Health services administration

Professor Bill Runciman believes much clinical care is inappropriate, and QI can be effective NOThe evidence that more care does not mean better care is overwhelming, and the scope for savings . . . is huge.1 There are many established health care practices and an ever-increasing number of advances that unequivocally represent value for money. However, we hear daily about unacceptable delays for public patients in access to both established and new high-value interventions. As quality improvement (QI) activities consume resources and do not provide direct clinical care, it has been suggested that resources be diverted from QI to fund more clinical care. There would be a powerful argument for this if clinical care was appropriate and properly delivered, and if all QI activities were futile and did not improve care or outcomes. However, neither is the case. Much clinical care is neither appropriate nor properly delivered. For common conditions for which evidence is available, patients receive appropriate care only about half the time, with enormous regional variations.2,3 In the United States, the quintile of the population that consumes 50% more health care resources per person than the lowest quintile does not have better outcomes or better perceptions of their care.4 On top of this, at least 10% of admissions to acute care hospitals are associated with health-care-associated harm, as are over a million general practice consultations each year in Australia.3 This is not a “good look” for a health care system that costs over $100 billion per year (nearly 10% of gross domestic product), and which is on a trajectory to becoming unaffordable. Diverting funds to “more of the same” will produce more of the same. With an ageing population and ever-increasing possibilities and expectations, there is an urgent need to provide rational care and redirect funding from ineffective or non-cost-effective practices.5 Continuing to fund inappropriate care and substandard practices automatically while denying high-value appropriate care to many of those in need represents institutionalised unethical practice. Well designed QI activities do not fail to deliver on improved care or outcomes; indeed, many represent remarkable value for money. Proper implementation of a “central venous line” care bundle can sustainably virtually eliminate deaths from catheter-related bloodstream infections.6 The effective use of surgical checklists can reduce perioperative morbidity by a third and mortality by nearly half — potentially saving thousands of lives each year in Australia.7 What is really remarkable is that uptake of these fairly straightforward interventions has been slow and patchy in Australia, opposed with the usual mantras about recipe-book medicine, erosion of clinical autonomy, and patients, contexts and practices somehow being different. There is no doubt that much QI activity has failed to use rigorous methods and has resulted in a plethora of poorly designed, underpowered local projects which lack credibility and have little impact on clinical practice. However, this should not lead to the reflex dismissal of all QI activities. The real problem is that current practices in both clinical care and QI are often deeply flawed. There are inherent difficulties in QI and health services research that underlie the general lack of progress. These have been summarised recently, and a carefully argued case made for the use of process as well as outcome measures, ideally incorporated into randomised cluster or stepped-wedge research designs.8 Another well argued approach is to develop national clinical registries to “target conditions or procedures . . . associated with large variations in processes or outcomes of care . . . that impact significantly on healthcare costs and patient morbidity”.9 Whether the approach taken is population-based, condition-based or both, national level research involving both public and private patients across all health care settings is needed. We need to be able to determine, on an ongoing basis, who is getting what care from whom and why, to decide what constitutes appropriate care and to develop clinical standards and tools to apply them. Like the examples cited above for central lines and surgery, the tools need to reflect clinical standards (either implicitly or explicitly), to constitute the mechanism by which compliance is documented, and allow easy audit (preferably electronic) that should form the basis for credentialling of individual clinicians and accreditation of health care services.10 Much needs to be done in retiring inappropriate care and ineffective QI; we simply cannot afford more of the same.3,5 The need for national clinical standards — for the meshing of QI and clinical care in our nationally funded system — is urgent. Inappropriate care and ineffective QI should not be funded. The money currently wasted would be better spent on creating a new amalgam of evidence-based care with built-in QI. The need for health care to be based on sound doctor–patient relationships will remain, but should be built on a foundation of both getting the basics right and being seen to do so.

William B Runciman FANZCA, FJFICM, PhD

Australian Health Ministers have endorsed the hospital standardised mortality ratio (HSMR) as a key indicator of quality and safety, and efforts are currently underway towards its national implementation. In the United Kingdom, Canada, the Netherlands and the United States, the HSMR has been used for several years within organisations to monitor performance and response to various quality and safety programs. In the UK and Canada, the HSMR is also publicly reported and used to compare performance between hospitals. The validity and reliability of the HSMR as a screening tool for distinguishing low-quality from high-quality hospitals remain in doubt, and it has not yet been proven that HSMR reporting necessarily leads to worthwhile improvement in quality of care and patient outcomes. Institutions may respond to an unfavourable HSMR by “gaming” administrative data and risk-adjustment models or implementing inappropriate changes to care. Despite its apparent low cost and ease of measurement, the HSMR is currently not “fit for purpose” as a screening tool for detecting low-quality hospitals and should not be used in making interhospital comparisons. It may be better suited to monitoring changes in outcomes over time within individual institutions.

Ian A Scott MHA, MEd, FRACP · Caroline A Brand BA, MPH, FRACP · Grant E Phelps MBA, FRACP, AFRACMA · Anna L Barker BPhty, MPhty, PhD · Peter A Cameron MB BS, MD, FACEM

Public reporting of patient outcomes following hospitalisation in Australia is limited compared with other countries. This will change, given recent commitments by state and federal governments to an Australian reporting program as part of health reform. There are numerous challenges in the design and implementation of such a program, including strategic decisions, statistical methods, and preventing risk aversion and perverse behaviour. Experience in other countries is likely to provide valuable lessons and tools for Australia as it seeks to build its reporting capacity.

Martin P Gallagher MB BS, FRACP, MPH(Hons) · Harlan M Krumholz MD, SM

A patient-focused learning health system, using integrated data sources, will facilitate optimal care of individuals and result in better care of our populations and society In this issue of the Journal, two articles report strikingly high use of health services in Australia.1,2 Lowthian and colleagues document a 75% increase in emergency ambulance transportations, and forecast another 46%–69% increase by 2015.1 Rosenwax and colleagues demonstrate that 96% of Western Australians dying of life-limiting illnesses were admitted to hospital in their last year of life.2 These authors raise three points: use of health care is expanding; solutions are needed to care for people with chronic complex illness; and we can improve understanding and solutions through analysis of growing datasets. Both studies use linked, large database analyses to understand care patterns. Remarkably, neither proposes algorithms to repeat the analyses at prespecified intervals to monitor change, link findings to other work through data integration, and test interventions. Rising health care use is obviously unsustainable, and the strain will magnify with more elderly people suffering coexisting chronic illnesses. Individual patient needs are also evolving, and here lies a critical tension. The scaling back of use of health care services seems straightforward; equally straightforward is the decision to admit this woman with refractory cancer pain to hospital, or to call an ambulance for this man with presyncope and facial numbness. Few contemporary patients have simple illnesses; it isn’t “just cancer”, but is a woman with multiple treatments for breast cancer, metastases, osteoporosis, heart disease and emphysema, any of which can stimulate hospitalisation; thus, health care use balloons. How do we reduce health care use — or at least stabilise it? Health promotion and better prevention is the obvious answer but the processes leading to potentially preventable illnesses among our ageing population are already well underway and unlikely to be substantially modified. A solution is needed, and we must find the right blend of interventions for patients and populations. Data-driven prognostication should guide understanding of an illness trajectory and facilitate decision making. Treatments should be personalised and interventions matched to the patients most likely to benefit. Continuous monitoring of outcomes and adverse effects should be used to ensure promotion of helpful interventions and discontinuation of ineffective or burdensome interventions. In other words, it’s time to make the transition from isolated findings and single research reports to “learning health care”.3 The care of individuals should be improved by the use of information about all preceding people with similar clinical scenarios, and information about care of a patient reinvested into the growing body of linked data to guide care in the future. In this paradigm, use of available data and evidence will ensure quality of treatments. The learning health care system forms around three fundamental purposes, which are to: generate and apply the best evidence relevant to each patient; propel scientific discovery as a “natural outgrowth of patient care”; and support quality assessment and improvement, spark innovation, enhance patient safety and maximise health care value.3 According to the United States Institute of Medicine: A ... comparative effectiveness research enterprise will require a supporting infrastructure [and] large-scale clinical and administrative data networks that enable observational studies of patient care ... New methods for linking patient-level data ... will promote inclusion of populations frequently omitted from clinical trials.4 Driving the learning health care system is a powerful, integrated, linked data network. Data sources include clinical care, health resource and administrative data, basic science information, clinical research datasets, and patient-reported outcomes.5,6 Patient-level data are used to inform individual care and summarised to improve general health care. Advances in information and data analysis technology will help clinicians temper professional judgement with clinically relevant evidence. Rapidly increasing health care costs within the context of the need to take care of individual people presents an important contemporary conundrum. A simple solution is not possible. We need a patient-focused learning health system to facilitate best care of individuals and target the right treatment at the right time, while reducing waste and harm. Better care of individuals wraps up to better care of populations and society.

