Health services administration

In reply: The main purpose of our recent article1 was to quantify estimates of pharmaceutical expenditure over the next decade using various assumptions regarding the price and use of generic statins. We report estimates of billions of dollars in potential savings associated with various scenarios that increase the current off-patent statin use in Australia from around 25% of prescriptions to between 50% and 100%. Simoens misinterprets our conclusions as recommending only using generic statins in Australia. We do not advocate any particular level of generic substitution, but argue that the optimal mix of patented and generic statins should be determined by using cost-effectiveness analysis. Simoens questions whether our results would change if we had compared statin prices with a country other than England. To address this issue we have compiled a comparison of current or recent wholesale price of 40 mg simvastatin across 13 countries in the Organisation for Economic Co-operation and Development (Box). Although there is some variation between countries, the main difference is with Australia, which has the highest wholesale price — about five times greater than the average price across all comparator countries. This price ratio is similar to the one used in our original study. Also, Simoens highlights several issues relating to alternative pricing arrangements for statins and other generic drugs in European countries. We agree that Australia may be able to learn from overseas experience when reforming its system of pricing generic pharmaceuticals. The impact on expenditure of the tendering system for supply of generic pharmaceuticals may have been counteracted by changes in prescribing behaviour in Belgium, but it has been successfully used in the Netherlands to cut the price of simvastatin and other major generics by over 80%. This has been estimated to save around 310 million euros annually.2 However, tenders are not the only way to reduce the price of generic pharmaceuticals. In Canada, the Ontario Ministry of Health and Long-Term Care has recently introduced a policy which sets the subsidy for generics at 25% of the original price under patent. Generic 40 mg atorvastatin, whose patent in Canada recently expired, now costs just A$17 per month.3 In contrast, under the recent Memorandum of Understanding4 between the Australian Government and Medicines Australia, the current wholesale price of A$61 for 40 mg atorvastatin will decline by only 16% after the patent expires in Australia in 2012, and there will be no further downward adjustment until at least 2014. Wholesale price of simvastatin 40 mg in 13 countries in the OECD* OECD = Organisation for Economic Co-operation and Development. * Comparator prices were converted to Australian dollars using the average exchange rate over the past 3 years, and 1 month supply was assumed to be equivalent to 30 tablets.

Philip M Clarke · Edmund M Fitzgerald

It is time for the medical profession to stand up Some 60 years ago, Lord “Tommy” Horder, the doyen of British physicians of that time, addressed a meeting on the theme “Whither medicine?”.1 He suggested that a visitor from Mars would have found such a question incomprehensible and would have responded, “Why, whither else than straight ahead ...” It was a time when the role of doctors was unambiguous: to care for patients and draw upon their scientific and clinical training to promote the “forging [of] still more weapons with which to conquer disease ...” Now move forward to present times and ask the same question. Sadly, the Martian will be confused. The central tenet of medicine has not changed, but the role of doctors certainly has. This has become blurred by the significant influx of other professionals into clinical practice, often usurping doctors’ roles through task substitution.2 We now have nurse practitioners and physician assistants in general practice, emergency medicine, rural and remote medicine, obstetrics, surgery and other areas of clinical practice. Nowhere is doctor displacement more evident than in general practice. Nurse practitioners now have access to autonomous practice, in which they enjoy Pharmaceutical Benefits Schedule prescribing rights and Medicare Benefits Schedule arrangements for which remuneration is not all that different to that of non-vocationally registered general practitioners.3 To further compound this sudden elevation of their role, nurse practitioners’ earnings will soon exceed the current reimbursements for non-vocationally registered practitioners, through indexation (J F O’Dea, Manager, Medical Practice Department, Australian Medical Association, Canberra, personal communication). Nurse practitioners operate within the framework of recent federal legislation that requires loosely formulated “cooperative agreements” with GPs — an arrangement that is ripe for entrepreneurial exploitation. One may well ask how we have come to this turn of events. Firstly, the powerful Australian Nursing Federation has been without