Health services administration

Deadly healthcare. James Dunbar, Prasuna Reddy, Stephen May. Brisbane: Australian Academic Press, 2011 (194 pp, $34.95). ISBN 9781921513756. This account of the lead-up to the 2010 trial of Jayant Patel — dubbed “Dr Death” by the media — is excellent, which is not surprising considering Professors Dunbar and Reddy’s background in health services implementation research at Deakin University, Victoria. Unfortunately, the same can’t be said for the authors’ coverage of the real impact of the Patel case on health regulation in Australia. The Australian Health Practitioner Regulation Agency (AHPRA) is mentioned only to record its establishment in July 2010. Missing is any reference to the Health Practitioner Regulation National Law Act (enacted in Queensland in 2009 and in the other states in 2010), which came into existence before the AHPRA and started to make it extremely difficult for a similar situation to occur today. The reader is left with the impression that little has changed and similar tragedies could occur today. But while there are no guarantees that a rogue doctor can no longer be appointed, regulation has changed radically since then. Today, complaints from doctors and the community are not so much about the cursory checking of international medical graduates’ qualifications but about the AHPRA requiring too much information. Patient safety is an explicit principle underpinning the National Health Practitioner Regulation Law, which created the Medical Board of Australia and the AHPRA. The authors fail to mention the new mandatory reporting laws that require health professionals to report those who place the health and safety of patients at risk. However, the facts about the Patel case provided in this book should be interesting for those new to regulation and clinical governance.

Merrilyn Walton

To The Editor: Bellomo quite rightly points out that medicine is now in an era when it is recognised that the amount of evidence being generated far surpasses most individual doctors’ ability to adequately deal with it.1 He suggests that “knowledge management may now be one of the major challenges of modern medicine”. However, is this a problem only needing to be confronted by those in medicine? I would suggest that it needs to be confronted by the Australian health care system as a whole, because a learning health care system is attainable only through implementation of system-wide change.2 In the recent final report of the National Health and Hospitals Reform Commission, three out of the five levers for action required to create an agile and self-improving health system involve elements of knowledge management.3 Hence, there is now much that needs to be done to achieve appropriate knowledge management across the Australian health care sector. We first need to recognise that knowledge is not only evidence that is gleaned from scientific studies (explicit knowledge) but also involves knowing what others are doing (tacit knowledge), as well as building on experience.4 The term “knowledge management” refers to the capacity to manage all of this at an organisational level. Further, we need to determine whether knowledge management is a problem that can only be solved within Australia by more resources being given to national bodies,1 or whether more innovative approaches are required. As knowledge management is now an issue for all organisations in the health sector, there is much to be gained from adopting an organisational learning focus2-4 as well as by understanding that an alteration in values (and culture) is required.4,5 Widespread acceptance of the need to identify and disseminate best practices will be required, even if it involves using evidence from international organisations to prevent both redundancy and duplication of effort locally.2,4

Deborah J Verran

Objectives: To examine the levels and growth rates of absolute funding to mental health research from 2001 to 2010, compared with other National Health Priority Areas (NHPAs), and the relative rate of mental health funding compared with other NHPAs, by taking disease burden into account. The quality of Australian research in mental health was also examined using objective indicators of research strength.Design and setting: Retrospective analysis of levels of funding overall and as a function of mental health domains using data from the National Health and Medical Research Council, with and without adjustment for burden of disease. A keyword analysis was used to assess the success rate of mental health project grant applications. Objective indicators of the quality of Australian mental health research were sought from citation indicators.Main outcome measures: Funding for mental health research relative to disease burden; funding according to disease category; project grant success rates.Results: Using actual and adjusted figures, mental health research received a lower proportion of health funding than other NHPAs, including cancer, diabetes and cardiovascular disease. Research projects into substance misuse and autism were proportionately better funded than those in anxiety, depression or schizophrenia. A significant proportion of mental health research funding was awarded to research into ageing. Citation data indicated that mental health research in Australia performed better than research in neuroscience, clinical medicine, microbiology, and pharmacology and toxicology, and at a comparable level to immunology research, despite poor levels of funding.Conclusions: Low levels of funding for mental health research appear to be largely attributable to low capacity. Mental health research in Australia is of high quality, and efforts are needed to build capacity.

Helen Christensen PhD, MPsychol(Hons) · Philip J Batterham MPH, PhD · Ian B Hickie MD · Patrick D McGorry PhD · Philip B Mitchell AM, MD, FRANZCP · Jayashri Kulkarni PhD

To the Editor: The editorial by Newman and colleagues on suicide and self-harm in immigration detention1 was a timely reminder of a contemporary issue that has aroused clinical, sociological and political debate. However, in providing a list of dot points for investigation, there was one curious omission. Although perhaps not politically correct or indeed comfortable for the authors, the well recognised possibility that suicide and self-harming behaviour could be politically motivated2 should also be addressed. This is important, not only because we as health professionals could be seen to be naive to ignore this, but, more specifically, so that inappropriate medicalisation of readily understandable distress does not occur.

Robert D Goldney

In reply: We thank Goldney for his thought-provoking response. We recognise that self-harm has multiple determinants, including mental disorders, but that it also attempts to influence or communicate. Acknowledging the political context that has created and sustains this issue, we also note long traditions of politically motivated self-harm and suicide, for example, by self-immolation or hunger strike; and that political protests using these methods — lip-sewing, cutting and self-burial — have occurred in Australian immigration settings. Our belief, based on extensive clinical engagement, is that the motivation for most self-harm and suicide in Australian immigration detention is not primarily political, but anchored in detainees’ deep despair. Many say that by killing themselves, they will end their pain and no longer be a problem to themselves, the government or their loved ones. As clinicians, we experience a tension — we acknowledge, with Goldney, the importance of not medicalising an area where the environmental and contextual influences so overtly create and maintain distress, yet we have a duty of care to reduce the risk associated with such behaviour and distress, irrespective of their origins. A pre-eminent challenge for professionals working in such stressful environments is to remain open to these multiple influences. We remain open to what the data will tell us about political and other contributing factors.

Michael J Dudley · Nicholas G Procter · Louise K Newman

To the Editor: Faunce and colleagues wisely called for the introduction of legislation modelled on the United States False Claims Act (FCA) in the Australian health care setting.1 Indeed, whistleblowers require protection and reward.2 The authors stated that the “key strengths of the US qui tam anti-fraud regime ... lie in its recovery of large amounts of public monies, its encouragement of good corporate practice” and noted that it is “largely compensatory or remedial rather than punitive”.2 However, the non-punitive nature of the regime is problematic. Settlements in the US may appear substantial. In 2009, Pfizer paid US$2.3 billion to settle a false claims action against their marketing of Bextra (valdecoxib).1 However, this sum represents only a small proportion of Pfizer’s overall profits, given that Bextra was marketed from 2001 to 2005 and the company’s profit for the first quarter of 2011 was US$2.2 billion.3 Clearly, pharmaceutical companies in the US cope with the FCA — their huge profits largely compensate for the settlements. “While the defense industry used to be the biggest defrauder of the federal government under the FCA ... the pharmaceutical industry has greatly overtaken the defense industry in recent years.”4 Between 1991 and 2010, settlements for criminal and civil monetary penalties reached a total of US$20 billion. Three-quarters of these occurred between 2006 and 2010.4 The message from the US experience is that non-punitive anti-fraud laws do not stop pharmaceutical companies from engaging in fraudulent activities.