Amy P Abernethy MD, FRACP, FAAHPM

The cost differential between these two drugs is no longer defensible Federal Health Minister Nicola Roxon recently met with an alliance of consumer, industry and other stakeholders to justify the government’s plan to indefinitely delay the listing of seven new medicines on the Pharmaceutical Benefits Scheme (PBS). She argued that, after considering the advice of the Pharmaceutical Benefits Advisory Committee (PBAC), it was the government’s responsibility to decide whether or not to list a new drug, taking into account other priorities across the health portfolio and current fiscal circumstances.1 Clearly, the cost of the PBS must be sustainable. However, there are other ways of reducing its cost apart from delaying the listing of drugs recommended by PBAC as cost-effective. The treatment of macular degeneration provides an illustrative example. Age-related macular degeneration (AMD) is responsible for almost half of all cases of blindness in Australia.2 In neovascular (or “wet”) macular degeneration, vision loss results from the abnormal growth and leakage of blood vessels in the macula. Ranibizumab (Lucentis), developed by Genentech and marketed by Novartis in Australia, is currently the only drug approved by the Therapeutic Goods Administration (TGA) and available on the PBS to treat wet AMD. It is administered as an intravitreal injection, usually 4–8-weekly, for 12 to 18 months or longer. The PBS-listed price of each injection is $1967. Ranibizumab is the antigen-binding fragment of a recombinant, humanised, monoclonal antibody that binds to vascular endothelial growth factor A (VEGF-A), the cytokine primarily responsible for blood vessel growth. The inhibition of VEGF-A reduces the permeability and growth of the neovascular vessels. Blindness is prevented in most patients, and the majority of treated patients go on to have some improvement in vision.3-5 Bevacizumab (Avastin) is an anti-VEGF-A humanised, monoclonal antibody (also developed by Genentech, and marketed in Australia by Roche; Genentech is a wholly owned subsidiary of Roche) that has been approved by the TGA for the systemic treatment of certain cancers. It was successfully used “off-label” for the treatment of wet AMD before ranibizumab became available, but has also been used to some degree since the availability of ranibizumab, especially in the United States, where patients bear more of the costs of drugs.5-7 It is prepared for ophthalmic use in a sterile pharmacy by taking a dose used in chemotherapy and splitting it for use in treating wet AMD for up to 25 patients. The cost of its off-label use has been significantly less than that of ranibizumab (around a 40th of the cost, at $50 per dose). Ranibizumab received PBS listing for use in treating wet AMD in 2007 and has since largely replaced bevacizumab for the treatment of AMD in Australia. Although therapy with ranibizumab has been successful, its PBS listing has come at great expense, costing taxpayers $237 million in 2010 (second only to atorvastatin and rosuvastatin). It is consistent with many of the principles of quality use of medicines (QUM), outlined in the National Medicines Policy,8,9 for ophthalmologists to select a PBS-listed therapy that has been demonstrated to be safe and effective. But advocates of QUM also emphasise the importance of choosing medicines that are cost-effective for individuals and the community. A recent study by the US National Eye Institute10 has raised the question of whether use of ranibizumab can be justified economically. The study compared bevacizumab and ranibizumab for the treatment of wet AMD, administered either monthly or as needed, in 1208 randomly assigned patients. At 1 year, bevacizumab and ranibizumab had equivalent effects on visual acuity, when administered according to the same schedule. Ranibizumab given as needed, with monthly evaluation, had effects on vision that were equivalent to those of ranibizumab administered monthly. The comparison between bevacizumab as needed and monthly bevacizumab was inconclusive. Differences in rates of serious adverse events were higher with bevacizumab but did not reach statistical significance, and require further study. Results from the second year of this study and from other comparative trials and experiential databases will provide additional information. Despite this new information having come to light, in Australia there is little motivation for clinicians, the pharmaceutical companies involved, or government bodies to pursue a broader economic agenda. There is no incentive for Australian ophthalmologists or patients to use bevacizumab off-label because the price to the patient for the PBS-listed ranibizumab is only that of the copayment, and the costs for the ophthalmologist visits are the same. There is little incentive for the sponsor of bevacizumab (Roche) to seek a new indication (wet AMD) for this drug — first from the TGA and then from PBAC — because of the substantial costs involved and the doubtful rewards. Also, the relationships between the companies involved appear to militate against moves that might change the present situation. Applications to both the TGA and PBAC are now fully cost-recovered by charges levied on the sponsor of the drug — a unique situation among equivalent developed countries. This provides a considerable disincentive for applications that are primarily in the public interest. While charges can be reduced or eliminated for so-called orphan drugs, this provision would not apply in this case because ranibizumab is currently available and patent-protected.11 And although it has been suggested that a third party, such as a Royal College, might sponsor an application to the TGA and PBAC in the public interest, this concept has foundered because the sponsor is also responsible for product liability. This leaves us with the question: what policy options might circumvent the difficulties outlined here and save taxpayers substantial amounts of money when treating neovascular AMD with anti-VEGF-A drugs? First, the drug committees and administrations of public hospitals with significant eye services could recommend off-label use of bevacizumab for AMD, in the light of the National Eye Institute study. Currently, in New South Wales public hospitals, there is no PBS access to ranibizumab. This would also accommodate public patients unable to pay for private ophthalmologist visits. Given the issues with bevacizumab of dose preparation, sterility and shelf life, combining services for efficiency and geographical coverage would make sense, as would amalgamating public clinics that already use bevacizumab off-label for other related indications (eg, diabetic retinopathy). Second, the government could consider ways in which it could withdraw the PBS listing for ranibizumab for the treatment of wet AMD, on the grounds that treatment with bevacizumab in public eye hospitals is likely to be more cost-effective. This is likely to be problematic for several reasons: the limited capacity of the public sector to provide this treatment; opposition by ophthalmologists operating privately and those who deliver public services; and opposition from the sponsor. Third, the government could negotiate with Novartis to reduce the cost of ranibizumab, or with Roche to apply to have bevacizumab approved and listed for use in treating AMD. It should be noted that the effort needed to register, list and distribute medicines internationally and in Australia should be considered in these negotiations, but the cost differential now extant in the light of the National Eye Institute study results is no longer defensible. Finally, the government could accept that it is the only body with the responsibility and capability of acting in the public interest in these matters. The Minister for Health and Ageing could ask the TGA and PBAC to consider listing bevacizumab for neovascular AMD in the public interest, perhaps with a temporary or provisional licence pending accumulation of more data, with the government accepting any liability that may accrue. Although the challenges of achieving an equitable solution to this problem are considerable, the significance to the PBS budget and subsequently for analogous situations is now a strong incentive for action.

