Health services administration

Caution is needed so that population‐level reductions in the stillbirth rate are not offset by iatrogenic harm to healthy babies The federal Minister for Health the Honourable Greg Hunt MP recently launched the Safer Baby Bundle — a national stillbirth program that aims to reduce stillbirth in Australia by 20% by 2023.1 The program is one of the responses to recommendations arising from the federal Senate's Select Committee on Stillbirth Research and Education.2 It draws from similar bundles of care in the United Kingdom that have been associated with successful reductions in stillbirth.3,4 Undoubtedly, these whole‐of‐population level programs are important and effective. However, because late pregnancy stillbirth can be prevented simply by delivering all babies early, they have the potential for harm. There are five components of the Safer Baby Bundle: supporting women to stop smoking in pregnancy; improving awareness of a safe maternal sleeping position; improving decision making about timing of birth; improving the detection and management of fetal growth restriction (FGR); and raising awareness and improving care for women with decreased fetal movements (DFM). Of these five components, the latter two have the potential to increase early delivery. FGR is the strongest contributor to the burden of stillbirth. If detected and managed, the risk of stillbirth is 20‐fold lower than if FGR remains undetected.5 Improving the detection of FGR is central to any program aiming to reduce stillbirth. But increasing FGR detection may also cause harm. In a French population, half of the babies suspected of FGR antenatally had normal growth.6 In Victoria, a greater focus on improving the detection of FGR quadrupled the number of babies delivered early for suspected FGR, from 741 in 2000 to 2996 in 2017.5 The number and proportion of these babies with a birthweight in the 10th centile or greater increased from 307 (41%) to 1597 (53%).5 Striving to increase the sensitivity of FGR detection decreased specificity. This is a problem because unwarranted early delivery is harmful to both immediate perinatal5,6 and longer term developmental outcomes.7 Similar risks exist for increasing awareness of DFM. It has long been recognised that there is a relationship between DFM and stillbirth. Women who report DFM have a 2.4‐fold increased risk of stillbirth.8 However, translating this into an effective intervention has been challenging. Thirty years ago, it was shown that the use of formal fetal movement counting charts failed to reduce stillbirth.9 More recently, a large randomised controlled trial — the AFFIRM trial — assessed a care package for women presenting with DFM. In over 400 000 women attending 33 health services in the UK, increasing the awareness of DFM and standardising the care of those women presenting with DFM did not significantly reduce stillbirth.10 Moreover, there was evidence of harm to both mother and baby. Despite clear guidance for clinicians about what investigations to offer women with DFM and under what circumstances delivery was merited,11 there was an increase in the rates of induction of labour and caesarean delivery,10 with an additional 500 babies born between 32 and 34 weeks’ gestation and 5000 more born between 34 and 37 weeks’ gestation. The number of babies requiring admission to a neonatal unit also increased.10 The fact that most women with DFM will go on to give birth to a healthy baby suggests that the care package assessed by AFFIRM needs to be better targeted to women at risk. So what lessons can be drawn from these experiences for the Australian Safer Baby Bundle? Foremost, it is to be aware of the potential harm of any intervention and to look for this harm. This is possible with the use of balance performance measures12 —essentially, measures of unnecessary early delivery such as the proportion of babies delivered for suspected FGR but who were normally grown, or the number of neonatal unit admissions of term babies. Stillbirth programs elsewhere did not embed balance measures as part of their planned evaluation. Benefiting from the lessons learned by others, the Australian Safer Baby Bundle will include these measures to ensure that strategies designed to reduce stillbirth are targeted towards babies who are at most risk.1 The ultimate goal of balance measures is to reduce the unintended harm of our interventions. At present, no strategy has been shown to increase the sensitivity of FGR detection without causing harm. Neither is there a reliable tool to differentiate patterns of fetal movement that correspond to adverse outcome from those that are just a normal event. It is likely that more discriminatory screening tools reside in improved use of ultrasonography and biomarkers that assess fetoplacental function13 or in a better understanding of circadian patterns of fetal movements.14 Until then, caution is needed so that population‐level reductions in the stillbirth rate are not offset by iatrogenic harm to healthy babies. It is crucial that the potential for unintended harm is made explicit and that measures of unnecessary early delivery are used to monitor progress of the Safer Baby Bundle implementation in Australia.

Roshan Selvaratnam · Mary‐Ann Davey · Euan M Wallace

Meeting the need for culturally appropriate discussions regarding patient values and preferences at end of life Advance care directives are pre‐emptive discussions that anticipate a future loss of ability to make or communicate decisions. There is no uniformity in advance care directives in Australia, with each state or territory having differing terminologies and requirements.1 The Northern Territory has the lowest population density but the highest proportion of Aboriginal people of any Australian jurisdiction.2 In the NT, an individual can make a common law or statutory advance care directive,3 referred to as an advance personal plan (APP).4 The NT APP enables documentation of legally binding directives in reference to resuscitation and life support, as well as the appointment of substitute decision maker(s).5 We have previously documented the utility of the NT APP for Aboriginal people but highlighted the need for a more culturally appropriate document.6 For patients with life‐limiting diagnoses reviewed at Top End Health Service (TEHS) hospitals, the APP could previously be used in conjunction with a not‐for‐resuscitation form. TEHS and community‐based clinicians noted clear patient care imperatives for a move away from decisions targeted solely towards cardiac arrest. Expanding capacity based on a more patient‐focused goals of care (GOC) framework also aligned with expanding evidence in the literature in support of such a focus.7 In the NT, there has been growing recognition of the need for improved discussions regarding patient values and preferences regarding end of life, informed specifically by cultural understandings.6,8 An important example of this includes determination of the site of death; for many Aboriginal people from rural and remote regions, the land holds particular spiritual and cultural significance.8 For such patients, the need to “finish up” (a culturally appropriate term for death and dying) “on country” (ancestral lands) may be paramount and may take precedence over life‐prolonging treatments in tertiary centres.8 Exploring cultural requirements The TEHS GOC committee was formed in March 2017. This group had wide stakeholder engagement across three TEHS hospitals and included medical, allied health, administrative, nursing, primary health care and Aboriginal practitioner representation. Through the committee, the NT Department of the Attorney‐General and Justice was enlisted to assist in updating the APP (governed under the Advance Personal Planning Act 2013 (NT)). Officers representing the Attorney‐General worked with the GOC committee to explore the core cultural values to be reflected in an updated APP. A Palliative Care Australia document was used as reference material for these discussions.9 The APP is a territory‐wide document (unlike the GOC) and the Attorney‐General's office additionally undertook consultation in Central Australia. An updated APP was released in June of 2018.4 New questions asked in the section concerning values and preferences (Section B) include: Where would you like to die/finish up? If nearing death, what is unacceptable to you? If nearing death, what are your goals/priorities? After death, what is important to you? People completing the APP are now able to specify cultural rituals such as ceremonial smoking, or to make a request for their body to be returned to their birth country. The capability to provide advance directives concerning cardiopulmonary resuscitation (CPR) if appropriate and other life‐sustaining treatments, as well as to nominate substitute decision makers, was retained. The ability to nominate a substitute decision maker in the event of future impairment of capacity is of utmost importance in the NT, as unlike other Australian jurisdictions, the NT does not recognise default decision makers (next of kin or responsible person in other states and territories).3 An educational video was produced with involvement of rural Aboriginal APP champions to illustrate the method and advantages of completing an APP. The new GOC form (Supporting Information) was progressively released throughout the TEHS in 2018. The trigger for commencing GOC discussions is if the treating clinician feels that their patient may be in their last year of life (the “surprise question”). This includes patients with advanced malignancy, end‐stage organ failure, dementia or other progressive neurodegenerative conditions. It also includes specific reference to GOC in neonatal and paediatric patients. Uptake of the form in this patient population remains small but important. The resuscitation component of the GOC form documents the appropriateness of rapid response/code blue calls as well as ceilings of care (possible options range from full intensive care unit care to supportive and palliative care). This allows staff caring for dying patients outside the hospice setting to obtain immediate clinical support as required, irrespective of whether CPR is to be performed. The GOC form also allows people to document their wish to remain in their regional hospital for end‐of‐life care. The implications of this and inherent ceilings of care require detailed discussion with patients and family. The TEHS GOC form also requires the documentation of barriers to understanding, cultural responsibility and patient wishes. For some Aboriginal people, in certain instances, the patient may not be the key decision maker (despite having decision‐making capacity). The appropriate clinical information — the “right story” — needs to be provided to the appropriate person, usually referred to as the “right person”.6 The GOC form provides structured assistance to the completing clinician, to consider the involvement of Aboriginal liaison officers, interpreters and the culturally defined right people. Finally, it requires the completing clinician to consider whether the patient wishes to finish up on country. The revised NT APP and the GOC form were significant steps towards improved and patient‐focused end‐of‐life care. The working group also recognised that improved documentation required a more comprehensive strategy informed by data collection and research, and enriched by communications training for clinicians in order to be robust and capable of developing over time. Data collection and research In February 2019, Royal Darwin Hospital participated in a Commonwealth‐funded national study, led by Advance Care Planning Australia, which captured the prevalence of advance care directives and other types of advance care planning documentation in Australian health and residential aged care facilities.10 These data were useful to Top End clinicians regarding the impact of the recently introduced GOC framework. Health records of people aged 65 years and older who had been admitted for 48 hours were reviewed for advance care directives and medical orders or clinical care plans. The GOC forms are non‐statutory (not based in legislation) and were classified as medical orders. The prevalence of medical orders in audited health records at Royal Darwin Hospital was 46%. By comparison, the average prevalence of medical orders across all participating hospitals was 49%. The majority of these reflected either some limitation of treatments or were aimed at symptom control. A small number of patients (eight out of 50) had both an APP and a GOC plan. Only one document showed an incongruence between the APP wishes and the GOC wishes. This was related to the documentation of CPR provision in a patient who had stated in their APP that they did not wish to have CPR. Despite being only a single example, this discrepancy is consistent with findings elsewhere indicating that clinicians have a tendency to provide more care or more interventions than patients would choose were their wishes specifically discussed and followed.11 Communications training As part of the strategy to enhance the concept of shared decision making, which underpins patient‐centred care, the TEHS provided the first set of communications training workshops in March 2019. The workshops were iValidate (developed and delivered by Barwon Health) and Paediatric SimCom training (developed by Deakin University). Over 40 clinicians including nurses, doctors, allied health workers, Aboriginal health practitioners from hospital and community as well as primary health care practitioners attended the training. Additional Aboriginal and non‐Aboriginal participants were trained “on the run” as actors and helped to develop scenarios alongside experienced iValidate simulation actors. This enhanced the cultural context and the clinical authenticity of the scenarios used. Further workshops were held in June and a workshop was held in a regional hospital in November 2019. Facilitator training has also commenced in parallel to the communications courses in order to develop a local facilitator faculty enhancing the sustainability of the program. Next steps The development of a GOC framework and a culture of shared decision making is an evolving process. The next step is specific research on the effectiveness of GOC frameworks from the patient's perspective and the development of communications training that is increasingly informed by the concept of shared decision making. Significant areas that remain to be addressed include an improvement of the end‐of‐life experience on wards outside of the hospice, bereavement services within the hospital, mortuary services, and services to those who wish to die in regional hospitals, at home or on country.