Alain Braillon

To calculate cost savings to the Australian federal and state governments from the reduction in twin and triplet birth rates for infants conceived by assisted reproductive technology (ART) since 2002, and to determine the number of ART treatment programs theoretically funded by means of these savings.

Georgina M Chambers BAppSci(MLS), MBA, PhD · Peter J Illingworth MD(Hons), FRANZCOG, CREI · Elizabeth A Sullivan MD, MPH, FAFPHM

Take another look at the cover of this issue of the MJA and you will see just how close Papua New Guinea (PNG) is to Australia’s Boigu Island. In 2004, Queensland Health established tuberculosis (TB) clinics on Boigu and Saibai islands in the Torres Strait to provide medical care for PNG residents with multidrug-resistant TB (MDR-TB) (Queensland Health spokesman, personal communication, Oct 2011). The strategy has been extremely effective in treating these difficult cases and has, as Vincent states, been credited with “there being no MDR-TB cases detected in the Australian population in this region”. It is not surprising, then, that TB experts are working to lobby the government to reconsider its decision to close these clinics by February 2012 and hand over care of these patients to services provided by PNG. PNG is a desperately poor country, ranked 137 out of 169 countries in the United Nations Human Development Index (http://hdr.undp.org/en/statistics). Its health services are largely in disarray. The position statement in this issue of the Journal (Reynolds et al) invokes the World Health Organization ethical guidelines for care of patients with TB to call for free, equal and comprehensive care for patients with TB who present within our borders. It insists that transfer to the home country for ongoing care should only be contemplated when it is known that adequate care will be available. It recommends that Australia provide financial and technical support to neighbouring countries with endemic TB. The authors of the position statement cite sound economic and scientific reasons, as well as the obvious humanitarian arguments, for their stand. For example, the WHO estimates that the cost of treating a patient with MDR-TB is about 100 times greater than that of treating a patient with drug-susceptible TB. According to the authors, substandard care of patients with TB is “the greatest contributing factor to the development of MDR-TB”. Brolan and colleagues examine the Torres Strait treaty as it affects the provision of health care by Australian clinics to residents of PNG. They point out that, while providing such care is not strictly allowed, the practice meets our humanitarian obligations while offering protection to vulnerable Aboriginal communities in north Queensland. While the Australian Government has pledged a large slab of financial support to improve PNG-based health services, and particularly to assist with providing TB treatment facilities in PNG’s Western Province (http://www.health.gov.au/internet/ministers/publishing.nsf/Content/mr-yr11-nr-nr175.htm), more time is needed. As Vincent says, effective TB control requires prompt identification and treatment as well as monitoring and contact screening. Only when PNG clinics can provide all this should care be transferred. It seems extremely unlikely that this will occur by the planned date of February 2012. Australia enjoys one of the lowest rates of TB in the world. King and colleagues, also in this issue, argue that this can in part be attributed to premigration screening, which they say benefits applicants, by earlier detection of their disease, and the Australian population, by avoiding exposure to people with active TB. Their argument of substantial cost savings with this approach is compelling. While it is impossible to completely protect Australia from TB coming to our shores, the two strategies of continuing to treat PNG residents and conducting premigration screening appear to be effective at reducing this risk and should be supported.

Annette Katelaris

We describe the implementation of an electronic medication management system (eMMS) in an Australian teaching hospital, to inform future similar exercises. The success of eMMS implementation depends on:a positive workplace culture (leadership, teamwork and clinician ownership) acceptance of the major impact on work practices by all staff timely system response to user feedback training and support for clinicians a usable system adequate decision support.

Richard O Day AM, MD, FRACP · David J Roffe BSc, BE(Elect), ME(Biomed) · Katrina L Richardson BPharm, DipHospPharm · Melissa T Baysari PhD · Nicholas J Brennan MB BS, FRACP · Sandy Beveridge MB BS, FRACP · Teresa Melocco BPharm, GradCertManag · John Ainge BSc, MB BS · Johanna I Westbrook PhD