Ken J Harvey MB BS, FRCPA · Richard O Day MD, FRACP · William G Campbell MB BS, FRANZCO · Wendy Lipworth MB BS, MSc, PhD

Medical Assessment Units (MAUs) provide an opportunity for multidisciplinary staff to manage recently admitted acutely unwell patients with complex medical illnesses. We propose concerted development of robust mechanisms for identifying and managing patients whose condition is unstable as they move through hospital departments. Track, trigger and response (TTR) systems (eg, medical emergency team calls and early warning scores) have been introduced to hospital practice, but evidence for their effectiveness is, so far, incomplete. The current variation in TTR systems within and between hospitals impairs intersite comparisons. A range of outcome measures, including risk of physiological deterioration, mortality and projected hospital length of stay, could be usefully investigated by future intersite collaborative research. More deliberate, systematic, evidence-based design of “response” in TTR systems may help in identifying patients who need early attention from skilled medical staff. We need more uniform TTR systems, more research on TTR systems and more multisite research; MAUs are ideally situated to address this important area.

Paul F Jenkins MB BChir, FRCPE, FRACP · Campbell H Thompson MD, DPhil, FRACP · Lorna L Barton MB BS, MRCP

The Australian Government is planning to pilot a model of prepaid funding for coordinated care of patients with diabetes in general practice. Patients will register with a practice that undertakes to coordinate their care, and practices will manage pre-allocated funds to provide services instead of billing Medicare. Systems to manage prepaid funds in Australian general practice have not yet been developed. In the model that has been proposed, practices with a small register of patients will be at risk of overspending, which may threaten practice viability and patient services. If the initiative is to have integrity, all patient services should be paid from the prepaid funds and patients should only attend the practice with which they have registered. Risks should be delineated and contingency plans made explicit before practices and patients commit to the initiative.

Douglas A Pritchard MB BS, FRACGP, PhD

To the Editor: Colchicine is an alternative to anti-inflammatory agents for the treatment of acute gout.1 It is potentially toxic and can cause multiorgan dysfunction, including hepatotoxicity, neutropenia, acute kidney injury, rhabdomyolysis and hypotension. We report three cases of toxicity from supratherapeutic dosing that occurred within 2 weeks of each other. In each case, no alternative diagnoses (in particular, sepsis) were considered likely. An 87-year-old man presented with vomiting after 3 days of profuse diarrhoea, nausea and generalised myalgia without other infective symptoms. He had been prescribed 0.5 mg colchicine daily, but he was taking 1.0 mg four times daily. Clinical features included generalised abdominal tenderness, pancytopenia, rhabdomyolysis and hepatic dysfunction. These resolved over 5 days with supportive treatment. A 67-year-old woman presented with lethargy, diaphoresis, fever, nausea, vomiting and diarrhoea. She had been prescribed 1.0 mg colchicine initially, then 0.5 mg every 6 hours “until diarrhoea develops”. She was taking colchicine every hour despite diarrhoea. Initial clinical features included tachycardia, hypotension, tachypnoea and fever. Multiorgan dysfunction developed rapidly and despite aggressive resuscitation, including an intra-aortic balloon pump and broad-spectrum antibiotics, she died within 24 hours. A 77-year-old woman presented with nausea, vomiting and profuse diarrhoea. She had been prescribed 1.0 mg colchicine three times daily “until diarrhoea develops”. On presentation, she was dehydrated but haemodynamically stable, with mild renal and hepatic dysfunction and creatine kinase level elevation. These resolved over 4 days with supportive treatment. A recent randomised controlled trial demonstrated that low-dose colchicine (1.8 mg over 1 hour) was as effective as a higher dose (4.8 mg over 6 hours). Further, the adverse effects of the lower dose were similar to placebo and significantly less than those of the higher dose.2 Adapting to the Australian formulation, 1.0 mg initially and 0.5 mg 1 hour later is now recommended.3 In contrast, repeat doses of 0.5 mg until clinical improvement or side effects (in particular, diarrhoea) was previously recommended. In the cases above, the apparent dosing regimen differed significantly from current recommendations. Ineffective patient education may have also contributed to the conditions of patients 1 and 2, who up-titrated their dose. Patients 2 and 3 persisted with dosing despite gastrointestinal symptoms. Health professionals should be aware of the new dosing recommendations. These are highlighted by the National Prescribing Service4 and the Australian medicines handbook.3 Patients with renal or hepatic impairment, or concomitant use of cytochrome P450 3A4 or P-glycoprotein inhibitors (eg, clindamycin), are at increased risk.5

Myles W H Smith · Darren M Roberts · Siobhann M Ritson · Richard O Day

To the Editor: I refer to the article by Cameron and Cooke,1 and the letter from Forero and colleagues.2 Cameron and Cooke correctly identified key problems associated with using a time-based process standard as a solution to poor patient outcome linked to overcrowding in emergency departments (EDs). They highlighted the need for monitoring to ensure “patient safety and quality of care are not compromised at any stage of the emergency pathway”. Forero et al challenged their assertion that the United Kingdom has replaced the 4-hour rule, and suggested there are three new time-based measures used as indicators of performance. Unfortunately, Forero et al have not noted the critical difference in new UK policies, in which no specific time cut-off is used as the benchmark for good performance.3 While acknowledging the importance of timeliness of care, “clinical outcomes and the experience of the patient” will be the focus of emergency care in the UK under the new Department of Health initiative effective April 2011.4 Surely Andrew Lansley’s (UK Secretary of State for Health) statement that “the four hour standard should be abolished”5 must mean nothing else but complete abandonment of this standard!. Concerns regarding a time-based performance indicator (and funding) were previously illustrated by Nocera in this Journal, who showed that numerical key performance has been a primary motivation for data fraud in Victoria and New South Wales, relating to ED waiting time.5 Furthermore, there is a possibility of admitting an unprepared patient to a ward at 4 hours,6 without acceptance of care by specialist team. A patient not properly worked up and sent to ward will not have the same automatic privileged access to critical care staff ratios or fast-tracked requests for pathology or radiology investigation provided in the ED. This can contribute to the excessive length of stay and, indirectly, hospital bed block. I caution against overly enthusiastic support for the 4-hour rule being instituted in Australian hospitals as a panacea to access block in the ED, and stress the need for better discharge planning, experienced patient flow and bed management, and improved hospital staff rostering for after hours. The latter include rethinking of ED doctors’ 24-hour staffing, with ED specialists attending to patients primarily,7 and junior doctors as assistants (if a 4-hour standard is to be attained), especially when facing an imminent glut of junior doctors, who will require close supervision, rotating through the ED.8

Shyan L Goh

To the Editor: We read with interest the recent cover article by Bhonagiri and colleagues detailing increased standardised mortality rates for patients admitted to Australian intensive care units (ICUs) out of hours.1 Have the authors considered a secondary analysis controlling for night-time staffing ratios? Aside from staffing levels, human factors such as the effects of fatigue and sleepiness due to circadian rhythm misalignment and sleep deprivation should be considered and further investigated. Studies have consistently shown that human cognitive and motor performance is substantially worse at night than during the day,2 due to the influence of the endogenous circadian clock. A recent study of emergency medicine registrars at an Australian tertiary hospital showed a 21% decrease in performance at night, in clinical scenarios of fellowship examination standard.3 Sleep during the day is of poorer quality and shorter duration than sleep during the night,4 resulting in chronic sleep restriction that exacerbates the impairment occurring in night work.5 Consecutive night shifts are associated with an increasing risk of accidents and injuries.6 In doctors, including consultants, inadequate sleep (fewer than 6 hours) is associated with harmful effects on patient outcomes.7 Despite our cultural beliefs, doctors are likely to suffer from the same biological effects of sleep loss and circadian rhythm disturbance as suffered by other humans. ICUs may provide one of the best hospital environments in which to study medical error, because of defined and limited personnel compared with non-ICU ward areas. ICUs also usually have better record-keeping and error-recognition systems, because of higher staff:patient ratios. Possible risk mitigation strategies include increasing the number of night staff, implementing oversight mechanisms for specified procedures and decisions, and ensuring that rosters and shift lengths are designed according to evidence linking sleep disturbance with poor patient outcomes. Such evidence should form the basis of any regulatory frameworks.

