicit that they are there to help learning during daily activities. The staff development program, “Teaching on the Run”, developed by the Education Centre at the Faculty of Medicine and Dentistry, University of Western Australia,8 aims to make teachers more effective. More recently, we have piloted another program, “Learning on the Run”, for junior doctors and students, to provide them with the skills to recognise opportunities and drive their own learning agendas. We agree with Brown and Arnold that learning and service are not mutually exclusive.2 By providing both junior doctors and senior medical staff with the necessary skills, many tasks within a day in the life of a new doctor could become a valuable learning experience. Whether this will ultimately translate into improved teaching and learning outcomes is a question we are continuing to explore.

Lisa Caputo · Fiona R Lake · Margaret Potter · Ian Rogers

To the Editor: The 21 July 2008 “general practice” issue of the Journal raises a number of important issues about the future of generalist medical care, including the role of the general practitioner in the care of cancer patients. The editorial by Weller and Harris acknowledges the importance of multidisciplinary teams, including the full gamut of primary care practitioners, in meeting the diverse needs of people with cancer, from diagnosis to long-term “survivorship”.1 Jiwa et al propose a new model of an “integrated primary care hub” — with a “cancer care coordinator” — as a possible solution to the challenges of providing good team-based care.2 However, creating an entirely new disease-centred role would seem to ignore much of the debate in the rest of the general practice issue. Multiple morbidity is an emerging reality in Australia, and it is a fact that many survivors of cancer will die from other chronic conditions. Disease-specific care coordinators are currently being promoted as the new model for delivering chronic disease management to the community, but how many of these care coordinators will be needed for patients such as those described by Britt et al?3 And who will coordinate the coordinators? Gunn et al make a strong case for the generalist primary care medical practitioner as the overarching coordinator of care.4 We must stop seeing our patients through the eyes of our disease-centred hospital colleagues. Instead, we must create new mechanisms that will allow the experts in generalism — GPs — to move away from predominantly “reactive, consultation-based medicine”4 to high-quality integrated care planning in coordination with other members of the primary care team.

Jon D Emery

Objective: To assess the effectiveness of the PAST (Pre-hospital Acute Stroke Triage) protocol in reducing pre-hospital and emergency department (ED) delays to patients receiving organised acute stroke care, thereby increasing access to thrombolytic therapy.Design: Prospective cohort study using historical controls.Setting: Hunter Region of New South Wales, September 2005 to March 2006 (pre-intervention) and September 2006 to March 2007 (post-intervention).Participants: Consecutive patients presenting with acute stroke to a regional, tertiary referral hospital.Intervention: PAST protocol, comprising a pre-hospital stroke assessment tool for ambulance officers, an ambulance protocol for hospital bypass for potentially thrombolysis-eligible patients, and pre-hospital notification of the acute stroke team.Main outcome measures: Proportion of patients who received intravenous tissue plasminogen activator (tPA), process of care time points (symptom onset to ED arrival, ED arrival to tPA treatment, and ED transit time), and clinical outcomes of patients treated with tPA.Results: The proportion of ischaemic stroke patients treated with tPA increased from 4.7% (pre-intervention) to 21.4% (post-intervention) (P < 0.001). Time point outcomes also improved, with a reduction in median times from symptom onset to ED arrival from 150 to 90.5 min (P = 0.004) and from ED arrival to stroke unit admission from 361 to 232.5 minutes (P < 0.001). Of those treated with tPA, 43% had minimal or no disability at 3 months.Conclusions: Organised pre-hospital and ED acute stroke care increases patient access to tPA treatment, which is proven to reduce stroke-related disability.

Debbie A Quain BA(Nursing) · Mark W Parsons PhD, FRACP · Allan R Loudfoot MBA · Neil J Spratt PhD, FRACP · Malcolm K Evans RN, BA(HealthManagement) · Michelle L Russell RN, CM · Angela T Royan BNursing · Andrea G Moore BNursing · Ferdinand Miteff MB ChB · Carolyn J Hullick FACEM · John Attia MD, PhD, FRCPC, FRACP · Patrick McElduff BMath, PhD · Christopher R Levi BMedSci, FRACP

To the Editor: We report the case of a 41-year-old woman who sought medical opinion about an unpleasant body odour, first noticed when she was 7 years old. After experiencing ridicule, distress, shame, anxiety and low self-esteem during her school years, she first consulted a doctor about the problem at the age of 17 years, then again 2 years later, followed by a further four doctors over the next 20 years. All dismissed her concerns, and she was repeatedly told that she had a hygiene neurosis. Investigations and treatments during this time included being “sniffed”, vaginal swabs and vaginal cauterisation. Finally, a general practitioner referred her to a dermatologist, who consulted a microbiologist, and the diagnosis of trimethylaminuria (TMAU), or fish malodour syndrome, was confirmed by urinalysis. Now having a name for her condition, she found an Internet-based support foundation and referred herself for genetic counselling. TMAU is caused by an enzyme deficiency due to mutations in the flavin-containing mono-oxygenase 3 (FMO3) gene,1 resulting in excess excretion of trimethylamine in urine, sweat and breath. It is diagnosed by clinical symptoms and urine analysis.2 The characteristic body odour resembling rotting fish can be intermittent, variable and influenced by diet, hormones and medications. Restriction of choline- and carnitine-rich dietary precursors (eg, fish, eggs, soybeans, peas) is difficult to maintain and effective in only 25% of patients.2 Acid soaps and body lotions can often reduce the odour.3 The metabolic and clinical manifestations of TMAU are generally regarded as benign, as there is no associated organ dysfunction. This designation, and the fact that the condition is often unrecognised by doctors, can have important ramifications including missed or delayed diagnosis.4 Affected individuals experience shame and embarrassment, fail to maintain relationships, avoid contact with people who comment on their condition, and are obsessive about masking the odour with hygiene products and even smoking. The malodorous aspect can have serious and destructive effects on schooling, personal life, career and relationships, resulting in social isolation, low self-esteem, depression, paranoid behaviour, and suicide.4, Psychosocial problems resulting from delayed diagnosis, body odour and the lack of cure are considerable, making this a far from “benign” disorder. Recognition of TMAU as a significant clinical entity and increased understanding of the issues patients face are needed. Awareness of the typical patient history would facilitate prompt metabolic diagnosis and pre-empt some of the associated psychosocial sequelae. Referral of patients for genetic counselling enables short-term psychosocial support and family cascade genetic testing. Consultation with a metabolic clinic for dietary management may also be beneficial.

Helen Mountain · Joanna M Brisbane · Amanda J Hooper · John R Burnett · Jack Goldblatt

