Health services administration

To the Editor: I found Van Der Weyden’s editorial “Whither medicine? The expansion of non-doctor practice”1 to be an unduly negative view of the emerging new clinical roles, such as nurse practitioners, in our health system. To imply, for example, that the access to prescribing rights for nurse practitioners is a significant challenge (rather than a help) to doctors is contrary to the experience of many such implementations of these roles. I have a clear view of the role of doctors. They should: be in charge and lead the decision-making process of multidisciplinary teams; be responsible for the cognitive and integrative aspects of clinical care, including the initial assessment and planning of management for undifferentiated patient presentations in all care settings; and provide high-level complex care, including procedural and diagnostic services that require their level of expertise. Doctors should not continue to provide clinical services that are not a good use of their considerable training and experience. These services, that could be provided by nurse practitioners, include routine monitoring and prescribing (under protocol and medical leadership) of maintenance treatments (such as haemodialysis treatment or routine diabetes review), and simple repetitive diagnostic or therapeutic procedures. In my experience, many doctors are bored with these intellectually limited aspects of their practice and find the quality of their clinical life substantially enhanced when given the opportunity to work in partnership with nurse practitioners. Again, in my experience, some tertiary-educated nurses are also bored with their limited clinical roles (still dominated by personal care) and can offer much more to the clinical team by focusing on the higher end of their skill base. There are clear differences between doctors and nurses in terms of selection process, education and training. However, this does not preclude both professional groups from looking at their scope of practice and focusing on the tasks that best use their expertise, rather than retaining roles based on custom and practice that are no longer relevant. If doctors embrace and lead the role redesign program, they can ensure that sensible delegations of their clinical tasks to other health practitioners can occur with benefit to all. Resistance and disengagement of doctors will not stop role redesign, as we clearly cannot sustain a health workforce in the future with a staffing model that has not changed materially for 100 years. Resistance and disengagement are more likely to lead to dysfunctional new roles being produced, without the necessary strong relationship with the medical profession required for the best patient care.

Brendan F Murphy

To the Editor: In his recent editorial,1 Van Der Weyden laments the “displacement” of doctors in modern health care by nurse practitioners and physician assistants, and bemoans the fact that discussion and debate about these matters is largely confined to medical tabloids such as Australian Doctor. In this context, the editorial cites unsubstantiated and inflammatory comments from Australian Doctor correspondents claiming that nurse practitioners place patients at risk.2,3 Remarks that nurse practitioners are “a disaster unfolding” and “people will die”3 are not only inflammatory but also inaccurate. Medical and nursing insiders have made these claims with self-appointed legitimacy and without evidence. They demonstrate a surprising level of ignorance about the role of nurse practitioners and the evidence base that supports their practice, particularly in emergency care.4 In an era where the drum of quality and safety in health care and evidence-based practice beats the loudest, where is the evidence to support such claims? Perhaps the lack of evidence is the reason why such claims implying that nurse practitioners present a risk to patients are housed in medical tabloids, where they escape the rigorous scrutiny of peer review that would otherwise expose this deficit. Van Der Weyden bewails that nurse practitioners are the only health professionals “whose skills and talents are extolled”.1 We doubt whether such trivialities are at the forefront of the minds of emergency nurse practitioners, who comprise a large proportion of nurse practitioners in Australia. As part of the broader health care team, their focus — and the focus of their physician, nurse and allied health colleagues — would be on the immediate and ongoing needs of their patients. Van Der Weyden asserts that an assumption of the equivalence of nurses and physicians underpins the political and industrial agenda for “doctor displacement” in general practice in Australia. Such an assertion is entirely moot. High-quality and safe health care cannot be realised by a monopoly of nurses, or physicians, or any other health profession. Nurses and physicians are only two of the many threads in the tapestry of high-quality, safe and evidence-based health care. Their success lies in symbiotic mutualism, not commensalism, amensalism, or parasitism. And, just like in tapestry, pulling any one thread from the fabric renders the picture incomplete.5 Unless there is substantial evidence to the contrary, bringing the safety of nurse practitioners into question is senseless, particularly given the well deserved support they have from their peers in the wider health community and their patients, both in Australia and overseas.

Ramon Z Shaban · Julie M Finucane · Dianne J Crellin

In reply: I welcome the comments of Murphy and of Shaban and colleagues on my recent editorial,1 which explored, as Shaban et al say, the “displacement of doctors in modern health care by nurse practitioners and physician assistants”. The main focus of the editorial was on the current philosophical relativism muddying the definition of what a doctor is and the academic qualifications underpinning all professional training. It calls for equally rigorous criteria to be applied to non-doctor practitioners and their scope for independent practice. Undoubtedly, the potential utility of non-doctor practice is dependent on bilateral mutualism, with a clearly defined scope of practice. However, the push for independent practice remains problematic. Whether there is a genuine commitment for bilateral mutualism to occur, beyond the usual rhetoric, is of concern — witness the recent difficult negotiations on defining the framework for cooperative practice, and the reticent views of doctors on the suitability of nurse practitioners and their scope for independent practice, as reported in Australian Doctor.2-4 The fundamental question, which must be addressed, is whether the granting of Pharmaceutical Benefits Schedule and Medicare Benefits Schedule privileges to non-doctors is simply a political strategy to create a two-tiered health system under the illusion of cost containment.

Martin B Van Der Weyden

Objective: To examine age and sex differences in the leading causes of prevalent disability in young Australians.Design, setting and participants: We analysed data from the 2003 Australian Burden of Disease and Injury Study, which estimated the prevalent disability burden attributable to 170 diseases and injuries, for younger adolescents (10–14 years), older adolescents (15–19 years) and young adults (20–24 years).Main outcome measures: The broad categories of disease and injury that are the main contributors to prevalent disability and the 10 leading disease and injury causes of prevalent disability, according to sex and age group.Results: Total prevalent disability rates are lowest in younger adolescents and highest in young adults. Mental disorders are the largest “contributor” to disability in young Australians, and anxiety and depressive disorders are the leading single cause. In young males, autism and attention deficit hyperactivity disorder cause similar levels of disability as do anxiety and depression. In young females, eating disorders are the second leading cause of mental disorder disability. Alcohol use disorders and schizophrenia make important contributions to disability in young adult males. Asthma is the most prominent cause of physical disability in all three age groups.Conclusions: There are substantial changes in both the pattern and level of disability burden across the three age groups that we studied. The increase in total prevalent disability that occurs from early adolescence to young adulthood should focus attention on the delivery of accessible and youth friendly health care as well as the effectiveness of transitions from child health services to adult health services.

Rebecca R S Mathews MPH · Wayne D Hall PhD · Theo Vos PhD · George C Patton MD, FRANZCP · Louisa Degenhardt PhD

New health roles and models are needed to address future workforce shortages in Australian health care. A pilot trial of introducing two United States-trained physician assistants (PAs) at Queen Elizabeth Hospital, from October 2008 to October 2009, demonstrated difficulties in introducing PAs into the South Australian health system. Unforeseen delays in planning and implementing the trial occurred. This led to a loss of personnel and a second round of recruitment. The PAs’ scope of practice was limited, and they could not demonstrate their work as they do in the US. Full use of their prescribing licence was not allowed until 3 months into the trial, and their authority to order radiology tests was limited. The issues faced at Queen Elizabeth Hospital could be avoided in future trials, ensuring a smoother trial period.