Emma Spencer · Eswaran Waran

To the Editor: Harms related to the inappropriate use of prescription drugs include fatal and non‐fatal overdose and are a significant public health concern in Australia.1 In response, Victoria recently introduced SafeScript (https://www2.health.vic.gov.au/safescript) — a system similar to the widely implemented real time prescription monitoring (RTPM) systems in the United States.2 The Victorian RTPM system is designed to help health professionals make safer decisions when supplying high risk medicines.3 RTPM systems have been associated with unintended consequences, such as a transition from pharmaceutical opioid use to illicit opioid use, which has been associated with an increased risk of overdose and spread of blood‐borne viruses.2,4 Indeed, a 2019 American study suggests that lowering prescription opioid supply through initiatives such as RTPM use will only have a modest effect on opioid‐related deaths, unless supported with a multipronged approach including increased access to pharmacotherapy and harm‐reduction services.5 In Victoria, the implementation of an RTPM system may be of more benefit than seen in the US since these services are widely available. We have begun to explore effects of the introduction of SafeScript through analysis of data collected through the Burnet Institute's SuperMIX study — a prospective cohort study of about 1300 people who inject drugs (https://www.burnet.edu.au/projects/89_supermix_the_melbourne_injecting_drug_user_cohort_study). We introduced questions related to RTPM use in March 2019, with a total of 387 interviews conducted since the implementation of SafeScript in Victoria. We found that 20% of participants (48/242) who used a medicine monitored by SafeScript reported being refused a prescription by a general practitioner. One‐third (16/44) of those who have been refused were requesting the prescriptions for the treatment of anxiety and 45% were refused two or more times by doctors. Three per cent of participants (8/245) reported having a prescription they had already been receiving withdrawn. In addition, six out of 241 participants were refused dispensing of a prescribed medicine by a pharmacist. One‐third of participants (15/47) who had been refused a prescription were told this was due to a risky combination of medicines or having multiple providers. A third of participants (14/45) who had been refused a prescription reported an intention to not seek medication from their doctors in the future. Most had moderate to severe anxiety (33/41) and depression (36/41) disorders measured through a self‐administered Patient Health Questionnaire (PHQ). In the case of refused prescriptions requested for the treatment of anxiety, ten out of 13 patients had moderate to severe anxiety disorder and 11/13 patients had severe depression disorder, suggesting unmet treatment needs in patients denied prescriptions. RTPM systems such as SafeScript may help prevent the inappropriate use of prescription medications. Our initial analysis provides early insights on the impacts of SafeScript on this cohort, indicating careful implementation is required, particularly for people who inject drugs living with concurrent mental illnesses. The use of RTPM systems may reduce medicine‐related harm if integrated mental health and drug treatment services are adequate. It is not clear whether this is the case in Victoria. It is important to understand what happens when people are refused prescriptions — what care they receive and whether this care is appropriate for their needs. Increased mortality following restrictions to prescribed medicines is reported elsewhere.2 Rigorous research should evaluate the impact of RTPM use in Australia to understand if similar outcomes are observed.

Dagnachew M Fetene · Peter Higgs · Suzanne Nielsen · Filip Djordjevic · Paul Dietze

The available tools are largely unregulated, and do not reliably guide people to the right care at the right time

Adam G Dunn

Objectives: To assess long term outcomes for Aboriginal and Torres Strait Islander (Indigenous) Australians admitted non‐electively to intensive care units (ICUs). Design: Data linkage cohort study; analysis of ICU patient data (Australian and New Zealand Intensive Care Society Adult Patient Database), prospectively collected during 2007–2016. Setting: All four university‐affiliated level 3 ICUs in South Australia. Main outcomes: Mortality (in‐hospital, and 12 months and 8 years after admission to ICU), by Indigenous status. Results: 2035 of 39 784 non‐elective index ICU admissions (5.1%) were of Indigenous Australians, including 1461 of 37 661 patients with South Australian residential postcodes. The median age of Indigenous patients (45 years; IQR, 34–57 years) was lower than for non‐Indigenous ICU patients (64 years; IQR, 47–76 years). For patients with South Australian postcodes, unadjusted mortality at discharge and 12 months and 8 years after admission was lower for Indigenous patients; after adjusting for age, sex, diabetes, severity of illness, and diagnostic group, mortality was similar for both groups at discharge (adjusted odds ratio [aOR], 0.95; 95% CI, 0.81–1.10), but greater for Indigenous patients at 12 months (aOR, 1.14; 95% CI, 1.03–1.26) and 8 years (adjusted hazard ratio, 1.23; 95% CI, 1.13–1.35). The number of potential years of life lost was greater for Indigenous patients (median, 24.0; IQR, 15.8–31.8 v 12.5; IQR, 0–22.3), but, referenced to respective population life expectancies, relative survival at 8 years was similar (proportions: Indigenous, 0.78; 95% CI, 0.75–0.80; non‐Indigenous, 0.77; 95% CI, 0.76–0.78). Conclusions: Adjusted long term mortality and median number of potential life years lost are higher for Indigenous than non‐Indigenous patients after intensive care in hospital. These differences reflect underlying population survival patterns rather than the effects of ICU admission.

William G Mitchell · Adam Deane · Alex Brown · Shailesh Bihari · Hao Wong · Rajaram Ramadoss · Mark Finnis

The number of tests for vitamin D deficiency in Australia rose steeply between 2000 and 2011, from 0.4 to 36.5 tests per 1000 population; the cost to Medicare increased from $1.1 million in 2000 to $95.6 million in 2010,1 and peaked at $151 million in 2012–13.2 Consequently, the Medical Benefits Schedule (MBS) items for testing (66608, 66609) were replaced in November 2014 by new items (66833–66837) with the aim of restricting testing to people at particular risk of vitamin D deficiency, including those with a history of osteomalacia or osteoporosis, elevated alkaline phosphatase levels, hyperparathyroidism, hypo‐ or hypercalcaemia, hypophosphataemia, malabsorption, chronic renal failure, deeply pigmented skin or chronic and severe lack of sun exposure, or a diagnosis of vitamin D deficiency, and people who used medications that reduce 25‐hydroxyvitamin D levels.3 The immediate effect of the new criteria was that the rate of vitamin D tests was 47% lower during 2014–16 than during 2013–14.4 However, the proportion of people tested who met none of the new MBS criteria increased from 71.3% to 76.5%, while the proportion with moderate to severe vitamin D deficiency increased only from 5.4% to 6.5%.4 Medicare data5 indicate that the testing rate has since increased, by 34% between 2015 and 2019, from 119 to 159 tests per 1000 population; the cost to Medicare rose 42%, from $73.7 million to $104.7 million (Box). The testing rate increased in all states; the rate for women increased by 30% (from 164 to 214 tests per 1000 population), and for men by 40% (from 74 to 105 tests per 1000 population) (Supporting Information, figures 1A,B). The most marked increases were for people aged 85 years or more, for whom the 2019 testing rate (women, 447 tests per 1000 population; men, 364 tests per 1000 population) exceeded the 2012 levels (women, 388 tests per 1000 population; men, 276 tests per 1000 population). Testing rates for people aged 0–25 years did not markedly change between 2015 and 2019 (Supporting Information, figures 1C,D). The Royal College of Pathologists of Australasia,6 like most medical authorities, does not recommend screening for vitamin D deficiency. The marked overall increase in testing since 2015 is not explained by changes in demographic or clinical factors, suggesting that at least some screening is unnecessary and that ordering doctors are either unaware of or do not support the new MBS vitamin D testing criteria. Evidence‐based guidelines6 and MBS policy, accompanied by education and audit activities, have failed to contain the level of vitamin D testing. Further, people who are socio‐economically disadvantaged or at particular risk of vitamin D deficiency, including Indigenous Australians, are still tested less frequently than other Australians.4 Finally, people at clear risk of vitamin D deficiency could be treated without testing, especially as the cost of supplementation ($2.25 per month) is only a fraction of that of a vitamin D test ($30.05). High quality research is needed to provide evidence for informing interventions that curb the use of low value tests in a health system that encourages a high volume of services, but not necessarily better value care. Box – Cost to Medicare of vitamin D testing (MBS items 66608 and 66609, 66833 to 66837), January 2000 – December 2019 MBS = Medical Benefits Schedule. Source: Medicare item reports.5 Our estimated rates for 2001 (2.3 per 1000 persons) and 2011 (140 per 1000 persons) differ from those estimated by Bilinski and Boyages1 using a different source of Medicare data. * The MBS items 66833 to 66837 were listed on 1 November 2014.