Patients who notice a red eye or other acute ophthalmic symptoms often present first to their general practitioner, optometrist or local hospital emergency department. Although the most common acute eye diseases in primary practice are the usually benign conditions of viral, bacterial and allergic conjunctivitis, rarer but more serious causes of red eye such as iritis, keratitis and acute glaucoma can lead to permanent loss of vision. The primary health care provider’s initial diagnosis and management can be critical to the patient’s ophthalmic outcome. In one United Kingdom study of 55 patients in which an ophthalmologist had diagnosed a red-eye disorder, only nine had been correctly diagnosed by the referring practitioner.1 To our knowledge, no study of the accuracy of diagnosis of eye conditions by primary health care providers in Australia has yet been published. We audited the hospital records of 1062 new patients presenting to the eye emergency services of the ophthalmology departments of the two major Brisbane hospitals, and analysed the accuracy of the diagnosis and implications of the initial care provided to these patients by their local doctor or optometrist. Lessons from practice Patients with acute eye problems presenting to primary health care providers are often misdiagnosed or mismanaged. Topical antibiotic therapy is overprescribed for acute eye conditions. Particular attention should be paid to sentinel warning symptoms — in particular the presence of one or more of pain, photophobia or blurred vision — as these symptoms almost always indicate serious acute eye disease rather than conjunctivitis. If a patient with a red eye reports pain, photophobia or blurred vision he or she should be given no treatment and referred immediately. Methods Patient records from consecutive presentations to eye emergency services of ophthalmology departments at two hospitals — Princess Alexandra Hospital (PAH) from 18 April to 25 October 2006 and the Royal Brisbane and Women’s Hospital (RBWH) from 1 July to 30 September 2006 — were collected and reviewed. Approval for the project was obtained from the Director of Surgery, Head of Ophthalmology and Ethics Committee of each hospital. Inclusion criteria were initial presentation to a primary health care provider (PHCP) — defined as a GP, optometrist or hospital emergency department doctor — and subsequent referral or patient self-presentation to an eye emergency service for the same complaint. The diagnosis in the ophthalmology department was compared with that by the PHCP, and the accuracy of diagnosis was determined. A preventable adverse outcome was deemed to have occurred if the patient had eye pain, loss of vision, or had been given inappropriate medication that could have been avoided with appropriate initial management or prompt referral. A further subjective assessment of the severity of the adverse outcome was then made. ResultsData were collected for 1062 patients during the designated periods at the two hospitals: 614 (57.8%) from PAH and 448 (42.2%) from RBWH. The referring PHCP was a GP in 50.4%, hospital emergency department doctor in 38.9%, and an optometrist in 10.7% of cases. The 10 most common reasons that PHCPs referred patients to ophthalmology departments are shown in Box 1. Accuracy of primary health care practitoners’ diagnosesA correct initial diagnosis (ie, matching the final ophthalmology department diagnosis) was given for 192 (35.9%) of the 535 patients referred by GPs, 173 (41.9%) of the 413 patients referred by emergency department doctors and 55 (48.2%) of the 114 patients referred by optometrists. Implications of initial inappropriate care by primary health care providersPreventable adverse outcomes: In 123 of the 1062 patients (11.6%), there was an adverse outcome resulting from misdiagnosis or mismanagement by the PHCP. Adverse outcomes in these 123 patients were mild in 63 (51%), moderate in 49 (40%) and severe in 11 (9%). Conditions that were misdiagnosed and subsequently associated with a severe adverse patient outcome are shown in Box 2. In most cases (74%), adverse outcomes were associated with misdiagnosis by PHCPs; in the remainder (26%), there had been a correct initial diagnosis, but subsequent incorrect treatment, or a significant delay in referral. In the 123 patients with preventable adverse outcomes resulting from misdiagnosis or mismanagement, the PHCP was a GP in 78%, an emergency department doctor in 17% and an optometrist in 5% of cases. The 11 most severe preventable adverse outcomes are described in Box 3. Topical antibiotic therapy: Of the total of 1062 patients, 199 (18.7%) had been prescribed topical antibiotic therapy at their initial consultation with their PHCP. Of the 535 patients referred by GPs, 108 (20.2%) had been prescribed antibiotic eye drops before referral. In 54% of these 108 patients, the therapy was judged inappropriate or unnecessary on ophthalmic review, and was ceased. Iritis: There were 59 patients with iritis (acute anterior uveitis), representing 5.6% of the total 1062 patients. Less than a third of patients with iritis (16 of 59; 27%) were diagnosed correctly by the PHCP. Eleven of the 59 patients with iritis (19%) were initially misdiagnosed as having conjunctivitis and treated with topical antibiotic therapy by their GP. Fourteen patients were given no diagnosis and no therapy. Seven patients had their condition misdiagnosed as red eye and were given no therapy. Iritis was misdiagnosed as glaucoma in three patients, hyphaema in two patients, keratitis in two patients, cataract in two patients, and as macular oedema and pain in one patient. The average time to referral or self-presentation to an eye emergency service for patients with iritis was 2.4 days (range, 0–16 days). DiscussionPatients with acute eye problems presenting to PHCPs, especially GPs, are often misdiagnosed or mismanaged. In most cases, this does the patient no harm — for example, misdiagnosing viral conjunctivitis as bacterial conjunctivitis and inappropriately prescribing antibiotic eye drops is unlikely to cause complications, and the patient will spontaneously recover from the infection. However, in some acute eye conditions, the prescription of topical antibiotics can be very harmful indeed — not through any ill effects of the drug, but through the subsequent delay in referral. In the case of serious acute eye conditions like severe iritis or acute glaucoma, a delay of even a few days can result in permanent loss of vision or even blindness. Examples of potentially serious eye diseases that may present to PHCPs are shown in Box 4. In our survey, of 11 patients identified as having had a preventable, severe adverse outcome, 10 had initially presented to their PHCP with a unilateral red eye. All 10 were incorrectly diagnosed as having conjunctivitis and all had been inappropriately prescribed chloramphenicol eye drops as treatment. All had reported ocular pain, photophobia or blurred vision to their PHCP at the initial consultation. The 11th patient had retinal detachment. There is a perception among many ophthalmologists that many GPs “call every red eye conjunctivitis” and that topical antibiotics are overprescribed for acute eye problems. In our review, in more than 50% of cases in which topical antibiotic therapy had been commenced by the PHCP, it was immediately ceased at the first ophthalmology review as being unnecessary or inappropriate. In addition to contributing to a serious delay in patient referral, topical antibiotic use can occasionally cause serious local and rarely systemic complications2 (eg, agranulocytosis from chloramphenicol). There may also be concerns that using antibiotics unnecessarily contributes to increasing antibiotic resistance of organisms.3 How can the situation be improved? A major problem is the lack of equipment, expertise and time available to a GP in a busy practice facing a new patient with an acute eye problem. Many eye conditions (including iritis and acute glaucoma) cannot be diagnosed without a slit lamp microscope and a means of measuring intraocular pressure — equipment that is rarely available to GPs. In addition, many GPs have had little ophthalmological training, and have limited time to spend with each patient. To address these problems, it is suggested that GPs pay careful attention to the symptoms reported by patients with eye complaints, given the difficulty of accurately evaluating their signs. Particular attention should be paid to sentinel warning symptoms — in particular the presence of one or more of pain, photophobia or blurred vision — as these symptoms almost always indicate serious acute eye disease rather than conjunctivitis.4 Patients reporting one or more of these symptoms should be given no treatment, and referred to an ophthalmologist urgently. It should also be recognised by GPs that although unilateral viral conjunctivitis is common, a single red eye should be viewed with more suspicion than bilateral red eyes, which are more likely due to conjunctivitis. 1 The 10 most common reasons that primary health care providers referred patients to ophthalmology department emergency services 2 Conditions originally misdiagnosed by primary health care providers, leading to adverse events for patients 3 Severe adverse outcomes in 11 patients as a result of misdiagnosis or mismanagement by primary health care providers* Patient Age and sex Ophthalmology department diagnosis PHCP diagnosis PHCP treatment Delay in referral Preventable adverse outcome 1 79 M Acute anterior uveitis Red eye Chloramphenicol eye drops 8 days Severe permanent vision loss and severe pain 2 55 F Acute anterior uveitis Conjunctivitis Chloramphenicol eye drops 7 days Moderate permanent vision loss and severe pain 3 77 M Acute anterior uveitis Red eye Chloramphenicol eye drops 10 days Severe pain 4 38 M Acute anterior uveitis Red eye Chloramphenicol eye drops 15 days† Severe pain 5 55 F Acute anterior uveitis Conjunctivitis Chloramphenicol eye drops 9 days Severe pain 6 26 F Bacterial keratitis Conjunctivitis Chloramphenicol eye drops 2 days Severe pain 7 95 F Herpes zoster ophthalmicus Red eye Chloramphenicol eye drops 3 days Mild permanent vision loss, severe pain, delay in commencing antiviral treatment 8 56 M Herpes zoster ophthalmicus Red eye Chloramphenicol eye drops 14 days Severe pain, delay in commencing antiviral treatment 9 77 M Neovascular glaucoma Herpes zoster ophthalmicus Chloramphenicol eye drops 7 days Severe pain 10 26 F Glaucoma and diabetic retinopathy Conjunctivitis Chloramphenicol eye drops 5 days Severe pain 11 29 M Retinal detachment No diagnosis Nil 7 days† Severe permanent vision loss M = male. F = female. PHCP = primary health care provider. * The PHCP was a general practitioner for all patients except Patient 10, who saw a hospital emergency department doctor. † Self-presented. 4 Examples of “red eye” diseases that may present to a primary health care provider

Michael O Statham MB BS(Hons), BAppSci(Optom)(Hons) · Anamika Sharma MB BS(Hons), BMedSci(Hons) · Anthony R Pane MB BS(Hons), MMedSc, FRANZCO

Journeys with the black dog. Inspirational stories of bringing depression to heel. Tessa Wigney, Kerrie Eyers, Gordon Parker, editors. Sydney: Allen & Unwin, 2007 (x + 280 pp). ISBN 978 1 74175 264 9. This is an inspirational book, useful to people who experience chronic depression. It holds the stories of over 600 people who entered a writing competition, challenged to write about their mood disorder — the black dog. Divided into logical sections, the text moves the reader from the experience of depression through to stories of healing and recovery. Innovatively, friends and family are also included in one section of the book, providing their insights into the difficulties people experience when they have a loved one with depression. I was pleased to see the “Staying on course” section, about adjuncts to medical treatment. My experience as a general practitioner and depression researcher is that many people find these things ofs equal, if not more, benefit than medication, particularly for those with moderate depression. Themes of having someone to talk to and really being listened to are prominent throughout the book. The tips for maintaining wellbeing at the end of the book are great and revolve around having a passion in life, being kind to oneself, living in the moment and savouring happiness when it does occur. The only limitation of the book is that it is weighted to the moderate to severe end of the spectrum of mood disorders, with many of the contributors having bipolar and long-term severe depression. Many of them are on medication and have been hospitalised. I would recommend Journeys with the black dog to my patients and to all people who live with or are touched by the black dog — it will provide inspiration to endure, survive and hopefully even thrive.