Phyllis B Ho MB BS · Guy J Maddern MB BS, PhD, FRACS

We do not have a health system with collaboratively oriented values. Reforms that former prime minister Kevin Rudd initiated, which are now Prime Minister Julia Gillard’s to prosecute, do not support such a health system. Reformers have consistently ignored present and potential values. A plan for reform of the health system must take into account differing stakeholders’ objectives and values and incorporate new values. This requires an agreement by stakeholders to embrace the common good. It will also need strong leadership and a willingness to embrace fundamental change.

Jeffrey Braithwaite MBA, PhD, FCHSM · Clare A Skinner MB BS, MPH, BA(Hons) · Mei Ling Döéry MB BS, BMedSci

To the Editor: Australia is in the process of making the most important change to its health care system since the implementation of Medicare.1 We agree with Cameron and Cooke that there are important lessons for Australia from the implementation of the 4-hour rule in the United Kingdom.2 As in Robert Zemeckis’s 1985 movie classic, Back to the future, the old question of “If I had the opportunity to do something again, what would I have done differently?” applies. We challenge the assumption that Australia is embarking on something that the UK has recently abandoned. The UK has not actually abandoned the 4-hour rule but expanded it into a suite of eight indicators that include three time-based measures, including total time in the emergency department (ED).3 Our concerns are about how the lessons learned by the UK can be applied in Australia in 2011 and beyond. Cameron and Cooke state that “Measurement systems should be in place to ensure that patient safety and quality of care are not compromised at any stage of the emergency care pathway”.2 The systems we have are neither universal nor integrated across the country. We need substantial data infrastructure, including comparable data linkage services across states. Of all the states, Western Australia has the most advanced national data linkage system. Yet even with the most sophisticated data systems in the world, proper impact assessment studies are required. Australia’s evaluation of the changes being made to rules and systems is neither systematic nor well standardised — to be safe and effective, innovation needs to be evaluated in coordinated and systematic ways.4 We also need systems-thinking approaches and simulation technologies to avoid repeating past mistakes. It is important to link theory and data to learn about the complex dynamics of ED patient flow and safety, and understand the consequences of our interventions.5 As suggested by Cameron and Cooke,2 we should focus on real-time, clinically relevant, consistent and comparable quantitative and qualitative data about patients, staff, processes, outcomes and facilities. We must learn to improve daily performance rather than sanction variable outliers. In conclusion, the lessons learned from the 4-hour target are relevant and appropriate for Australia. Cameron and Cooke have highlighted some of the dangers, including those of inadequate measurement.2 We need timely, integrated and linked data and an explicit theory of performance. We should aim to manage the risks by appropriately funded research and implementation strategies to improve this significant policy intervention while maintaining patients’ outcomes, experience and safety, and the timeliness of instigating their care.

Roberto Forero · Geoff D McDonnell · Sally M McCarthy · Peter Nugus · Jeffrey Braithwaite · Kenneth M Hillman · Daniel M Fatovich · David Mountain · Frank F Daly · Gerard J Fitzgerald · Drew B Richardson

Australia should lead in the effort to reduce the huge burden of non-communicable diseases When it comes to global health, the international aid effort is almost entirely focused on the immense burden that communicable diseases inflict on the world’s low- and middle-income nations. But the world is also facing what United Nations (UN) Secretary-General Ban Ki-moon describes as “a public health emergency in slow motion”.1 Across the globe, non-communicable diseases (NCDs) — principally heart disease, cancer, diabetes, kidney disease and chronic lung disorders — are imposing ever greater burdens on individuals, families, health systems and economies. The World Health Organization believes that NCDs now account for some eight million premature deaths (before the age of 60 years) each year in low- and middle-income countries. Altogether, there are an estimated 35 million NCD deaths each year, with around 80% occurring in low- and middle-income countries.2 Deaths from NCDs are projected to increase by 17% worldwide in the coming decade, with the largest increase (27%) occurring in Africa. The highest absolute number of deaths will be in Australia’s local regions: the Western Pacific and South-East Asia.2 And yet, much of this burden is avoidable, with around 80% of heart disease, stroke and type 2 diabetes and over a third of cancers deemed preventable by eliminating shared risk factors, including tobacco use, poor nutrition, physical inactivity and alcohol misuse. Despite the growing burden that NCDs inflict on the developing world, a pittance — just 2.3% — of overall development assistance for health was dedicated to NCDs in 2007.3 This is even more surprising given the impact that NCDs have on productivity. The World Economic Forum, an organisation of private, mostly multinational companies, already considers chronic disease in both developed and developing nations to be a major risk to the global economy.4 While prevention and treatment of NCDs make sound economic sense, calls for help from developing nations have met with little response. The UN said in a report on NCDs last year that “requests for technical support to scale up efforts, through aid and expertise, remain largely unanswered”.5 There is, however, some light at the end of the tunnel. Things are starting to change. After a concerted campaign by international chronic disease organisations and collective action by Commonwealth and Caribbean countries, the UN has agreed to hold a special summit on NCDs, the first health summit since the landmark HIV/AIDS gathering a decade ago. To be held in New York on 19–20 September 2011, the summit will consider what action might be taken to help all countries, but especially those of low and middle incomes, to meet the NCD challenge. It is clear that NCDs must become a key part of the global health and development agenda. This is the goal of the NCD Alliance,6 a coalition convened by the World Heart Federation, Union for International Cancer Control, International Diabetes Federation and the International Union Against Tuberculosis and Lung Disease. While the global campaign is being waged, an Australian group — Australians for Global Action on NCDs — has formed to encourage the Australian Government to help lead global change, by seeking tangible outcomes from the UN summit and playing a strong role beyond it, particularly in the Western Pacific region. Although much remains to be done at home, particularly for Aboriginal and Torres Strait Islander peoples and those from lower socioeconomic backgrounds, Australia should also boost efforts to assist developing nations in our region escalate their NCD-prevention efforts and improve screening, early detection, treatment and palliation. A gathering organised by our group at Parliament House on 2 March 2011 will help sell the message to federal politicians, many of whom are already sympathetic to the cause. Over the coming 7 months, the world will be looking to countries with strong records in prevention and management of chronic disease to help set the agenda for the UN summit on NCDs. While this includes nations across the income spectrum, Australia should be thrusting its hand in the air. We have much to offer. For example, Australia has been a leader in tobacco control. Robust action, including price hikes, comprehensive advertising bans and investment in social marketing, has seen smoking rates plummet in Australia, from 34% of the adult population in 1980 to less than 20% today.7 So, what do we want from the UN summit? Work is underway to define the best possible outcomes, but there is growing international consensus among NCD Alliance members around six primary objectives: Governments must have NCD plans and be accountable for progress. The existing WHO Framework Convention on Tobacco Control should be fully implemented. There must be a global commitment to prevention of NCDs. Globally agreed approaches to treatment and care must be forged. Resources must be available to deliver effective interventions and enhance the capacity of developing nations to meet the NCD challenge. NCDs must be prominently included in the targets that will follow the current Millennium Development Goals. Reducing the burden of NCDs will take dollars. It will take courage. And it will take long-term commitment. But it will pay for itself many times over by helping countless millions of people to lead longer, healthier, happier and more productive lives.