peer in influencing an ideologically driven federal Minister for Health and Ageing and promoting the cause of its members. Secondly, there is the federal government’s implicit agenda of fostering competition through levelling financial rewards and downgrading comparative professional intellectual standards. Underpinning this ongoing absurdity is the fallacious assumption that equivalence (between doctors and nurse practitioners) exists, where there is none. Paradoxically, coverage and critique of these policy developments have mostly been confined to the medical tabloids — exemplified by recent letters in Australian Doctor (Box). We must ask ourselves: what can be done at this late stage? The role-substitution campaign has been based on a blurring of what defines a doctor and what a doctor does. These questions of identity have occupied overseas institutions such as the Royal College of Physicians and Surgeons of Canada, in its CanMEDS project,6 and the medical colleges and British Medical Association in the United Kingdom, with similar projects.7 But it remains an inescapable and uncomfortable fact that the respective university selection processes for medicine and nursing, and their subsequent training, are poles apart — in content, depth of learning, and intellectual rigour. These inherent differences have been specifically designed to meet the needs of distinct and differing roles — valuable roles, which work best in a symbiotic relationship. Unfortunately, we have no accepted definition of a doctor in Australian medicine. It is long overdue! For too long there has been a tendency to devalue excellence and achievement. Furthermore, it could be claimed that organised medicine might be more affirming of the skill and expertise of doctors and less appeasing and accommodating of clinical practice by non-doctors. In short, doctors need to affirm their expertise, as currently the only practitioners whose skills and talents are extolled, especially by the Minister, are nurse practitioners. It is time for the profession to stand up. Recent letters about nurse practitioners, published in Australian Doctor*4,5 Editor As a registered nurse and third-year medical student, I am very concerned. I can’t believe the range of medications they are being allowed to prescribe. If nurses want these rights, they should go back to uni and earn the right through hard work and gain the knowledge to safely prescribe. I wonder if Nicola Roxon and the rest of people responsible for allowing this would be happy to see a nurse practitioner and have them prescribe. Or would they rather see a doctor? This is a disaster unfolding. People will die and who will be held accountable? Do these nurse practitioners even have professional indemnity insurance or are they relying on their unions to bail them out when trouble arrives? Tracey Milton, Griffith University, Gold Coast, Qld Editor I will have to find out if I can work with a nurse I can trust to be a team with me. I am concerned they will be like the midwives who are saying they do not want to team with specific doctors, but with hospitals. I am not going to take any consequences for a nurse who does something inappropriate, but it seems I will if I am in collaboration with them. I have always respected and supported nurses and encouraged their university training. I did not know that it was all to make me irrelevant as a GP [general practitioner]. Even I do not prescribe some of the more highly specialised medications. I guess it will be nurses and specialists in a few years’ time. Thank goodness I will be retired by the time that happens. I feel like GPs have been made a fool of and hugely disrespected by the government. Dr Gwenyth Francis, Sydney, NSW Editor What a wonderful state of affairs. There is little doubt that a lot of what passes through general practice is relatively straightforward and, in the past, many of the problems would have been attended to by the commonsense of a mum or grandmother rather than any doctor or nurse. The problem is that one never knows in advance the simple case from the complex or at times, life-threatening case. The nurse (like grandma, the next-door neighbour or, dare I suggest, the local pharmacist) is going to get good outcomes for these simple problems — as would the patient, in most instances, if they did nothing. None of the preceding groups are trained to diagnose and treat the more complex group of illnesses that may have adverse, or even fatal, outcomes if left unattended. The art of the GP is to identify the proportionately small number of serious problems from the simplistic chaff. If each patient has only one serious or life-threatening episode in their lifetime, and this is missed by a nurse practitioner or other less-well-trained health worker, that could be 100% of the population with unnecessary morbidity or mortality. Federal Health Minister Nicola Roxon is a disgrace for supporting these idiotic policies ... Dr John Griffits, South Tweed, NSW * Copyright: Australian Doctor. Reproduced with permission.