Governments and international agencies need to embrace quality regulation of pharmaceuticals as well as contingency plans For the first time in six decades, intravenous penicillin will not be available on hospital shelves in Australia. CSL Limited, who distributes benzylpenicillin in Australia, has been informed by their supplier that due to international floods and disasters, there is a critical global shortage. CSL gave Australian hospitals less than 2 weeks’ notice, and have warned that resumption of local supply is not expected until December 2011. Shortages of critical life-saving medicines are an increasing threat to public health.1 Although there have been no official medication shortages in Australia in 2011, the true problem is unrecognised here and is escalating internationally. In the United States, there have been 198 drug shortages over the past 3 months,2 more than double that for the entire year of 2007.3 The only organisation in Australia attempting to alert prescribers to impending shortages, the Society of Hospital Pharmacists of Australia, has listed only seven medications to date, while the Therapeutic Goods Administration, which only notifies prescribers once drugs are beyond critically short supply, has listed none. The reasons behind these shortages are complex and include increased demand, manufacturing delays, recalls, shortages of ingredients, and the realities of business in a competitive international market.1,4 For many medicines, there are only a few sites worldwide, mainly in India and China, that manufacture pharmaceutically active ingredients. Some of these sites are the sole source of multiple active ingredients.5,6 With the opacity of international manufacturing processes, it is very challenging even for governing agencies to understand where medicines are sourced, and subsequently to anticipate geopolitical supply chain vulnerabilities or breaches in quality and safety.5,6 Australia, which produces less than 5% of the pharmaceuticals it consumes,7 is particularly vulnerable. Shortages in essential medicines occurring at a local hospital level are most commonly a result of international trade and manufacturing issues, as attested by recent shortages in heparin,8 propofol9 and injectable antibiotics.10 However, with increasing instability in climate, a natural disaster locally or distantly could significantly interrupt manufacture and supply chains, and could lead to unexpected disaster-associated mortality globally. To better understand our local vulnerabilities, we conducted a hypothesis-generating study by analysing consumption and stock reserve of essential medications in our hospital system. The Hunter New England Local Health Network in New South Wales provides hospital care to a population of 413 000 people in a defined geographical area, broadly representative of the Australian demographic.11 We hypothesised that the hospital pharmaceutical reserve was less than 30 days’ supply for a significant proportion of commonly used essential medicines. Further details of our study method are shown in Box 1. Of the 378 essential medicines on our modified list (Box 1), 3% had less than 7 days’ reserve, 24% had less than 30 days’ reserve, and 26% had more than 3 months’ supply. There were 76 medicines that were high volume and these generally had the least stock reserve, with 51% having less than 30 days’ supply. Medicines used in more acute settings, for instance anti-infectives, analgesics, intravenous fluids and anticoagulants, had relatively small reserve capacity, but all had at least 7 days’ supply (Box 2). There was 34 days’ supply of benzylpenicillin, with 27 defined daily doses prescribed each day in the hospital network. Medicines used for chronic conditions generally had greater reserve capacity, with most having more than 1 month’s supply. Only one of the 25 antihypertensive agents and one of four statins had less than 30 days’ supply. Two of the five antianginal agents, three of the five antidiabetic agents and four of the six diuretic agents had more than 3 months’ supply. Low-volume medicines, representing 138 agents, generally had large reserve capacity, with 62% having more than 3 months’ supply. HIV medicines and cytotoxic drugs had low reserve capacity (Box 2), a reflection of pharmacy policy designed to reduce cost and expiry of expensive medicines with short shelf lives. For local disasters, most hospitals would be able to act as community reserves of essential medicines, particularly those used in the treatment of chronic disease, for which most hospitals will have substantial reserve supplies. It has previously been demonstrated that interruption to the supply of medicines to those with chronic health problems contributes significantly to disaster-associated mortality.12 It is imperative that hospital pharmacies are designed to be protected from flooding and damage from natural disasters, that local suppliers are integrally involved in disaster planning, and that there is contingency for hospitals to act as large-scale community dispensaries if required. This is particularly the case for hospitals in northern Australia, where the risks of flooding are greater and where the supply chain is more geographically vulnerable. Our study brings into question the utility of the National Medical Stockpile. There are more cost-effective ways of sourcing non-surge-related essential medicines; for instance, hospital and community requirements for antihypertensive medicines will not surge in the event of a disaster, but oseltamivir would surge in the event of an influenza pandemic, as would antidotes in the event of mass poisoning. With appropriate national or state linking of hospital pharmacy databases of essential non-surge drugs, similar to the NSW Register of Lifesaving Drugs, medicines could be mobilised rapidly to where they are needed and the stockpile could be significantly downsized. There is no official mechanism for identifying drug shortages in Australia. Setting up a monitoring system — for example, via a sentinel hospital pharmaceutical supply — could help identify impending drug shortages locally and allow earlier rationalisation to mitigate such events. Legislation could be enacted to compel manufacturers and wholesalers to report compromise of manufacture or supply. Although many developed countries have registries of efficacious “essential” drugs, there have been no previous attempts to define nationally relevant essential medicines in terms of disaster management and supply chain vulnerability. Our study does not attempt to develop such a list but defines usage of classes of medicines. A national list could be simplified to include a single medicine from each subclass with strategically valuable attributes, for instance, medicines that are manufactured locally. A national list of essential medicines would enable local regulatory bodies such as the Therapeutic Goods Administration to focus on supply chain issues of critical drugs. International efforts need to focus on sustainable supply of essential medicines and equipment. The WHO needs to consider environmental threats to key international manufacturing plants of essential medicines, and could incorporate such requirements into good manufacturing practice guidelines. From a longer-term perspective, pharmaceutical supply, similar to food security, is likely to become a more prominent global problem. Governments and international agencies such as the WHO have an obligation to embrace not just quality regulation of pharmaceuticals but also contingency plans for unforeseen global events; events that are increasingly severe as climactic variables become more unpredictable and extreme. From an Australian perspective, this means adopting policy that encourages local manufacturing industries to have some capacity to fill the gaps in essential pharmaceuticals and medical equipment if they ever appear, and it requires national procurement decisions to be based not just on cost but also on sustainability. 1 Consumption and stock reserves of essential medicines in the Hunter New England Local Health Network: study method A local list of essential medicines was derived from the 2010 World Health Organization (WHO) model list of essential medicines (http:/www.who.int/medicines/publications/essentialmedicines), modified by a clinical pharmacologist (A J), a general physician (S Q) and four hospital pharmacists (L H, J K, R P, R J), and grouped into 26 drug classes. Three classes were excluded (representing 3% of 378 medicines) because they were not managed by the pharmacy. We excluded 110 WHO-listed medicines because they were not stocked. We included 108 medicines not listed by the WHO because they were replacements for the WHO-listed medicines (eg, alteplase replaced streptokinase) or were the pharmacological and clinical equivalent of a WHO-listed drug. Stock of a medicine was measured on 2 June 2011 using WHO defined daily doses (DDD) or a unit corresponding to clinical use (eg, a single-use vial of ketamine). We calculated the annual and daily medicine consumption over the previous year using pharmacy databases and iPharmacy software (iSOFT, Banbury, Oxf, UK). We calculated stock reserve on the basis of daily medicine consumption and stock amount. High-volume consumption was defined as > 0.05 DDD/hospital bed/day. Low-volume consumption was defined as < 0.005 DDD/hospital bed/day. 2 Stock reserves of essential medicines, by subclass Subclasses with more than 30% of medicines having < 30 days’ supply No. of medicines in subclass Proportion of subclass < 30 days’ supply Medicines used for anxiety disorders 1 100% Opioid analgesics 5 80% Medicines used in substance dependence 3 67% General anaesthetics 4 50% Local anaesthetics 6 50% Antacids and other antiulcer medicines 8 50% Oxytocics 4 50% Vitamins and minerals 6 50% HIV medications 18 45% Antibacterials (systemic) 27 44% Cytotoxic medicines 20 40% Anti-infective medicines* 77 36% Parenteral fluids* 11 36% Gastrointestinal medicines* 26 31% Medicines affecting coagulation 6 30% Antifungals (systemic) 10 30% * Entire class has less than 30 days’ supply.

Simon Quilty MB BS, MPhilPH, BEng · Lisa M Harris BSc, BPharm · Jacqueline Kewley BPharm, GradCertPH · Alison Jones FRACP, FRCP · Robert Pearce BPharm, GradDipBA · Rosemary James BPharm · Forbes McGain FANZCA, FCICM