Dev A S Kevat · Andrew R Davies · Peter A Cameron · Shantha M W Rajaratnam

To the Editor: Indigenous Australians have a higher risk of vision loss from preventable and treatable causes than non-Indigenous Australians1 and have been reported to attend eye care services at a lower rate than non-Indigenous Australians.2 Here, we report results from the National Indigenous Eye Health Survey1 which indicate that many Indigenous Australians with vision problems have accessed eye care services but not as frequently as recommended by the National Aboriginal Community Controlled Health Organisation (NACCHO) and the National Health and Medical Research Council (NHMRC), particularly for high-risk groups of patients with diabetes.3,4 The survey methods have been reported elsewhere.1 Briefly, 1694 Indigenous children and 1189 Indigenous adults from 30 communities across Australia had a standardised eye examination and completed a questionnaire in 2008. Recruitment rates were 84% for children aged 5–15 years and 72% for adults aged ≥ 40 years, and 96% of responses to questionnaire items were complete. Seventy-nine per cent (936/1189) of Indigenous adults reported vision problems, of whom 83% (778/936) had sought care from an eye care service (Box 1). Similar to previous studies,5 we found use of eye care services increased with increasing age, but being male and having no education were barriers to accessing services. There was a significant association between higher education levels and higher rates of using of eye care services, with the odds for using eye care services being the highest among those with the highest level of education (data not shown). These factors should be considered when designing public health messages on the importance of using eye care services. As elsewhere in Australia, optometric services were the most frequently used facilities (49%, 378/778) across all regions except very remote inland, where primary health care services had the highest reported usage (33%, 49/149). Participants from very remote coastal and very remote inland regions were twice as likely to consult an ophthalmologist compared with the other regions (Box 2). Twenty-three per cent (179/769) of participants with vision problems reported that they had last seen someone about their vision problem within the previous year, 67% (519/769) within the previous 3 years, and for 33% (250/769) it had been ≥ 3 years. Only 20% (87/444) of participants with self-reported diabetes had seen someone about their vision problem within the previous year. NACCHO recommends that Indigenous adults aged ≥ 40 years should be screened for reduced visual acuity at least every 2 years,3 and NHMRC guidelines recommend that Indigenous adults with diabetes have their eyes checked every year.4 Our results show that we are far from reaching these targets. As regular eye examinations have the potential to reduce the incidence of vision loss, this is a matter of great concern. The importance of regular eye examinations and follow-up, particularly for high-risk groups, should be emphasised to health care providers and the community. Reasons given for not seeking eye care were: not enough time (41%, 62/153); condition not severe enough (22%, 33/153); too expensive (17%, 26/153); eye care not available in area (14%, 22/153); decided not to seek care (14%, 22/153); transport or distance issues (10%, 15/153); and waiting time too long (10%, 15/153). The two most common reasons for not seeking care indicate a lack of awareness about the importance of regular eye examinations, possibly because of a lack of culturally appropriate public health messages. 1 Self-reported history of vision problems, facilities used and resolved vision problems for Indigenous adults 2 Indigenous adults with self-reported vision problems, by facility used and region Primary health care (n = 255) Hospital (n = 48) Optometrist (n = 378) Ophthalmologist (n = 91) Not specified (n = 6) No consultation (n = 156) Total χ2 P Major city 34 (31%) 6 (6%) 48 (44%) 7 (6%) 0 13 (12%) 108 22.5 < 0.01 Inner regional 39 (28%) 4 (3%) 71 (52%) 8 (6%) 1 (1%) 14 (10%) 137 17.7 < 0.01 Outer regional 51 (34%) 6 (4%) 56 (37%) 13 (9%) 1 (1%) 25 (16%) 152 18.3 < 0.01 Remote 55 (28%) 9 (5%) 79 (40%) 12 (6%) 2 (1%) 42 (21%) 199 — 0.16* Very remote coastal 27 (14%) 8 (4%) 81 (43%) 30 (16%) 2 (1%) 41 (22%) 189 — 0.87* Very remote inland 49 (33%) 15 (10%) 43 (29%) 21 (14%) 0 21 (14%) 149 12.7 0.03 * Fisher exact test.