Martin B Van Der Weyden MD, FRACP, FRCPA

Obesity, linked to chronic disease, and global warming, linked to climate change, may be indicators of serious problems with our consumption-based economic system About 15% of the world’s population are now overweight or obese, and this is considered to be a factor in the rising incidence of chronic diseases.1 Excessive carbon concentrations now also exist in the atmosphere (50% higher now than 50 years ago), with implications for the environment and climate disruption.2 Although it is not immediately obvious, there is a connection between these two phenomena, with energy being the common factor — excess energy intake over expenditure in the case of obesity, and excess carbon from energy sources over the capacity of environmental “sinks” (oceans, soil, plants) to absorb carbon in the case of the environment. This suggests there may be a common distal driver, in which case obesity and global warming could be symptoms of a broader environmental disorder — similar “canaries” in the same “mineshaft”. Body fat in humans is essential for survival. Too little causes health problems (insulin resistance, type 2 diabetes, etc), as does too much. Unknown factors (probably genetic) seem to define a point — which may vary widely between individuals — beyond which further expansion of fat cells is limited, leading to a “spillover” of excess fat into ectopic stores (muscle, blood, viscera, etc). Before this point is reached, fat stores seem to be benign, or even healthy,3 even in some obese individuals. Beyond this, fat appears to become toxic, and to become linked to chronic disease,4 possibly through the medium of a form of low-grade systemic inflammation, or “metaflammation”.5 Metaflammation was shown over a decade ago to be distinct from classical inflammation. It seems to be caused not just by “spillover” fat, but also by lifestyle and environmental factors, some of which can cause obesity (poor diet, inactivity, inadequate sleep, etc), but many of which may not.6 Non-alcoholic fatty liver disease (NAFLD), often a precursor to chronic disease in the presence of such lifestyle behaviours without obesity7 or visceral fat,8 supports this idea, as does a reduction in NAFLD with exercise independent of weight loss.9 In this sense, obesity might be just a canary in a mineshaft, signalling bigger problems in the overall environment. But if obesity is the canary, what constitutes the mineshaft? A clue can be gained from looking at pro- and anti-metaflammatory stimuli. We have suggested elsewhere10 that pro-inflammatory “inducers”11 are new, arising as a result of the industrial revolution of the late 19th century, whereas those that are anti-inflammatory (or neutral versions of those causing inflammation) have been familiar to humans for thousands of years. The hypothesis proposed from this is that the human immune system reacts (albeit at a lower level than to injury or microbial invasion) to stimuli to which it has not had time to adapt.12 Metaflammation is thus to chronic disease what inflammation is to injury and acute disease. Inflammation normally relates to a physiological condition. However, it can apply, at least metaphorically, to the external (ecological), as well as the internal (biological) environment. The body is unable to “soak up” glucose as a result of insulin resistance, and this leads to metaflammation and biological abnormalities in the form of chronic diseases. In the broader ecological environment, the biosphere is unable to soak up or “sequester” carbon dioxide (and other greenhouse gases) because environmental sinks are overwhelmed by emissions from the oxidation of fossil fuels,2 resulting in a form of inflammation and “carbon resistance” in the ecosphere. This leads to potential ecological “abnormalities” that are metaphorically similar to the chronic diseases related to insulin resistance. Our metaphorical mineshaft can be identified by tracking back the causes of both forms of “inflammation” in a classical epidemiological fashion, as shown in the Box. From this, it is clear that the mineshaft is the modern postindustrial environment, in which a principal driver has been the system of exponential economic growth, particularly that driven by the use of fossil fuels. But how can something that has been so good for human health and wellbeing as economic growth be regarded as negative? The answer lies in the inherent dynamism of any growth system. There is little doubt that growth has been the biggest