Australians for Global Action on NCDs*

Objective: To assess the accuracy of data linkage across the spectrum of emergency care in the absence of a unique patient identifier, and to use the linked data to examine service delivery outcomes in an emergency department (ED) setting.Design: Automated data linkage and manual data linkage were compared to determine their relative accuracy. Data were extracted from three separate health information systems: ambulance, ED and hospital inpatients, then linked to provide information about the emergency journey of each patient. The linking was done manually through physical review of records and automatically using a data linking tool (Health Data Integration) developed by the CSIRO (Commonwealth Scientific and Industrial Research Organisation). Match rate and quality of the linking were compared.Setting: 10 835 patient presentations to a large, regional teaching hospital ED over a 2-month period (August – September 2007).Results: Comparison of the manual and automated linkage outcomes for each pair of linked datasets demonstrated a sensitivity of between 95% and 99%; a specificity of between 75% and 99%; and a positive predictive value of between 88% and 95%.Conclusions: Our results indicate that automated linking provides a sound basis for health service analysis, even in the absence of a unique patient identifier. The use of an automated linking tool yields accurate data suitable for planning and service delivery purposes and enables the data to be linked regularly to examine service delivery outcomes.

Julia L Crilly BNurs, MN(Hons), PhD · John A O’Dwyer BCompScInfEng(Hons) · Marilla A O’Dwyer BEng(Hons) · James F Lind BS BM, BMedSci, FACEM · Julia A L Peters MB BS · Vivienne C Tippett BA, GradDipPsych, MPH(BiostatEpi) · Marianne C Wallis RN, BSc(Hons), PhD · Nerolie F Bost BNurs, MN · Gerben B Keijzers MB BS, MClinEpi, FACEM

Objective: To quantify women’s uptake of Medicare Benefits Schedule mental health items, compare characteristics of women by mental health service use, and investigate the impact on Medicare costs.Design, setting and participants: Analysis of linked survey data and Medicare records (November 2006 – December 2007) of 14 911 consenting participants of the Australian Longitudinal Study on Women’s Health (ALSWH) across three birth cohorts (1921–1926 [“older cohort”], 1946–1951 [“mid-age cohort”], and 1973–1978 [“younger cohort”]).Main outcome measures: Uptake of mental health items; 36-Item Short Form Health Survey (SF-36) Mental Health Index scores from ALSWH surveys; and patient (out-of-pocket) and benefit (government) costs from Medicare data.Results: A large proportion of women who reported mental health problems made no mental health claims (on the most recent survey, 88%, 90% and 99% of the younger, mid-age and older cohorts, respectively). Socioeconomically disadvantaged women were less likely to use the services. SF-36 Mental Health Index scores among women in the younger and mid-age cohorts were lowest for women who had accessed mental health items or self-reported a recent mental health condition. Mental health items are associated with higher costs to women and government.Conclusion: Although there has been rapid uptake of mental health items, uptake by women with mental health needs is low and there is potential socioeconomic inequity.

Julie E Byles BMed, PhD · Xenia Dolja-Gore BMaths, GradDipMedStats, MPhilMedSci · Deborah J Loxton BPsych(Hons), PhD · Lynne Parkinson BSc(Hons), PhD · Jennifer A Stewart Williams BCom(Econ), MCom(Econ), PhD

The move to national registration of doctors presents both threats and opportunities for the manner in which doctors seek health care and for providing assistance to doctors who may be impaired by illness. The most striking threat is the regressive nature of the provisions for mandatory reporting of ill doctors. The new system should be grasped as an opportunity to achieve national agreement on resourcing adequate services to help distressed doctors and to foster education and research into the health of doctors and medical students. The new system also provides opportunities to explore ways of encouraging doctors to improve their poor record of not attending to their own health, such as denying Medicare rebates for most doctors who self-refer.

Kerry J Breen MB BS, MD, FRACP

To the Editor: Before and since 1 July 2010, when the National Registration and Accreditation Scheme for health practitioners commenced, the claim that mandatory reporting laws will deter impaired doctors from seeking help has frequently been made. It was on the basis of this claim that Western Australia legislated to exempt health professionals from reporting impaired practitioners they are treating. At a recent conference of the Royal Australian College of General Practitioners, a representative of a medical indemnity organisation labelled the mandatory reporting laws a disgrace because the health of impaired doctors who are deterred from seeking help for this reason would be put at risk. However, she also indicated that the problem was more one of perception than reality because doctors feared triggering a mandatory report automatically if they sought help from another doctor for a perceived impairment.1 It is a problem of perception because, under the laws, only doctors whose impairment places the public at risk of “substantial” harm are required to be reported.2 If doctors have an unreasonable fear of mandatory reporting, we can infer that many are unaware of the details of the laws, in particular the reporting thresholds. Yet an argument against introducing the laws was that doctors were already under an ethical obligation to report, to the relevant authority, unprofessional conduct, impairment or performance that would put patients at risk.3 For this argument to be valid, doctors would need to be aware of the details of mandatory reporting because the Medical Board of Australia’s code of conduct for doctors states, in its list of ethical obligations, that doctors should be aware of their reporting obligations.4 So this particular argument does not appear to be valid. Because medical professionalism puts the wellbeing of the patient first; because psychological or physical health status may affect professional performance; and because the Board, like the state boards that preceded it, has a primary duty to the safety of the public — any doctor whose impairment poses a substantial risk or, in the absence of that doctor’s insight, any treating doctor who considers that a substantial risk exists should surely feel ethically compelled to report the matter to the Board. No doctor whose impairment does not pose a substantial risk should feel deterred from seeking medical help. The consequences for impaired doctors who are reported under the new legislation are no different from those of reporting a doctor when it was “merely” an ethical requirement — being placed on an impaired practitioners’ register and supported, managed and monitored, while, in most cases, continuing to practise. If impaired doctors and their treating doctors feel deterred by mandatory reporting laws, we are entitled to conclude that there was, and continues to be, significant non-compliance with the ethical obligations that arguments against mandatory reporting depend on.