Kelsey L Hegarty

To the Editor: The study by Nichols and colleagues1 and the associated editorial by Hughes2 struck a chord of familiarity for me, as patient safety issues are currently high on the political agenda in the United Kingdom. An estimated 850 000 incidents of harm or near harm affect National Health Service (NHS) hospital patients in the UK each year.3 In April 2004, the Health Foundation (an independent charity that aims to improve the quality of UK health care), together with the Institute for Healthcare Improvement, launched the Safer Patients Initiative (SPI). The four hospitals initially chosen to participate conducted hospital-wide programs to radically improve patient safety, with the aim of reducing adverse events by 50% by October 2006. In November 2006, Phase 2 was launched, adding 20 more sites.3 These hospitals meet regularly to report on progress and exchange ideas. Discrete projects focus on medicines reconciliation, ward-based care, critical care, and perioperative care. The overall aim of the SPI is to improve the patient safety culture within each organisation. Specific targets for all participating hospitals include a 15% reduction in mortality of in-hospital patients; 300 days between central line bloodstream infections in critical care units; 80% of blood sugar levels in diabetic patients falling within their target treatment range; a 30% reduction in cardiac arrest calls; and 50% reductions in methicillin-resistant Staphylococcus aureus bloodstream infections, harm from anticoagulation, and surgical site infections. In my intensive care unit, hand hygiene compliance among medical staff has been regularly audited and has improved from a range of 20%–90% per day to 60%–100%. This compares favourably with a recent Australian hand hygiene initiative.4 When practice improvements are shown in one location, the project team takes on the responsibility of spreading these across the hospital. Initial scepticism from senior clinicians and nurses in my hospital has generally been replaced by cooperation and, in many cases, ideas for other ways to improve delivery of safer clinical care. Large multisite evidence-based trials in intensive care units in the United States showed that, with focused effort on sterile technique and catheter care and by rectifying lapses in standard procedures, a reduction of 66% in catheter-related bloodstream infections was possible.5 The SPI is trying to replicate results such as these within a relatively short period. My intensive care unit has now gone 190 days without a line-related bacteraemia; previously, we had infections almost every month. The SPI Phase 2 completion date is November 2008, with full national reporting due at that time. It is intended that practice improvements will then be spread across the NHS. The experience in my hospital has been that sharing experiences both within the hospital and externally has led to tangible progress in this area.

Peter J Shirley

Objective: To determine whether a 5-day course of oral prednisolone is superior to a 3-day course in reducing the 2-week morbidity of children with asthma exacerbations who are not hospitalised.Design, setting and participants: Double-blind randomised controlled trial of asthma outcomes following a 5-day course of oral prednisolone (1 mg/kg) compared with a 3-day course of prednisolone plus placebo for 2 days. Participants were children aged 2–15 years who presented to the emergency departments of three Queensland hospitals between March 2004 and February 2007 with an acute exacerbation of asthma, but were not hospitalised. Sample size was defined a priori for a study power of 90%.Main outcome measures: Difference in proportion of children who were symptom-free at Day 7, as measured by intention-to-treat (ITT) and per-protocol analysis; quality of life (QOL) on Days 7 and 14.Results: 201 children were enrolled, and there was an 82% completion rate. There was no difference between groups in the proportion of children who were symptom-free (observed difference, 0.04 [95% CI, − 0.09 to 0.18] by ITT analysis; 0.04 [95% CI, − 0.17 to 0.09] by per-protocol analysis). There was also no difference between groups in QOL (P = 0.42). The difference between groups for the primary outcome was within the equivalence range calculated post priori.Conclusion: A 5-day course of oral prednisolone confers no advantage over a 3-day course for children with asthma exacerbations who are not hospitalised.Trial registration: Australian Clinical Trials Registry ACTRN012605000305628.

Anne B Chang MPHTM, PhD, FRACP · Ronald Clark PhD, FRACP · Theo P Sloots BSc, PhD · David G Stone FRACP · Helen L Petsky BN · Donna Thearle BN · Anita A Champion BPharm · Coralie Wheeler BN · Jason P Acworth FRACP

To the Editor: Bethanechol is a parasympathomimetic agent similar to acetylcholine that is known to be a selective stimulant of smooth muscle in the gastrointestinal tract and urinary bladder. It is normally used to treat non-obstructive urinary retention and has not previously been known to have any effect on skeletal muscle. Adults with cerebral palsy usually slowly deteriorate over the years, with gradually increasing muscle tone, worsening speech, mobility difficulties and a loss of independence. There has been no change in their management for decades. While working in a residential facility for adults with cerebral palsy, we serendipitously found that bethanechol significantly reduced the muscle spasticity in a patient for whom it was initially used to treat micturition difficulty. Seven other patients who were wheelchair-bound with cerebral palsy were then progressively given bethanechol in increasing doses. All patients and/or their carers were advised that the medication was being used experimentally, and all consented to participate in a clinical trial. The results are summarised in the Box. In all patients, bethanechol treatment was ceased for a week once the clinical benefits had been established, and all deteriorated during that week. None of the patients suffered any detectable side effects from the use of bethanechol, but many were already taking a proton-pump inhibitor that may have protected them from any gastrointestinal adverse effects. A synergistic interaction between bethanechol and another medication (eg, diazepam) was excluded as an explanation for the results obtained, as no other medication was common to all patients. Bethanechol’s effect seems to be long-lasting, as the first patient has now been using it for 6 months with no deterioration in his improved muscle tone. A Medline search revealed no studies in which bethanechol had been used as a treatment for cerebral palsy. Although our sample was very small, the fact that every patient improved indicates that a larger trial of bethanechol for cerebral palsy is warranted. Clinical outcomes for eight patients with cerebral palsy after treatment with bethanechol Sex (age in years) Diagnosis Final daily dose of bethanechol* Clinical effects M (41) Ataxic and spastic quadriplegia 60 mg Reduced muscle spasm, improved joint movement and speech, improved sense of wellbeing F (53) Ataxic and spastic quadriplegia 60 mg Improved arm movement and speech, looser muscle tone, more relaxed F (47) Spastic quadriplegia, kyphoscoliosis 60 mg Able to abduct legs from previously clamped closed position, loss of leg spasm pain, improved speech, muscle spasm induced by touch eliminated M (68) Spastic quadriplegia, dysphagia 60 mg Less stiffness, speech clearer, easier for carers to move, improved sense of wellbeing M (58) Rigid spastic quadriplegia 60 mg Less limb muscle spasm, improved arm and trunk movement, markedly improved speech F (44) Spastic quadriplegia, epilepsy 60 mg Improved arm and leg movement, easier to roll M (49) Spastic quadriplegia, athetosis 30 mg Chronic spasmodic jerks ceased completely, speech better, able to play carpet bowls better, back extension improved M (68) Spastic quadriplegia, kyphoscoliosis 60 mg Less muscle pain, less back spasm, easier for carers to lift, felt happier and more relaxed * Given orally in three divided doses.

Warwick J Carter

Objective: To report patient responses to the General Practice Assessment Questionnaire (GPAQ) as a measure of satisfaction with health care received from Australian general practitioners.Design, setting and participants: A clustered cross-sectional study involving general practice patients from 30 randomly selected general practices in Victoria. Between January and December 2005, a screening survey, including a postal version of the GPAQ, was mailed to 17 780 eligible patients.Main outcome measure: Scores on the six GPAQ items.Results: We analysed data from 7130 patients who completed the screening survey and fulfilled our eligibility criteria. Levels of patient satisfaction with general practice care were generally high: mean GPAQ scores ranged from 68.6 (95% CI, 66.1–71.0) for satisfaction with access to the practice to 84.0 (95% CI, 82.2–85.4) for satisfaction with communication. Intracluster correlations for the GPAQ items ranged from 0.016 for overall satisfaction with the practice to 0.163 for satisfaction with access to the practice. Compared with national benchmarks in the United Kingdom, the GPs and practices participating in our study were rated higher on all six GPAQ items. Multivariable mixed effects linear regression showed that patients who were older, rated their health more highly, visited their GP more frequently and saw the same GP each time tended to express greater satisfaction with their care.Conclusion: Generally patients reported high levels of satisfaction with GP care. Greater satisfaction with care was associated with older patients, good health, more frequent contact with the GP, and seeing the one GP consistently.

Maria Potiriadis GradDipClinEpi, BAppSc · Patty Chondros MSc(Stats), GradDipEpiBiostats, BSc(Hons) · Gail Gilchrist PhD, GradDipAlcDrugStud, BA(Hons) · Kelsey Hegarty MB BS, FRACGP, PhD · Grant Blashki MB BS, FRACGP · Jane M Gunn MB BS, FRACGP, PhD