To the Editor: I would like to add some detail to the article by Shaw and colleagues1 on the costs of screening for diabetes and glycated haemoglobin (HbA1c) testing. At face value, using the 85% Medicare Benefits Schedule (MBS) rebate, the item for HbA1c testing costs $1.85 less than the item for a glucose tolerance test (more than 10% cheaper), but it is a little more complicated than these simple figures suggest. In 2010, 295 023 glucose tolerance tests (item number 66542) were claimed on the MBS — up 61% on the number ordered in 2004 (183 090)2 — which reflects the increase in ordering by general practitioners, who I believe are more aware of the increased incidence and prevalence of one of the most common chronic diseases in Australia. I also believe that it reflects the use of the glucose tolerance test as the definitive test for diabetes (rather than relying on a single fasting glucose level) in private practice. In contrast, 1 021 247 HbA1c tests (item number 66551) were claimed in 2010, versus 911 623 in 2004 — up by only 12% over the same 7-year period.2 This reflects “coning” of pathology items in the MBS. There are two types of cone that affect billing of HbA1c tests: the “grand cone”, which restricts billing to the three most expensive items ordered by a GP on a single occasion (regardless of the number of tests ordered), and the “temporal cone”, where only four HbA1c tests can be billed in any 1 year. The glucose tolerance test has no temporal restrictions and is usually performed on its own, so it avoids the grand cone, but the HbA1c test is often ordered with a bank of other tests (eg, as part of diabetes monitoring) and is thus not usually billed to Medicare. In my practice, only 30% of reported HbA1c tests can be billed to Medicare, hence the cost to Medicare per reportable test is about a third of the listed rebate of $14.40. Furthermore, as Shaw et al point out, HbA1c testing cannot currently be billed for the diagnosis of diabetes, although my personal observation is that many doctors are already using this as a screening test. There are essentially three powerful drivers for HbA1c testing: the increased prevalence of diabetes, the (honest) push to test HbA1c levels every 4 months (through care plans etc) and the use of HbA1c tests to diagnose diabetes. I believe that Medicare currently pays for less than 40% of these tests and that this proportion will fall as more HbA1c tests are requested. The majority of the costs for HbA1c testing are subsidised by pathology practices — which, philosophically, I find quite odd. These points need to be taken into account when undertaking a cost–benefit analysis of screening for diabetes in Australia.

Len D Moaven

To the Editor: My observations over the past 10 years as an ambulance paramedic are consistent with the growth in demand for emergency and non-emergency ambulance services in Melbourne.1 Strong demand has been forecast to continue because 60% of patients who are eligible for emergency transport do not currently use ambulance services.2 The increasing demand for ambulance services — an essential component of the Australian health care network — necessitates the development of valid, reliable indicators of quality and safety in prehospital health care, to maintain and improve the quality of that care. As part of the Australian Commission on Safety and Quality in Health Care’s National Indicators Project, the Australian Institute of Health and Welfare (AIHW) has proposed 55 indicators of quality and safety in health care that represent a whole-of-system approach.3 However, this cannot be achieved without the inclusion of ambulance indicators. The AIHW indicators focus mainly on facility-based services (eg, hospitals) and underestimate the interdependence of the health care network. Ambulance services routinely collect information from the wider health care community, representing transported and non-transported patients, including clinical intervention and outcome parameters. These data can be used to identify interventions and outcomes attributable to prehospital health care practice. Improvements in patient sequence management,4 based on Ambulance Victoria research and data from specialised trauma and cardiac arrest registries,5 suggest that ambulance interventions can result in tangible benefits. Ambulance-specific process and outcome indicators would enable more precise attribution of outcomes to prehospital care and assist in apportioning health outcomes across the wider health network. This would directly benefit hospitals because pressure for increased public accountability currently ascribes performance based on risk factors that hospitals cannot influence. Enhanced prehospital indicators could supplement and expand the range of risk parameters that hospitals currently use to adjust hospital performance indicators; this would help mitigate the limitations inherent in comparative public reporting.6 Longer-term benefits include the implementation of alternative models of evidence-based practice, encompassing “treat-and-leave protocols”, and identification of non-hospital referral avenues. Safety is a crucial aspect of alternative practices, and protocols must be formulated and monitored in the light of valid and reliable indicators. Inclusion of ambulance indicators in the National Indicators Project would place ambulance services in a key position to ensure that timely access to safe, high-quality health care is maintained and improved.

Paul A De Vincentis

Objective: To determine perceptions of barriers to admission to subacute care from acute hospital care, and barriers to subsequent discharge from subacute care.Design, participants and setting: Web-based survey of key stakeholders using Likert scales and closed questions. Prompts were emailed repeatedly to potential participants in Australia between 15 May and 24 July 2009. Participants were physicians working in inpatient rehabilitation medicine and aged care units, as well as senior hospital managers with responsibility for patient flow.Main outcome measures: Perceived admission and discharge barriers in subacute care.Results: Half of the 101 respondents reported barriers to admission to subacute hospitals as moderate, severe or extreme, and 81% reported a similar grading of severity for barriers to discharge. There was no relationship between these perceptions and whether respondents worked only in the public hospital system (barriers to access: χ2 = 0.02 [df = 1; P = 1.0]; and barriers to discharge: χ2 = 0.0 [df = 1; P = 1.0]). The most commonly reported barriers to admission were: availability of beds (61% of respondents); physical, environmental and equipment inadequacies (62% of respondents); and allied health or nursing staff issues (55% of respondents). The most commonly reported barriers to discharge included: waiting for a more appropriate setting of care (76% of respondents) and funding for home modifications, equipment or carers (55% of respondents). There was no relationship between respondents’ position and their reporting of various admission (χ2 = 6.2; df = 8; P = 0.6) or discharge barriers (χ2 = 13.8; df = 12; P = 0.3).Conclusion: There is a strong perception among key stakeholders in subacute care that there are major barriers to patient admission and discharge. Redistributing proposed funding for inpatient subacute beds to measures for overcoming these barriers is likely to improve patient flow though the whole hospital system.

Peter W New MB BS, MClinEpi, FAFRM(RACP) · Peter A Cameron MB BS, MD, FACEM · John H Olver MB BS, MD, FAFRM(RACP) · Johannes U Stoelwinder MB BS, MD, FRACMA

To the Editor: The Journal is to be commended for this important discussion on quality improvement (QI) by Millar1 and Runciman.2 It is important to understand that if doctors are not engaged in changes to health service provision, including QI, such changes will be ineffective.3 Not surprisingly, unengaged doctors can “prove” the lack of an effect of a QI initiative and return to doing what they have always done. Millar comments on the “division between QI and clinicians”.1 Why this division? Why is there a lack of engagement, and a lack of common purpose, values, and beliefs? Professional responsibilities as defined by the American College of Physicians (ACP) in 2002 include “commitments” to, among others, “improving quality of care”, “improving access to care”, and “a just distribution of finite resources”.4 The 2009 Royal Australasian College of Physicians Professional Qualities Curriculum provides a very similar list of responsibilities for all physicians.5 It may be time for many doctors to step onto the common ground and out of the ivory tower. It is time that doctors become able to view themselves as only one part of a larger system that exists solely to provide health care for patients and the population. Teamwork and collaboration with non-medical health professionals (including managers) may often be undervalued from a “doctor-centric”, and often “hospital-centric”, perspective. It is also high time that health organisations and many managers become serious about involving clinicians, initiating “true” clinical leadership, and engaging and communicating in a meaningful way. Clinical leadership, clinical governance and “teamwork” have unfortunately become almost slogan-like, stale entities that appear in health policy plans and strategy documents without much meaning or consequence. One day, clinical care may be better and have more resources because of better implementation of QI that actually engages clinicians.

