Health services administration

Complex reforms and increasing financial strains on the UK National Health Service make it almost inevitable that patient care will suffer.

Tony Kirby BSc(Biological Chemistry)

Never let the truth get in the way of a tidy timesheet.

Rosalind J McDougall

A review of clinical records of patients treated in Canberra and Sydney identified 10 patients who were likely to have suffered “deathcap” mushroom poisoning between 1999 and 2012. Despite treatment according to current standards, including use of the purported antidote silibinin, eight developed significant hepatotoxicity and four died.

Darren M Roberts PhD, FRACP · Michael J Hall FACEM · Morna M Falkland BPharm · Simone I Strasser MD, FRACP · Nick A Buckley MD, FRACP

Participant engagement and careful planning are key to a successful cohort studyIn the beginning there was an idea ... and funding. The project might never have started if not for a serendipitous meeting between an accountant for the Raine Medical Research Foundation and a young obstetrician. The Foundation had been established 30 years earlier by the bequest of Mary Raine (Box 1), a successful businesswoman who ...

Charlotte M McKnight MB BS · John P Newnham MB BS, MD, FRANZCOG · Fiona J Stanley MB BS, MD, MSc · Jenny A Mountain MBA, MClinEpi · Louis I Landau MB BS, MD, FRACP · Lawrence J Beilin MB BS, MD, FRACP · Ian B Puddey MB BS, MD, FRACP · Craig E Pennell MB BS, PhD, FRANZCOG · David A Mackey MB BS, MD, FRANZCO

Indigenous Australians have six times more blindness than the national average, but 94% of the vision loss is preventable with eye examinations and timely access to treatment. The Roadmap emphasises regional needs-based planning for service delivery and accountability.

Hugh R Taylor MD, FRANZCO, AC · Andrea I Boudville MIH · Mitchell D Anjou MScOptom

To the Editor: Harrison and colleagues present data which confirm that inequitable distribution of mental health care is increasing under the Better Access program.1 They discount our promotion of the central role of general practitioners in the more restricted Better Outcomes program2 and our advocacy for GPs to resume those key activities despite lack of support under the Better Access program.3 The fatal decision that accompanied ...

Sebastian P Rosenberg · Ian B Hickie

In reply: We share Rosenberg and Hickie’s belief that general practitioners should play a central role in mental health care. We showed with Bettering the Evaluation and Care of Health (BEACH) data that GPs have played this role in both Better Outcomes and Better Access.1 Rosenberg and Hickie rely on administrative data to make inferences about clinical practice. They assume that GPs not claiming review items ...

Christopher M Harrison · Graeme C Miller · Helena C Britt

Objective: To use patient-level data, clinical information and linked Medicare records to assess the distribution of benefits (rebates) across income groups, including benefits relating to chronic conditions such as the Chronic Disease Dental Scheme (CDDS).Design, setting and participants: Nationally representative, cluster-stratified survey (the Australian Hypertension and Absolute Risk Study) involving 322 general practitioners who each collected clinical data on 15–20 patients aged ≥ 55 years ...

Rachel J Knott BEcon(Hons I), BCom · Alan Cass MB BS, FRACP, PhD · Emma L Heeley BSc(Hons), MSc, PhD · John P Chalmers MD, PhD, FRACP · David P Peiris MB BS, PhD, FRACGP · Philip M Clarke BEc, MEc, PhD

New South Wales data from the 45 and Up study indicate that bariatric surgery for severe obesity is largely available to those who can afford private health insurance and associated out-of-pocket costs, with poor access in populations who are most in need.

Rosemary J Korda PhD · Grace Joshy BSc(Mathematics), MSc(Biostatistics), PhD · Louisa R Jorm BVSc, MSc(Epidemiology), PhD · James RG Butler BEcon, MPolEcon, PhD · Emily Banks MB BS(Hons), PhD, FAFPHM

FOR MOST AUSTRALIAN DOCTORS, a child dying from malnutrition, malaria or tuberculosis is something you read about in textbooks, not see in your day-to-day practice. Yet for doctors like Damien Brown, a volunteer with humanitarian organisation Médecins sans Frontières (MSF), it is an all too regular reminder of the impact that conflict, weak governance, and a lack of essential services have on the health of ...

Natalie J Gray

Australians have recently invested more than A$400 million in wagers on “the race that stops a nation”, while the United States has held a US$6 billion election in which one of the central issues was the cost of health care. It seems like an ideal time to think about picking winners and counting costs.

Ann Gregory · Ruth Armstrong

Public and private payers, professional bodies and government agencies are now engaged in identifying “low-value” health care practices that should no longer be funded. The challenge in this is to develop evidence-based, transparent methods for undertaking this process, that are sensitive to the needs and concerns of patients and clinicians.

Ian A Scott MB BS, FRACP, MHA

To the Editor: We write to express our concerns with the article by Runciman and colleagues on the appropriateness of health care delivery in Australia.1 Our concerns focus on the issue of stroke care and the notion that poor compliance with guidelines is interpreted as “inappropriate” patient care. This study did not measure hard clinical end points, such as stroke recurrence, when evaluating the appropriateness of ...

Thanh G Phan · Velandai K Srikanth

To the Editor: The article by Runciman and colleagues1 has attracted much interest within the profession and in the lay press. However, there are serious methodological flaws in their study. The first issue is with the choice of clinical guidelines for assessing patient care. Although we have evidence for what is “best” practice in some areas, we are lacking this evidence in others. Hence, many of ...