Louisa Gordon · Mary Waterhouse · Ian R Reid · Rachel E Neale

Investment is urgently needed in repurposed drugs which could ease the burden of the COVID-19 pandemic

Jennifer H Martin · Nikola A Bowden

The existing system is failing to deliver the care that Australia expects Australia's aged care has changed considerably in recent decades. In response to consumer demand, old institutional‐style nursing homes have been progressively phased out in favour of better facilities. Home‐like furnishings and decor and single bedrooms personalised with residents’ own belongings have increasingly become the norm. In the process, they have become residential aged care facilities (RACFs), and there is no longer a distinction between low and high care.1 At the same time, older people want to stay in their own homes longer and have increasingly been able to do so because more community care is now available. Along with significant accommodation bonds and other charges, this has also served government objectives of reigning in the costs of Australia's ageing population.1 Contemporary residential care is no longer a lifestyle choice, it is now primarily for people who can no longer live at home. However, funding and staffing have not kept pace with this change.1 Aged care residents’ needs People living in RACFs now are typically very frail and have complex physical, cognitive and social care needs. During 2018, we independently assessed 5000 people living in RACFs.2 Only 15% of residents were independently mobile, one in two (50%) required mobility assistance, and over a third (35%) were not mobile. The bedridden group was at greatest risk of pressure injuries. People living in RACFs are vulnerable; the typical resident lacks energy and struggles with everyday activities. Most residents (> 80%) need help with activities such as showering, getting dressed or using the toilet. Moreover, many residents have memory, understanding and communication problems. Almost half of the residents find it difficult to interact with others and may become distressed when care staff try to assist them with personal hygiene, for example. Mental health problems are rife. Agitation is the most prevalent problem (43%), followed by depression (35%) and irritability (35%).3 There are about 180 000 residential care beds in Australia occupied on any one day by permanent residents.4 About 60 000 permanent residents die each year and about the same number take their place.5,6 The number of residents who die in their RACF is unclear. What is known is that many thousands are transferred to hospital due to staff not having the skills, confidence, capacity, resources or back‐up to provide the care they need.7 Neglect, the recently released interim report of the Royal Commission into Aged Care Quality and Safety, concluded that “substandard care is much more widespread and more serious than … anticipated”.7 Staffing in residential aged care facilities To inform its work, the Royal Commission requested a research study be carried out into residential care staffing.1 This involved a review of staffing standards internationally and an assessment of current Australian staffing levels against international and national standards. Australian staffing levels were calculated based on a time and motion study we conducted in 2018.3 Residents in Australia receive on average 188 minutes of care per day, which includes 36 minutes by registered nurses, 8 minutes by allied health professionals (mostly physiotherapists) and 144 minutes by personal care assistants.1 Anecdotally, registered nurses and allied health professionals are required to spend a disproportionate amount of time on paperwork for funding purposes, leaving even less time to spend on care. Adequate care time and staffing mix and levels So how can we tell if a RACF is providing adequate care time and has the right mix of staff? Our Royal Commission research considered these questions.1 The international literature consistently reports that staff time requirements are driven by resident function, cognition, behaviour and technical nursing requirements, and our 2018 research confirmed that these same drivers apply in Australia.3 The clear evidence in the international literature of a direct causal relationship between staff numbers and skill mix and resident safety and quality outcomes is equally applicable to Australia.8,9,10 Over 150 studies documented in systematic reviews, primarily from the United States, Canada, the United Kingdom and northern Europe, confirm a “strong positive impact of nurse staffing on both care process and outcome measures”.11 Organisational factors, such as professional staff mix (ratio of registered nurses to total staffing levels), staff turnover rates, use of agency staff, and consistency in staffing also have an impact on quality. We found that the five‐star rating system used in the US by the Centers for Medicare and Medicaid Services (CMS) is the most relevant system internationally for judging aged care in Australia. It has a strong evidence base and has been in widespread use for nearly 20 years.12 While it does not address allied health staffing levels, it could be developed to do so if such an approach were adopted in Australia. The CMS considers the amount of care time provided to residents by nursing and personal care staff and adjusts this according to the needs of residents in each home. The outcome is a rating of between one and five stars. The more stars the better. The five‐star threshold is the point at which there is no evidence of any additional quality improvements for residents (Box).12 As seen in the Box, Australian RACFs rate poorly compared with US RACFs. They also do badly compared with the standards in place in Germany and Canada and with the standards set down by the state governments of Victoria and Queensland.1 Research into the CMS system found that homes are more likely to “experience quality concerns” when staffing levels fall below a certain level.12 This threshold is equivalent to the minimum requirement for a three‐star rating (ie, 30 minutes of registered nurse time and 215 minutes of total time). Therefore, we determined that anything less than three stars is inadequate for Australian RACFs.1 Using these metrics, more than half of all Australian aged care residents (57.6%) are in RACFs that have inadequate (one or two stars) staffing levels. A little over a quarter (27.0%) are in RACFs that have three stars, 14.1% of residents are in RACFs with four stars, and 1.3% are in RACFs with five stars, which we consider best practice.1 Bringing all RACFs in Australia up to at least three stars would require an average staffing increase of 37.3% in those RACFs currently rated one or two stars, which would result in an overall increase of 20% in total care staffing across Australia. Achieving four stars would increase total staffing by 37.2% and five stars by 49.4%. Importantly, these increases are total numbers for the sector as a whole and need to be adjusted according to the mix of residents when applied to individual RACFs.1 The best international benchmark for allied health staff currently is from the Canadian province of British Columbia, which recommends a minimum of 22 minutes of allied health services per resident per day. Only 2% of Australian aged care residents currently receive this level of care. An additional 175% in allied health staffing is required to achieve this international standard.1 The evidence is clear Our research was requested by the Royal Commission against a background of numerous examples of poor quality care experienced by older people living in RACFs.1 A recurring theme has been the lack of staffing to meet the wide‐ranging and increasingly complex needs of residents — assertions that have been supported by the results of our research.1 It is clear from our research and from the evidence presented to the Royal Commission that there is a compelling case for additional resources in RACFs. This includes improving the staffing mix and increasing staffing levels to an acceptable standard. As the Royal Commission's interim report notes,7 the existing system has failed to ensure residents receive quality care. It is no longer acceptable to describe RACFs simply as a person's home or for advocates to argue that what is required is a social model of care delivered with a wellness philosophy.13,14,15 While on the surface it sounds attractive and in line with what consumers want, the evidence from the Royal Commission is that these arguments are now being used as a justification for inadequate care.7 Conclusion Residents in Australian RACFs have a right to be safe and to receive clinically competent and adequate care. This care needs to be provided within a non‐institutional environment that is respectful of individual choices and affords every resident the opportunity to be meaningfully engaged to the extent possible. There does not need to be a trade‐off between a social model of care and a clinically competent model. Aged care residents have a right to both and do not have the time to wait. Box – Star rating system for aged care facilities: comparison between Australia and the United States