Anna-Lena M R Arnold · Lucy Busija · Jill E Keeffe · Hugh R Taylor

Our health and medical research sector is under threat and needs the support of the clinical community Until quite recently, it was believed that peptic ulcers were caused by stress and lifestyle and that the most effective treatment was a bland diet and rest. However, in 1982, two Australian medical researchers (Barry J Marshall and J Robin Warren) discovered the bacterium Helicobacter pylori and demonstrated its role in gastritis and peptic ulcer disease.1 Thanks to this discovery, millions of people worldwide are now cured of peptic ulcer with a short regimen of antibiotics and acid secretion inhibitors. This is just one of hundreds of examples of effective translation of Australian health and medical research into clinical practice and, importantly, better outcomes for patients. Over the past 50 years, health and medical research has saved the Australian health care system trillions of dollars and delivered better quality of life for all Australians. It is estimated that between 1960 and 1999, medical research was responsible for a longevity gain of 8 years worth $2.9 trillion and gains in quality of life worth $2.5 trillion in avoided health expenses.2 Regrettably, these hard-won advances now stand to be undermined by potential cuts to National Health and Medical Research Council (NHMRC) funding in the May federal Budget. Over the past decade, the nation’s research community has achieved a level of critical mass, thanks to the vision and leadership of successive governments. But the sector was coming off a very low base and, compared with overseas competitors, Australian Government funding for research as a proportion of gross domestic product still remains low, at only 0.11%–0.12%.3 Over the same period, demand for medical research and the knowledge to cope with emerging disease patterns has grown with the inexorable rise in chronic disease, an ageing population and the impact of globalisation on health epidemics. In order to manage these new health challenges with the financial resources available, we will inevitably see more and more health care delivery taking place in the community and away from acute settings. In preparation for this seismic change, we need research breakthroughs and long-term, evidence-based solutions. A cut to the annual $775 million NHMRC budget will not just affect Australians today but will compromise the health outcomes of our children, grandchildren and great-grandchildren. Health and medical research is an essential component of the current health reform agenda and plays a vital role in providing better outcomes for a self-improving health system. A large proportion of Australian health and medical research is now focused on translational outcomes, such as disease prevention, improved clinical care, and new diagnostics, therapies and vaccines, which have a demonstrated capacity to reduce the nation’s health budget and deliver better patient care. Indeed, without such research, the impact of health reform on patient-relevant outcomes such as death and disability will remain substantially uncertain. Another illustrative example of Australia’s contribution to global health gains is the development by Professor Ian Frazer and colleagues, in collaboration with CSL Biotherapies, of the quadrivalent human papillomavirus vaccine (Gardasil; Merck Sharp & Dohme) for cervical cancer prevention. According to an Access Economics report, the vaccine is expected to prevent around 70% of cervical cancers and result in significant economic returns in averted health care costs in Australia.4 As well as making significant contributions to global health, it is crucial that we maintain a strong Australian health and medical research sector in order to identify solutions for unique local health problems. Last year, researchers at The George Institute launched a major international trial of a very low-cost, once-a-day “polypill” for the prevention of cardiovascular disease. This treatment is particularly promising for Australia’s Indigenous communities, for whom cardiovascular disease is the leading cause of death and disability. Compared with other Australians, Indigenous Australians suffer heart attacks at three times the rate, at an average of 10–15 years younger, and have 3–4 times higher rates of diabetes.5 We are unlikely to “close the gap” in Indigenous health by reading reports of research conducted in the United States or Europe. Moreover, cuts to research funding will seriously impair Australia’s ability to respond effectively to health crises, through delays in access to the latest and most effective vaccines and treatments. This applies equally to mobilising a rapid and successful response to acute emergencies such as severe acute respiratory syndrome, pandemic (H1N1) 2009 influenza or, in the context of the recent floods, outbreaks of Ross River fever. For all these reasons, a cut to the NHMRC budget will increase health care costs in the long term and harm the Australian economy, through the failure to use the capacity of existing and new state-of-the-art facilities, a downturn in productivity and lost intellectual property as we are forced to “buy back” health innovations from international pharmaceutical and device companies. There is also the very likely spectre of our brightest scientists and clinicians leaving Australia for rapidly growing biomedical research hubs in Asia and beyond, as well as a loss of future capacity through the failure to train an adequate research workforce. Interestingly, in the United Kingdom, medical research has been protected, despite wide and deep cuts in other public sectors, and in the US, biomedical research has been identified as a priority for government support by President Obama. India, China and Singapore are also making unprecedented investments in medical research and associated intellectual and capital infrastructure. Proposed funding cuts will place emerging Australian medical researchers in a particularly vulnerable position, given that their training extends over a 10–15-year period. The effects of reducing training places, even in the short term, through a reduction in any of the funding programs will be felt for more than a decade. It would only take a small cut to the NHMRC budget to have a serious impact on medical research outputs, denying Australians access to the best available preventive therapies, diagnostics and treatments, today and in the future. For this reason, the medical research sector has been forced to take its fight public in a bid to safeguard leading research programs that are a lifeline for children and adults suffering from heart disease, cancer, genetic diseases and many other forms of serious illness. The support of Australia’s clinical community will be crucial to ensuring that our research sector continues to deliver translational benefits to Australians. There are a number of ways clinicians can provide this support. Writing letters to and raising the issue with members of parliament and the Prime Minister is critical to maintaining the profile of this issue. Research Australia has developed an online petition to the federal government (http://researchaustralia.org/personal-stories/petition-to-federal-government.html), and concerned clinicians can vote for community advocacy organisation GetUp! to take on the campaign (http://suggest.getup.org.au/forums/60819-campaign-ideas/topics/61385-i-suggest-a-campaign-about-/filter/top). More information is available at the Discoveries Need Dollars website (http://www.discoveriesneeddollars.org).

Garry L R Jennings MD, FRACP · Stephen MacMahon DSc, PhD · Geoffrey A Donnan MD, FRACP

Objective: To evaluate the effectiveness of redesigning and streamlining perioperative services.Design: A before-and-after evaluation, with retrospective analysis of de-identified administrative data.Setting: A major tertiary hospital, Melbourne, Australia.Participants: Patients undergoing elective surgery, February 2005 – February 2010.Intervention: Implementing a process redesign to streamline clinical pathways for elective surgery, with a focus on the patient journey from referral to discharge, and establishing a separate, dedicated elective surgery facility.Main outcome measures: Numbers of patients waiting beyond national recommended waiting times for elective surgery; hospital-initiated postponement (HIP) rates for elective surgery; and lengths of stay (LOS), both combined and for specific diagnostic-related groups.Results: The clinical process redesign resulted in a sustained downward trend in the number of elective surgery patients waiting longer than national recommended maximum waiting times. HIP rates were reduced to 1% in the dedicated elective surgery facility, and there was a significant reduction in the combined LOS, as well as the LOS for the most common surgical procedures (P < 0.001).Conclusions: Clinical process redesign of perioperative services and collocation of a separate elective surgery centre improved (i) timeliness of care for elective surgery patients and (ii) key indicators (LOS and HIP rates) for planned elective admissions.

Judy A Lowthian MPH, BAppSc(SpPath), LMusA · Andrea J Curtis BSc(Hons), PhD · Bernadette L Comitti DipAppSc(Nsg), GradDipBusinessAdmin · Peter A Cameron MB BS, MD, FACEM · Martin J Keogh GradDipCritCareNsg, GradDipManagement · William R Johnson MD, FRACS, FRCS · James Tomlinson MB BS, FRACP, FANZCA · Andrew M Stripp BBehavSc(Hons), MSc(ClinPsych)

Psychiatrist Diana McKay explains why she chose the public hospital system PUBLIC: There’s nothing like surprising your medical colleagues. Almost a year ago, I announced to some colleagues that, after 6 or so years primarily in private practice as a psychiatrist, I was shutting up shop and returning to work as a staff specialist in a busy public hospital. There was a notable pause before the congratulations ensued. Friends and private patients asked me why was I going to work in the public sector? I gave a mixture of responses, such as wanting to improve “the system”, becoming more involved in teaching, and a desire to use my skills with those unable to pay privately for them. Personally, with my children getting older, I felt I had more energy — and hopefully more wisdom and patience — to invest in an often demanding health system. I’m now not quite at my first anniversary of being fully back in the public sector. Professionally, it has been both challenging and rewarding. I’m lucky enough to work in a teaching hospital small enough to enable personal relationships to be the key currency of professional connections. My immediate colleagues are a small but cohesive group, who meet regularly to discuss service and clinical difficulties (there are always several to raise) in a thoughtful manner. Our management team is happy to listen to new ideas, although (it goes without saying) innovation must always involve innovation with the budget as well. Relationships between professions are respectful, and the “us” and “them” dynamics that I have experienced elsewhere seem little apparent. The passion and commitment of staff are evident throughout the hospital. The clinical variety is considerable, with the need for further study and reflection much in evidence. I am often reminded of Hippocrates’ aphorism “ars longa, vita brevis” (the craft is long, life is short) as I search online for the latest information on treatments and complications to discuss with my patients. The work can be difficult, but it is a privilege to work with people often at their most vulnerable — frequently people I would not have seen in private practice because they could not have paid for my services there. A sense of contributing to social justice has been one reward of my return to the public sector. It is not, however, all a land of milk and honey. Being on-call is tiring, and can be stressful at times when there is demand for inpatient services but access block preventing patients from being admitted. Somehow, the hospital and I have found a path through these occasions, again, with the goodwill of many staff who work together to ensure a bed is found for someone who needs it. Other challenges include the stark realities of the gaps in our system generally, with care provided to those with intellectual disability being one example. It’s hard not to feel guilty when a person is sent away because their needs are not part of our purview, particularly when I’m aware of what limited options are available anywhere. Although it feels a bit infra dig to mention remuneration, it is true that a staff specialist earns less than someone in the same specialty in private practice. This difference is less stark in my non-procedural specialty than in others, but must be acknowledged. There are the benefits of being an employee: paid holidays, study leave, a training allowance (with some irritations attached — just ask me about the interpretation that a computer does not constitute study “equipment”) and no late-night chat sessions with my accountant discussing the benefits of cash versus accrual accounting. The money — even if it is less than I could earn elsewhere — arrives with pleasing regularity in my bank account, with the needful done. The inexplicable delays in organising some basic things like email access has provided ample opportunity for me to revise the serenity prayer (http://en.wikipedia.org/wiki/Serenity_Prayer). I suggest all staff specialists keep a copy near their elderly computers to assist them in times of bureaucratic or information technology crisis. Another challenge can be the freedom to join in public debate, even in a forum such as this. The New South Wales Health code of conduct reminds me of many very pertinent and sensible things, but also that I must not use my job title when engaging in sociopolitical debate; hence my vanilla listing in this article. I have watched a few colleagues thoughtfully ignore this stipulation and speak out on issues they feel are in the public interest, and I wonder how I would manage if (or when) I were in the same situation. I have spoken about my own outcomes in this debate, but little about the outcomes of those who matter most in any health care debate — the patients. It seems to me that the jury is out on whether the public or private sector provides the best outcomes, with lack of access to data limiting the confidence with which conclusions can be drawn.1 From my personal viewpoint, it matters less to me how health care is delivered than how it can be accessed. At present the rather fragmented Australian health care system allows only some people access to private health care, and this seems inequitable. If we want private and public good for ourselves and our patients, we need to consider how the principle of universal access can more effectively integrate both sectors. This would be truly innovative.