GPs can play a crucial role in screening for problem gambling Problem gambling is a significant mental health problem in Australia. Estimates of the prevalence of serious gambling problems in Australia range from 1% to 2% of the general adult population, with higher rates in specific groups.1 An estimated 2.5%–5% of the Australian adult population display at-risk gambling behaviour (according to standard diagnostic criteria).1 The prevalence of problem gambling exceeds that of stroke and coronary heart disease, and is comparable with the estimated prevalence of type 2 diabetes in Australia.2 Further, problem gambling has been shown to be strongly comorbid with other health and mental health problems with high burdens of disease.3 A large-scale study in the United States found that 73% of pathological gamblers (as defined by the Diagnostic and statistical manual of mental disorders,4 fourth edition [DSM-IV]) had an alcohol use disorder, 38% had a drug use disorder, 60% had nicotine dependence, 50% had a mood disorder, 41% had an anxiety disorder, and 61% had a personality disorder.5 A recent Australian study found that, compared with non-gamblers, problem gamblers had a relative risk of 18.8 of having a severe mood disorder, and were over four times more likely to have hazardous alcohol use.6 The causal nexus between depression, excessive alcohol use and problem gambling is not known, but the associations are very strong. Thus, problem gambling is a significant clinical problem with high prevalence that is strongly associated with other high-burden health problems; it therefore warrants attention in primary care practice. In 1999, the Australian Medical Association released its pioneering position statement, Health effects of problem gambling.7 The statement noted that medical practitioners need to be aware of “the adverse impacts of problem gambling” and its comorbidities. It recommended that practitioners include gambling as part of lifestyle risk assessment. Despite this recommendation, many Australian general practitioners are not screening for gambling problems in their patients.8 This may be because they lack the requisite knowledge and tools to deal effectively with problem gambling when it is identified.8 How can this be remedied? Internationally, various medical associations have devised policy statements and toolkits to guide medical practitioners in the treatment of problem gamblers and their families. In 2007, the British Medical Association released protocols for the treatment of gambling addiction within the United Kingdom’s National Health Service.9 These protocols advise that practitioners develop an awareness of problem gambling, its prevalence within key population groups and its comorbidities, and recommend education and training for GPs. The American Medical Association has endorsed policies on problem gambling, emphasising the importance of patient education about the risks of gambling, and has published a patient information sheet in the Journal of the American Medical Association.10 Some jurisdictions in the US have released clinical protocols to help health professionals screen for and treat problem gambling. Essentially, there is international agreement that GPs routinely encounter problem gamblers and that an effective response is required. However, what should this response be? The first step must be effective screening. But how should patients be screened, and who should be screened? The most popular diagnostic tools for problem gambling are the Canadian Problem Gambling Index,11 the DSM-IV criteria for pathological gambling,4 and the South Oaks Gambling Screen.12 However, these tools are too time consuming for routine use in primary care practice. Recently, we developed a one-item screening test for use in primary care practice with beyondblue and Victorian Government funding. We have found that answers to the question “Have you ever had an issue with your gambling?” closely predict answers to the full Canadian Problem Gambling Index tool.6 We wish to extend the screen to include family members of problem gamblers, as they also experience serious difficulties as a result of their family member’s gambling.13 As for who should be screened for problem gambling, we recommend screening patients with anxiety and depressive symptoms or high drug or alcohol use, because of the high rates of comorbidity of these conditions. Those who screen positive to the question “Have you ever had an issue with your gambling?” should be referred for further assessment and treatment by appropriately trained specialist practitioners in problem gambling. There is a developing body of research on treatment for problem gambling.14 The major therapies include counselling, cognitive behaviour therapy and drug treatments. At present, there is limited evidence from randomised controlled trials for their effectiveness. It is recommended that problem gambling interventions be delivered by specialists. Family members may also require treatment for psychological problems because of the impact of their family member’s gambling. Most gambling treatment services accommodate both gamblers and their family members. All Australian jurisdictions have networks of publicly funded practitioners who specialise in the treatment of problem gambling, and a wide range of psychologists and psychiatrists provide treatment in mental health and private practices. However, GPs are well placed to detect and initiate treatment for this debilitating psychological problem.

Shane A Thomas PhD · Leon Piterman MMed(Primary Care), MEdSt, FRACGP · Alun C Jackson PhD

Objectives: To explore general practitioners’ perceptions of their preparedness for an influenza pandemic, the changes they would make to their practice, and the ethical justifications for their planned actions.Design and setting: A qualitative study was performed among South Australian GPs between March and October 2007. A semi-structured interview was carried out with each participant in his or her practice, and the interviews were audio-recorded, transcribed and analysed thematically.Participants: 10 GPs were recruited: five from a metropolitan Division and five from a rural Division of General Practice.Results: Some participants felt they would not be able to cope with an influenza pandemic, while others felt it would simply mean an increase in their workloads. Most respondents considered creating separate waiting rooms, moving the reception desk outside of the practice and delaying all non-urgent consultations in order to deal with a pandemic more effectively. Respondents mentioned the conflict between their various roles and responsibilities as a primary source of tension when thinking about the way they would organise their work in the event of a pandemic. A number of GPs said they would not practise in the event of a pandemic, as they felt their responsibility to their families outweighed that to their patients.Conclusions: Professional codes of ethics should include guidance about the scope of the duty to treat during infectious disease outbreaks. The community has to uphold the value of reciprocity, and ensure that GPs and their families are provided with support during a pandemic and are given the opportunity to be actively involved in pandemic preparedness planning.

Olga Anikeeva BHlthSci(Hons) · Annette J Braunack-Mayer PhD, BMedSci(Hons) · Jackie M Street PhD, BSc(Hons), GradDipPrimaryHealthCare

At the time of his death in Georgetown, in Queensland’s Channel Country, Cyril Swaine had enjoyed a successful medical career of over 50 years, spent within and outside Australia, remaining active and moving with the times in a profession that was undergoing unimagined expansion and specialisation. Cyril was born on 1 November 1919 in the Adelaide Hills, the eldest of six children, into times that were frequently hard. He was mentored at an early age by a local general practitioner, Carl Jungfer, a later icon for Australian general practice. On graduating in medicine at the University of Adelaide, Cyril entered the wartime Royal Australian Air Force, serving in Malaya and rising to the rank of Squadron Leader. In 1947, he joined the Repatriation Department in Adelaide, gaining expertise in the management and treatment of tuberculosis. After 9 years in the Repatriation Department, Cyril spent a year working as a Senior Medical Officer at the then-active Woomera Rocket Range, followed by 14 years in general practice at Woodville in Adelaide. The next 13 years were spent in Indonesia and Papua New Guinea working for a mining company, where his practice included occupational and industrial medicine and was enlivened by obstetrics and emergency surgery. In 1983, he returned with his family to Cairns in Queensland with plans to semi-retire. But for a person of his great intellect and altruistic spirit, this proved difficult, and his practice actually expanded to include younger partners and a second site. He became active in Rotary and was elected to the executive of the Cairns Division of General Practice. In 1999, Cyril sustained two accidents that finally forced him to retire. Cyril relocated to Georgetown, where his wife Pam took up a position as Director of Nursing at the hospital. Cyril died there on 14 August 2007 from ischaemic heart disease. His requiem mass in Georgetown was notable for the attendance of many colleagues who had been flown into the relatively remote town courtesy of the Royal Flying Doctor Service. It was suitable recognition for a man who was described during his eulogy as displaying tremendous integrity, loyalty and honesty, and who epitomised the Christian ethic in his professional and personal life. He is survived by his wife Pam and children Marie, Stephanie, Brook and Justin. A son David predeceased him.

Peter P Thomas

Australia’s GPs are meeting the challenges of change, while maintaining some constancies A few short years ago, the death of general practice as we knew it was reported.1 However, as suggested by our cover image of the mythical phoenix (Box), with its reference to Ovid’s poem Metamorphoses — “what is called birth is change from what we were, and death the shape of being left behind” — there is another explanation. This perceived “death” may, in fact, have been the preface to a significant cycle of change now manifesting in general practice in many countries around the world, including Australia. These changes, reflected in the articles in this general practice theme issue of the Journal, are many. They include already evolving pandemics of chronic illnesses, including cancer (see Weller and Harris, "Cancer care: what role for the general practitioner?"; Jiwa et al, "Timely cancer diagnosis and management as a chronic condition: opportunities for primary care"), accompanied by the increasing realisation that patients with chronic illness often have multiple morbidities (see Knox et al, "Estimating prevalence of common chronic morbidities in Australia"; Britt et al, "Prevalence and patterns of multimorbidity in Australia"). Parallel with changes in the epidemiology of disease, there have also been changes in health care policy and funding, including a wide array of systems for remunerating practices for their services, all of which need to be acknowledged and some of which could do with a degree of rethinking (see Ashworth and Jones, "Pay for performance systems in general practice: experience in the United Kingdom"; Kirby et al, "Sharing or shuffling — realities of chronic disease care in general practice"). Much discussion and debate about the possibilities for further change have followed the election of the Rudd federal Labor government, particularly the proposed introduction of GP Super Clinics2 (see Kidd, "What impact will the change of federal government have on Australian general practice?"). The announcement that a National Primary Health Care Strategy is to be developed, with strong general practice input into the committee formed to steer the process, is a welcome indication of government interest.3 On the other hand, recent budget cuts to general practice programs such as after-hours services and e-health, and changes to the immunisation incentives program, send a contradictory message.4 Undoubtedly, major challenges surround the issues of general practice workforce and changing roles for general practitioners in clinical practice (see Thistlethwaite et al, Addressing general practice workforce shortages: policy options; Willcock, "Getting back into the emergency department: diversifying general practice while relieving emergency medicine workforce shortages"). Interesting and challenging questions are being asked about what sort of clinician might be best equipped to provide health care for patients with several complex, chronic illnesses. In a world of increasing specialisation and subspecialisation, including within general practice, it is paradoxical that the role of the generalist will become more important in providing comprehensive, coordinated and accessible care for all (see Gunn et al, "The promise and pitfalls of generalism in achieving the Alma-Ata vision of health for all"). This same need underpinned an earlier rebirth of general practice in the 1950s.5 Though much has changed in the world and in general practice, some constancies remain. As highlighted by Professor Trisha Greenhalgh in her keynote address at this year’s General Practice and Primary Health Care Research Conference in Hobart (http://www.phcris.org.au/conference/browse.php?confID=758), people in the community continue to want a knowledgeable, skilled and altruistic family doctor who understands evidence, but who also knows how to apply it with understanding and humanity. We believe this to be an apt description of a typical Australian GP. The phoenix — “and all things change” “The themes of rebirth and renewal of the phoenix legend are universal; the fire can represent illness, death of course, or perhaps another kind of adversity from which, with courage, we might emerge changed by the experience, perhaps stronger.” Dr Kate Hansford, General Practitioner, Hobart, Tasmania. Artworks by other GPs are also featured in this issue.