Roland J Meyer

To the Editor: I would have thought that, in 2011, any debate pitting fee-for-service against salary models of remuneration was both stale and futile. These debates, such as the one entered into by Peat1 and Travis,2 have been around since Bismarck introduced health insurance for workers in Germany. Surely we have come to realise, after more than a century of varied health insurance schemes and health services around the world, that it is a matter of horses for courses. A single payment system, whatever it is, will be inappropriate if applied universally in any country. There is a place for fee-for-service delivery, accompanied by insurance; there is a place for salaried service; and there is even (heresy for some!) a place for that form of salary called “capitation”. Each system has its merits and its faults, which have been discussed ad nauseam by health economists too numerous to refer to (two publications serve as examples3,4); there is nothing new under the sun. Debates such as this generalise the behaviour of a few miscreants to all salaried or fee-for-service practitioners. This is clearly unfair to both groups. Australia is fortunate that, back in the 1970s, our profession was able to stave off a Canadian-style, single-payer system. Our graduates can choose their method of remuneration — and, however they have been paid, we have distinguished colleagues who have achieved much and, regrettably, a few rogues. In the latter respect, we are no different from any other profession or trade. Why not abandon the ideologies underlying both sides of the debate, face these facts and have both systems in place, where each is appropriate, rather than trying to apply a single solution everywhere? I am reminded of the wisdom of Anthony Ashley Cooper, third Earl of Shaftesbury; “The most ingenious way of becoming foolish is by a System”.5

Peter C Arnold

To the Editor: Outpatient non-attendance remains a major problem that significantly drains the ability of hospitals to provide efficient and effective outpatient services.1,2 Our earlier pilot study demonstrated the effectiveness of short message service (SMS) text message reminders in improving attendance at the outpatient department in Melbourne’s Royal Children’s Hospital (a 250-bed tertiary referral hospital).3,4 We present the results of a follow-up retrospective cohort study that examined the effect of the following eight factors on failure to attend (FTA): sex, native language, distance lived from hospital, day of appointment, time of appointment, wait time (days from scheduling to appointment), socioeconomic status (SES), and SMS reminders. Data included all outpatient appointments (65 535) in the period July 2005 to January 2006. Incomplete data meant that 44 appointments were excluded, leaving 65 491 episodes for the analyses. The patients were classified into three SES groups: low (G1), middle (G2) and high (G3). This classification was based on the Jarman score (a proxy for SES) derived from the patient’s residential postcode.5 Similarly, patients were classified into three groups based on distance between the patient’s residence and the hospital: < 25 km, 25–50 km and > 50 km. Univariate and multiple logistic regression analyses confirmed that all factors other than sex were significantly associated with FTA. We also found that the two populations with and without SMS reminders were significantly different. We conducted a stratified analysis for the two groups and the summary results are presented in the Box. Our analysis shows that FTA rates improve by 5.34% (from 14.85% to 9.51%), and confirms the effectiveness of SMS reminders in lowering FTA. It shows that native language, distance lived from hospital, SES and wait time are significantly associated with FTA across both groups. Although SMS reminders resulted in higher improvement in attendance for non-English speaking patients compared with English speakers (8.33% versus 4.1%), those patients still had higher odds of missing an appointment. Lower SES was associated with an increased likelihood of defaulting. Longer waits until the appointment resulted in lower odds of attending, and odds of attending improved with increased distance from the clinic. Together these results suggest that in addition to SMS reminders, interventions targeted at specific groups may improve attendance rates and cost effectiveness. Stratified analysis of factors contributing to outpatient failure-to-attend rates, by SMS reminder No SMS reminder (n = 20 871) SMS reminder sent (n = 44 620) Factor FTA OR FTA OR Aggregate 14.85% 9.51% Native language English 13.04% 1* 8.94% 1* Non-English 21.35% 1.62† 13.02% 1.30† Distance lived from hospital < 25 km 15.89% 1.36† 10.28% 1.51† 25–50 km 13.77% 1.20†† 8.71% 1.28† > 50 km 11.36% 1* 7.16% 1* Socioeconomic status Low (G1) 17.51% 1.37† 12.28% 1.57† Middle (G2) 14.84% 1.34† 9.26% 1.22† High (G3) 12.11% 1* 8.26% 1* Wait time (from scheduling to actual appointment) < 15 days 8.40% 0.42† 5.94% 0.45† 15–30 days 16.40% 0.90‡ 9.48% 0.74† > 30 days 18.13% 1* 12.40% 1* SMS = short message service. FTA = failure to attend. OR = odds ratio. * Baseline comparison group: OR = 1. † OR significant at P < 0.001. ‡ OR significant at P < 0.05.

Sean R Downer · Kannan Sethuraman · Devanath Tirupati

To the Editor: NSW Health’s latest initiative, www.emergencywait. com.au, is a website that presents real-time information about estimated waiting times at 58 emergency departments (EDs) in New South Wales. Similar websites have been used in other Australian states, including South Australia, Western Australia and Victoria, as well as overseas, in Ontario, Canada, and in Memphis, Tennessee. I am concerned that this initiative will be counterproductive and will add further congestion to our already overcrowded EDs. Extended waiting times are a longstanding problem at EDs. They have traditionally been attributed to staff shortages, delays in pathology and imaging tests,1 and inadequate funding. However, there is another major contributor to waiting times that rarely attracts attention in the lay media — the overwhelming number of patients who inappropriately seek medical attention in EDs and would be better served by a general practitioner. Much of the work in EDs involves treating patients with non-acute and non-urgent problems. Recent examples from my personal experience include a man requesting a prescription for antiepileptic medication, a perimenopausal woman with many months of irregular menstrual bleeding, and a young man with a common cold. All of these patients bypassed their GPs, despite their attendances being within normal business hours. A logical outcome of www. emergencywait.com.au is an increase in the number of non-acute, non-urgent presentations to EDs that are seen to be “quiet”. For alongside each hospital’s estimated waiting time, the website presents a list of nearby hospitals with the number of patients waiting at each, thereby enabling patients to compare EDs and attend the least busy one. Formal studies are scant, but crude American data indicate a 6%–10% increase in ED patient volume since waiting times were publicised.2 Although the transparency of www.emergencywait. com.au may help our EDs to share more equitably the burden of inappropriate patient attendances, I expect that it will increase the overall number of such attendances and ultimately increase waiting times. Australian EDs provide excellent, prompt care for patients who have been in accidents or emergencies, but they are neither equipped nor designed to look after individuals who meet neither of these criteria. The solution to overcrowded EDs lies not in websites that publicise waiting times, but in convincing the public that emergency rooms are for emergencies.

