Health services administration

However rates of Staphylococcus aureus bacteraemia are reported, the aim should be to reduce them

Diane E Watson

However rates of Staphylococcus aureus bacteraemia are reported, the aim should be to reduce them

Allen C Cheng · Leon J Worth

Travel from remote areas to access health care could be contributing significantly to carbon emissions

Colleen Cheek · Timothy Skinner · Isabelle Ellis

Revalidation for doctors working in the UK is complex, and its implications on the workforce remain to be seen

Heinz Tilenius

The convergence of seemingly small events accruing over time can have severe consequences. This is a central message of many aircraft accident investigations. For instance, an attempt to streamline maintenance procedures for an engine mount created the conditions for the United States’ deadliest aeroplane crash in 1979 (http://www.airdisaster.com/reports/ntsb/AAR79-17.pdf). The investigation found a constellation of interacting factors — design deficiencies, faulty maintenance practice, failures of regulatory oversight and flawed aviation industry economics. As noted in relation to a later aeroplane crash (http://www.theatlantic.com/magazine/archive/1998/03/the-lessons-of-valujet-592/306534), it was a “system accident”. The complexity of aviation systems creates conditions for small changes to interact with other system elements across technical, organisational and cultural domains to produce significant outcomes that are hard to predict and control. All clinicians recognise the complexity of health care delivery. The system accident idea has been adopted enthusiastically by some exponents of ways to improve clinical safety, despite more recent reservations about its applicability (Health Serv Res 2006; 41: 1654-1676). Nevertheless, the assessment of clinical mishaps and adverse events requires a systems approach (not only technical, but also organisational, social and cultural). As a starting point, registries are powerful tools for systematically detecting and monitoring clinical problems and adverse events, and for informing interventions. The study by Roxanas and colleagues of Australia and New Zealand Dialysis and Transplant Registry data (doi: 10.5694/mja13.10435) shows that the incidence of end-stage renal failure due to lithium therapy, although small, is growing. They express concern that accepted doses of lithium over a long time may result in irreversible renal impairment and end-stage disease, reinforcing the need for regular and frequent monitoring of renal function. Registry data analysis is the monitoring system providing the backbone for reducing risks for those receiving lithium therapy. There is also a need for systems to oversee and analyse incidents in whole areas of health care. Cunningham and colleagues (doi: 10.5694/mja13.11347) point out that, in the case of chiropractic practice, there is little in place for monitoring for adverse incidents. Without such a system, proper investigation of incidents in chiropractic care cannot occur. Significantly greater challenges exist in assessing health impacts of activities with complex influences from societal and cultural practices in the community. Clenbuterol — a β2-adrenergic agonist with anabolic as well as bronchodilating properties, registered only for veterinary use and banned in sport — is now illicitly used in the community to aid bodybuilding and weight loss. Brett and colleagues (doi: 10.5694/mja13.10982) report a case series of clenbuterol toxicity reported to the NSW Poisons Information Centre. Details of cases suggest that it is also being used for deliberate self-harm, and that accidental ingestion has occurred. While the authors acknowledge that the study presents an incomplete picture of actual use in the community, would a deeper engagement with ideas from complexity science help in understanding the complexity of substance misuse? What additional systems need to be put in place for us to know and perhaps anticipate changing patterns of use? No matter how complex the health problem, data registries will always have a central role in disease and health care monitoring and practice. Presently, patients often need to explicitly consent to their information being added to a registry. Olver (doi: 10.5694/mja13.10695) examines the ethical dimensions of opt-out consent, where patient data are automatically added unless consent is expressly refused. He argues that this approach is acceptable in the context of low-risk research and for improving clinical quality. Although not called a registry, the concept has been used for decades in civil aviation for mandatorily collecting flight data and operational feedback from aviation personnel. Only relatively recently have similar approaches taken hold across a broad range of health care activities. Decades of research and application of safety assurance and improvement systems in aviation and other industries have resulted in a critical respect for the complexity of many human endeavours — the importance of monitoring outcomes and processes, understanding why and how incidents happen, and appreciating the multifaceted nature of the solutions. There are certainly limitations to mapping approaches to aviation safety to health care systems. But the analogy provides a useful starting point and source of ideas. Preventing adverse health outcomes and health care incidents matters enormously to the community. Just as a systems approach has led to civil aviation being appreciably safer, it should also be pursued by those wanting well founded solutions to complex, multidimensional problems in health.

Astika Kappagoda

A first step for a virtually unregulated industry

Bernard E Tuch FRACP, PhD, GAICD · Dominic M Wall BSc(Hons), FFSc(RCPA), PhD

As the states maintain control over public hospitals, the federal government needs a simple, outcomes-based funding model

Johannes U Stoelwinder MD, FRACMA, FAFPHM

Bringing chiropractors in line with other Australian health professionals

John E Cunningham · Joanne Benhamu · David Hawkes

Timely study with pressure on funders to provide evidence of wider impacts of research

Claire Donovan MA, BA(Hons), DPhil · Linda Butler BEcon · Alison J Butt BSc(Hons), PhD · Teresa H Jones BSc, MSc · Stephen R Hanney PhD, MA, BSc(SocSci)