single contributor to human health in history.13 However, any form of exponential growth must eventually meet its limits. Leading up to this, one might expect to see diminishing returns on investment. In terms of health, this time may have arrived. Data from Sweden, the United Kingdom and other countries over the past 200 years show an initial close relationship between health and growth, but since the 1970s, a reversed relationship, in which further growth results in reduced progress in health.14 Increases in obesity, which follow from the consumption required to feed the growth system beyond the “epidemiological transition” (where the incidence of chronic diseases surpasses that of infectious diseases)15 in developing countries, is one consequence. Greenhouse gas emissions, which are related to the consumption driving obesity, also closely follow the business cycle at the micro level, as well as the growth in gross domestic product (GDP) at the macro level.16 A “sweet spot”17 in the material phase of growth therefore appears to have been reached and, in some aspects, overshot in developed countries, as reflected by the diminishing rate of return in health, as well as ecological wellbeing, from further growth. Obesity (and greenhouse gases), within this framework, represents a canary. In times past, canaries were taken into mineshafts to warn of problems with air quality, indicated by their sudden collapse. The mineshaft in our metaphor is the economic system — specifically monetary growth, as measured in terms of GDP and its consequent consumption — that drives the modern industrial environment. To attribute the epidemic in chronic disease to this is not fanciful. It is clear from the lessons of developing countries like India and China that chronic diseases are related to changes that occur with economic development past a certain point — the epidemiological transition. The fact that chronic diseases begin to increase rapidly around the same time as a society’s carbon footprint begins to grow is not coincidental. Unsequestered greenhouse gas emissions are the manifestation of a mineshaft of growth beyond a threshold of positive returns. Obesity — and climate change — are merely “collateral damage in the struggle for modernity”.17 The dramatic worldwide increase in obesity is the most visible biological warning that our consumer-driven, macroeconomic environment (the mineshaft) is in need of an overhaul. While it is imperative for us to keep trying, attempts to reduce obesity at the population level, and to control climate change at the world level, without dealing with these broader economic and environmental issues, is like trying to resuscitate an asphyxiated canary while leaving untouched the mineshaft that caused the asphyxiation. Epidemiological course of biological and ecological “inflammatory” processes

Garry J Egger MPH, PhD · John B Dixon MB BS, PhD, FRACGP

Objectives: To describe current use and possible effects of Australian medical school fitness-to-practise policies (FTPPs), and to define and benchmark FTPP best practice.Design, setting and participants: A questionnaire-based study of Australian medical schools was conducted in August 2009.Main outcome measures: Use of FTPPs by medical schools; criteria used in FTPPs; remediation processes; numbers of students excluded for professional misconduct, reasons for exclusion, and year of study at time of exclusion.Results: The questionnaire was completed by 15 of 19 medical schools to which it was sent, and 12 schools reported using an FTPP. There was wide variation in the FTPP criteria used by individual schools, and use of an FTPP appeared to be independent of medical student registration with state medical boards and type of course entry. There were no apparent differences in medical student exclusion rates between schools with FTPPs and those without. The most common reason for exclusion was persistent inappropriate attitude or behaviour, including poor attendance, and most exclusions occurred by the third year of study.Conclusions: Most Australian medical schools use FTPPs, but these policies are variable and lack proven effectiveness. The variations in the numbers of students excluded by the different medical schools for unprofessional behaviour suggest discrepancies in the medical schools’ abilities to detect and manage students with problems in this area. Previous calls to develop a nationally consistent approach to the management of poorly behaving students should be addressed.