Sean Mackay

To the Editor: The CareTrack study1 has produced considerable debate that has mostly focused on its aggregated findings about compliance with appropriate health care delivery. There needs to be much wider discussion, not about the aggregate figure, but about the variation, such as the 39 health care providers for whom compliance varied between 32% and 86%. Such unwarranted variation in health care has been identified elsewhere ...

Paresh Dawda

In reply: The CareTrack Australia study1 has received support for its general recommendations, but also some criticism. Here, we address the issues raised by commentators. Levels of evidence: Phan and Srikanth, and Mackay join previous commentators2,3 in calling into question the key CareTrack finding — that adult Australians received appropriate care at 57% of eligible health care encounters in 2009 and 20101 — because 71% of indicators ...

William B Runciman · Tamara D Hunt · Natalie A Hannaford · Peter D Hibbert · Johanna I Westbrook · Enrico W Coiera · Richard O Day · Diane M Hindmarsh · Elizabeth A McGlynn · Jeffrey Braithwaite

To the Editor: Duckett makes a compelling argument for introducing non-pay for non-performance.1 However, such a scheme will not produce discernible results, for two reasons. First, interventions such as “time out” and surgical checklists have proven successful in reducing rare but clearly defined events, such as wrong-site surgery and retained foreign bodies.2 Not paying when these errors occur will have no impact on efforts to reduce ...

Sue M Evans · Peter A Cameron · John J McNeil

In reply: Evans and colleagues present their critique of my proposition1 to use incentives based on adverse events recorded in routine data as an alternative — it is not. Routine data, audits and registries all have a place in the quest to improve safety of care in hospitals. The financial impact of non-pay for non-performance may be small. However, early evidence from the United States suggests ...

Stephen J Duckett

Using a multiplatform approach, the authors identify 156 potentially ineffective and/or unsafe services listed on the Australian Medicare Benefits Schedule that warrant further consideration. Reducing the use of existing services that offer little or no benefit relative to the cost of their public subsidy would allow funding to be reallocated to more beneficial or cost-effective services.

Adam G Elshaug MPH, PhD · Amber M Watt MPH · Linda Mundy MPH · Cameron D Willis PhD

Health workforce governance: improved access, good regulatory practice, safer patients. Stephanie D Short, Fiona McDonald, editors. Farnham, UK: Ashgate Publishing, 2012 (xix + 272 pp, $110). ISBN 9781409429210. ENSURING THAT we produce a health workforce that is well trained, “fit for purpose”, equitably distributed, and that delivers effective and safe health care is a key responsibility of all those involved in medical education, health governance and health policy making. Various health scandals have drawn the attention of the public to failures in health governance, and raised considerable doubt about the ability of the health professions (and in particular doctors) to self-regulate in a way that will protect the public. This ambitious academic text seeks to link the “three pillars” of health workforce governance: access to health services; regulation of health service providers; and patient safety and quality of care. The book is edited by experienced Australian academics with backgrounds in health economics and law, respectively, and its scholarly tone reflects this. Contributors have been deliberately selected by the editors from a wide range of disciplines, and comprise academics, regulators and health professionals from Australia, Canada and Indonesia, both well known and less well known. While the major focus of the text is Australian, some chapters describe examples drawn from the Indonesian and Canadian contexts — these would have been more useful if their relevance to health workforce governance in the Australian context had been made more explicit or, alternatively, if the whole text had a more clearly articulated global focus. Although this disciplinary variability is promoted as a strength, it does produce chapters that vary dramatically in approach and relevance. The book is divided between chapters that are a pleasure to read (and take notes from) and those that focus on describing micro-policy changes and leave the reader with a sense of frustration and many questions unanswered. While this is a book of great relevance to scholars interested in health workforce and governance and there are some outstanding chapters, the patchy quality overall and lack of a coherent narrative linking the chapters limits its relevance for a broader audience.

Sarah L Larkins

Helicopter emergency medical services (HEMS) have a considerable history in Australia, with operations in Sydney dating back to 1973. HEMS have evolved from their original use in water-based search and rescue to become an established mode of medical transport in the local health system, helping to alleviate the “tyranny of distance” that restricts equitable access to health ...

Colman B Taylor BPhEd, MND · Stephen Jan BEc, MEc, PhD · John A Myburgh PhD, FCICM, FAICD

Joyce contends in her recent article that “medical workforce supply levels follow a predictable, if lengthy, cycle between phases of shortage and surplus”. If this is the case, the scramble by the Australian Health Ministers’ Advisory Council to find internships for graduating medical students represents a stunning lapse in workforce planning. Marked growth in student numbers has occurred since the early 2000s, ...

Michael A Bonning · William J Milford · Rob D Mitchell

To the Editor: The recent editorial by Kefford1 fails to mention that (i) the 5-year survival for malignant melanoma is excellent at 89% for males and 91% for females; (ii) treatment with the new melanoma drug ipilimumab for the 1279 people who died from melanoma in 2007 would cost the Australian Government $156 million based on the quoted drug cost of $120 000 for a course of four injections; and ...

Graeme W Morgan

To the Editor: Kefford’s contention that making cancer drugs affordable requires coherent policy and cannot be left to market forces1 is correct. Two new drugs, ipilimumab and vemurafenib, are now approved by the United States Food and Drug Administration and the Australian Therapeutic Goods Administration for use in metastatic melanoma. However, their efficacy in a minority of patients is low. The cost of this palliative treatment ...

Sonia Fullerton