Kathy Eagar · Anita Westera · Conrad Kobel

Usual care must be rapidly adapted to isolate, assess and test large numbers of patients during the COVID‐19 pandemic Coronavirus disease 2019 (COVID‐19), which is caused by severe acute respiratory syndrome coronavirus 2 (SARS‐CoV‐2), emerged in China in late 2019.1 COVID‐19 is an example of a high consequence infectious disease that may present to an Australian hospital. These infections are uncommon in Australia and, in most cases, were imported from overseas. Less frequently, there is onward local transmission, such as during the influenza A(H1N1)pdm09 pandemic in 2009. High consequence infectious diseases present unique challenges to Australian hospitals. Their rarity leads to unfamiliarity and loss of institutional knowledge between events. Many hospitals operate at near maximal capacity between outbreaks and have limited surge capacity.2 Protocols designed to manage single patients require adaptation to situations where larger numbers of patients require isolation, assessment and testing for infection. While every Australian hospital has a mass casualty or disaster protocol, these are developed for all hazards and may not address problems specific to high consequence infectious diseases, including: the need to rapidly identify and isolate potentially infectious patients to prevent nosocomial transmission; the complexity of rapid triage and assessment on frequently evolving epidemiological and clinical grounds; the difficulty of differentiating high consequence infectious diseases from more common but clinically similar conditions;3 the absence of rapid diagnostic tests to aid clinical decision making; and the potential for a prolonged surge for weeks to months during which time the workforce may be affected by both infection and absenteeism. Here we describe the strategic approach of the Royal Melbourne Hospital to triage and screen patients who have presented at risk (or concerned that they are at risk) during the early phases of COVID‐19. Our resources may be of value to other organisations refining their triage and clinical algorithms. The Royal Melbourne Hospital response The Royal Melbourne Hospital is an adult tertiary referral centre and the designated state‐wide provider for quarantinable diseases. The emergency department (ED) treats over 80 000 patients annually. From 6 January 2020, we instituted tools to identify at triage those patients with risk factors for COVID‐19 and rapidly isolate them. Initially, there was capacity to assess patients in one of three existing negative pressure rooms. On 25 January, the first patient with COVID‐19 in Australia, who had arrived in Melbourne on a flight from Guangzhou, was confirmed. The Victorian Department of Health and Human Services informed all passengers on the flight of their possible contact with the patient, leading to a significant surge in presentations to the Royal Melbourne Hospital. Box 1 presents an overview of the challenges in managing high consequence infectious diseases and details of our coordinated approach. Key components that can be used by other services are detailed below. Governance Unlike other major incident responses, which tend to be short‐lived, response to an outbreak requires a sustained response that will inevitably have an impact on other clinical services. A governance process that includes executive sponsors and senior clinical leaders is essential. The Royal Melbourne Hospital COVID‐19 response leveraged an existing code brown (external emergency) pandemic subplan and clinical code yellow (internal infectious disease emergency) plans as a governance framework. A governance group including medical and nursing executives and senior clinicians from the ED, infectious diseases, infection prevention services and microbiology meet regularly. A single standard operating procedure exists on our hospital intranet that provides all clinically relevant information for frontline health care workers (eg, personal protective equipment guidelines, current case definitions, patient assessment algorithms). It is updated frequently given the dynamic situation and, thus, functions as a living document for staff. This document provides 24/7 access to an authoritative source that supports junior and senior staff alike to feel confident in their practices and approach. Infrastructure Establishment of a fever clinic. A particular design feature that may be adopted by other facilities is the rapid establishment of an out‐of‐department fever clinic. In response to the first surge of patients, we rapidly repurposed the nearby hospital transit lounge, which was closed for the weekend, into a fever clinic (Box 2). The clinic received its first patient within 2 hours of notification from the Victorian Department of Health and Human Services of the first local case. In its first 7 days, we assessed 109 patients. We discharged over 90% of patients within 4 hours of arrival. We retain this model as patient numbers continue to increase. In this model of care, patients are physically segregated from the rest of the ED into a dedicated rapid assessment and treatment space from their arrival, limiting exposure to other patients. The main benefit of this approach is that cases yet to be identified can be an important contributor to nosocomial transmission; therefore, early separation and detection are vital.4,5 However, immediate recognition of cases is difficult due to unfamiliarity with the disease, overlap in clinical presentation with more common illnesses, and due to patient wait times. Our fever clinic model of care was based on the success of this model in Toronto and Taiwan during the severe acute respiratory syndrome (SARS) outbreak,6 where no transmission was reported in these facilities despite hospital exposure being implicated in the majority of cases in these regions (eg, it was the presumed source of exposure for 72% of patients in Toronto7,8). It has also been reported as an effective strategy for triaging patients in Wuhan for COVID‐19.9 Similar approaches appear to have been used in other countries, but detailed descriptions are not yet available in the literature. In Australia, segregation of major incident patients was exemplified by the Royal Darwin Hospital, which functioned as the forward receiving hospital for medically evacuated patients during the 2002 Bali bombings.4 The benefits of establishing a fever clinic include: protecting an existing environment for the maintenance of business continuity; facilitating protocolised interventions for spatially clustered groups of patients; providing a physical location to send additional disaster resources without cluttering areas of core business; and enhancing record‐keeping. Limitations of our approach include the additional staffing required, operational impact of loss of transit lounge, staff unfamiliarity with the location of resources (such as resuscitation trolleys), and a slightly further distance from resuscitation bays if patients deteriorate. Moreover, we were also concerned about the risk of stigmatisation of patients who are seen to be segregated from the main ED waiting room cohort. Implementation of electronic self‐registration and self‐screening. A surge related to an emerging infectious disease provided our clerks’ department with a confluence of unique administrative and logistical challenges. These included: a high proportion of patients came from a non‐English speaking background; contact tracing and follow‐up requires accurate registration and an extended suite of contact details, but usual disaster response medical records protocols generate only anonymised patient registrations; non‐clinical staff (ward clerks) unfamiliar with personal protective equipment would be required to extensively interview patients to confirm details at some point; patients came in bursts, producing delays in registration; manual screening paperwork and registration papers provide a potential fomite for disease transmission; and our ED is paper‐free under usual circumstances. We developed a novel solution to this problem, leveraging the fact that over 91% of Australian citizens and over 96% of Chinese citizens own a smartphone5,10 and converted an initial paper‐based bilingual screening tool to an online one. This is hosted using the research electronic data capture (REDCap) tool (www.projectredcap.org).11 Patients are directed to a secure website optimised for use on a smartphone. The registration portal is free to use. They answer questions regarding their epidemiological risk (such as a detailed travel history, or being a health care worker), clinical risk factors (such as being immunocompromised) and symptoms. Results are immediately fed to remote clinical computers where ward clerks can register the patient without direct patient contact and clinicians can see screening information before their clinical encounter. While not yet tested under a pandemic scenario, we anticipate this method of self‐registration may be particularly useful in the event of a significant surge in patient numbers. Triage sieve and sort of patients can be rapidly undertaken by clinicians who are fed real‐time registration data. Compared with usual mass casualty principles, the inclusion of epidemiological data in the electronic tool is valuable for triage in this setting to screen out the relatively high proportion of patients with perceived, but not actual epidemiological risk factors. Our REDCap infrastructure is available in the Supporting Information for adaptation by other health services. Conclusion The importation of emerging infections into Australia is rare, and onward transmission is rarer still. As the Royal Melbourne Hospital received a surge in patients who required screening for COVID‐19 relatively early during the current outbreak, our recent observations may provide opportunities for other hospitals to enhance their preparedness and response plans. We prioritise prevention of nosocomial transmission (using a scalable, separated fever clinic) early planning for worsening surge (adopting scalable solutions) and clear clinical governance (providing malleable and accessible centralised resources). Box 1 – Elements of the Royal Melbourne Hospital clinical response Element of response Challenges Approach used Clinical governance Multiple clinical units involved, with tangible impacts on business as usual activity and frequent changes to the model of care and the expectations Where possible, we operated within existing plans and policies. Daily executive and head of unit level huddles were instituted initially, and then stepped down to weekly as needed, producing hospital agreement on messaging and expectations of all teams and sharing of information between executive, infectious diseases (ID), infection prevention services (IPS) and emergency medicine (EM). COVID‐19 multidisciplinary working groups were formed within the ED and ID clinical units Infrastructure A space was needed to accommodate the extra patients while maintaining infectious isolation among them, and between them and the rest of the ED census A graduated response used with existing ED negative pressure rooms used for small numbers, a cohort subwaiting area was created when several patients were present in the ED at once, and a separate fever clinic was created in the nearby transit lounge used for surge response Infection prevention and control practices Transmission dynamics are incompletely understood and there is a risk of nosocomial amplification (especially during aerosolising procedures) Education sessions, posters, and videos used to reinforce PPE training; nebulisers removed from dedicated treatment space; hand sanitiser stations; PPE stations and infectious waste bins deployed; and a SOP employed for aerosolising procedures (Supporting Information) Clinical care (including triage, assessment and testing) There is rapidly evolving understanding of clinical and epidemiological characteristics of the disease. Staff lack familiarity with the disease and with the roles performed (concierge nurse, fever clinic doctor), while the normal ED and hospital functions need to continue alongside Creation of a SOP including clinical algorithms for triage, assessment and biological sampling as a living document hosted on the hospital intranet, and updated as needed and used as a single source of truth for clinical staff. Gradual transition to algorithm‐driven assessment by junior medical staff to free up senior staff for unwell patients. Action cards with role descriptions were provided in the SOP for all fever clinic staff Communication with patients Initially, most patients were Mandarin‐speaking Bilingual signage (English and Mandarin) deployed in the fever clinic, and bilingual patient resources and screening questionnaire generated. Discharge information sheets specific to different tiers of risk were translated into Mandarin and provided to all patients discharged from the fever clinic Human resources Maintenance of staff competence and confidence essential for safety and prevention of absenteeism Regular education sessions to provide updated clinical information and epidemiology, train in PPE, and answer questions COVID‐19 = coronavirus disease 2019; ED = emergency department; PPE = personal protective equipment; SOP = standard operating procedure. Box 2 – Floor plan of the Royal Melbourne Hospital fever clinic and guiding principles for a fever clinic COVID‐19 = coronavirus disease 2019; PPE = personal protective equipment; SOP = standard operating procedure.

Amanda M Rojek · Martin Dutch · David Camilleri · Emma Gardiner · Emma Smith · Caroline Marshall · Kirsty L Buising · Nicola Walsham · Mark Putland

We need to make primary care careers attractive: the future of our health system depends on it

Nicholas J Glasgow · Kirsty A Douglas

Objective: To describe uptake of hospital in the home (HIH) by major Australian hospitals and the characteristics of patients and their HIH admissions; to assess change in HIH admission numbers relative to total hospital activity. Design: Descriptive, retrospective study of HIH activity, analysing previously collected census data for all multi‐day hospital inpatient admissions to included hospitals during the period 1 January 2011 – 31 December 2017. Setting, participants: Nineteen principal referrer hospital members of the Health Roundtable in Australia. Main outcome measures: HIH admissions by diagnosis‐related group (DRG); patient and admission characteristics. Results: 80 167 of 2 185 421 admissions to the 19 hospitals included HIH care, or 3.7% (95% CI, 3.6–3.7%) of all admissions. Median length of stay for admissions including HIH (7.3 days; IQR, 3.1–14 days) was longer than that for those that did not (2.7 days; IQR, 1.6–5.1 days). For HIH admissions, the proportion of men was higher (54.4% v 45.9%), the proportion of patients who died in hospital was lower (0.3% v 1.4%), and re‐admission within 28 days was less frequent (2.3% v 3.6%). The 50 DRGs with greatest HIH activity encompassed 65 811 HIH admissions (82.1%), or 8.4% (95% CI, 8.4–8.5%) of all admissions in these DRGs. HIH admission numbers grew more rapidly than non‐HIH admissions, but the difference was not statistically significant. Conclusions: HIH care is most frequently provided to patients requiring hospital treatment related to infections, venous thromboembolism, or post‐surgical care. Its use could be expanded in clinical areas where it is currently used, and extended to others where it is not. HIH activity is growing. It should be systematically monitored and reported to allow better overview of its use and outcomes.