Malcolm H Parker

To the Editor: In their paper, Campbell and colleagues list the potential pitfalls of introducing pay-for-performance into Australian primary care.1 They emphasise that, in Australia, the electronic medical records used in general practice would not support the introduction of a scheme such as the Quality and Outcomes Framework (QOF) that is in place in the United Kingdom. In 2009, we demonstrated that it was quite possible to apply a QOF in a large Australian general practice by adapting the in-built search facility of a commonly used medical records program.2 We concluded that the introduction of a QOF in Australia would drive up the quality of our care. The non-clinical standards of a QOF are already similar to those set by the Royal Australian College of General Practitioners for accreditation and could be readily achieved. Campbell and colleagues suggest that the QOF is expensive and without proven benefits.1 This is incorrect. As predicted, the QOF has not only led to a reduction in cardiovascular disease events, but the benefit is greatest in the lowest socioeconomic groups.3 It is now possible to measure the cost effectiveness of a QOF, which is likely to show that it pays for itself by way of reduced morbidity and health service costs.4 Rather than argue for general practitioner remuneration based on pay-for-performance to be less than 20%, one should err on the side of caution, which recognises that 20% has ensured a massive public health gain for the British population. Now that 95% of GPs use computers, at least for prescribing,5 it is plausible that an Australian QOF could be developed, but pay-for-performance may need to include some pay-for-data incentives.

Mark A J Morgan · James Dunbar

In reply: Our article, which related to clinical care, not non-clinical standards, was intended to generate debate, and the points raised by Morgan and Dunbar are important ones. We address the central issue, which relates to the intended purpose of introducing a pay-for-performance scheme, similar to the Quality and Outcomes Framework (QOF) in the United Kingdom, into Australian general practice. Morgan and Dunbar state in their letter, “Now that 95% of GPs use computers for prescribing”; this emphasises that it would not be a level playing field. Even if all indicators only related to prescribing, at least 5% of practices would be disenfranchised. That statement also appears to presume that 95% of practices use compatible and comparable clinical codes. The UK witnessed years of computerisation and clinical code usage across a wide range of clinical issues before the introduction of the QOF. Elliot-Smith and Morgan adapted “the in-built search facility of a commonly used medical records program”, and introducing a QOF-like scheme in Australia would involve this investment in all practices. The percentage of income attributed to pay-for-performance is a political decision, and most people who are involved in the QOF in the UK strongly believe that it is too high. Whatever level is set, it must result in a level playing field for practices.

Stephen M Campbell · Anthony Scott · Rhian M Parker

Palliative care is becoming fundamental in the starting line-up of care choices For Australian patients with advanced, incurable illness, particularly cancer, the option of referral to specialist palliative care services can seem to be a random and discretionary default option that is sometimes called on when all possibilities for life-extending treatment have been exhausted or cannot easily be accessed. Palliative care services (distinct from palliative chemotherapy) provide a broad range of inputs to patients and their carers and loved ones, including specialised medical and nursing management and advice on symptom control; psychological, emotional and spiritual support; practical nursing care; advice and assistance with goal setting and end-of-life care; and bereavement counselling and support. Despite offering these and other unique strategies in the field of cancer management, these specialist palliative care services sometimes stay on the substitute’s bench until called on late, when all else has failed. In Australia, despite having had principles of goal setting and broad palliative care education as part of the medical curriculum for over 20 years,1-3 and despite evidence of the benefits of referral to specialist palliative care services,4 only 42% of patients who die of advanced cancer and other terminal illnesses in the country’s busiest acute hospital are referred to a specialist palliative care service.5 Patients with haematological malignancies are referred less frequently than patients with solid tumours.6 Although oncologists in Australia report that they favour early referral for specialist palliative care, with a concurrent rather than sequential model of care,7 patients are usually referred late. In one large, integrated Australian palliative care service, patients had a median length of survival after referral of 54 days, representing the final 17% of their illness duration.8 Perceived barriers to improving palliative care referral and provision include inadequate communication about goal setting and resuscitation orders; inadequate symptom control; and lack of resources, including inadequate bereavement counselling of caregivers.7 A Queensland senator recently called Australian palliative care services “an under-resourced shambles”.9 In Australia and elsewhere, there have been increasing efforts to more accurately define the benefits or otherwise of early referral to palliative care services for patients with an incurable and progressive illness. However, research has been difficult, and randomised controlled trials have not been of high impact. Now, the results of two recent prospective, randomised studies from the United States10,11 will help to broaden Australian clinicians’ and the public’s understanding of the role of specialist palliative care services in the care of patients with advanced, incurable cancer and the advantages of early referral. Although the evidence from these studies has limited application in Australia because of differences in the US and Australian health care systems, the models of care being tested are similar to current Australian models, and the results have the potential to significantly shape practice and policy in this increasingly important part of health care.9 A non-blinded randomised controlled trial reported by Temel and colleagues10 provides a watershed moment in oncology and palliative care. One hundred and fifty-one ambulatory patients referred to an outpatient thoracic oncology clinic for newly diagnosed non-small cell metastatic lung cancer were randomly allocated to standard oncology care with or without referral to a palliative care team. The primary outcome was change in health-related quality of life at 12 weeks. Patients in the early palliative care group had better quality of life and fewer depressive symptoms compared with those receiving only standard care (Box). The various goals of new interventions in cancer treatment include improving survival; reducing treatment toxicity; improving quality-of-life scores (eg, mood); and reducing the financial costs of treatment. This study achieved all these goals with just the modest intervention of an average of four visits from the specialist palliative care team in the first 12 weeks. Importantly, the median survival time of 8.9 months was at least as good as would be predicted and expected for the control group. The improvement in overall survival of 2.7 months (30%) for the intervention group who were referred for early palliative care was equal to or greater than that achieved for comparable patient groups with chemotherapy versus best supportive care12 or the addition of the new and very expensive targeted agents cetuximab or bevacizumab to chemotherapy.13,14 It was achieved despite significantly fewer patients receiving aggressive end-of-life care. The size of the survival benefit may have been reduced because 14% of the control group also received early referral to a specialist palliative care service for symptom control and had 1–2 palliative care visits during the 12 weeks. A survival advantage from early palliative care referral has been suggested previously,15 but will need to be replicated by studies in other care settings and in patients with other types of cancer. Possible weaknesses of this study are the lack of blinding and lack of patient comorbidity data. Extra time spent with health care professionals, rather than any specific palliative care intervention, may have contributed to the improvements seen. But if this were so, this effect would also have been expected in studies showing benefits of chemotherapy plus best supportive care versus best supportive care alone, whereas no difference was shown in survival advantage between these groups.12 Also, even though the patient groups were balanced for types of chemotherapy and other treatments at enrolment and for the number of courses of chemotherapy during the study, more detailed data on specific chemotherapy regimens are lacking. Wright and colleagues11 followed 333 patients with advanced cancer from their enrolment until their death. Those referred to specialist palliative care services had better outcomes when treated outside an acute hospital (Box). Assessment of their carers at enrolment and after the death of the patient showed that those who were assisted in providing care at home until the patient’s death had significantly less risk of developing post-traumatic stress disorder or prolonged grief disorder. In the future, as we seek to confirm and understand more about how these improvements were achieved in patients receiving specialist palliative care, early referral for palliative care should become part of all arms of any randomised trial of advanced cancer treatment, particularly when a new treatment is being compared with best supportive care or current best treatment. The results of the two studies discussed here provide the best evidence yet for the multiple benefits of early referral to palliative care services in the care of patients with advanced, incurable cancer. They show that early referral can improve all measurable outcomes for patients by as much as, or more than, new and expensive treatments. Further, they show that early referral can help patients and carers better understand and choose between their treatment options near the end of life, reducing futile use of finite medical resources, debilitating treatments such as continuing cycles of chemotherapy in very advanced stages of illness, and acute in-hospital interventions at the end of life. The incidence of subsequent emotionally and financially debilitating psychological and psychiatric sequelae in the carers of these patients can be reduced. Because of new high-quality evidence, palliative care is rapidly moving from being an ancillary and sometimes discretionary medical treatment option to being fundamental in the starting line-up of care choices for patients with advanced cancer. If early referral for specialist palliative care were an expensive new drug, it would quite appropriately be marketed as a major advance in improving the care of patients with incurable cancer. Two recent US studies showing benefits of early specialist palliative care in patients with advanced cancer: overview Temel et al10 Research question: Does early referral of ambulatory patients with newly diagnosed metastatic non-small cell lung cancer to a specialist palliative care service affect patient-reported outcomes, use of health services and quality of end-of-life care? Design Non-blinded randomised controlled trial; 151 lung cancer patients referred to an outpatient clinic Standard oncology care versus standard care with referral to a palliative care team (seen within 3 weeks, and at least monthly until death) Groups well balanced for all known prognostic factors, initial cancer therapy, and baseline quality of life and mood Quality of life and mood assessed at baseline and 12 weeks Data on end-of-life care derived from medical records Findings Patients assigned to early palliative care received an average of four palliative care visits in 12 weeks (range, 0–8 visits) Patients in the intervention group had better quality of life than patients assigned to standard care Proportion of patients with clinical depression decreased in the intervention group from 22% to 16% and increased in the control group from 25% to 38% (P = 0.01) Fewer patients with early palliative care compared with standard care received aggressive end-of-life care (33% v 54% of those who had died by time of analysis; P = 0.05). Median survival was significantly longer among patients receiving early palliative care (11.6 v 8.9 months; P = 0.02) Wright et al11 Research question: Is the place of death for patients with cancer associated with patients’ quality of life at the end of life and psychiatric disorders in bereaved caregivers? Design Prospective, longitudinal multisite study; 333 patients with advanced cancer and their caregivers Patients followed from enrolment to death (median, 4.5 months) Quality of life at end of life assessed by caregiver report within 2 weeks of death Caregivers’ mental health assessed at baseline, and 6 months after patient’s death Findings Patients who died in an intensive care unit or hospital experienced more physical and emotional distress and worse quality of life at the end of life compared with patients who died at home with palliative care Death in an intensive care unit was associated with a greater risk of post-traumatic stress disorder in carers compared with death at home with palliative care (21.1% v 4.4%; P = 0.02) Death in hospital was associated with heightened risk for prolonged grief disorder in carers compared with death at home with palliative care (21.6% v 5.2%; P = 0.02)