Alexander M Owen

Gambling and diagnostics are related, but strangely reversed, in the way that prior events can affect our clinical judgements The year was 1913; the location, the roulette tables of a Monte Carlo casino. For the previous 10 spins of the wheel, the ball had landed on black. A red was overdue, so the punters began to bet more aggressively against the trend. But the 11th spin produced yet another black number. As did the 12th, and the 13th ... and the longer the run of blacks continued, the more convinced the gamblers became that the subsequent spin would yield a red. Their wagers accelerated. Their losses snowballed. For it was only after 26 consecutive black numbers (by which time few could afford to continue betting) that the streak finally came to an end. It was perhaps the most profitable night in the casino’s history: records were set, fortunes were lost, and the “Monte Carlo fallacy” was born. Also known as the “gambler’s fallacy”,1 it describes the erroneous belief that the outcomes of recent random events have some bearing on future random events. It dictates that if a flipped coin yields 10 consecutive heads, then the likelihood of a subsequent tails is increased, because the coin seems “due” for a tails. Intellectually, we know this law of averages makes no sense: a coin has no memory, so every time it is flipped, there is an equal chance of either side appearing face-up, regardless of what happened on previous flips. Certainly, the odds of flipping heads 10 times in a row are remote — one in 1024, to be exact — yet this number also represents the odds of having any other pattern of heads and tails in a 10-flip series. Although we know this to be the case (undoubtedly, so too did many of the gamblers on that night in Monte Carlo), it is all too tempting to disregard the laws of probability and be seduced by pseudologic. In our clinical practice, it is similarly easy to be fooled by apparent patterns, and unduly influenced by any recent experiences that remain prominent in our minds.2 However, for clinicians, the Monte Carlo fallacy seems to work in reverse: rather than a string of similar events prompting us to think we are “due for a change”, we may instead feel that the “run” is more likely to continue. For example, if, within a short space of time, two patients presenting with hypotension are found to be hypoadrenal, then it may be tempting to look for this unusual diagnosis in all future hypotensive patients, even though other diagnoses may be more common, more likely, and easier to diagnose without expensive investigations. If a patient has a fall while in hospital, and then dies unexpectedly from an unidentified intracranial bleed, we may feel compelled to request a brain scan for any subsequent patient who has such an accident. We may do this even when the patient appears unhurt, and our clinical judgement would otherwise suggest that such a test is not indicated. While the outcome for the first patient was tragic, it in no way affects the likelihood that a second patient’s (unrelated) fall will also have life-threatening complications — just as the first 25 black roulette numbers had no bearing on the outcome of the 26th. Our approach to any clinical situation is guided by the accumulation of our previous experiences, but somehow the most recent ones seem to bear the most weight. Ultimately, we are human, and humans are pattern-seeking creatures. We see faces in amorphous clouds, and stars scattered across the night sky form images before our eyes. And to this pattern-seeking ability we owe much of our understanding of medicine: the linking of infection outbreaks to geographical areas has identified sources of contamination, and the observation of disease trends has revealed unrecognised side effects of drugs. A great deal of our knowledge today has been acquired through observing the unusual, the unexpected and the uncommon, and continuing to do so will certainly teach us more. However, in day-to-day clinical medicine, the old maxim rings true: common things occur commonly.

Alexander M Owen MB BS(Hons), BSc(Med)Hons

To the Editor: Childhood communication disorders (CCD) affect up to 20% of 4-year-old children.1 Early intervention is important2 and a variety of health and education professionals may provide assistance, including speech pathologists (SPs), paediatricians, general practitioners and others. The type and amount of help provided to preschool-aged children in Australia is unknown, nor are the costs empirically described. Using data from the Early Language in Victoria Study (ELVS),1,3 a prospective study of a large Australian cohort of children, we describe the use of services for CCD, out-of-pocket costs to families and costs to the health system. ELVS participants were recruited at 8 months of age, at routine child health checks in maternal and child health centres in Melbourne during 2002. Parents completed questionnaires at baseline (when the child was 8 months of age) and at each birthday.3 In-depth questions about use of services were included for the first time at 5 years. These questions covered SP assessment and treatment, visits to other professionals for CCD concerns, and out-of-pocket expenses for all services, within the preceding 12 months (ie, when children were in their fourth year). Of the original cohort, 983 families (51%) completed the service-use questionnaire. Sixteen per cent had used services (one-third of whom used more than one service); 11% had accessed SP treatment, and 6% had accessed other professionals. The number of service occasions per year for each professional, and the associated costs, are shown in the Box. Children accessing SP treatment received a median of 10.8 therapy hours within 12 months (interquartile range, 4.3–17.3; range, 0.5–104); 28% received ≤ 5 hours and 13% received > 25 hours. Costs of all services accessed in the period, including health system costs and parent out-of-pocket expenses, varied from $34 to $16 546. Our data show that some children received very little intervention for CCD within a 12-month period. Given the critical importance of communication skills to school achievement, this is of concern. We also demonstrate a substantial financial outlay associated with the treatment of CCD in Australia. These data are likely to be generalisable given the nature of this prospective cohort and the reliability of our health care cost estimates. The results highlight the immense variability in service use and the potential burden of cost to government and families associated with CCD. Our data do not describe service use before 4 years of age, nor have we included indirect costs such as travel and parental time away from work. Thus, they represent a starting place for understanding total costs. Costs to the health care system and families for childhood communication disorders services provided to children aged between 4 and 5 years in the Early Language in Victoria Study cohort Cost per family for 1 year using the service Service Median number of visits per year (IQR; range) Health care system cost* per visit ($) Median health care system cost ($) (IQR; range) Median out-of-pocket costs ($) (IQR; range) Median combined costs (health care system + out-of-pocket) ($) (IQR; range) Speech pathologist (treatment) 15.2 (6.5–26; 1–52) 49 742 (318–1273; 49–2545) 498 (173–1040; 0–4117) 1061 (472–2256; 49–6662) Paediatrician 2 (1–3; 1–10) 119 (initial) 59 (subsequent) 178 (119–237; 119–296) 250 (120–320; 0–500) 328 (178–511; 119–776) General practitioner 2 (1–4; 1–10) 34 (standard) 67 (34–151; 34–336) 40 (0–75; 0–294) 101 (34–181; 34–495) Psychologist 3 (1.5–4.5; 1–8) 49 147 (61–233; 49–392) 575 (105–889; 0–1300) 502 (157–1027; 49–1545) Otolaryngologist 2 (1–3; 1–8) 119 (initial) 59 (subsequent) 178 (119–237; 119–534) 210 (120–358; 65–1200) 239 (119–438; 119–1734) Hearing specialist 1 (1–2; 1–4) 49 49 (49–98; 49–196) 0 (0–2; 0–1000) 50 (49–98; 49–1098) Early intervention† 10 (1.5–28; 1–48) 240 2400 (300–8160; 240–11 520) 112 (0–600; 0–720) 2400 (300–8638; 240–12 240) All services na na 661 (238–1273; 34–14 426) 413 (91–1306; 0–4500) 1061 (335–2460; 34–16 546) IQR = interquartile range. na = not available. * Health care system costs were Medicare Benefits Schedule (MBS) fee rates charged at the applicable rebatable level (ie, 100% for GP services and 85% for other services).4 † Early intervention services, which are not covered by the MBS, were estimated from existing cost estimates.5