Diana R McKay MB BS, BSc(Med), FRANZCP

Neurosurgeon Terry Coyne explains why he left the public hospital system PRIVATE: After completing my specialist training and overseas fellowship, I spent 11 years working between five and six sessions a week as a visiting medical officer (VMO) in neurosurgery at adult and paediatric public hospitals. The remainder of my working week, I worked in private practice. Several years ago, I resigned from my public appointments. There were a number of reasons for this. I accept that things may be different now, that my circumstances may have been unique to me or to my specialty, or that I was too sensitive. Nonetheless, my reasons for leaving the public system are outlined, in no particular order, below. A feeling of constant combat with administration: I had the feeling that, as a clinician, I was essentially a cost generator, and needed to be kept in check. That I was there to help ill people get better seemed to be beside the point. Negative interaction with administrators ranged from the petty (our department secretary was forbidden from sending letters related to a College exam I was organising — this was my personal responsibility because it “didn’t relate directly to patient care”) to the outright hostile (being told the views of VMOs at a departmental meeting were of no interest because “in this hospital, the tail doesn’t wag the dog”). I was once at a hospital meeting where we VMOs were told that if we didn’t like the way the hospital worked, there were many South African doctors “just waiting to take your place”. While I initially enjoyed the jousting, over time, the constant antagonism began to grind me down, and coming to work was just no longer enjoyable. Lack of guaranteed indemnity: This is an important issue in my specialty, in which compensation settlements can be large. Private medical defence organisation contracts generally exclude public hospital work. While there were verbal assurances from administrators that “VMOs would be covered”, this was never put in writing, and all the written documentation I ever saw allowed the state government to exercise discretion as to whether a VMO would be indemnified in the event of a claim. Two of my colleagues were denied indemnity before my resignation because, although surgery was undertaken in public hospitals, the alleged negligent action was deemed by health department administrators to have occurred outside the hospital grounds and was therefore the surgeon’s personal responsibility. Difficulty reconciling different standards of care: This was manifest in several ways. I found it difficult to see enough outpatients in my weekly clinic to keep the outpatient waiting time acceptable. Taking a reasonably complete history, examining patients and reviewing the findings of investigations takes a certain time, particularly if this is also combined with teaching registrars, residents and medical students. The number of patients that would occupy an entire day of consulting in private practice would be scheduled for a 2–3-hour public clinic. When I tried to reduce the clinic appointments to a more manageable number, the waiting time to attend the clinic quickly blew out to more than a year. Frequent cancellation of my weekly operating list: This was largely because most of my patients require postoperative care in the intensive care unit (ICU) or high-dependency unit (HDU). My weekly operating day was a Monday, and the ICU and HDU were frequently full of patients with problems like trauma and drug overdose after the weekend, which meant my patients could not have their surgery. In addition, a number of public holidays fall on a Monday and, while surgery considered reasonably necessary can generally be negotiated in a private hospital, only absolutely urgent cases could be done in the public hospital. This is understandable, but I was still left with the problem of having patients needing surgery some time that week, but now with no time allocated to perform it. Better operating theatre equipment in the private sector: This was the case during my 11 years in the public system. Examples included higher quality operating microscopes and image guidance technology. Financial aspects: No VMO attends a public hospital to become rich. However, it shouldn’t be the case that a VMO all but pays to work there. I was spending a third of my time at the public hospital, but the costs of running my private practice continued 100% of the time. When I left the public system, based on practice costs spread over a nominal 45-hour week, my net rate as a VMO was $30 an hour. I therefore had to either accept that my family would live on what I could earn during the remainder of the week, reduce my VMO hours (not easy to do in my specialty while still providing a reasonable service), or just work more hours in private practice and abandon any hope of a balanced lifestyle. Ultimately there was no single reason why I left the public system. It may have been possible to tackle some or all of my issues, but, at the time, I felt the chances of achieving any meaningful change were poor. There are many good aspects of a public appointment, including the chance to help those who are less well off, the sense of giving something back to the system that provided much of one’s training, and more opportunity to teach and mentor the next generation of surgeons. However, over time, the negative aspects came to outweigh the positive. I take some comfort in the fact that I wasn’t the only one feeling this way; 12 months before my resignation, my public hospital department had two full-time staff and three VMOs. Two years later, of those five, only one full-timer remained; the others had moved into full-time private practice.

Terry J Coyne MB BS, FRACS

This article critically analyses the prospects for introducing United States anti-fraud (or anti-false claims) laws in the Australian health care setting. Australian governments spend billions of dollars each year on medicines and health care. A recent report estimates that the money lost to corporate fraud in Australia is growing at an annual rate of 7%, but that only a third of the losses are currently being detected. In the US, qui tam provisions — the component of anti-fraud or anti-false claims laws involving payments to whistleblowers — have been particularly successful in providing critical evidence allowing public prosecutors to recover damages for fraud and false claims made by corporations in relation to federal and state health care programs. The US continues to strengthen such anti-fraud measures and to successfully apply them to a widening range of areas involving large public investment. Australia still suffers from the absence of any comprehensive scheme that not only allows treble damages recovery for fraud on the public purse, but crucially supports such actions by providing financial encouragement for whistleblowing corporate insiders to expose evidence of fraud. Potential areas of application could include direct and indirect government expenditure on health care service provision, pharmaceuticals, medical devices, defence, carbon emissions compensation and tobacco-related illness. The creation in Australia of an equivalent to US anti-false claims legislation should be a policy priority, particularly in a period of financial stringency.

Thomas A Faunce LLB(Hons), BMed, PhD · Gregor Urbas BA, LLB (Hons), PhD · Lesley Skillen BA(Hons), LLB(Hons), LLM

To the Editor: The juxtaposition of articles by Braithwaite and colleagues1 and Ho and Maddern2 (a description of a trial of physician assistants [PAs] in Adelaide) provides an interesting contrast between what should be happening in health care and what is happening. While Braithwaite and colleagues argue for a value-driven change, the type of change that is occurring at the moment is that of role substitution. This is exemplified by Ho and Maddern’s assertion that “PAs ... would ... improve the quality and quantity of medical service”. The intent is to provide a substitute doctor. This is referred to as “task” substitution or transference, with the inference that those under discussion, whether PAs or nurse practitioners (NPs), will only perform a limited role — some of the tasks of a doctor. In South Australia, PAs are able to order investigations and prescribe. The former editor of this journal, Martin Van Der Weyden, discussed this issue in 2008,3 labelling it “doctor displacement”, a term that Brooks and Mitchell disputed.4 They said “[PAs] will never be able to practise independently; they will always have to practise under supervision and within the scope of practice of their supervisor”. The Health Legislation Amendment (Midwives and Nurse Practitioners) Act 2010 (Cwlth), however, provided NPs with access to the Pharmaceutical Benefits Scheme and the ability to prescribe. Any supervision by doctors seems nominal, with independent practices being set up, some attached to pharmacies. There is less supervision of NPs by the medical profession than that given to trainees in teaching hospitals, and they are effectively independent practitioners. It could be argued that United States-trained PAs are even better trained than Australian-trained NPs, and Brooks and Mitchell’s statement that they will “never” practise alone is hardly reassuring. Proponents of NPs and PAs justify their use4 by reference to a shortage of health professionals. It isn’t reasonable to take from one area of need (nursing) to bolster another area of need (medicine), and the rapid increase in medical undergraduates and increase in immigration of overseas-trained doctors renders medical workforce projections unreliable. Role substitution by PAs and NPs will only perpetuate the problems we now face, while introducing new problems related to limited training and skills and fragmentation of care. Australian GPs, traditionally well trained and highly skilled, and with the ability to manage complex problems, are the core of our health system. Proposed changes devalue their contribution by making the inevitably fatal assumption that the sick patient is easy to recognise and triage.