Michael Montalto · Patrick McElduff · Kristy Hardy

The origins, scope and significance of the 2019–2020 Climate Health Western Australia Inquiry

Tarun S Weeramanthri · Sarah Joyce · Revle Bangor‐Jones

Reducing smoking during pregnancy among Aboriginal and Torres Strait Islander women is a national priority, but there has been little exploration of their experiences and desired support

Michelle Bovill

Objectives: To assess the capacity of intensive care units (ICUs) in Australia to respond to the expected increase in demand associated with COVID‐19. Design: Analysis of Australian and New Zealand Intensive Care Society (ANZICS) registry data, supplemented by an ICU surge capability survey and veterinary facilities survey (both March 2020). Settings: All Australian ICUs and veterinary facilities. Main outcome measures: Baseline numbers of ICU beds, ventilators, dialysis machines, extracorporeal membrane oxygenation machines, intravenous infusion pumps, and staff (senior medical staff, registered nurses); incremental capability to increase capacity (surge) by increasing ICU bed numbers; ventilator‐to‐bed ratios; number of ventilators in veterinary facilities. Results: The 191 ICUs in Australia provide 2378 intensive care beds during baseline activity (9.3 ICU beds per 100 000 population). Of the 175 ICUs that responded to the surge survey (with 2228 intensive care beds), a maximal surge would add an additional 4258 intensive care beds (191% increase) and 2631 invasive ventilators (120% increase). This surge would require additional staffing of as many as 4092 senior doctors (245% increase over baseline) and 42 720 registered ICU nurses (269% increase over baseline). An additional 188 ventilators are available in veterinary facilities, including 179 human model ventilators. Conclusions: The directors of Australian ICUs report that intensive care bed capacity could be near tripled in response to the expected increase in demand caused by COVID‐19. But maximal surge in bed numbers could be hampered by a shortfall in invasive ventilators and would also require a large increase in clinician and nursing staff numbers.

Edward Litton · Tamara Bucci · Shaila Chavan · Yvonne Y Ho · Anthony Holley · Gretta Howard · Sue Huckson · Philomena Kwong · Johnny Millar · Nhi Nguyen · Paul Secombe · Marc Ziegenfuss · David Pilcher

Early empirical evidence provides grounds for optimism about eliminating HCV by 2030

Marianne Martinello · Behzad Hajarizadeh · Gregory J Dore

Out‐of‐pocket expenses for cancer care are of growing concern for patients, clinicians, service providers, non‐governmental organisations, private insurers, and politicians. Contrary to popular belief, there is no direct link between the cost and quality of care. Out‐of‐pocket expenses are a particular problem for patients who live further from treatment centres, are younger, or have later stage disease.1 Adults (18 years or older) with pathologically confirmed colorectal, lung, prostate or breast cancer from four rural (Midwest, South West, Great Southern, Goldfields) and two outer metropolitan (Joondalup/Wanneroo and Rockingham/Peel) regions of Western Australia were identified in the WA Cancer Registry. Between 1 April 2014 and 31 April 2017, eligible patients were invited to complete questionnaires requesting demographic, financial, and treatment information, including all costs during treatment, as reported previously.2 We used log‐linked generalised linear models with gamma distribution, adjusted for age and sex, to estimate out‐of‐pocket expenses (with 95% confidence intervals [CIs]) for participant characteristics found to be significantly associated with out‐of‐pocket expenses in univariate analyses (online Supporting Information). The study was approved by the WA Country Health Service Ethics Committee (reference, 2014:10) and the Department of Health WA Human Research Ethics Committee (reference, 2014/26). One hundred and seventeen of the 119 outer metropolitan participants (98%) and 294 of the 308 rural participants (95%) incurred out‐of‐pocket expenses for their cancer care, chiefly for surgery, medical tests, and medical appointments. These costs ranged between $51 and $106 140 for outer metropolitan participants, and between $13 and $20 842 for rural participants. Fifty‐three rural participants (17%) and 39 outer metropolitan participants (33%) spent more than 10% of their household income on cancer care (data not shown). Among rural participants, mean out‐of‐pocket expenses were higher for men ($1988; 95% CI, $1605–$2461 v $1362; 95% CI, $1092–$1699), for people with private health insurance ($2455; 95% CI, $1973–$3053 v $1103; 95% CI, $877–$1386), and for people who were married ($2086; 95% CI, $1749–$2489 v $1297; 95% CI, $975–$1725), had undergone surgery ($1990; 95% CI, $1684–$2351 v $1360, 95% CI, $1005–$1839), or had worked prior to being diagnosed with cancer ($2084; 95% CI, $1643–$2644 v $1298; 95% CI, $1038–$1625) (Box). Among outer metropolitan participants, mean out‐of‐pocket expenses were higher for men ($5217; 95% CI, $3928–$6928 v $2247; 95% CI, $1756–$2875), for people with private health insurance ($4670; 95% CI, $3588–$6078 v $2510; 95% CI, $1853–$3401), and for those who had undergone surgery ($5434; 95% CI, $4260–$6932 v $2157; 95% CI, $1541–$3020), worked prior to being diagnosed with cancer ($5471, 95% CI, $3952–$7573 v $2143; 95% CI, $1643–$2794), resided in areas of high socio‐economic status ($4299; 95% CI, $3235–$5712 v low, $1859; 95% CI, $1374–$2516), or were receiving chemotherapy ($4286; 95% CI, $3162–$5810 v $2735; 95% CI, $2116–$3534) (Box). It is perhaps surprising that out‐of‐pocket expenses were higher for people in outer metropolitan areas, who presumably lived closer to treatment centres than rural residents. However, these findings are consistent with the recent report that out‐of‐pocket spending on non‐hospital Medicare‐subsidised services and specialist services was higher for metropolitan patients than for those in regional areas.4 The higher out‐of‐pocket expenses for people with private health insurance or undergoing surgery indicate the importance of health care funding arrangements and the magnitude of the costs borne by patients. The marked variation in out‐of‐pocket expenses reported here and by others5 highlights the need for easily accessible information about services, medical costs, and gap payments for all health care services. The Informed Financial Consent website coordinated by the Australian Medical Association,6 consumer organisation fact sheets, and professional body initiatives are steps in the right direction, but their impact is yet to be determined. Problems that still need attention in the unregulated private fee‐setting environment in Australia include price discrimination in some specialist sectors.7 Bundles of care for cancer treatment that would allow patients and their families to better understand and plan for expenses should be explored. Box – Estimated mean out‐of‐pocket expenses for cancer‐related health care (with 95% confidence intervals) for outer metropolitan and rural patients, by patient characteristics significantly associated with higher out‐of‐pocket expenses in univariate analyses* * For outer metropolitan patients, marital status, and for rural patients, socio‐economic status and chemotherapy were not significant predictors of out‐of‐pocket expenses, and were therefore not included in the final models. †Index of Relative Socio‐economic Disadvantage (IRSD):3 low (most disadvantaged), deciles 1–4; moderate, deciles 5–6; high (least disadvantaged), deciles 7–10.

Neli S Slavova‐Azmanova · Jade C Newton · Christobel M Saunders

To the Editor: We welcome the recent article by Secombe and colleagues1 highlighting the impact of alcohol policy reforms in the Northern Territory, namely the influence of the minimum floor price on critical care admissions.1 We agree that the social costs and harms of alcohol in the NT are too high,2 and are reassured by the improved health outcomes associated with the implementation of emerging alcohol policies.3,4 There have been, however, other notable alcohol and social policy investments in the NT, including the introduction of Police Auxiliary Liquor Inspectors (PALIs). PALIs are uniformed inspectors, stationed at takeaway alcohol outlets, who seek to prevent the consumption of alcohol in restricted areas. These areas include all land defined as Aboriginal land as per the Aboriginal Land Rights (NT) Act 1976,5 within 2 km of a licensed venue, and in certain regulated public and private areas. PALIs ascertain where individuals purchasing alcohol will be consuming their purchase by requesting a form of identification, alongside questions regarding intended drinking location. If a valid (non‐restricted) address cannot be provided, purchase is not permitted. The first squad of PALIs graduated on 20 August 2018. As noted by Secombe and colleagues, the minimum floor price was introduced on 1 October 2018. Considering the time of implementation of both policies, it is imperative that we better understand the intersection between PALIs, the minimum floor price and other alcohol policy initiatives, such as the Banned Drinker Register.6 The recent analysis by Secombe et al provides a partial snapshot of the impacts of a highly complex public health issue. Given that a suite of alcohol policies has been introduced by the NT Government to combat alcohol‐related harms,6 a more sophisticated evaluation approach is required to understand these relationships. This means a broader range of data sources need to be used to evaluate the impacts of alcohol policies in the NT. This should include health, police, corrections, domestic violence, child protection, and education data. Furthermore, to advance comprehensive understandings of these alcohol reforms, it is also imperative to include qualitative approaches that explain how and why different alcohol policies work.