Jemma Skeat · Lisa Gold · Melissa Wake · Obioha C Ukoumunne · Sheena Reilly

To the Editor: Bismark, Spittal and Studdert observed that complaints clustered around certain doctors.1 They state that, in Victoria, extrapolations from their findings indicate that 1% of the medical workforce in private practice accounts for nearly 20% of complaints, and that male surgeons who have practised for more than 30 years are the doctors who are most complained about.1 Bismark and colleagues established that complaint-prone doctors are more likely to be male, surgeons or psychiatrists, to have trained in Australia and to have been in practice for at least 30 years. They agree with previous studies that suggest that the inherent risks of surgical procedures and the relative visibility of poor surgical outcomes are likely to play a role, and also note that the potential for power imbalances between doctor and patient is high in both surgery and psychiatry. That training outside of Australia was found to have a “protective effect” may seem surprising, but this fits my view about what most often motivates a patient to complain about a doctor when something goes a little astray. My belief, based on a long period of surgical practice and of observing other doctors, largely surgeons, is that a common stimulus to make a complaint when there is a degree of dissatisfaction is a perception that the doctor was overconfident, perhaps to the point of arrogance, and had little personal interest in the patient’s welfare. The lower self-confidence of some overseas-trained surgeons could therefore lessen the likelihood of complaints being made about them, whereas the supreme confidence of some highly experienced Australian-trained surgeons may go against them when something goes wrong. Good manners, kindness, demonstrations of personal interest and concern, and a degree of humility all discourage complaints! In an article subtitled “Arrogance: the biggest sin of all”,2 in the United Kingdom Telegraph, in 2009, Dr James LeFanu appropriately commented, “The virtues of generosity, cheerfulness and discretion should be the hallmark not just of medicine, but of all the liberal professions. How many doctors live up to these ideals is, of course, impossible to quantify, but certainly some readers of this column take a rather jaundiced view”.2

John A Buntine

To the Editor: Echoing Scott and colleagues’ recent call for caution regarding the use of hospital standardised mortality ratios for benchmarking and public reporting,1 we have concerns about the use of infection rates as hospital quality indicators. The National Healthcare Safety Network (NHSN) at the United States Centers for Disease Control and Prevention defines central line-associated bloodstream infection (CLABSI) as occurring where the patient has “a recognized pathogen cultured from 1 or more blood cultures and organism cultured from blood is not related to an infection at another site”.2 This and other criteria (for organisms associated with skin contamination and in children) are also used as quality indicators by VICNISS (the Victorian hospital-acquired infection surveillance system) and the Australian Commission for Safety and Quality in Health Care. The infection prevention unit at Alfred Health in Melbourne recently assessed three cases of hospital-acquired bacteraemia as having met the NHSN/VICNISS definition of CLABSI. This assessment was disputed by Alfred Health’s intensive care unit and we sought further opinions from other infectious diseases physicians and infection control practitioners to adjudicate, in the absence of established criteria to determine whether the bacteraemia was due to infection at a site other than the central line. We received conflicting advice. These three cases would have comprised a third of the CLABSI cases at our hospital in the 6 months to April 2011, and thus significantly impact on our reported quality assurance indicators. Similar common situations may arise in considering cases of bacteraemia in patients who have central lines in the context of chemotherapy-related mucositis; in patients with extensive burns; where cultures are only taken from central lines (rather than from peripheral venepuncture); where there are single blood cultures of enterococci of doubtful clinical significance; and where there are unconfirmed clinical foci of deep infection.3 Previous published work suggests that interrater agreement remains poor, despite changes to the definition of CLABSI.4 Other infection rates are associated with other problems as outlined by Scott and colleagues.1 For example, the current NHSN risk stratification system for infection (http://www.vicniss.org.au/Resources/HCWType1Manual/Type1Manualv6_0708.pdf) related to coronary artery graft surgery is poorly discriminatory, as most patients fall into risk index categories 1 or 2, and statistical calibration of this system is poor.5 Interrater reliability of classification of superficial infections has also been shown to be poor.6 The relatively low rate of infections in patients undergoing coronary artery surgery may result in large stochastic variation, particularly in hospitals performing relatively few such procedures. Public reporting of infection rates is probably inevitable. However, such data should be restricted to indicators that have been shown to validly reflect preventable infections, using definitions that are reliable, and with the appropriate caveats regarding their limitations.

Allen C Cheng · Pauline Bass · Carlos Scheinkestel · Tim Leong

Objective: To review the uptake of seasonal influenza vaccination among hospital health care workers (HCWs) in Australia to date.Data sources: We searched MEDLINE and EMBASE (up to September 2010) and bibliographies of relevant reports for studies examining seasonal influenza vaccination (uptake, attitudes and/or programs) among Australian hospital HCWs. Studies relating to pandemic (H1N1) 2009 influenza vaccination or other types of health care facilities were excluded.Study selection: 15 articles were assessed, of which 10 met inclusion criteria.Data synthesis: The 10 studies were conducted between 1997 and 2008 and reported vaccination rates of hospital HCWs of 16.3%–58.7%. Two of three studies documenting uptake rates of > 50% were associated with active implementation of vaccination policies or interventions. Uptake rates by occupational group ranged from 29% to 58.3% for physicians, 19% to 56.4% for nurses, 23% to 57.7% for allied health professionals, and 18% to 66.7% for ancillary or support staff. Coverage rates in hospitals that provided the vaccine free of charge to staff (with or without an informational campaign) were no higher than in other hospitals.Conclusion: While seasonal influenza vaccination uptake was higher in hospitals with documented intervention programs, coverage is still low and does not appear to be affected by the provision of free vaccine to staff. State or institutional policies or mandates are likely needed to increase HCW uptake of seasonal influenza vaccination.