Ann T Gregory MB BS, GradDipPopHealth · Nicholas A Zwar MPH, PhD, FRACGP

General practice is still somewhat adrift in the complex world of cancer services General practice has not traditionally had a central role in cancer care. Typically, general practitioners have had the task of identifying and referring patients to specialists in a timely manner, but have stayed on the periphery of cancer care until patients reach the palliative stage. But the climate is changing — driven partly by the growing burden of cancer and the need to expand and diversify the workforce. The prevalence of cancer has increased substantially in Western countries,1,2 largely due to the ageing of the population: in Australia, by the age of 75 years, the risk of cancer is 1 in 3 in men and 1 in 4 in women.1 There is now an explicit recognition that GPs should be involved in all stages of the cancer journey, from first presentation to palliative care, and that service reforms must incorporate more significant roles for primary care.3 This has found its way into policy and practice in the United Kingdom and Australia, where service guidance emphasises integration of services and urges all those involved in delivering cancer services to better connect the various stages of the cancer journey and to provide care that is accessible and convenient — all predicated upon significant primary care input.4,5 Management of cancer is complex. It requires specialised skills and knowledge, access to sophisticated diagnostic and treatment facilities, and often long-term management of symptoms and recurrences. Despite this complexity, when cancer patients are asked about how their care could be improved, their requests are often simple: they want to know who is in charge of their overall care, they want ready access to care that is convenient and non-threatening, and they want reassurance that they will have access to specialised services if needed.6 A diagnosis of cancer has a profound psychosocial impact, and those who care for cancer patients need to address a range of complex and often rapidly changing needs. Ideally, cancer care should be provided by teams, supported by a network of services. The concepts of multidisciplinary teams and managed clinical cancer networks have been widely advocated,7 but the place of primary care within these teams has remained poorly defined and highly variable.8 This variability is demonstrated by urban–rural differences: in Australia, rural GPs tend to play a more active role in treating cancer patients than their urban counterparts. General practice is still somewhat adrift in the complex world of cancer services. In this issue of the Journal, Jiwa and colleagues describe the many challenges faced by general practice in providing cancer care that is truly integrated with other parts of the health care sector.9 They emphasise that integrated care is required at all stages of the cancer journey. Just as cancer screening should link public health and clinical perspectives, post-diagnosis treatment needs a range of health care providers, including GPs, to be part of the team effort. Effective communication between specialist and primary care services is an essential component of this integration. There is growing emphasis on the concept of survivorship in cancer patients — rightly so, as cancer has taken on the characteristics of other chronic illnesses such as diabetes and coronary heart disease. Increasing numbers of patients have very prolonged periods of survival after cancer diagnosis, and die with their illness rather than of it. Survivorship is a very positive concept, and general practice, with its capacity for multidimensional care, is well placed to play a leading role in improving services for people living with cancer, providing follow-up that addresses patient priorities, and developing more personalised care for cancer survivors.10 This typically involves “survivorship care plans”, which include a range of tools for health care providers and users. It features heavily in the UK’s Cancer Reform Strategy.5 A challenge for primary care is to recognise its unrealised potential for promoting survivorship and to develop new models of care that allow it to do so.11 Primary care must be able to respond to rapidly changing health care needs of cancer patients in an appropriate and flexible manner. If we are to develop and test new models with enhanced roles for primary care, we need to better define and understand current patterns of care. Do GPs and primary care teams provide the kinds of services that cancer patients need? How well do they detect and manage recurrence of disease and toxicity from treatments? Do they provide the kinds of psychosocial support cancer patients need, and do they help or hinder truly integrated care? How well do they address issues of patient choice, and how good are they at providing education and support? The experiences and needs of cancer patients and their carers vary tremendously. We have perhaps been slow, in general practice, to respond to the needs expressed by our cancer patients. But if we take time to listen to our patients, from the time of diagnosis to death and bereavement, many ideas emerge about how the services we provide could be improved. Cancer patients have a range of illness and social trajectories, their patterns of wellbeing fluctuate, and they often perceive a lack of integration in the services they receive.12 GPs also need to maximise their contribution to primary prevention of cancer, especially in relation to smoking cessation and lifestyle risk factor management — despite the challenges of time constraints, practice systems and patients’ reluctance to change.13-15 To meet the challenges of the future and to adapt to changing health service environments, general practice must be prepared to evolve.16 A better understanding of the role of primary care in cancer management is vital if we are to improve outcomes and quality of life in our cancer patients.3,17 We need to know how primary care can contribute to new models of care. At present, there is little evidence on which to base service design and innovation. We need to develop new, genuinely integrated models of care that address important priorities for cancer patients, such as the availability of care close to home, timely management of symptoms, early detection of recurrences, and comprehensive psychosocial support. Until we have done so, GPs will remain at the periphery of cancer management, and there will be ongoing confusion over how we can make our most effective contribution.

David P Weller FRACGP, FAFPHM, PhD · Mark F Harris FRACGP, MD

P4P has raised the quality of primary care in the UK, but broader performance indicators are needed to accurately reflect the scope of general practice Pay for performance, or “P4P” as it is often known, is now centre-stage in primary care in the United Kingdom. P4P promotes change in clinical behaviour by offering financial rewards in return for achieving certain predefined targets. Both sides of the P4P “equation” are currently the subject of much debate: how generous should the financial reward be (the first “P”); and which performance indicators (the second “P”) should be used as the basis for calculating eligibility for the reward? From the foundation of the UK National Health Service (NHS) in 1948, general practitioners derived their income largely from capitation. Income was related more to the quantity than the quality of care. In 1990, and against much resistance from within the profession, the first performance targets were introduced into primary care. There were just two: rates of cervical smears and childhood vaccines. All this changed in 2004, when GPs accepted a new contract that radically promoted the role of P4P. This new contract tied about 25% of GP income to the achievement of a panoply of performance indicators. Large financial rewards were within reach for GPs able to achieve targets set for 147 performance indicators (subsequently revised to 135 indicators in 2006 and further revised to 128 in 2008). Details of the original 147 performance indicators and the mechanism for tying them to financial rewards have been well documented.1 The overall structure is known as the “Quality and Outcomes Framework” (QOF). In essence, the indicators are a mix of clinical indicators covering the management of 10 long-term conditions (eg, diabetes, coronary heart disease, hypothyroidism) and a series of indicators covering managerial, organisational, educational, prescribing and “patient experience” aspects (eg, undertaking an approved patient survey each year) of primary care. The clinical indicators are a mix of process indicators (such as creating a disease register or conducting a specific investigation), intermediate, or proxy, outcome measures (such as reduced cholesterol levels), and true outcome measures (such as improved epilepsy control). Achievement of an indicator is converted into “quality points”, which are weighted according to the perceived workload required to attain the target set for each indicator. Each quality point attracts a fee — currently set at £126 (A$260) for the average-sized general practice (5891 patients) — and the maximum attainable score is currently 1000 points. Since 2004, the components of the QOF have been revised twice. New indicators for an additional nine long-term conditions (eg, chronic kidney disease) were added in 2006, and in its latest 2008 incarnation, there are 80 clinical and 48 non-clinical indicators. What have been the positive consequences of P4P in UK primary care? The introduction of the QOF has demonstrated that GPs in the UK have achieved far higher quality standards than expected — at least, as budgeted for by government pay negotiators. In 2007, 5% of practices achieved the highest possible score, and the mean achievement of all practices in England was 95.5% of the available points.2 Such a demonstration of success has the potential to both affirm professional pride and to provide some evidence to the general public to justify the additional taxation that has been required to fund P4P. As with most systems of P4P, there is evidence that rewarded activity has increased. Substantial increases have been documented in some of the intermediate outcomes, such as blood pressure, cholesterol and glycosylated haemoglobin control, and also in the proportions of heart attack and stroke patients treated with aspirin.2 The overall rise in standards has been accompanied by a narrowing of the health inequality gap (as measured by the QOF) between least- and most-deprived neighbourhoods. Taken together, these achievements should translate into substantial national public health gains. What have been the unintended consequences of P4P in UK primary care? The success of P4P has been challenged from several perspectives. First, in the case of several QOF indicators, the achievement gains pre-dated the introduction of the QOF and, since then, the improvement rate has continued at a similar pace. For example, evidence has accumulated that overall cholesterol control was improving long before 2004.4 Second, high achievement may be interpreted as targets that were too easy to attain. For example, maximum QOF points are awarded for achieving target blood pressure control in just 60% of patients with diabetes, and the target blood pressure was set at 145/85 mmHg, which is above the value given in most guidelines. Third, GPs may indulge in “gaming” to boost their tally of QOF points — either by under-counting the number of patients on each disease register (only including those for whom target achievement is more readily accomplished) or by using the process of “exception reporting”, whereby GPs can decide whether it is “unsuitable” for a patient to be considered for a given clinical target on grounds such as “maximum tolerated therapy”, extreme frailty, or not responding to three letters inviting them to an appointment.5 More fundamentally, P4P has divided GPs on issues of professionalism. For some GPs, the electronic QOF prompts that accompany a consultation with a patient act as useful reminders and allow the GP to give more thought to deeper issues during the consultation. For others, these prompts represent the intrusion of a reductionist, points-driven approach to patient care that undermines professional autonomy.6 Furthermore, it is readily apparent that measures of patient satisfaction, patient enablement, listening skills, continuity of care, and many of the aspects of general practice that give GPs their greatest professional satisfaction lie outside the scope of any of the performance indicators. There are no measures of the psychosocial problems so common in primary care, nor of many medical conditions (such as any of the chronic gastrointestinal diseases). Indeed, even the advocates of the QOF would concede that probably only a quarter of all registered patients have any of the conditions for which QOF points are available. It is thus clear that P4P in its current form only rewards a small proportion of the overall work of a GP. Finally, the QOF has proven costly. Should such a large proportion of GP income be determined by these indicators, many of which lack a robust evidence base? Since its introduction, a vigorous debate has continued on balancing the “pay” component of P4P with the “performance” component. The higher than expected performance resulted in higher than expected costs, which contributed to NHS overspending in the early years of the new contract (although spending has now been reined in). What are the lessons for Australia? In the UK, the QOF was introduced as a “big bang” solution, without prior piloting. From our perspective as UK-based researchers and practising GPs, we think that perhaps the single greatest lesson from this experience is that piloting might have avoided many of the unintended consequences of P4P in primary care. Although P4P focuses attention on the quality of care, the definition of quality should be multifaceted and derived from evidence-based guidelines and the collective views of GPs, public health specialists and, importantly, patients. Performance indicators undoubtedly need to change over time, either because the evidence base has changed or because the original indicator has become redundant, and a transparent and robust system needs to be devised for regular updating of indicators and targets. An evolving QOF can act as a means to translate research evidence into practice. Simply put, the QOF has the capacity to “cut the implementation corner”. Although contentious, P4P represents a bold attempt to redefine the quality standards of primary care, such that best-practice targets quickly become the norm, expected by patients, health service planners and doctors alike. Beyond this, the next challenge is how P4P can evolve into rewarding a broader, more pluralist definition of quality and not merely the narrow focus of those things that are easy to measure.