Sarah C Clifford · Kalinda E Griffiths · James A Smith

Opportunities to recognise and invest in general practice research need to be realised General practice research is essential to quality general practice, building an evidence base for over 27 000 general practitioners working within the specialty who provide medical care to the majority of Australians.1 Over eight in ten Australians consult with their GP at least once per year, and two million people are seen each week in general practice.2,3 General practice, a medical specialty, is the first point of access to the health system, providing longitudinal care for all. It is essential for the delivery of efficient, equitable and effective health care services.4 General practice is unique, complex and continuing to evolve. A GP must have a good working knowledge of 167 problems to cover 85% of the conditions that they see most frequently,5 and management of multimorbidity has become the norm. The number of general practices appears to be declining, practices are becoming larger, and the proportion of GPs who are practice owners is decreasing.6 General practice research is key to optimising health care in this evolving context, but needs to be supported by the profession, funders and our professional colleges. Current challenges General practice has traditionally been seen as an applied discipline, rather than one with an academic underpinning, and research has therefore been undervalued. The undervaluing of general practice research is reflected in current research funding and a paucity of opportunities during specialty training. The proportion of National Health and Medical Research Council funding to primary care research has been consistently low,7 and this has continued in the current Medical Research Future Fund budget, with only $5 million of $392.5 million for the 2019–20 financial year specifically allocated to primary care,8 despite primary care being noted as a medical research and innovation priority for 2018–2020.9 The Medical Research Future Fund 2019 investigator grant opportunity for early to mid career researchers included primary care research as one of its 11 research priority areas, but it will not be known if general practice research specifically has been supported until the results of that round are released. In the context of this undervaluing, GPs who have completed PhDs have expressed concerns about insecure academic career pathways,10 and the current ageing GP research workforce may not be replaced.11 Additional barriers to general practice research include lack of funding for Australia and New Zealand's academic primary care peak body (the Australasian Association for Academic Primary Care), general practice research networks, and payments to adequately compensate practices for the time and resources required to participate in research. Recent achievements Despite the challenges, general practice has a long tradition of rigorous, detailed and credible scientific research. This work covers a broad range of research questions, utilising a range of methodologies and frameworks (Box). However, general practice research outcomes are often less visible as hospital admissions avoided, diseases prevented, complications averted and health services redirected are key outcomes.4 The generalist nature of primary care means that research must deal with heterogeneous populations, multimorbidity and complex health service delivery. What would health care look like without general practice research? Primary care is the most efficient, equitable and effective place to deliver health care for most of the population,4 and is underpinned by a growing scientific knowledge base as research in and about general practice has evolved and grown over the past 50 years.12 Research in this setting is required as never before, with an ageing population, increasing rates of multimorbidity, and management continuing to move out of the hospital and into the community setting.13 There is no other academic specialty that will focus on generalist care in the community, and general practice is integral to research translation. Without general practice, the health outcomes of the population will be poorer and less equitable, and associated with increased health costs.4 Contextual knowledge of primary care is essential for credible and relevant general practice research. It is hard to imagine research into cardiology, for example, without the involvement of cardiologists. However, it is not uncommon for research in health services and primary care to not involve GPs, or to involve them at a late stage in development. Without GP involvement, research outcomes are unlikely to be fit for the general practice environment or appropriate for patients attending primary care. Academic GPs play important roles in both research and teaching, including training academic GP registrars and supervision of primary care researchers and students more broadly. They contribute to shaping the policy and practice environment through representing general practice on guideline development groups and engaging with international colleagues to develop and implement research methodologies suitable for the primary care environment. Without support of general practice research and training, this expertise would be lost. GPs and practice staff work with academic GPs and play a critical role in the development and implementation of interventions, recruitment and data collection and interpretation. Without compensation for their time (participation in research often results in loss of income) and without the infrastructure of practice‐based research networks, this practice knowledge cannot be harnessed. Data collected from general practice that is not interpreted through a generalist lens with an understanding of the context in which general practice operates can result in conclusions that do not reflect practice. A lack of focus on general practice research and academic opportunities will have a flow‐on effect to the recruitment of new GPs. To build interest in general practice more broadly, attention needs to be paid to medical students who often believe there is little intellectual challenge in the profession and a lack of academic opportunities.14 The national General Practice Student Network, a network for medical students interested in general practice supported by General Practice Registrars Australia, provides an opportunity for academic GPs and the Royal Australian College of General Practitioners (RACGP) to link with medical students to showcase opportunities for GP research, teaching and academic training. Towards the future Vocational training will be transitioned to the RACGP and the Australian College of Rural and Remote Medicine from the federal Department of Health in January 2022. This presents a real opportunity for shaping the future of general practice training by acknowledging the importance of research to the discipline, expanding current academic registrar programs and encompassing key Australian Medical Council accreditation recommendations, including that appropriate candidates can enter research training during specialist medical training with opportunities to undertake intercalated research degrees.15 This would provide a foundation for a supported path in GP academia. The RACGP Expert Committee – Research is currently developing a research strategy that will address these issues. Advanced Health Research Translation Centres and Centres for Innovation in Regional Health exist around Australia, and are partnerships of hospitals, research institutes and universities developed to accelerate translation of research into clinical care. As these structures currently stand, primary care is often lost among the multitude of hospital partners and clinicians and researchers who have little experience of, or interaction with, general practice. The Centres work together as the Australian Health Research Alliance, which currently does not include primary care as one of its system level initiatives. A focus on primary care would provide a more meaningful option for engaging with community general practice and primary care, working collaboratively with properly funded and sustainable practice‐based research networks that have led to successful innovations in other parts of the world. The GP academic community would welcome closer collaboration with both the Medical Research Future Fund and the Australian Health Research Alliance. The promise of big data has huge implications for general practice, with many heralding this as the beginning of a new era, but big data without appropriate expert interpretation is likely to lead to misunderstanding. General practice has a long history of working with data, starting with Charles Bridges‐Webb developing the first general practice survey in 1961, laying the groundwork for the Bettering the Evaluation and Care of Health (BEACH) program.2 Large general practice datasets are now held by NPS MedicineInsight, Primary Health Networks, and departments of general practice (for example, the UNSW electronic Practice Based Research Network and the Data for Decisions program at the University of Melbourne). The ability to track the patient journey between primary care and hospitals is being realised through linked datasets. The National Primary Health Care Data Asset is now under development, and it is critical that this includes oversight and input of GP clinician‐scientists to ensure that data are not misinterpreted. General practice is an academic specialty based on an international body of literature and decades of research. However, in Australia we still have a way to go to understand why primary care works in our context, how to best implement change, and how to teach best practice to new clinicians. Recognising and investing in the value of general practice research will require a systems approach that includes medical student training, vocational training, and support of research infrastructure and GP clinician‐scientists to enable research and research training in general practice and translation into practice and policy. This investment in general practice research and infrastructure should reflect the size of general practice in Australia, the population it serves, and the proportion of the associated Medicare spend. Box – Examples of general practice research informing clinical practice and health service design Research Key findings and implications for general practice General practice research involvement ASPirin in Reducing Event in the Elderly (ASPREE)12 Higher all‐cause mortality was found in healthy older adults in Australia aged over 70 years of age who received daily aspirin. This suggests that aspirin may not be of benefit for primary prevention of cardiovascular disease in this age group Mark Nelson (principal investigator) and Nigel Stocks were authors on this randomised controlled trial. Australian GP Associate Investigators in clinical practice recruited 87% of the 19 114 patient participants What treatments are effective for common colds in adults and children? Decongestants alone, or with antihistamines or analgesics, can be helpful for adults with nasal symptoms, but other commonly recommended treatments such as echinacea, vapour rub and heated, humidified air have no evidence of effect Systematic review led by Mieke van Driel13 Comparing non‐sterile to sterile gloves for minor surgery: a prospective randomised controlled non‐inferiority trial14 Non‐sterile gloves are not inferior to sterile gloves in regard to wound infection for minor skin excisions in general practice Trial led by Clare Heal, conducted in a single private general practice in Mackay, Queensland How to increase uptake of long acting reversible contraception (LARC) through general practice15 Online GP training in effectiveness‐based contraceptive counselling, together with GP access to rapid referral to a LARC insertion clinic increases LARC uptake by women Cluster randomised controlled trial in 57 general practices in Melbourne led by Danielle Mazza Bettering the Evaluation and Care of Health (BEACH)2 The BEACH dataset, consisting of almost 1.8 million GP–patient encounters recorded between 1998 and 2016, has been used to inform general practice research, education and policy Each year, about 1000 GPs recorded data about 100 consecutive patient encounters, contributing to the development of the BEACH dataset. Graeme Miller was the Medical Director of BEACH Clinical outcomes of an integrated primary–secondary model of care for individuals with complex type 2 diabetes: a non‐inferiority randomised controlled trial16 GPs with special interests working with a Beacon model of integrated care for diabetes achieved clinical outcomes that were not inferior to hospital‐based specialist clinics, with greater patient satisfaction Claire Jackson co‐led the development and evaluation of the Beacon model, which has now also been adapted and utilised in Western Australia Composite Abuse Scale17 The Composite Abuse Scale was developed as a research tool to classify women according to type and severity of abuse. It has been translated into eight languages and is considered the standard for assessing women's self‐reported experiences of abuse The Composite Abuse Scale was developed by Kelsey Hegarty and used in a cluster randomised controlled trial to identify women who screened positive to intimate partner violence and who may benefit from brief counselling from their GP

Jo‐Anne E Manski‐Nankervis · Elizabeth A Sturgiss · Siaw‐Teng Liaw · Geoffrey K Spurling · Danielle Mazza

An effective approach can only be achieved by a national strategy for averting opioid-related deaths