Ian E Haines MB BS, FRACP, FAChPM

Not so long ago, The Australian ran a story1 that instantly reminded me of the memorable misquoted line from the Kevin Costner movie Field of Dreams: “If you build it, they will come”. The headline boldly proclaimed: “Another super clinic to get by with no doctors”. It continued: A second Gillard government GP super clinic is destined to open its doors without a doctor. The $7 million clinic ... will not have a doctor but will be staffed by up to 40 allied health workers, including psychologists, nurses and diabetes educators. ... [it is but one] of the original 36 GP super clinics promised during the 2007 election campaign. The appearance of super clinics without the necessary complement of doctors on staff contravenes government policy that GP super clinics must include general practitioners. This phenomenon prompted the Opposition primary health spokesman to observe that the GP super clinic program had “become like a rolling episode of Yes Minister. Another day, another GP super clinic without a doctor, another example of how three years on this program had been mismanaged, overly promoted and under-delivered.” This turn of events is but another example of the political and bureaucratic bloody-mindedness so alive in health these days. What folly, to never for one moment consider the uneasiness of GPs and organised medicine about the utility of GP super clinics. The political decision has been made, and money is no object. It is reminiscent of the roll-out of the Divisions of General Practice some years ago. Apparently, the Divisions are now destined to metamorphose into Medicare Locals. And the wheel goes around and around! Costner’s character in Field of Dreams desperately wanted a baseball field. But if the story of GP super clinics in Australia were to be made into a movie, would Nicola Roxon, the federal Minister for Health, transform the memorable line to: “We will build it ... but will they come?”