Mark Ashworth DM, MRCP, MRCGP · Roger H Jones DM, FRCP, FRCGP

The new government is working hard to keep its promises, but it is too early to tell what long-term impact its new programs will have on health care delivered through general practice On 24 November 2007, the people of Australia elected a new Labor government. In the lead-up to the election, the Labor Party made many health care commitments. Here, I summarise and comment on the new government’s strategies and policies that can be expected to have an impact on general practice. What was promised, what has happened since the election, and what are we still waiting for? National Primary Health Care StrategyOn 17 November 2007, the then Shadow Health Minister, Nicola Roxon, advised that a Rudd Labor government would develop a National Primary Health Care Strategy. Primary care — like GPs [general practitioners] and allied health professionals — is crucial to keeping people healthy and out of hospital. The best way to equip our health system to deal with the challenges of the future is to boost primary care services.1 A promise of long-term planning was made through the development of a “long term strategy for delivering this care into the future”. Elements of the strategy would include: Examining providing incentives for GPs to practise quality preventative health care, including through longer consultations and evidence-based management of chronic disease; An increased focus on multi-disciplinary care from primary care teams; A review of the Medicare Schedule in an effort to alleviate the crippling red tape burden on GPs; $220 million investment in GP Super Clinics, which will be driven by local health professionals, and build upon the great work they are already doing in local communities; [and] Reforming the Rural Medical Infrastructure Fund to ensure funding gets to the communities that need it. The federal 2008–09 Budget papers state that a reference group of stakeholders and experts will be convened to develop the National Primary Health Care Strategy.2 Comment: While such a strategy is welcome, it needs a much wider scope. There is an urgent need to reduce the pressures on the nation’s general practice workforce and increase the number of GP registrars in training, while at the same time increasing the capacity of Australian general practice to train an increasing number of medical students, registrars and practice nurses. Further, the government has made few announcements to date about future roles for Australia’s network of Divisions of General Practice. The need for a more coherent approach to policy and service delivery was a major focus in the discussions of the health stream at the Australia 2020 Summit, held on 19–20 April 2008, which declared an ambition to have “one health system” with “single governance, management and funding” by 2020.3 GP Super ClinicsOn 26 August 2007, the Labor Party released a policy entitled New directions for Australia’s health — delivering GP Super Clinics to local communities.4 This promised to: provide infrastructure funding to establish a greater range of convenient and quality services in local communities — particularly in rural and regional areas and where Medicare has not been utilised to its fullest because of workforce shortages. Implementation of the GP Super Clinics Program is underway — GP Super Clinics have been announced for 31 localities across Australia,5 and “different processes” are being used to select the organisation that will “construct/refurbish and operate” each clinic. Comment: Any initiative to provide new centres of excellence in primary care service delivery and multidisciplinary health professional education and training in areas of need should be welcomed, but this funding only supports 31 such centres. An independent evaluation could be beneficial to determine whether the proposed GP Super Clinics are being planned for the 31 localities of greatest primary care need in Australia, to ensure the plans have the support of the local community and local GPs, and to ensure that there is no unnecessary duplication of existing services. Every primary care clinic in Australia needs the capacity to work within a framework that is relevant, timely and sustainable.6 Preventive health strategyOn 21 February 2007, the then Shadow Health Minister called “for consideration of a national preventative health taskforce ... to evaluate and make recommendations to Government on the basis of the safety, effectiveness and cost-effectiveness of prevention programs”.7 A focus on preventive health continued throughout Labor’s election campaign, including a commitment to an additional $15 million over 3 years for the National Tobacco Strategy.8 On 9 April 2008, the government announced the establishment of the National Preventative Health Taskforce, chaired by a Fellow of the Royal Australian College of General Practitioners. The taskforce, made up of health experts from around Australia, will develop strategies to tackle the health challenges caused by tobacco, alcohol and obesity, and develop a National Preventative Health Strategy by June 2009. The Government also announced that it would take immediate action to ensure preventive health measures become a key part of health funding agreements between the Commonwealth and state and territory governments.9 Prevention also received strong support from the members of the health stream at the Australia 2020 Summit.3 Comment: It remains unclear how the taskforce and the national strategy will involve general practice, in its long established role as a major site for providing preventive health care10 and health promotion advice.11 Given its seemingly strong commitment to prevention, it was surprising that the government announced reduced funding of general practice immunisation incentives in the federal 2008–09 Budget.2 National Health and Hospitals Reform CommissionOn 23 August 2007, the Labor Party made a promise to “establish a $2 billion National Health Reform Plan over four years to improve Australia’s health system and ensure better health services for patients in hospitals”.12 The plan would include: $2 billion in investments to deliver improved health outcomes for patients in Australia’s health care and hospital system [and a] commitment that a Rudd Labor Government [would] seek to take financial control of Australia’s 750 public hospitals if State and Territory Governments have not begun implementing an agreed National Health Reform Plan by mid-2009. [Further,] within the first 100 days of the election, a Rudd Labor Government — through COAG [Council of Australian Governments] — [would] establish a National Health and Hospitals Reform Commission to develop Federal Labor’s National Health Reform Plan.12 On 28 February 2008, federal Cabinet approved the establishment of the National Health and Hospitals Reform Commission.13 The Commission released its initial report, Beyond the blame game: accountability and performance benchmarks for the next Australian Health Care Agreements, on 8 May 2008, outlining 12 health care challenges and a series of proposed performance benchmarks.14 Comment: General practice perspectives are well represented on the National Health and Hospitals Reform Commission. With Labor in government not only nationally but also in each state and territory, there is an unparalleled opportunity to redress barriers and cost-shifting in our health care system that impact on health care delivery, access and equity. From a primary care perspective, the initial set of proposed benchmarks appear limited, but the Commission is welcoming comment and is engaging in an extensive process of consultation with the community and stakeholders. Aboriginal and Torres Strait Islander healthOn 13 February 2008, the Prime Minister, Kevin Rudd, apologised to the Stolen Generations. In his speech to federal parliament, he said: Let us resolve to ... provide proper primary and preventive health care for [Indigenous] children, to begin the task of rolling back the obscenity that we find today in infant mortality rates in remote Indigenous communities — up to four times higher than in other communities.15 This followed the commitment he made on 26 November 2007 to offering such an apology early in the new government’s term.16 Since the election, the Prime Minister has set a goal to halve the gap in infant mortality rates between Indigenous and non-Indigenous children within a decade, and to close the 17-year gap in life expectancy between Indigenous and non-Indigenous Australians within a generation,17 as well as making a commitment to provide an annual progress statement on closing the life-expectancy gap.18 As part of an earlier commitment “to improving Indigenous health, including through [a] $260 million Indigenous early childhood package”,19 an announcement was made on 23 April 2008 that the government would provide more health services for Indigenous families through funding to expand child and maternal health services and to boost primary health care service delivery in areas where health services are lacking.20 An announcement was made in the federal 2008–09 Budget of some funding increases for Indigenous health.2 Comment: Real action is now needed in Indigenous health, but what that action will be and what roles general practice will take are yet to be developed. As one solution, the health stream at the Australia 2020 Summit called for the establishment of a Health Equalities Commission for all Australians, with a focus on Indigenous health and other disadvantaged communities.3 Health care in rural AustraliaOn 12 September 2007, the Labor Party made a commitment to reform the Rural Medical Infrastructure Fund, to improve health infrastructure in rural communities.21 A further list of promises followed on 17 November 2007, including that “GP Super Clinics will be established in areas where there is under-utilisation of Medicare funded services, which will particularly include rural areas” and that the “National Health and Hospitals Reform Commission will be asked to explicitly identify a long-term plan for improving rural health services”.19 A promised audit of Australia’s rural and regional health workforce was released on 30 April 2008.22 Comment: Equity of access to health care services and equity of health care outcomes should be available to all people in Australia, regardless of where they live. Each of the reforms announced by the new government needs to have a specific focus on its impact on people living in rural and remote Australia. Dental healthOn 18 September 2007, the Labor Party made a promise to fund up to one million additional dental consultations for Australians needing dental treatment, by establishing a $290 million Commonwealth Dental Health Program.23 The Rudd government’s First 100 days report advised that negotiations had commenced with state and territory governments on the plan’s implementation.17 In a further development, the government announced on 2 March 2008 that it would “invest up to $360 million over three years in a Teen Dental Plan to make it more affordable for families to keep their kid’s teeth in good health”, and that this plan, assisting a million young Australians, would become operational on 1 July 2008.24 Comment: General practice organisations have long advocated for improvements in access to dental health services, especially for people on low incomes. Healthy Kids CheckOn 10 April 2007, the Labor Party made a commitment to develop a Healthy Kids Check, which would include an assessment of each child’s basic health such as teeth, hearing, balance and sight.25 This check would “ensure all children starting school receive a health and early skills assessment so they get off to the best start in life”. Comment: In the federal 2008–09 Budget, it was announced that new Medicare items would be developed to allow a “GP or a practice nurse [to assess] health indicators such as height, weight, eyesight and hearing”, and that this item would be claimable at the same time as the immunisation for 4-year-old children.2 Climate changeOn 30 May 2007, Kevin Rudd, then Leader of the Opposition, outlined Labor’s Framework for Climate Change. “We must immediately ratify the Kyoto Protocol to show we are serious and want to help forge a global solution”, he said.26 True to this commitment, the first official act of the new government was the ratification of the Kyoto Protocol on 3 December 2007.17 Comment: Global warming remains a concern for many Australian GPs, who have an important role in preparing for and responding to climate change-related threats to human health.27 In the words of one GP, responding to a conference presentation about health care reforms and innovations in general practice: “The rest of this is all very interesting, but if we don’t do something about climate change, it may all be irrelevant”. General practice is at the core of many of the health initiatives of the new government, and GPs need to be engaged in these developments, both as individuals having the opportunity to comment on each program, and through the viewpoints and advocacy of representative organisations. One of the national health initiatives currently under development that was not promised by the Labor Party is the new National E-Health Strategy, which is being developed through the Department of Human Services in Victoria on behalf of the Australian federal, state and territory health departments. E-health will be a crucial component of many of the government’s new health care initiatives. The new Australian Government is working hard to keep its pre-election health promises (see summary in the Box), and many of the programs announced have the potential to improve aspects of primary care. However, it is a shame that the National Primary Health Care Strategy is being developed after several of the initiatives that should be its core components have already been announced. General practice is accustomed to having to respond to piecemeal strategies from government, but it would be better if these programs were integrated in a way that supports the whole system in the delivery of high-quality primary care. Perhaps this is the intent of the new government, but it is too early to determine the likely long-term impact of these programs on the health care delivered to the people of Australia through general practice. Summary of the Rudd government’s health promises and actions to date Date Promise Action taken 21 Feb 2007 National Preventative Health Strategy Taskforce established 9 Apr 2008 30 Mar 2007 Ratify the Kyoto Protocol Protocol ratified 3 Dec 2007 10 Apr 2007 Healthy Kids Check Announced in Budget 13 May 2008 23 Aug 2007 National Health Reform Plan Commission established 28 Feb 2008 26 Aug 2007 GP Super Clinics Under development 18 Sep 2007 Commonwealth Dental Health Program Under development 17 Nov 2007 National Primary Health Care Strategy Under development 26 Nov 2007 Apology to the Stolen Generations Apology made 13 Feb 2008