Nicholas Lintzeris

The conventional treatment for brain metastases is whole brain radiotherapy (WBRT).1 But there has been a gradual move to managing limited brain metastases with stereotactic radiosurgery (SRS),2 and delaying or avoiding WBRT because of its effects on cognition and quality of life. Data on contemporary SRS practice for managing brain metastases in Australia are, however, very limited.3 We performed a population‐based linkage study, analysing data from the Victorian Cancer Registry and the Victorian Radiotherapy Minimum Data Set (VRMDS). We included all patients with solid tumours (ICD‐10 codes C00–C80), but excluding primary central nervous systems malignancies (ICD‐10 codes C69–72), who received brain radiotherapy in Victoria between 1 January 2012 and 31 December 2017. The primary outcome was the proportion of patients treated with SRS. Although SRS refers to large single fraction radiotherapy, patients treated with fractionated “stereotactic radiotherapy” were also classified as receiving SRS. In addition, because of potential coding inconsistencies, patients who had no more than four fractions of radiotherapy and were treated with “volumetric modulated arc therapy” or “intensity modulated radiation therapy” were also classified as receiving SRS. Differences in factors of interest by SRS use were assessed in Pearson χ2 (categorical variables) and Student t or Mann–Whitney U tests (continuous variables). Temporal changes were assessed with the Cochran–Armitage test for trend. Factors associated with SRS use were assessed by logistic regression, with year as an ordinal categorical variable; variables for which P < 0.10 in univariate analyses were included in the multivariate model. The study was approved by the Austin Health Human Research Ethics Committee (reference, LNR/18/Austin/34). A total of 3961 patients who received radiotherapy for brain metastases were included, of whom 1116 (28%) received SRS. The proportion of patients receiving SRS increased from 27% (105 of 388) in 2012 to 35% (287 of 821) in 2017 (for trend: P < 0.001). The mean age of patients who received SRS (63.5 years; standard deviation [SD], 12.5 years) was lower than for those who did not (65.2 years; SD, 12.5 years). Factors that influenced SRS use included socio‐economic status, primary cancer type (about half the patients with melanoma received SRS, and about one‐quarter of patients with other cancer types), treatment institution type (public institutions, 31%; private institutions, 24%), and location (metropolitan centres, 34%; regional centres, 5%). Remoteness of patients’ area of residence was not a significant factor. In multivariate analyses, age, primary cancer type, treatment centre type, and location were significant factors for SRS use (Box). While the VRMDS captures all radiotherapy delivered in Victoria, it does not include data on patients’ performance status, numbers of brain metastases, the extent of extracranial disease, and other factors that would allow evaluation of the appropriateness of SRS for individual patients. Another limitation is potential misclassification of radiotherapy classified as “SRS”, as the VRMDS did not include data on radiotherapy dose. As evidence supporting the use of SRS for managing brain metastases grows, we would expect SRS rates to rise.6,7 While SRS was less frequently used in regional centres, patients living in regional areas were as likely to receive SRS as patients living in metropolitan areas. It is nevertheless important to ensure easy and convenient access to SRS services for all cancer patients in Victoria. Box – Baseline characteristics of 3961 patients who received radiotherapy for brain metastases, Victoria, 2012–2017 Stereotactic radiosurgery Multivariable analysis: odds ratio (95%CI) P Received Not received Number of patients 1116 (28%) 2845 (72%) Age at first treatment for brain metastases (years) < 55 266 (33%) 543 (67%) 1 55–59 157 (32%) 331 (68%) 1.11 (0.86–1.44) 0.42 60–64 161 (28%) 419 (72%) 0.89 (0.69–1.14) 0.35 65–69 177 (26%) 502 (74%) 0.85 (0.67–1.08) 0.19 70–74 153 (25%) 448 (75%) 0.88 (0.68–1.14) 0.33 75 or more 202 (25%) 602 (75%) 0.78 (0.62–0.99) 0.045 Mean (SD) 63.5 (12.5) 65.2 (12.5) — — Sex Men 528 (28%) 1373 (72%) — — Women 588 (29%) 1472 (71%) — — Primary cancer type Lung 419 (24%) 1344 (76%) 1 Breast 203 (28%) 512 (72%) 1.24 (1.00–1.53) 0.05 Melanoma 252 (47%) 277 (52%) 2.89 (2.32–3.59) < 0.001 Gastrointestinal 93 (28%) 235 (72%) 1.37 (1.03–1.80) 0.028 Genitourinary 73 (28%) 189 (72%) 1.33 (0.97–1.80) 0.07 Other 76 (21%) 288 (79%) 0.80 (0.60–1.06) 0.12 Socio‐economic status (quintile) 1st (most disadvantaged) 188 (24%) 612 (77%) 1 2nd 189 (27%) 501 (73%) 1.12 (0.87–1.44) 0.39 3rd 202 (26%) 572 (74%) 1.02 (0.79–1.30) 0.90 4th 220 (26%) 618 (74%) 0.90 (0.70–1.14) 0.38 5th (least disadvantaged) 317 (37%) 542 (63%) 1.19 (0.94–1.50) 0.14 Remoteness classification5 Major city 780 (29%) 1949 (71%) — — Inner regional 261 (26%) 732 (73%) — — Outer regional/remote/very remote 75 (31%) 164 (69%) — — Treatment institution type Public 744 (31%) 1656 (69%) 1 Private 372 (24%) 1189 (76%) 0.10 (0.07–0.14) < 0.001 Treatment institution location Metropolitan 1071 (34%) 2071 (66%) 1 Regional 45 (5%) 774 (95%) 0.58 (0.49–0.68) < 0.001 Year of first brain metastasis treatment 2012 105 (27%) 283 (73%) 1 2013 111 (25%) 342 (76%) 1.01 (0.72–1.41) 0.95 2014 147 (25%) 439 (75%) 0.86 (0.63–1.18) 0.35 2015 207 (25%) 633 (75%) 0.79 (0.59–1.06) 0.12 2016 259 (30%) 614 (70%) 1.10 (0.83–1.47) 0.50 2017 287 (35%) 534 (65%) 1.41 (1.06–1.88) 0.017 CI = confidence interval; SD = standard deviation. * Index of Relative Socio‐Economic Disadvantage.4

Wee Loon Ong · Therese Ming Jung Kang · Gishan Ratnayake · Morikatsu Wada · Jeremy Ruben · Sashendra Senthi · Roger L Milne · Jeremy L Millar · Farshad Foroudi

Ambient air quality in Australia is regulated by the National Environment Protection Measure (NEPM), which sets a maximum 24‐hour mean concentration of 50 μg/m3 for particulate matter less than 10 μm in diameter (PM10) and 25 μg/m3 for PM2.5. Each state and territory is required by the NEPM to annually report all breaches of this standard, including the sources of pollution.1 We analysed NEPM reports for Western Australia to identify days during 1 January 2002 – 31 December 2017 on which atmospheric particulate matter levels exceeded air quality standard levels, and classified them according to the most frequently reported sources of pollution: prescribed burns, wildfires, and other (crustal particles such as dust, wood smoke, and indeterminate). During 2008–2013, exceedances caused by smoke from prescribed burns, wildfires, and wood smoke were all recorded by the WA Department of Environment Regulation as “smoke haze”. For this period, we therefore applied a random forest algorithm, a machine learning method that uses a random sample of observations for known classifications to predict the classifications for new data.2 We included the variables month, day of the week, temperature, and pollution level as model predictors. To estimate background PM2.5 level, we obtained historical hourly values for PM10 and PM2.5 from the WA Department of Water and Environmental Regulation3 and calculated historical monthly means, excluding days on which particle levels exceeded the air quality standard. We estimated daily PM2.5 concentrations attributable to smoke events by subtracting the background PM2.5 level from measured daily values. Applying standard methods for assessing the health impact of air pollution,4 we estimated the numbers of premature deaths, hospitalisations for cardiovascular and respiratory problems, and emergency department presentations with asthma attributable to elevated PM2.5 levels. We used the value of statistical life (VSL)5 to estimate costs associated with premature mortality. The VSL is based on the willingness to pay for reduced risk of premature mortality, and does not take into account underlying health status, age, or life expectancy of individuals. Deaths associated with acute exposure to increased air pollution are more likely among people at greater risk because of advanced age or chronic illness.6 We estimated hospital service costs according to the mean cost of each episode of care as reported in the Independent Hospital Pricing Authority national cost data collection report7 and the Health Policy Analysis emergency care costing report.8 We also undertook a sensitivity analysis in which we excluded data for 2008–2013, when exceedances caused by smoke from prescribed burns, wildfires, and wood smoke were all recorded in NEPM reports as “smoke haze”. Further details on our methods, including underlying assumptions and limitations, are included in the online Supporting Information. During 2002–2017, particulate air pollution exceeded the national standard on 271 of 5844 days (4.6%), including 197 days (73%) attributable to prescribed burns or wildfires. We estimated that 41 (95% confidence interval [CI], 15–68) premature deaths, 99 (95% CI, 19–182) hospitalisations for cardiovascular problems and 174 (95% CI, 0–373) for respiratory conditions, and 123 (95% CI, 70–179) emergency department visits with asthma were attributable to elevated PM2.5 concentration (Box 1). Total estimated health costs were $188.8 million (95% CI, $68.1–311.1 million); $97.1 million (51%) was attributable to prescribed burns and $77.7 million (41%) to wildfires. Mean estimated health costs were lower on days affected by smoke from prescribed burns ($703 984; 95% CI, $254 064–$1.2 million) than those affected by wildfire smoke ($1.3 million; 95% CI, $475 000–$2.2 million), although more days were affected by prescribed burns (138) than by wildfires (59). The estimated smoke‐related costs of wildfires were highest in 2012 ($24.8 million); in many years, prescribed fires often accounted for most health‐related costs, peaking in 2017 ($24.1 million) (Box 2). In our sensitivity analysis excluding the period 2008–2013, the relative costs by source were similar (prescribed burns, 53% [$58.4 million]; wildfires, 38% [$41.6 million]; Supporting Information). Particulate matter in fire smoke is associated with adverse health outcomes,9 even at relatively low concentrations.10 Landscape fire smoke was the greatest contributor to excessive atmospheric particulate matter levels in WA during 2002–2017 and was associated with substantial health costs. Our estimates of the health impacts may be conservative, as we included only days when PM2.5 concentrations exceeded the national standard, excluding smoky days on which the air quality standard was not breached. Further, our selection of health outcomes did not encompass the total health burden attributable to smoke exposure. Our study highlights the different smoke‐related health effects and costs of infrequent severe wildfire and regular prescribed burning. While prescribed burning reduces the risk of wildfire, better understanding and incorporation into control strategies of the full health impacts of each type of fire are needed for sustainable fire management.11 Box 1 – Estimated health burden attributable to elevated PM2.5 concentrations, Western Australia, 2002–2017, by particulate matter source Outcome Estimated number of cases (95% confidence interval) Prescribed burns Wildfires Other Total Excess deaths (any cause) 21 (8–35) 17 (6–28) 3 (1–5) 41 (15–68) Hospital admissions, cardiovascular 51 (10–94) 41 (8–75) 7 (1–13) 99 (19–182) Hospital admissions, respiratory 89 (0–192) 72 (0–154) 13 (0–27) 174 (0–373) Emergency department attendances, asthma 63 (36–91) 51 (29–75) 9 (5–13) 123 (70–179) Box 2 – Estimated health costs tributable to elevated PM2.5 concentrations, Western Australia, 2002–2017, by particulate matter source