The federal government, less than 6 months old, faces many challenges in health care. Establishing priorities will be useful if they guide attention and resources towards where they are likely to offer the best yield in promoting health and providing care for sick and injured people, while honouring the principles of efficiency and equity in the way that we do things and to whom we attend. The Journal has asked six health leaders to suggest policy pointers — matters that, in their opinion, warrant the attention of the new government and about which policy might be developed for effective action. The first response is by eminent Melbourne health economist and academic Stephen Duckett (doi: 10.5694/mja13.00224). Duckett sets out his call for policy under three headings — keeping the Medicare promise, going beyond the provision of services and ensuring good governance. He splits his proposals into what a first-term and second-term government might aspire to do. His wide experience in health service management makes his recommendations especially pertinent. Brian Head, program leader in policy analysis at the University of Queensland, wrote “Policy decisions emerge from politics, judgement and debate, rather than being deduced from empirical analysis. Policy debate and analysis involves an interplay between facts, norms and desired actions, in which ‘evidence’ is diverse and contestable” (Aust J Public Admin 2008; 67: 1-11). Policy that works distils evidence from several sources. It includes the kind that supports evidence-based medicine, but there is also the evidence that comes from an assessment of political feasibility and evidence that comes from what we might call experience. Doctors are often frustrated when the evidence they present, from both basic and clinical science and from professional experience, is trumped by politics. But the nature of a democracy is such that this is to be expected. Policy on initial screening for acute life-threatening disease benefits greatly from medical input. Although, strictly, it is case finding, the study by Parsonage and colleagues (doi: 10.5694/mja13.10466) evaluates the use of a more sensitive troponin test for more quickly determining the presence of myocardial damage in line with an “accelerated biomarker” strategy for assessing and managing suspected ischaemia and infarction. Their findings validate the use of this strategy, formulated by the National Heart Foundation of Australia and the Cardiac Society of Australia and New Zealand. Here, medical evidence informs the policy that governs the interaction between patients and health care provision. Because enthusiasm frequently runs ahead of utility when it comes to screening, Maxwell and colleagues (doi: 10.5694/mja13.10974) advocate for a national framework for newborn bloodspot screening. Such frameworks have proved their worth in other countries, and one is needed here. Kane and colleagues (doi: 10.5694/mja13.10955) welcome progress in the use of cell-free fetal DNA tests of maternal serum for aneuploidy screening (and the extension of related tests to pregnancy outcome prediction) in the first trimester even though these tests have some distance to travel before sensitivity, specificity and predictive value will be clear. Ah, the delight of reading an article that describes success in closing a gap — any gap! Gaps so often cause lamentation with no design for a bridge. Tideman and colleagues (doi: 10.5694/mja13.10645; see linked editorial by Carroll and Thompson doi: 10.5694/mja14.00016]) describe a splendid cardiology network in South Australia that supports patients who have had acute myocardial infarction and who live in places remote from major hospitals in receiving appropriate timely and evidence-based care. The network involves providing advice from metropolitan hospital specialists to rural health practitioners, carefully stratifying patients into three risk categories to determine who needs reperfusion angiography most urgently, and then organising it. The mortality gap between city and rural dwellers was consequently abolished. Here, policy built the bridge to bring rural outcomes closer to city ones. In all of these examples, policy served as a vehicle for organising thought and care. It is critical to achieving the best clinical outcomes. The challenge to our nation is to ensure that our state and federal policies are as sound as we can help make them. We doctors do not make the policies, but we contribute positively and importantly to them.

Stephen Leeder

Good health policy crosses multiple parliamentary terms, and acknowledges that there are no simple answers

Stephen J Duckett PhD, DSc, FASSA

Many doctors do not appreciate the significance of the Code

Ian R Gough

A doctor who is an effective follower will also be a much better clinical leader

Erwin Loh

Does Australia need a revalidation process as part of renewing medical registration?

Kerry J Breen MB BS, MD, FRACP

Is the researcher held to a higher standard than the clinician?

Ian A Harris MB BS, MMed(ClinEpi), PhD · Justine M Naylor BAppSc(Phty), PhD

Current guidelines disregard sugar content when assessing foods for inclusion in school canteens

Kieron B Rooney

Enforcing vaccination or mask-wearing leads to increased vaccination rates among heath care workers

Rhonda L Stuart · Elizabeth E Gillespie · Peter G Kerr

To the Editor: Zimmet draws attention to the looming catastrophe of diabetes.1 However, there is a concomitant health catastrophe — climate change, “the biggest global health threat of the 21st century”.2 We believe that it is not useful to argue whether diabetes or climate change is a greater threat to health. Rather, diabetes and climate change are predictable manifestations of contemporary human ecosystems: The conjoined processes of ...

Rosalie Schultz · Peter Tait

Most junior doctors’ informal and formal education doesn’t add up to much — are we investing enough in them?

R Kim Oates MD, DSc, FRACP · Kerry J Goulston MD, FRACP · Craig M Bingham BA, DipEd, MA · Owen F Dent PhD

A focus on overuse of psychotropic drugs in aged care facilities is too narrow and will not help solve overall problems

Jeffrey C L Looi MD, FRANZCP, AFRACMA · Stephen Macfarlane MB BS, MPM, FRANZCP

To provide quality health services, we need to collect meaningful data and invest in embedded research and development

Julie A Halton

To the Editor: I would like to commend Penington for his insightful opinion piece regarding the challenges facing the Australian health system over the next decade.1 I, and I am sure many others, share his warranted concern regarding the future of quality and safety in health care in a politically charged, target-based funding system. As highlighted by Penington, the recently published McKeon report provides a suggested ...

Justin M Nazareth

A screening checklist has proved successful in Queensland

Jennifer K Broom · Mark D Kelly · Alex F Broom