Martin B Van Der Weyden

Joining university to clinical service, research to practice The model of the academic health science centre (AHSC) arose decades ago in the United States,1 and is now internationally well established, with 17 centres in Canada, eight in Holland, five in the United Kingdom, two in Singapore, but none in Australia. An AHSC is where a leading university joins with a major tertiary health care provider in a tripartite mission of excellence in clinical service, research and education. AHSCs drive a care continuum from innovation, to bedside, to the community, endeavouring to ensure that the latest advances and highest standards reach patients. They are so well established abroad that the debate has moved on to extending AHSCs into systems or networks to embrace primary health care and global responsibilities.2 Curiously, Australia’s National Health and Medical Research Council (NHMRC) makes no mention of AHSCs in its 2010–2012 strategic plan,3 despite its own external review (the Zerhouni Review) advocating creation of at least a few Australian centres of world-class excellence in translational and clinical research.4 Similarly, AHSCs did not attract serious discussion in the report of the Council of Australian Governments (COAG) National Health and Hospitals Network (NHHN) Agreement (April 2010), although the detail at least acknowledges that engagement with university clinical schools and research centres is critical to translating clinical research into practice, ongoing professional development and training the next generation of clinical leaders.5 Strong advocacy for AHSCs to be introduced in Australia has apparently been ignored,6,7 with Brooks warning that our nation is failing to capitalise on global developments in academic medicine.7 So what are the barriers? First, there is a culture clash between federally funded autonomous universities and state-funded hospitals managed as a separate conglomerate in each state and subject to local politics and regional priorities. Indeed, the emphasis in state health departments, it seems, is more on homogeneity than the excellence strived for in academia. This engenders turf wars between universities and hospitals over their diverse missions, priorities, operational frameworks and employment conditions, with process and contracts frustrating attempts to bridge the gap. Cost shifting replaces what should be cost sharing. The second barrier is that the three AHSC pillars — research, education and health care — are overseen by three separate federal government departments and thus three separate ministers. Third, there are additional players in the research sector — the independent medical research institutes — who, although affiliated with universities and tertiary hospitals, have at times eschewed translational links with clinical medicine in favour of basic science. Finally, Australian health care is delivered in a pluralistic mix of private and public funding. Yet none of these issues is unique to Australia or insurmountable, especially when one considers the complexities of the US health care environment where AHSCs began. Cultural cringe may be a further hurdle for AHSC advocates. The NHMRC has foreshadowed the concept of “advanced health care centres”,8 seemingly in response to sensitivities among its political masters about use of the term “academic”. Surely, however, the Australian public are now mature enough to embrace excellence rather than mediocrity in health care, just as they do in sport? In fact, perceived anti-intellectualism is not uniquely Australian, as the case for retaining the term “academic” similarly needed pressing in the UK. Simply put, the best doctors treat patients, do research and train tomorrow’s health care providers. There is now an international association of academic health centres,9 whereas a web search for the “advanced” variant suggests instead a primary and community care focus. The advent, in mid 2011, of Local Hospital Networks, a central plank of the COAG NHHN Agreement,5 offers a pivotal opportunity to introduce AHSCs. Indeed, the simultaneous introduction of Medicare Locals, organisations intended to integrate and coordinate primary care services, provides a serendipitous platform to extend AHSCs into primary care. Ring-fencing hospital leadership from state health bureaucracies will be essential, particularly given the watered-down version that survived COAG. We should not underestimate the challenges of change management, which will require both top-down and bottom-up approaches to unite hospitals and universities, primary care and medical research institutes in a single mission. The choice of governance method is perhaps best determined locally;10,11 an integrated model with a single organisational structure is the ideal, but affiliated models may be more achievable with multiple partners. The NHHN should foster economic support for AHSCs through the 60% federal funding proposed for research and training in public hospitals (100% in primary care),5 and it will be crucial that new monies be spent at the interface of training, service and research. The real challenge will be winning the hearts and minds of federal and state politicians. As in Europe and North America, politicians will need convincing of the economic benefits of linking research to health and embedding research and training as core business in our leading hospitals and primary care networks. Although our international competitiveness in biomedical science is an important pay-off in its own right, the things that swung the argument abroad were improved patient outcomes and cost efficiencies. How many AHSCs does Australia need? With critical mass and existing academic strength as prerequisites, the number will depend on the extent to which AHSCs develop around universities or existing teaching hospitals, or amalgamate to form geographic clusters. Experience in the UK points to competitive national selection being a valid means of testing commitment and the strength of joined-up partnerships. We advocate a similar international review process here, say with four to six AHSCs designated in the first wave. The time is ripe for Australia’s health systems to grasp this opportunity to move from good to great and establish world-class AHSCs in an Australian context.

Nicholas M Fisk PhD, MBA, FRANZCOG · Steven L Wesselingh BM BS, PhD, FRACP · Justin J Beilby MD, MPH, FRACGP · Nicholas J Glasgow MB ChB, MD, FRACGP · Ian B Puddey MB BS, MD, FRACP · Bruce G Robinson MD, MSc, FRACP · James A Angus BSc, PhD, FAA · Peter J Smith MD, FRACP, FRACPA

The medical and psychosocial needs of children and adolescents differ from those of adults, and this should be reflected in the care they receive in all areas of a health service. Children and adolescents must be accommodated separately to adults to ensure that their unique needs are met and risks of harm are minimised. The Standards for the care of children and adolescents in health services have been developed by a working group of clinicians, health service providers and consumer advocates based on a combination of available research evidence, published best practice guidelines and multidisciplinary expert consensus. Stakeholder input was obtained through invitations to comment, and pilot testing of the Standards was conducted in six metropolitan, regional and rural hospitals. The Standards provide detailed recommendations in the areas of recognising rights; the provision of child-, adolescent- and family-friendly health service facilities; the availability of child- and adolescent-specific equipment; and the importance of appropriately trained staff. To facilitate implementation and allow ongoing performance monitoring, the Standards have been developed for use alongside the Australian Council on Healthcare Standards Evaluation and Quality Improvement Program. The Standards provide a vehicle to ensure patient safety and to facilitate the provision of high-quality care for children and adolescents in Australian health services.

Melissa K Hill BSc(Hons), PhD · Marjorie Pawsey MB BS, DPH · Anne Cutler MEd(Health) · Joanna L Holt BSc, MHP · Sharon R Goldfeld FRACP, FAFPHM, PhD

Electronic referrals and discharge summaries can improve the quality and timeliness of clinical communication. The electronic summary care record (SCR) extends the concept of digital health summaries to create a perpetually updated and centrally stored summary of care, extracting key data from local systems after each encounter. The only major SCR evaluation to date, in England, found that rates of usage were low, and any impact on care was difficult to quantify. The SCR is seen by some as a first step to building a national distributed shared electronic health record (SEHR). However, the SCR may be a problematic diversion, creating a need for centralised databases, while the SEHR can function by sharing locally stored records, letters and discharge summaries. Uncertainty about the quality and provenance of SCR data raises concerns about patient safety, as key data may be absent and old data may persist, partly because of a lack of ownership of the summary. A national e-health strategy should emphasise the true stepping stones to a distributed and shared electronic record, including encouraging the uptake and meaningful use of electronic clinical records, clinical messaging, electronic discharge summaries and letters, and services such as decision support and e-prescribing, all of which have good evidence to support them.