Patrick S Hanrahan

Enhancing patient care. A practical guide to improving quality and safety in hospitals. Alan Wolff, Sally Taylor. Sydney: MJA Books, 2009 (234 pp, $49.95). ISBN 9780977578665. Wimmera Hospital, in Horsham, western Victoria, has a well deserved reputation for promoting quality and safety. Here, Alan Wolff, Wimmera’s medical director, and Sally Taylor, its clinical risk manager, outline the steps they followed in developing a rigorous quality management process at the hospital. This is indeed, as claimed, a practical guide and is recommended for all those interested in clinical governance. The Wimmera model appropriately distinguishes between safety and quality, and outlines steps to promote quality and assure safety. In terms of how the book might have been strengthened, I think a chapter outlining what a board safety and quality committee might do would have been useful. Further, the book has its provenance in a regional hospital and there is a question in my mind about whether all the elements of the Wimmera model are scalable. The book also de-emphasises the role of routine data for tracking safety in hospitals. Although hospitals can track their own trends over time using routine data, this sort of monitoring is much more powerful when it involves comparison with other like facilities. The model’s approach to management of adverse events focuses too much on the visible, the “event”, and tends to de-emphasise the myriad small things (eg, the incidence of pneumonia) which might together contribute to a poorer experience of hospitalisation. The book could also have been strengthened by incorporating guidance on how to structure investigations, when they are called for. The Queensland approach (“pyramid model”) of looking at data, casemix, resources, processes of care and professional issues is a valuable one.1 The book rightly identifies the health professional involved in an adverse event as the “second victim”. The medical director might also be seen as the “third victim”. The role of the medical director is a hard one, especially in a small hospital. It means holding to account local colleagues, often people with whom one has worked for many years. It is an isolated role and one deserving of more support. The authors are to be commended for making this hard journey an easier one.

Stephen J Duckett

Australia is developing a national performance framework aimed at measuring health outcomes across the health system. Clinical registries provide a clinically credible means of monitoring health care processes and outcomes, yet only five Australian registries currently have national coverage. At a national level, clinical registry development should be prioritised to target conditions or procedures that are suspected of being associated with large variations in processes or outcomes of care and that impact significantly on health care costs and patient morbidity. Registries should also aim to capture information across care interfaces and to monitor the medium and long-term safety and effectiveness of specific devices, procedures and drugs.

Sue M Evans PhD · Ian A Scott MEd, MHA, FRACP · Niall P Johnson PhD · Peter A Cameron MB BS, MD, FACEM · John J McNeil MSc, PhD, FRACP

Interprofessional learning and practice can be positively self-reinforcing and can promote improved care. Australia is showing leadership in the field of interprofessional collaboration. Changing attitudes to interprofessional collaboration is a key to improving health care. Implementing interprofessional collaboration requires a multifaceted approach, and research to underpin it.

David R Greenfield PhD · Peter Nugus PhD · Joanne F Travaglia PhD · Jeffrey Braithwaite PhD

To the Editor: We would like to congratulate Gandy and colleagues on their recent article in which they assess outcomes and patient flow in an acute care surgery (ACS) model.1 We have also performed a retrospective historical control study that examined the effect of an ACS model on assessment time and time to operation for acute appendicitis. Our findings were presented in poster format at the Royal Australasian College of Surgeons Annual Scientific Congress in Perth in May 2010.2 We introduced an ACS model in 2007 at Nambour General Hospital, a 350-bed regional hospital on Queensland’s Sunshine Coast. Our model differs in certain details from the model used by Gandy and colleagues at Prince of Wales Hospital, but is similar in principle. The aim of the ACS model was to provide an in-house consultant surgeon to be more available and more directly involved in the care of emergency surgical patients. In our study, the outcome measures included time to assessment of the patient in the emergency department by the surgical registrar, and time to operation after this assessment. We performed a retrospective chart audit of 569 patients who underwent emergency appendicectomy in the calendar years 2006 and 2008. The ACS model resulted in an increase in both time to assessment (198 minutes in 2006 compared with 263 minutes in 2008; P < 0.0001 [t test]) and time to operation (597 minutes in 2006 compared with 793 minutes in 2008; P < 0.0001 [t test]). These results surprised us. Various explanations were postulated, including the trend of an expanding local and regional population on the Sunshine Coast placing a greater demand on the emergency theatre through the study period. Like us, Gandy and colleagues did not see a reduction in time to theatre and in fact “observed no significant change in time from presentation to arrival in theatre”. This was explained on the basis of “an increase in the number of patients treated conservatively overnight”. We have reviewed our data and found a similar trend, with 35% of patients in 2006 and 54% in 2008 managed conservatively overnight. This may, to some extent, explain our surprising results. Our appendicectomies in both historical control patients and those treated in the ACS model were all performed laparoscopically, thus removing one of the confounders experienced in the Prince of Wales Hospital data. A comparison of these two sets of data emphasises the fact that to measure time to assessment and time to operation in isolation misses the important concept of reduction in complication rates, as successfully demonstrated by Gandy and colleagues1 (we did not record complication rates in our study). This process of assessment could be taken a step further with a cost–benefit analysis looking at the presumed reduction in costs associated with the anticipated lower rate of complications resulting from the involvement of the consultant surgeon.