Paul M McGurgan MB BCh, MRCOG, FRANZCOG · Debbie Olson-White · Marie Holgate · Di Carmody RM, MPH

I was the first in my family to be able to go to university, and like so many other students, I didn’t have any idea of what I wanted to be. However, the offer of a teacher’s college scholarship meant that this cane farmer’s son could afford to go to the University of New England (UNE), with its great system of residential colleges. Raised on a farm on Warregah (Box 1), an alluvial island in the Clarence River in northern New South Wales, I had attended Chatsworth Island Primary School, which boasted two or three teachers, depending on student numbers. The headmaster, Mr Woolley, was a fan of English grammar and, as a result, many of my postdoctoral students (and my daughters) have had to endure grammar lectures. National Health and Medical Research Council, Canberra, ACT. Warwick P Anderson BSc(Hons), PhD, Chief Executive Officer warwick.andersonATnhmrc.gov.au High school was in Maclean, two river crossings away. Country high schools were then, as ever, under pressure. I remember mathematics in second year needed to be taught in the headmaster’s garage. There were two pivotal moments at high school that led me into science; one involving a balloon and the other, the beach. In first year science, our teacher Mr Whelan asked us whether, in our opinion, air had weight. Of course we all said “no” — who could feel the weight of air on us! So he weighed a balloon deflated and then reweighed it inflated and, of course, the balloon had gained weight. This was such a simple lesson and I can still recapture the thought that I had then — that what seemed obvious was, in fact, wrong; a powerful message that has stayed with me. Then, in my final year of school, Colin Cork, our biology teacher, showed us how to see what all of us NSW coastal kids had seen, but not seen — that the shore between low and high tides was “understandable” on the basis of science, on the basis of the biology or the living flora and fauna and their interactions with this environment. We learned how plant and animal habitats were affected in understandable ways by their relative exposures to water, sun and the environment. In short, he showed that science made a familiar place for enjoyment also a place of understandable complexity and beauty. The cane gang that cut our crop for many years was from the local Aboriginal settlement on Ulgundahi Island, the next island to ours. They were dignified men. I remember my father saying to me that we were the luckiest cane growers in the district because this gang was the most reliable, hardworking and honest. The settlement was later moved to Maclean, the local town. My mother gave birth to my younger brother in Maclean hospital, sharing a room with an Aboriginal woman with whom she kept in touch. I remember being astonished when my mother told us that this Aboriginal mother was terrified that the authorities would come and take her baby away. I know now of course that this was the time of the Stolen Generation, but at the time it seemed unthinkable and very alarming to us. I am very grateful to my parents for their involvement with these Aboriginal people, and for the values they passed on to their children My first residential college experience at UNE was of eight “freshers” sharing a long dormitory without heating through an Armidale winter. There were frozen pipes in the mornings and a long, cold bus ride out to the university for breakfast. This was not an exceptionally conducive environment for studying, although I can’t blame the accommodation for the modest four bare passes I managed in my first year, one only after a supplementary exam in January. Fortunately, in second year I stumbled into the UNE subject, physiology, fell in love with learning about homoeostasis and integration of the body systems, and graduated in 1968 with first class honours. I will forever be indebted to Max Webster and the rest of the Physiology Department for such a stimulating learning environment. Beginning in researchMy interest in medical research as a power for good and for alleviating human suffering might be attributed, in part, to growing up in a small community where everyone knew everyone else, and knew all their trials and tribulations. In small communities, it is easy to understand that not everyone is born with the same opportunities, and that family circumstances and ill health or disability profoundly affect people’s start in life. In our small school and community, people with disabilities, ill health, bad luck or accidents were people we knew well and lived near. Undoubtedly, too, my father’s type 1 diabetes, which killed him at 51, had a significant effect on my career choices. How could it be that the failure of such a small and, on the face of it, simple gland could result in so much ill health, even when insulin was replaced by injection? Research in the past decade has shown us that early environment is crucial. So, it is very probable that my love of learning, a belief in fairness, in taking responsibility for one’s actions and in working hard and in helping others comes from growing up in a hardworking rural farming community, consisting largely of third- and fourth-generation immigrants from Scotland. The Chatsworth district was then