Nicolas Borchers Arriagada · Andrew J Palmer · David MJS Bowman · Fay H Johnston

It is imperative that we prepare for the worst, and that we do it now As the Editor‐in‐Chief of the MJA, I'm in the very privileged position of being among the first to critically evaluate early and emerging data forwarded to the Journal. I can also talk to experts around the world because of my medical and academic links. In January 2020, early on in what is now the SARS‐CoV‐2 pandemic, I remember seeing the first data on the outbreak of COVID‐19 in China, the estimated R0 values, and the initial models of exponential spread. Evidence from past outbreaks provides many lessons, including the importance of public health responses going very hard and very early, well before all the epidemiologic data are in.1,2 I therefore watched with increasing alarm that, despite early warnings from the World Health Organization, the initial responses of many governments around the world were limited and slow. I remember when I first saw the disturbing Imperial College modelling for the United Kingdom and the United States, including the different impacts of mitigation and suppression strategies in terms of hospital deaths from COVID‐19.1 In Australia, the messages have yet to fully sink in. On 26 March we published a new model of COVID‐19‐related mortality and hospital admissions, validated against Italian data.3 The model is simple and grim; it describes a hypothetical Australian hospital admitting new cases of confirmed COVID‐19 infection day after day, assuming that one in 20 patients require intensive care for 10 days, and that the COVID‐19 community case load increases by 20% each day. From day 15 — about the time when it is expected that available ICU beds run out — mortality steadily increases, as has happened in Italy. Those familiar with outbreak modelling know how complex such models can be and how many unknowns need to be imputed, especially early in a new outbreak; some employ supercomputers for their calculations, and can take months or years to build their model. Further, the predictive validity of complex models in an outbreak may not apply in other locations because human behaviour is complex and unpredictable.4,5 For this reason, simple models may be more robust; at least early on, when they matter most.6 Many have spoken out about the public health measures needed to slow the spread of SARS‐CoV‐2, and bolder action has recently been taken in Australia and elsewhere; those medical leaders who have stepped up and the political leaders who have heeded their advice early enough will have helped save lives. The next wave of heroes will soon emerge as frontline clinicians in hospitals care for patients during the COVID‐19 surge. At the time of writing (26 March), major preparations are underway to increase ICU bed and ventilator capacity, and personal protective equipment (PPE) is being donned to protect staff. According to current COVID‐19 surge modelling, however, it won't be enough. The health workers who will be on the COVID‐19 frontline and manage the sickest patients will need our greatest support, every single one of them. We will need to ensure that PPE stocks are not wasted and that they are replenished quickly, a clear government priority supported by the suspension of non‐urgent elective surgery announced by the federal government. I hope that manufacturers will be directed to produce everything we need, and quickly; we would re‐tool factories in wartime and not rely alone on private companies to step up (although some have). Some may dislike the wartime analogy, but it resonates with me. We will need to work together to support our medical teams. For families with two health professionals and dependents, we should not place both carers at high risk of exposure and severe disease. This will not be a straightforward rostering task, particularly outside major hospitals and in rural Australia. We need a statewide, and preferably a national plan; closing our internal borders must not impede sensible rostering and medical team deployment. Training needs to ramp up for all staff, and consist of more than simple online videos. We need a clear plan if PPE runs low or out. And we need clear triage rules about which patients should be ventilated if beds run short; health professional leaders and the community must together discuss the complex medical and ethical problems involved, and guidance needs to be finalised as soon as possible. Mental health support will be important, as post‐traumatic stress disorder will be a serious risk for ventilated patients and for staff; I suggest resting staff as much as possible now so that they are healthy, physically and mentally, when they are really needed. We will also require our health system leaders to understand that at a time like this every hospital should have a strict command and control structure led by senior clinicians and health professionals, with a designated clinician leader; bureaucrats primarily concerned with finances and political considerations must move to the sidelines. The Australian Health Practitioner Regulation Agency (AHPRA) is working to determine the role of medical students in this hour of need. Those close to graduating could play direct clinical roles under close supervision if they volunteered, but we need to start upskilling them now if this is to be worthwhile; it takes time to transition from being a medical student to a fully functioning, safe and competent intern. Doctors are being recalled from retirement in the UK and parts of Australia. I hope that this strategy will not be needed, as it places the most vulnerable in the profession in the wrong place. We must also protect staff financially and professionally. The indemnity implications for doctors required to work outside their scope of usual practice are unclear and must be resolved quickly. I am a gastroenterologist, and I am fully prepared to work on COVID‐19 wards or fill gaps in non‐COVID wards if required. But what if I make mistakes? And if I die, will insurance cover my family? The MJA has stepped up to play its part in meeting this crisis, including ultra‐rapid review of SARS‐CoV‐2 manuscripts and pre‐print publication of unedited papers, to ensure that the newest data and viewpoints are available as soon as possible. In addition, all SARS‐CoV‐2 articles will be fully accessible without fee. Our medical and structural editors are working from home, carefully reviewing every submission, but the MJA will continue to publish as usual in these extraordinary times. The ultra‐rapid review and publication model entails a risk of error, but sharing important information too slowly is a much greater hazard. We will transparently correct and update the preprints if appropriate, and we will of course apply our usual high standards of review and editing to refine them before we publish their final versions online and in print. Models matter, even if they are imperfect representations of the real world.7 While the projections reported in this issue3 may represent a worst case scenario and may not come to pass, it is better that we prepare for the worst, and now. Over the coming months it's going to take courage, brains, and a concerted and unified effort by the medical profession and other health professionals to manage SARS‐CoV‐2. Let's not leave anyone behind.

Nicholas J Talley

Primary care is the single most significant contributor to positive health outcomes,1,2 but the number of general practitioners in Australia has been falling, a situation previously described for nations with poorer health outcomes.2 The reasons for the decline are many,3 but this phenomenon has not been described in detail in the peer‐reviewed literature. We have therefore examined the registration categories, as recorded by the Australian Health Practitioner Regulation Agency (AHPRA), of people who graduated from the University of Western Australia (UWA) medical school during 1985–2007. Our study was approved by the UWA Human Research Ethics Committee (reference, RA 4/1/1627). We included all active medical practitioners who graduated (MBBS) from UWA during 1985–2007 and were registered with AHPRA in December 2019. We included all doctors listed by AHPRA as practising GPs, whether vocationally registered or with college membership, in our GP category; 65 of the 93 1985–1987 graduates registered by AHPRA as GPs did not have postgraduate qualifications, but only five of the 56 2004–2007 graduates. AHPRA registration as a GP was about half as likely for 2004–2007 graduates as for 1985–1987 graduates (relative risk [RR], 0.46; 95% confidence interval, 0.35–0.60). This decline in entry into general practice was accompanied by an increase in the proportion of graduates with general registration status alone (in 2004–2007 v 1985–1987: RR, 3.01; 95% CI, 1.97–4.61) (Box). These findings are consistent with the recently reported drop in the proportion of medical graduates who intend to enter general practice,5 which may lead to a further decline in the number of AHPRA GP registrations. We also found an equally concerning increase in the number of doctors practising as generally registered practitioners alone during 2007–2019, presumably waiting for the opportunity to enter their preferred medical specialty. This problem, first discussed without data in the MJA in 2012,6 has not attracted the attention of policymakers. The reduction in size of the primary care workforce is felt most keenly in rural communities, where dependence on primary health care is more pronounced, but urban practices also struggle to recruit new fellows.2 The causes of this problem include the perceived lower status of general practice, the generally lower income provided by Medicare fees, the burden of practice accreditation, and specialist‐focused teaching in medical schools. Further challenges for rural practice include problems of work–life balance and the focus on fly‐in/fly‐out specialist services instead of developing extended scope primary care models for regional and remote communities. One limitation of our study is that the AHPRA general registration data need to be compared with college registries for accuracy. Our findings nevertheless suggest that solutions for the general practice problem are urgently needed if Australia is to continue enjoying some of the best health outcomes in the world. Box – Category of registration for University of Western Australia medical graduates, 1985–2007, as recorded by the Australian Health Practitioner Regulation Agency (AHPRA)* * Data as at 28 November 2019; data shown for categories with at least 25 graduates during 1985–2007. Total number of practising graduates registered with AHPRA, by graduation year: 1985–1987: 237; 1988–1991: 355; 1992–1995: 355; 1996–1999: 370; 2000–2003: 426; 2004–2007: 419. † Includes all medical graduates who have completed an accredited internship in Australia or New Zealand and are not required to complete any additional supervised practice to become eligible for general registration; those who completed a recognised internship elsewhere and have additionally satisfactorily completed 47 weeks of full‐time approved supervised practice in Australia; those who have previously held general registration in Australia; those who have completed the competent authority pathway; and Australian Medical Council certificate holders in the standard pathway who have completed a period of approved supervised practice in Australia.4

Denese Playford · Jennifer A May · Hanh Ngo · Ian B Puddey

The potential of modern mass communication techniques for managing chronic disease should be explored further

Yang Si · Xiaoqiang Xiao · Cai Xia · Jiang Guo · Qiukui Hao · Qianning Mo · Yulong Niu · Hongbin Sun