Simone L Geere · Ratna Aseervatham · David Grieve

How one man’s vision to fund health research grew to become the country’s largest non-government funder of research into mental illness This year marks the 30th anniversary of the founding of Australian Rotary Health (ARH), a uniquely Australian organisation operating under the auspices of Rotary International (a worldwide organisation of humanitarian service clubs) that allows Rotary clubs to support health research. From small beginnings, ARH has evolved to become a key non-government funder of research relevant to preventing and treating mental illness. ARH had its birth in 1981, when Ian Scott, a bank manager from Mornington in Victoria, heard a radio interview about the tragedy of sudden infant death syndrome (SIDS) and the lack of funding available for research into the problem. He resolved to do something about it. As a member of Rotary, Ian approached his club with an ambitious proposal to set up a research foundation, with a principal of $2 million to provide funds for health research, and the initial grants to be allocated to research into SIDS.1 Scott’s aims were achieved within a few years. By 1983, the Australian Rotary Health Research Fund had been established, and in 1985 the first grants were given for research into SIDS. By 1987, the initial goal of raising $2 million had been reached through appeals to Rotary clubs and Rotarians to donate some of their fundraising money to ARH. The organisation had spectacular success with its initial grant funding, when a study investigating the incidence of SIDS in Tasmania identified prone sleeping position of infants as a key risk factor.2 Within 5 years of this finding, promotion to parents of the importance of infant sleeping position led to a dramatic decline in the incidence of SIDS.3 Subsequently, ARH gradually grew and supported research in a range of other areas including environmental health problems of the aged, adolescent health, family health, Ross River virus, and first aid and emergency care. A major change in direction occurred in 2000, when it was decided that ARH would fund mental illness research. This decision was in response to the Global Burden of Disease Study, which found that mental illness was a major source of disease burden and the biggest source of disability globally,4 and findings from the 1997 National Survey of Mental Health and Wellbeing, which showed that around one in five adults in Australia were affected with mental disorders in a 12-month period.5 The move into mental illness research was strongly supported by senior policymakers in the then Commonwealth Department of Health and Aged Care.1 Support for mental illness research has continued for over a decade, and ARH is now the largest non-government funder of research in this area. During this time, ARH has also offered PhD scholarships and postdoctoral fellowships, and supported research symposia. Support from ARH has complemented research funding provided by the National Health and Medical Research Council (NHMRC) by focusing on more applied projects, particularly intervention research, that offer more immediate benefits to the community. ARH has also supported work in its earliest stages, when research questions and ideas are still evolving and data are needed to guide planning for larger-scale proposals. It has been a major source of support for emerging areas such as prevention of mental illness in children and adolescents, and innovative approaches to treatment such as e-therapy. A strong partnership has developed between ARH and the Australian Government Department of Health and Ageing, which has encouraged ARH to broaden its focus beyond supporting research. This reflected the recognition by policymakers that Rotary clubs had the potential to play an important role in destigmatising mental illness, because their membership encompasses influential members of local communities who could lead the way for greater understanding and acceptance of people affected by mental illness. To facilitate this work, the Department funded ARH to run community forums on mental illness across Australia. This involved Rotary clubs organising meetings in their local community where mental health professionals, people with mental health problems and carers presented information and personal experiences, and local mental health services promoted what they had to offer. More recently, the Department has engaged ARH to increase community understanding of mental illness by supporting Rotary clubs to deliver Mental Health First Aid courses in their local communities.6 Despite the significant support that ARH provides to Australian health research, the demand for funding continues to greatly exceed the available funds. In 2010, ARH was only able to fund 10% of applications it received for mental illness research projects. To overcome this problem, ARH is broadening its base of support beyond Rotary clubs, which have to date been the major sources of donations. In 2011, ARH will launch a national appeal to the Australian public for funding to support mental illness research. Over 30 years, ARH has grown from one man’s vision to fund health research to become an organisation that plays a key role in supporting research relevant to mental illness, funding research training, and advocating for the needs of those with mental disorders. This reflects the recognition by ARH of the benefits of involving Rotary clubs as agents for health promotion and stigma reduction, rather than simply as a source of research funds. No other country has involved Rotary clubs in this way, but we believe it is a model that deserves to be emulated.

Anthony F Jorm PhD, DSc, FASSA · Michael G Sawyer MB BS, PhD, FRANZCP · Joy Gillett OAM

Terminal decline. A surgeon’s diagnosis of the Australian health-care system. Dr Mohamed Khadra. Sydney: Random House, 2010 (xiii + 263 pp, $34.95). ISBN 9781864711370. THE AUTHOR of this work is a respected surgeon, educator and author, who has done more than most in giving back to the community in which he now lives, as well as to other, more distant, communities. It is therefore disappointing that his latest book is a passionate but superficial tour through the recent history of the Australian health care system. It lacks the rigour required for such analysis. Many of the key political and medical figures involved in the introduction of universal health insurance were interviewed. Not surprisingly, they provide a retrospective justification for their stance of some decades ago. The method of diagnosis is lacking, in that there was no attempt to revisit contemporary texts and media of the time under evaluation. There is much extrapolation from powerful anecdote, leading to gross generalisations and oversimplification of the issues under discussion. There is an almost paranoid obsession with the meddling bureaucracy who obeyed the command to go forth and multiply. The obsession is justified to some extent but does not provide the entire explanation for the system’s woes. Reference to “an anti-doctor nurse turned journalist” bobs up out of nowhere. A glass half empty approach is adopted, from the title through to the denouement. There is repetitive pining for the days, viewed through rose-tinted spectacles, when the medical profession ruled the system and uninsured patients allegedly received wonderful care from charitable consultants. However, once the negativism has passed, which, unfortunately, is not until near the end of the book, the author makes some reasonable recommendations for cure. The publication is more suited to a series of media articles. If one is looking for serious investigative journalism, then the book does not, at least in the opinion of this reviewer, represent value for money.

Allan D Spigelman

To the Editor: Nash and colleagues have produced another report on medicolegal matters and Australian doctors.1 This report, and one that preceded it in 2009,2 are derived from responses to a questionnaire from nearly 3000 doctors. The survey showed that 65% of respondents had been involved in “medicolegal matters”. From a mass of data, the authors conclude that medicolegal concerns impact on doctors’ practice of medicine. As potential benefits of medicolegal matters, they list improved communication of risk to patients, disclosure of diagnostic uncertainty, and better methods to track test results and non-attenders. Negative impacts included increased referral to specialists, ordering more tests, and seeing fewer patients. The authors recommend targeted training in patient safety and medicolegal aspects of practice to help doctors to be “better informed”. However, as 65% of the group had been involved in medicolegal matters, it seems unlikely they need to be better informed about them. In the title and throughout the article, there is much emphasis on the word “perceived”. With this heavy emphasis on perception, it might be thought that the key finding was that fear of a medicolegal matter was greater than the reality. In fact, the reverse was found. Of those who had experienced medicolegal matters, 46% had considered retiring early, 39% considered giving up medicine and 38% considered reducing hours of work. The respective figures for those who had not experienced medicolegal matters were 29%, 22% and 21%. The difference was highly significant. An inescapable conclusion is that medicolegal matters result in large numbers of demoralised doctors. The reality is worse than the perception. Unfortunately, the obvious question — What was the outcome of the medicolegal matter? — was not included in the survey. Given the numbers involved, it seems likely that for many doctors, although the outcome was favourable, the process had a profoundly negative effect on their work. Forty-one per cent now regard every patient as a potential litigant. A logical response to these data might have been to ask: (1) Could there be a problem with the way medicolegal matters are conducted? and (2) Is the demoralisation of a large percentage of the medical workforce good for society? Neither question was asked here. This is perhaps not surprising as, in their previous article, the authors questioned, without embarrassment and on the basis of a questionnaire, whether “psychiatric morbidity in doctors is a cause or effect of the medicolegal process”.2 This study is “one of the largest [of its kind] in the world”. Sadly, the authors’ negativity towards doctors and their unquestioning allegiance to current medicolegal practice have greatly diminished its value.

Padraic J Grattan-Smith

In reply: I agree with Grattan-Smith that current medicolegal processes have profoundly negative effects on doctors. I do not agree that my coauthors and I have “negativity” towards doctors and an allegiance to current medicolegal practice. Our aim was to investigate the impact of medicolegal matters on Australian doctors — their emotional response and their practice changes.1,2 We have shown that doctors who have a current medicolegal matter have higher levels of psychiatric morbidity,2 and that most doctors believe they change how they practise due to medicolegal concerns — more so in the case of doctors who have experienced a medicolegal matter.1 Justice Ipp and colleagues,3 when reviewing the law of negligence for the Commonwealth of Australia in 2002 with the objective of limiting liability and damages arising from personal injury or death, made note of the lack of empirical evidence in the submissions they received. We have now provided some empirical evidence of medicolegal matters from the doctors’ perspective. If such a review were conducted now, I would suggest the current medicolegal systems are not good for patients, for doctors, or for the health system in general. The evidence from our studies1,2 now allows a more informed conversation on this issue to take place.

Louise M Nash