Holly Seale BSc, MPH, PhD · C Raina MacIntyre MB BS, PhD, FAFPHM

Obstetrician Brian Peat believes salaried doctors are favourably placed to provide best-practice care That any sane nation, having observed that you could provide for the supply of bread by giving bakers a pecuniary interest in baking for you, should go on to give a surgeon a pecuniary interest in cutting off your leg, is enough to make one despair of political humanity. George Bernard Shaw, The doctor’s dilemma (1906)1 A number of studies have consistently shown that fee-for-service payment is associated with an increase in the number of diagnostic tests and procedures performed when compared with payment by salary or capitation.2 It is more difficult to show that this is a bad thing; however, as imperfect tests are applied to populations of lower prevalence for a condition, we would expect more false-positive results. Also, since all procedures carry complications, we would expect there to be more complications.3 Even if salaried doctors, on the other hand, may be at risk of underservicing, this is addressed by peer review and outcome audit. Salaried payments have the advantage of lower administration costs. A substantial cost of the fee-for-service system is in recording individual items and arranging payments. This may be relatively simple when the item of service is a simple consultation, but more difficult when the items are complex. A portion of the cost is also in preventing fraud, rorting of the system and simple overservicing. In private practice, overheads, including rent and clerical staff, are substantial and may be important in giving a competitive edge in the pursuit of patients.4 Overall, the cost of a fee-for-service system looks greater than a salaried workforce; however, this is not necessarily so. It depends on supply and demand. General practitioners are in relatively high supply and receive low fee-for-service payments. Competition means they can only charge a modest patient copayment. Specialists, on the other hand, are in low supply and can generally charge large copayments. Salaried specialists, being currently in low supply, are able to negotiate relatively high salaries with money for holidays, professional development and superannuation. Salaried doctors have no conflict of interest in the doctor–patient relationship, which engenders a patient’s trust, and reduces anxiety for the practitioner. They are in a better position to consider all aspects of the patient’s health, and to appropriately delegate tasks knowing they will not be out of pocket. This is particularly an issue as we see more lifestyle-related, chronic illness that does not fit into the short-consultation model. Fee-for-service items created for the management of chronic illness are an improvement. However, they can still distort best practice if seen merely as dollar amounts requiring expenditure. In a practice where patients with chronic illnesses are treated, a doctor may be required to take on the role of team leader, a difficult role to provide an item of service for; however, it is one well suited to a salary package.5 A list of items of service that are funded by a third-party payer may, in practice, limit the doctor to offering only those options — otherwise, the patient may feel pressured to accept and cover the full cost of the service. If it were possible to provide a fee for service that was linked to an improvement in health, it may be difficult to attribute any improvement to the actions of the doctor. Unfortunately, in many areas of medicine, especially surgical procedures, good evidence from clinical trials that links health interventions to better health is lacking. Without such evidence, doctors may be likely to choose to perform the better-remunerated procedures. How does the method of payment affect relationships between doctors? When I started as a staff specialist I was told by a visiting medical specialist colleague that I was “a coat not a suit”. Nevertheless, I think if we perform our respective roles the relationships should not have problems. However, beware of salaried doctors undercutting doctors paid through fee-for-service arrangements at the local private hospital! Bitter fighting can break out between doctors if one craft group thinks it is getting a worse deal than another. It would be simple to change the current balance of numbers of salaried doctors and those receiving fee-for-service payments. Simply roll back some of the more outrageous subsidies to private practice, such as the thirty per cent health insurance rebate and the safety net, and direct that money to providing more salaried positions. Private hospitals face the difficulty of doctors acting in concert to resist moves by the hospital or the health insurers to lower costs by employing salaried doctors. Perhaps, as the medical workforce increases in number over the next few years, we will see a relative oversupply in some areas break this deadlock. Finally, in talking to our trainees and medical students, I have found there is enthusiasm for a salaried payment system. They do not see medicine as a business in which a craftsperson hawks their wares among the populace for a fee. Rather, they see themselves as providing a social service.

Brian B Peat MB BS, FRANZCOG

Urologist and AMA Victoria past president Douglas Travis believes fee-for-service encourages productivity and transparency From the perspective of doctors, patients and funders, fee-for-service is the best method of remuneration because it provides the best transparency, accountability and incentive for everyone. As a patient, you pay for what you get, and, as a doctor, you get paid for what you do. There are a number of claims for and against the fee-for-service model. I am focusing here on the specific issue of the best method of remuneration for a doctor’s efforts, and do not intend to address the separate issues of public versus private medicine, or free services versus out-of-pocket services. The first claim is that payment on a fee-for-service basis encourages overservicing.1 Theoretically, this could be true, but it is a small-volume threat. The reality is that the overwhelming majority of doctors are flat out doing the necessary work for their patients. They simply don’t have time to overservice. In fact, salaried remuneration encourages underservicing. While many salaried doctors do work excessive hours to cope with ever-expanding workloads, it is the human condition to watch the clock and not put in the maximum effort when you are paid by the hour. This risk outweighs the risk of overservicing under fee-for-service arrangements. In addition, the transparency of fee-for-service makes employers more accountable to doctors, reducing the potential for exploitation of doctors’ goodwill in both the public and private systems at all pay grades. Fee-for-service is also said to result in people being unable to afford medical care. However, the method of remuneration of doctors does not determine the cost of a service to the patient. For example, general practitioners who bulk bill are paid on a fee-for-service basis, but their patients have no out-of-pocket expenses. Conversely, private radiology and pathology companies often pay salaries to doctors, but patients pay out-of-pocket expenses. It is the quantum of remuneration to doctors, not the method, and the level of rebates from third parties that influence the end cost to patients. There are concerns that fee-for-service encourages doctors to try to provide more services in a given period of time, with resulting compromises to the quality of services provided. This is a theoretical problem, as proven by decades of high-quality fee-for-service work in Australia. Doctors have been and can be trusted to provide quality work in a fee-for-service environment. Fee-for-service is said to cause doctors to work excessive hours to their detriment. I contend that many salaried full-time doctors, in both the public and private systems, work excessive hours to their detriment, motivated by work addiction or greed. Work addiction and greed are difficult issues, which in themselves are the problem — not the method of remuneration. Another misconception is that, because fee-for-service is tied directly to patient services, there is no incentive for doctors to maintain continuing medical education (CME) or other quality improvement (QI) activities. However, QI can be incorporated into fee-for-service remuneration2 — for example, practice incentive payments are, in reality, fee-for-service payments related to QI. In any case, regulators are stepping into the quality field — CME is mandatory in order to maintain registration, and practice accreditation is spreading through all forms of medicine. Even if, in the past, fee-for-service meant you could theoretically ignore QI and CME, that era has gone. The area for which fee-for-service is not an appropriate funding model is research and teaching. Research work should be salaried. Likewise, remuneration for teaching should be time based, or if a doctor wishes to do it for nothing, so much the better. The fee-for-service model should have no impact on teaching and research. It might be argued that governments and other employers are ideologically opposed to fee-for-service, but what they are opposed to is uncapped, uncontrolled expenses, and to paying doctors remuneration deemed to be “excessive”. Most public-system fee-for-service schemes that have been stopped were uncapped and consequently led to budget blowouts, and were discontinued for that reason. In fact, governments are rushing headlong into fee-for-service remuneration at the macroscopic level in health, as shown in the establishment of the Independent Hospital Pricing Authority;3 it is just that it is called “activity-based funding”. Block funding (the equivalent of a “salary” model of funding) is on the way out because fee-for-service is better for all parties. In summary, I believe that fee-for-service remuneration encourages productivity, is more transparent and provides better accountability for all parties than a salary-based method of remuneration.

Douglas G Travis MB BS, FRACS(Urol)