Michael R Kidd MD, FRACGP

Objectives: To estimate prevalence of selected diagnosed chronic diseases among patients attending general practice, in the general practice patient population, and in the Australian population, and to compare population estimates with those of the National Health Survey (NHS).Design, setting and participants: In late 2005, 305 general practitioners each provided data for about 30 consecutive patients (total, 9156) as part of the BEACH (Bettering the Evaluation And Care of Health) program, a continuous national study of general practice activity. GPs used their knowledge of the patient, patient self-report, and medical records as sources.Main outcome measures: Crude prevalence of each listed condition currently under management among surveyed patients, and adjusted prevalence for the general practice patient population, and the national population.Results: 39.6% of respondents had none of the listed conditions diagnosed; 30.0% had a cardiovascular problem (uncomplicated hypertension, 17.6%; ischaemic heart disease, 9.5%); 24.8% had a psychological problem (depression, 14.2%; anxiety, 10.7%); 22.8% had arthritis, mostly osteoarthritis (20.0%); 10.7% had asthma; and 8.3% had diabetes, mostly type 2 (7.2%). Adjustment to the population attending general practice resulted in lower estimates for cardiovascular disease, arthritis and diabetes but had little effect on prevalence of asthma and psychological problems. After adjusting for non-attenders, about one in five people in the population had a cardiovascular problem, a similar proportion had a psychological problem, 14.8% had arthritis, and about 10% had asthma, hyperlipidaemia and gastro-oesophageal reflux disease. Estimates were similar to NHS results for any arthritis, asthma, and malignant neoplasms; higher for any cardiovascular problem; far higher for specific cardiovascular diseases, cerebrovascular disease and hyperlipidaemia; and almost twice the NHS estimate for psychological problems (particularly depression and anxiety). Estimates for type 1 diabetes aligned with NHS results, but were far higher for “all diabetes” and type 2 diabetes.Conclusions: This study offers an alternative, perhaps more accurate, approach to measurement of disease prevalence than the NHS approach, which relies on respondent self-report alone. It provides valid prevalence estimates with the help of GPs at a fraction of the cost of the NHS. This study could be repeated annually to augment other data sources and better define existing health needs in the population.

Stephanie A Knox BA(Hons), MPH, BSc · Christopher M Harrison BPsych(Hons), MSocHealth · Helena C Britt BA, PhD · Joan V Henderson BAppSc(HIM)(Hons), PhD

Objectives: To estimate the prevalence and patterns of multimorbidity in a sample of patients attending general practice, in the population who attended general practice in 2005, and in the Australian population.Design, setting and participants: Secondary analyses of data from a study of prevalence of selected conditions (a substudy of the BEACH [Bettering the Evaluation And Care of Health] program); data were provided by 305 general practitioners for 9156 patients seen in July–November 2005, based on knowledge of the patient, patient self-report, and medical records. Listed conditions were classified according to the Cumulative Illness Rating Scale morbidity domains.Main outcome measures: Prevalence of morbidity in each domain; prevalence of specific patterns of multimorbidity (defined as presence of morbidity in two or more domains).Results: Prevalence of multimorbidity was estimated as 37.1% of surveyed patients, 29.0% of people who attended a GP in 2005, and 25.5% of the Australian population. Prevalence and complexity (number of domains present) increased with age: 83.2% of surveyed patients aged 75 years or older had multimorbidity, 58.2% had morbidity in three or more domains, and 33.4% in four or more. Prevalence of multimorbidity did not differ between the sexes. The most common morbidity combinations were arthritis/chronic back pain + vascular disease (15.0% of sample), a psychological problem + vascular disease (10.6%) and arthritis/chronic back pain + a psychological problem (10.6%). We estimate that 10.6% of people attending a GP in 2005 and 9.3% of the population have arthritis/chronic back pain + vascular disease (± other morbidity types studied), and this group accounted for about 15.2 million Medicare-claimed general practice encounters in 2005.Conclusions: This study provides the first insight into prevalence and patterns of multimorbidity in Australia. Knowledge of the common combinations of multimorbidity may help in planning the health services needed in the future by an ageing population with an increasing burden of multimorbidity.