Enrico Coiera MB BS, PhD

Reports of adverse events related to calcium supplementation should be supported by rigorous evidence Calcium is an essential nutrient, not only because of its major role in bone, where 99% of it is stored, but because of its central role in neuromuscular function. It is this latter role that explains why ionised calcium in the blood and tissue fluids is one of the most tightly controlled analytes of those that are commonly measured.1 However, maintenance of the calcium level in tissue fluids carries with it the penalty of continuous loss of calcium through the kidneys, bowel and skin, even on a low calcium intake, which is why the recommended daily calcium allowance for adults is relatively high, at 1000 mg.2 Nutritional deficiencies of other minerals, such as magnesium and phosphate, are rare because their tissue fluid levels are not tightly controlled but vary with intake and, therefore, so does their excretion. Calcium is different; reducing calcium intake has a marginal effect on extracellular calcium (and therefore on calcium excretion) because bone is mobilised to maintain the calcium level, which leads sooner or later to the development of osteoporosis. This is the case in laboratory animals3 and, by implication, in humans. Osteoporosis is therefore the index disease for calcium deficiency,4 just as rickets and osteomalacia are the index diseases for vitamin D deficiency; however, there is some overlap between them because the secondary hyperparathyroidism associated with hypovitaminosis D5 increases bone resorption. This is not to suggest that all adult osteoporosis is due to calcium deficiency, but simply to point out that the increase in bone resorption which follows menopause6 can be largely or wholly explained by the fall in calcium absorption and rise in obligatory calcium excretion which occur at this time,7 and also occur in oophorectomised animals.8,9 (The loss of a direct antiresorptive action of oestrogen on bone at menopause cannot be excluded but is probably quantitatively much less important.) For these reasons, it has become standard practice to recommend calcium supplementation to postmenopausal women, increasingly with vitamin D, to prevent or delay bone loss and reduce fracture risk. In the largest meta-analyses, calcium with vitamin D in adequate dosage reduces fracture risk by 25% or more, but vitamin D alone is not effective.10,11 Until very recently, calcium supplementation was not thought to cause any significant side effects. However, a New Zealand team recently reported an increase in the mean rate of mainly self-reported myocardial infarction in participants who were allocated to receive calcium supplements in five prospective trials for which patient-level information was available.12 Although the effect was not significant in any of the trials individually, it was significant at the 5% level in the whole series and has attracted sufficient media attention to endanger the use of calcium in the prevention of osteoporosis in postmenopausal women. An extension of this case against calcium recently appeared in this Journal, in a position statement on fracture prevention in aged-care facilities that was co-authored by one member of the New Zealand team.13 The article not only ignores the seminal work of Chapuy and colleagues on fracture prevention with vitamin D and calcium in aged care homes,14 but specifically opposes the general use of calcium supplementation on four separate grounds, none of which are directly referenced. The first is that long-term compliance with calcium supplementation is very poor, whereas in most trials it is not significantly different from compliance with placebo.15 The second is that the anti-fracture efficacy of calcium is marginal, despite overwhelming evidence to the contrary in the largest meta-analyses.10,11 The third is a bizarre claim that calcium could increase the rate of hip fracture; this is only supported by one trial (by one of the co-authors of the position statement) in which the adverse effect was not remotely significant in participants who complied with calcium supplementation,15 which is widely regarded as an anomaly and is contradicted by a later meta-analysis.16 The final is that calcium supplementation could increase the risk of myocardial infarction, which is highly contentious and negated by the latest meta-analysis of 17 trials.17 These negative statements about calcium (which are not reflected in the article’s abstract) are coupled with the promotion of bisphosphonates — particularly the intravenous variety — despite the fact that virtually all the bisphosphonate trials have incorporated calcium supplements. It may therefore be relevant that this article arose from a meeting financed by a pharmaceutical company that happens to market an intravenous bisphosphonate and gave some form of assistance to six of the 10 authors.13 Since it is clearly stated that this meeting was endorsed by the Royal Australian College of General Practitioners, the Australian and New Zealand Bone and Mineral Society and Osteoporosis Australia, there is a strong implication that these bodies also support the article itself. It is questionable whether such public bodies should lend their authority to a position statement of uneven quality and which runs the risk of being seen as commercially driven.

B E Christopher Nordin MD, FRACP, DSc

Timeliness is important only to the extent that high-quality patient care is preserved Increasing demand for emergency care has worsened access to acute hospital services across the developed world. Australia’s response has been a mixture of time-based emergency department (ED) targets to drive process improvements, efforts to divert patients from EDs into community-based services and changes to accelerate hospital-wide processes and patient discharges. There has also been increased investment in bed capacity, although not commensurate with rising demand. Seasonal planning has been undertaken for both acute and sub-acute sectors. Despite these initiatives, access to acute hospital care has become measurably worse.1 The Australian Government has announced the introduction of a 4-hour rule that guarantees all emergency patients access to a hospital bed within 4 hours of arrival if clinically appropriate; the target will apply to critically ill patients (triage category 1) by January 2011, and to all patients by January 2015.2 Almost simultaneously, the United Kingdom Government has announced that it will replace England’s 4-hour standard with measures of patient outcome and safety,3 designed to deliver continuous improvements in standards in EDs. A look at the experience in England and why the decision has now been taken to move away from a time-based standard may reveal lessons for Australia about how to implement its new rule. The 4-hour emergency access standard in England is different from the guarantee announced in Australia because it allows for fewer exceptions, requiring that all ED patients be admitted, transferred or discharged within 4 hours of arrival in the ED. It has been in place for nearly 10 years, with a 98% operational threshold since 2003 to allow for the small number of patients who need more than 4 hours of ED care. Despite some obvious attempts at gaming and data manipulation,4 it has genuinely reduced length of stay overall in EDs and won patients’ approval.5 Before the introduction of the standard, there was evidence of patients having long waits in EDs before being seen by a doctor and before being transferred to a ward. The causes of delays were variable between hospitals.6 Also as a direct consequence of the 4-hour standard, innovations7 to manage patient care more efficiently have been introduced, including new models of care (eg, clinical decision units to fast-track care of patients with minor injuries). However, initiatives to reduce ED attendances have had little success. In fact, they may have led to poor practice in some hospitals, such as premature discharge and transfer of patients from the ED, resulting in preventable deterioration and mortality.8 Investment in the UK National Health Service (NHS) has doubled in recent years,9 with increased hospital staffing and capacity, increased resourcing of EDs and increased investment in community social care. The 4-hour standard has been the single major performance measure of the processes of the UK’s emergency care system. NHS organisations were strongly performance managed against this standard, with penalties for not achieving it. Hence, a lot of effort was expended to meet the target. In most EDs, accurate data collection systems are now in place to track patients, but are not necessarily available throughout the rest of the patient journey. Research has shown a link between length of stay in the ED and various outcomes, but it is not known whether overall patient outcomes have improved or deteriorated as a result of the 4-hour target. The Mid Staffordshire Trust review10 found that an excessive focus on time-based targets caused a significant increase in patient mortality and a major outbreak of hospital-acquired infection. But an independent report from Harvard University found “no evidence for any of the dysfunctional effects”.11 A recent Nuffield Trust report5 suggested that the emphasis on time in EDs had resulted in increased referral of patients between agencies, but no real improvement in efficiency and possible decline in efficiency. The over-focus on time-based medicine may result in work dissatisfaction for staff and decreased training opportunities. Additionally, the patient contact time may be reduced or hurried, potentially decreasing both patient and doctor satisfaction. The evolving approach in England aligns to the incoming UK coalition government’s commitment to freeing the NHS from what it sees as unnecessary micro-management through the imposition of process targets. Its more holistic approach is to hold the NHS to account for clinical outcomes and the quality of patients’ experiences, and to allow local decisions on processes and structure; results of a dashboard of clinical quality indicators will be published to encourage continuous improvement. Nevertheless, the UK Government recognises the clinical importance of timeliness of care and has said that it will include it in the dashboard of indicators. The lesson for Australia is that although introduction of a rigid time-based target to empty EDs is seductively simple and potentially effective in solving a single problem, there are significant dangers. Measurement systems should be in place to ensure that patient safety and quality of care are not compromised at any stage of the emergency care pathway. This requires a significant investment in information technology and highly developed monitoring of patient care processes and outcomes, including national registries for high-risk, high-cost patients and national audits of important standards of care. Clinicians in both countries agree that best care combines optimal outcome, patient experience and timeliness, and involves looking at the whole emergency care pathway from the first call for help until return home.

Peter A Cameron MD, FACEM · Matthew W Cooke PhD, FCEM, DipIMC

Objective: To compare the level and determinants of job satisfaction between four groups of Australian doctors: general practitioners, specialists, specialists-in-training, and hospital non-specialists.Design, participants and setting: National cross-sectional questionnaire survey as part of the baseline cohort of a longitudinal survey of Australian doctors in clinical practice (Medicine in Australia — Balancing Employment and Life [MABEL]), undertaken between June and November 2008, including 5193 Australian doctors (2223 GPs, 2011 specialists, 351 hospital non-specialists, and 608 specialists-in-training).Main outcome measures: Job satisfaction scores for each group of doctors; the association between job satisfaction and doctor, job and geographical characteristics.Results: 85.7% of doctors were moderately or very satisfied with their jobs. There were no differences in job satisfaction between GPs, specialists and specialists-in-training. Hospital non-specialists were the least satisfied compared with GPs (odds ratio [OR], 0.56 [95% CI, 0.39–0.81]). For all doctors, factors associated with high job satisfaction were a good support network (OR, 1.72 [95% CI, 1.41–2.10]), patients not having unrealistic expectations (OR, 1.48 [95% CI, 1.25–1.75]), and having no difficulty in taking time off work (OR,1.48 [95% CI, 1.20–1.84]). These associations did not vary across doctor types. Compared with GPs, on-call work was associated with lower job satisfaction for specialists (OR, 0.48 [95% CI, 0.23–0.98]) and hospital non-specialists (OR, 0.25 [95% CI, 0.08–0.83]).Conclusion: This is the first national survey of job satisfaction for doctors in Australia. It provides an important baseline to examine the impact of future health care reforms and other policy changes on the job satisfaction of doctors.

Catherine M Joyce BA(Hons), MPsych, PhD · Stefanie Schurer MSc, PhD · Anthony Scott BA, MSc, PhD · John Humphreys BA(Hons), DipEd, PhD · Guyonne Kalb MEc, PhD

Professional ethical codes identify the issue of conflict of interest, which can distort doctors’ objective judgements concerning the best interests of patients. Legal fiduciary duties may be owed by doctors to patients in situations of potential conflict of interest. Prescribing and dispensing functions have been largely legally separated to prevent conflicts of interest arising. The advent of integrative medicine has been accompanied by an apparent growth of in-house selling of therapeutic products. Medical merchandising constitutes a prima-facie conflict of interest and may amount to notifiable conduct under the Health Practitioner Regulation National Law provisions. We believe that doctors who sell therapeutic products should adhere to strict conditions to avoid significantly departing from accepted professional standards. Doctors who have a reasonable belief that a colleague is failing to comply with these conditions could consider notifying the Medical Board of Australia.

Malcolm H Parker MB BS, MLitt, MD · Jon L Wardle BHSc(Nat), MPH · Michael Weir BA, LLM, PhD · Cameron L Stewart BEc, LLB(Hons), PhD

To the Editor: Readers of the Journal’s editorial on the importance of clinical patient-outcome monitoring asking “Where are the clinical data?”1 will be pleased to know that the state of Victoria collects considerable data on surgical outcomes. Since 2001, the Department of Health’s Victorian Surgical Consultative Council (VSCC; http://www.health.vic.gov.au/vscc/) has monitored surgical outcomes in the state’s public hospitals. Monitoring of both morbidity and mortality outcomes is combined with voluntary and mandatory case reporting and a high level of participation of hospitals and surgeons. It is compulsory for hospitals to report a range of sentinel adverse events and undertake corrective strategies. Data about surgical inpatients are obtained from discharge coding in medical records statewide, and the chief executive officers and directors of surgery of health services with “outlying performance” are invited to analyse the case records and provide their findings to the VSCC. A VSCC subcommittee, the Surgical Outcomes Information Initiative, promulgates the conclusions in a de-identified manner to hospitals, surgeons and trainees, with a view to improving safety, systems and surgical outcomes. Since 2008, deaths of public hospital patients that occur under surgical care are monitored by the Victorian Audit of Surgical Mortality (VASM, derived from the VSCC), which covers most surgical specialties, and is soon to embrace private hospitals and, hopefully, gynaecological surgery as well. De-identified educative information from autopsies and case analyses is offered to surgeons and trainees, whose participation in case reporting and assessing is now a professional requirement of the Royal Australasian College of Surgeons (RACS). Surgical mortality as monitored by the VASM is now bi-nationally compared through the RACS’s overarching Australian and New Zealand Audit of Surgical Mortality. Victoria’s Department of Health has longstanding collections of data for anaesthetic, obstetric and perinatal outcomes, with similar consultative councils. Several surgical specialties have for over a decade collected and promulgated their morbidity and mortality information. The Melbourne Vascular Surgical Association requires its members to participate in clinical outcome audits, as does the Australian and New Zealand Society for Vascular Surgery. Other specialties that audit outcomes are orthopaedic surgery (the bone and joint registry), transplantation surgery and cardiac surgery. Surgeons’ general experience of clinical patient-outcome monitoring is that of enthusiasm for its professional and community benefits, including the benefit of knowing that Australia’s overall surgical standards are comparable with the world’s best. The incentive remains to improve data capture, patient safety and eternal clinical vigilance, and these endeavours deserve support.

Peter L Field

To the Editor: Clarke and Fitzgerald showed that substantial savings could arise from the implementation of alternative pricing arrangements for off-patent statins that provide incentives to reduce prices and increase generic substitution.1 This is exemplified by comparing statin prices between Australia and England. Europe offers some more lessons with respect to savings based on generic medicine usage and how they can be attained. The size of savings reported by Clarke and Fitzgerald needs to be interpreted with caution. A scenario of 100% generic substitution is proposed. Such a scenario has not been observed in any European country and, for therapeutic reasons, is probably not desirable.2 Furthermore, the comparator country matters: for instance, generic medicine prices in England are lower than in France, the Netherlands and Germany, but are higher than those in Scandinavian countries.3 Finally, the implementation of a tendering system for statins may create unintended effects, such as a switch in prescribing behaviour. For example, the Belgian tendering system for simvastatin reduced expenditure on off-patent medicines containing simvastatin by 30%, but increased expenditure for patented medicines containing atorvastatin or rosuvastatin by 16% and 40%, respectively.4 Clarke and Fitzgerald’s article does not go into detail on how savings can be attained through use of generic medicines. The majority of European countries regulate generic medicine prices by pricing rules or reference pricing. For instance, the implementation of a minimum price difference between originator and generic medicines is the driver of savings arising from generic substitution in some countries, including France, Portugal and Spain. The reference pricing system in Norway stimulated generic competition to a greater extent and led to lower prices than regulation that imposed maximum prices.4 However, price regulation may constitute a barrier for further price competition: no additional price reductions may occur beyond those imposed by regulation.4 The European experience also indicates that the ability of the generic medicine industry to deliver competitive prices can be achieved if it is assured a high volume of the pharmaceutical market. High volume is dependent on demand-side measures that create incentives for physicians, pharmacists and patients to use generic medicines. For example, a European study showed that savings as a result of price competition are higher in countries that have a higher market share of generic medicines.5 Therefore, demand-side measures are critical to increase the generic substitution rate and to maximise the effect of competition based on generic medicine prices.

Steven R A Simoens