Helena C Britt BA, PhD · Christopher M Harrison BPsych(Hons), MSocHealth · Graeme C Miller PhD, FRACGP · Stephanie A Knox BA(Hons), MPH, BSc

To the Editor: We conducted a qualitative study to explore the perspectives of general practitioners and allied and other health professionals on their interactions in the care of patients with chronic disease, especially where Team Care Arrangements (TCAs) are involved. We interviewed 16 clinicians from urban and rural New South Wales who were involved in the care of patients with type 2 diabetes, ischaemic heart disease and hypertension — four GPs, two practice nurses, two medical specialists and eight allied health clinicians. Interviews took place from late 2006 to early 2007. While all those interviewed felt that a coordinated approach provided optimal management of chronic disease, this did not always seem to translate into smooth working relationships. Allied health clinicians and medical specialists described two types of attitudes of GPs to team care. They perceived some GPs as accepting of the involvement of others in patient care, leading to mutually respectful and highly satisfying working relationships. However, they felt other GPs did not value the opinions of allied health professionals and referred patients to them to fulfil a process (either for TCAs or at the patient’s request), or saw them as competitors. As one urban allied health clinician said, “I think they’ve got to realise that we’re not there to compete, we are there to assist”. TCAs provide financial incentives for GPs to coordinate care.1 We have previously reported that multidisciplinary care plans are associated with improved attendance at allied health services and improved metabolic control for patients with diabetes.2 However, in the present study some respondents felt that TCAs were little more than “paper shuffling” — predominantly a mechanism to attract reimbursement, rather than to facilitate two-way communication. Although TCAs provide an opportunity for communication between health care professionals, they have not overcome all the barriers to communication, especially in cases where an interprofessional relationship based on clear understanding of each other’s roles has not already been established. Our findings suggest that relationship-building and discussions about roles in shared care, including the power differentials between professionals, would improve the functioning of TCAs. Other recent studies have also reported on the lack of effective collaboration between GPs and other health professionals in managing chronic conditions.2,3 Respondents felt that it was uncommon for clinicians to discuss and agree on a plan of care. Optimal management of chronic disease requires a team approach and, consistent with other studies,4,5 we found that all the professional groups interviewed acknowledge the desirability of team care and its potential to improve patient outcomes. With increasing emphasis on team care, it is imperative that policies fund and facilitate a real team approach that is in the best interests of patients — one that places greater emphasis on two-way communication rather than paper shuffling or gatekeeping. This requires working with allied health professionals, medical specialists and GPs to improve communication and trust between clinicians. The Divisions of General Practice must surely be well placed to facilitate this process.

Sue E Kirby · Joyce L Chong · Maureen Frances · Gawaine Powell Davies · David A Perkins · Nicholas A Zwar · Mark F Harris

One in three men and one in four women in Australia will be diagnosed with cancer in the first 75 years of life. The majority will survive the cancer and ultimately die from unrelated causes. Many cancer patients and their families will experience some physical, social, economic and psychological sequelae, regardless of the prognosis. A recurring theme is that patients are disadvantaged by the lack of coordination of care and their needs are not being adequately met. We argue that greater integration of care through a multidisciplinary team of professionals, peer support groups and primary health practitioners functioning within a care hub could offer better practical and psychosocial supportive care for patients and their families.

Moyez Jiwa MD, MRCGP, FRACGP · Christobel M Saunders FRCS, FRACS · Sandra C Thompson FAFPHM, PhD · Lorna K Rosenwax BAppSc(OT), MSc, PhD · Scott Sargant BPharm, MPS · Eric L Khong MB BS, PGradDipPrimHlthCare, FRACGP · Georgia K B Halkett BMedRad(Hons), FIR, PhD · Gloria Sutherland BAppSc, PGradDipHlthEd · Hooi C Ee MB BS, FRACP, PhD · Tanya L Packer BSc(OT), MSc, PhD · Gareth Merriman BAppSc(Psych) MPsych, PhD · Hayley R Arnet BHSc(Pod), PGradDipHlthInform

To the Editor: The observational study by Henderson and colleagues1 is important, as it is the first to look at the effect of advertising in clinical software on prescribing behaviour in Australia. However, the stated conclusion — that “exposure to advertisements in clinical software has little influence on the prescribing behaviour of [general practitioners]” — requires qualification, as there were potentially important confounders including the effects of other forms of pharmaceutical promotion that were not evaluated. Evaluating the effect of a single advertising medium in isolation from concurrent activities (eg, print advertising, pharmaceutical detailing, provision of sample packs) is problematic. Pharmaceutical promotion relies on a range of activities to influence prescribing — multiple activities are synergistic, even if a single strategy shows little or no effect.2 Similarly, from a quality prescribing perspective, numerous studies show that changing prescriber behaviour is most effective when multiple strategies are used.3 There is evidence to suggest that providing information in clinical software at the point of decision making influences prescribing behaviour; for example, prompts are effective in reminding clinicians about preventive interventions such as Pap smears and immunisations.4,5 Since the study was done, another form of promotion by pharmaceutical companies has been introduced in the “advertising software” — “drug support” prompts. These prompts are linked to specific drugs and contain sponsored information from a pharmaceutical company. Users of the software may find it difficult to identify these prompts as a form of advertising, because their format and design are similar to clinical decision support prompts such as drug interaction alerts. Clinical software has become an essential tool, with a potentially powerful influence on prescribing. If promotional messages are to be permitted in clinical software, at the very least they should be clearly labelled as such, so that the user can distinguish them from genuine decision support. Prescribing should be based on the clinician’s sound knowledge of a drug’s indications and its relative benefits and harms, and patient treatment preferences and value for money. Advertising of medicines in any form may not be in the patient’s best interest.

James F Reeve · Judith M Mackson · Michelle Sweidan · Margaret Williamson

To the Editor: General practitioners play an influential role in the improved health care of people with intellectual disability (ID) through assessment, diagnosis, and development and maintenance of health plans. GPs also help patients access specialist health care and community-based services.1 Recent initiatives by the International Association for the Scientific Study of Intellectual Disabilities (IASSID) and Medicare Australia have been introduced to develop a national strategy for GPs and other health practitioners in their contribution to the promotion of health care for people with ID. With the support of the World Health Organization, the IASSID set health targets for people with ID. These in turn contributed to a national strategy for improved health care for people with ID.2,3 Medicare Australia introduced Medicare rebates for people with ID on 1 July 2007 (Medicare Benefits Schedule Items 718 [“Attendance by a medical practitioner . . . at consulting rooms for a patient with an intellectual disability”] and 719 [“Attendance by a medical practitioner . . . not being an attendance at consulting rooms, a hospital or residential aged care facility for a patient with an intellectual disability”]).4 These rebates aim to provide a structured clinical framework, allowing more time for GPs to spend with patients with ID to assess their overall health and plan for their long-term care, thus improving the quality of service through improved decision making in the context of prescribed medication, specialist referrals and hospital admissions.1 GPs can implement a health assessment program aimed at enhancing interactions between the adult with ID, his or her carer and the GP through the systematic gathering of a health history and review and, subsequently, development of a health action plan.2 To assist GPs in their assessment of patients with ID, Lennox and colleagues have developed the Comprehensive Health Assessment Program (CHAP).2 The CHAP is a 21-page booklet, split into two parts. The first part covers the medical history of the patient with ID and is filled out by the patient’s carer and brought to the GP. The second part is the CHAP assessment, completed by the GP. The CHAP assessment involves a review of the medical history, a targeted examination, and assistance for the carer in completing a health action plan. A 1-year post-intervention review has shown a substantial increase in GPs’ attention to the health needs of adults with ID, with concomitantly more disease detection.2 Thus, these initiatives have demonstrated positive clinical outcomes for this group of patients. Comment: The research is clear that people with intellectual disability have been receiving inadequate health care. A seminal population study clearly demonstrated that they experience high levels of unmet health need, with 42% of health conditions persistently undiagnosed and half of the conditions that are diagnosed inadequately managed.1 Their life expectancy is much lower than the general population — about 20 years lower for people with severe disabilities.2 These unmet health needs are partially addressed by the Comprehensive Health Assessment Program (CHAP) one-off health review. In the only randomised controlled trial of the health assessment process, we found a significant increase in health promotion and disease prevention, and greater case finding.3 We believe the CHAP enhances communication between adults with intellectual disability, their carers and their general practitioners. The widespread use of an annual health review now afforded by Medicare Australia provides an example of best practice in the health of this neglected group of Australians. This change was achieved after sustained collaborative lobbying driven by the Australian Association of Developmental Disability Medicine and the National Council on Intellectual Disability (New South Wales branch) — an advocacy organisation — and supported by other national medical organisations. While these changes are welcome, they are not enough, as half a million Australians4 (a population at least as large as the Indigenous population) with intellectual disability continue to experience poor health care while being excluded from most generic research. We call upon the Australian Government to act to regularly monitor and assist in the development of strategies to improve the health of this population. Would any other population of this size and health status receive such scant attention in the national discourse?

Kathryn A Vanny · Michael H Levy · Susan C Hayes · Nicholas G Lennox · Miriam T Taylor