almost entirely populated by 19th century Scottish immigrants. This may be pushing an argument too far, but the values of the Scottish enlightenment were strong in that society. I find it disturbing that now, in the 21st century, there is an apparent retreat from reason in many Western societies, and often a retreat from science. Many people seem to regard their own views and beliefs as being of equal value to any other, whether or not they are founded on any factual, scientific or logical base. There are many examples, such as the widespread use of such alleged therapies as homoeopathy, or the belief that crystals have magic healing powers. My father died when I was in my third year at university, but thanks to support from the War Widows Guild (established by Jessie Vasey), I was able to complete my Bachelor of Science degree with honours. I joined John Ludbrook, Professor of Surgery at the University of New South Wales, as a PhD student, and then transferred to the University of Adelaide with him when he became Professor of Surgery there. South Australia was in the throes of electing Don Dunstan as its state political leader, and the 3 years of my PhD and living in a postgraduate college in the great city of Adelaide at the end of the 1960s were memorable. John Ludbrook talked Francis Moore, Professor of Surgery at Harvard Medical School and the (then) Peter Bent Brigham Hospital, into taking on a science-trained Australian postdoctoral Fellow, and I had a marvellous time for two and a half years working on a wide range of research topics, eventually publishing 11 articles from that time. We invented a novel way of measuring pulmonary oedema,1 we set up a computer-driven postoperative fluid system for open heart surgery2 and we studied how best to maintain cardiac output during open heart surgery.3 I also worked with Cliff Barger, the legendary Professor of Physiology at Harvard Medical School, and this started me on my life-long interest in the pathogenesis of high blood pressure. Cliff and his postdoctoral Fellows, working with dogs that were integral parts of the laboratory group, showed that modest restriction of blood flow to the kidney resulted in a rise in arterial blood pressure within minutes; all the while the dogs were awake, although napping peacefully. The Fellows in Cliff’s group seem to have gone on to remarkable careers: Victor Dzau is now chancellor for health affairs at Duke University and president and Chief Executive Officer (CEO) of Duke University Health System, and Ed Miller is Dean and CEO of Johns Hopkins Medicine. Hypertension is a major health problem in both developed and developing countries. The World Health Organization estimates that it causes over seven million deaths each year.4 It has been estimated that almost a billion people world-wide have high blood pressure, with two-thirds of these living in developing countries.5 High blood pressure is not glamorous, but is a silent disorder and still largely of unknown cause and therefore hard to prevent. It is astonishing to think that for most people with hypertension, we still have no real understanding of what causes their blood pressure to rise. This rise is slow and incremental in most people and we rely on animal research for much of our progress towards understanding the pathogenesis. That the kidney is at the centre of causation seems likely. To maintain plasma filtration, and thus continued body fluid homoeostasis and life, ultrafiltration in the kidney requires blood pressure in the kidney’s glomeruli to be more than 15 mmHg higher than the oncotic pressure exerted by plasma proteins. That is, the blood pressure in the kidney matters, whereas for other organs it’s the flow of blood and its delivery of oxygen that is mainly regulated. To be teleological, it can be argued that there has been powerful evolutionary pressure to establish physiological control mechanisms that set overall arterial pressure in order to maintain just this glomerular blood pressure at the levels required. This reasoning can explain the results of experiments shown in Box 2 — when glomerular pressure was reduced by abruptly narrowing the supplying renal artery, arterial pressure soon rose and restored the renal arterial pressure beyond the narrowing, but at the expense of much higher arterial blood pressure overall.6,7 In 1974, after two and a half years in Boston, I longed to get back to Australia. I can still remember marvelling at the wonderful eucalypt forests during my first few months back, and the quality of the relations between ordinary human beings. I had not been sure where I wanted to come back to, so I wrote to both Paul Korner, Professor of Cardiology at the University of Sydney, and Derek Denton, founder of the Howard Florey Institute in Melbourne. Paul answered promptly saying “come”, I responded immediately saying “yes”, and arrived back only to be told that he had accepted a job in Melbourne as Director of the Baker Medical Research Institute and had invited me to come with him. The Baker Medical Research InstituteThe thought of moving to Melbourne was initially a jolt. For people from northern NSW, it was traditional to think of Melbourne as somehow inferior, if we thought about it at all. However, I liked Melbourne from the first day. It is a great place for health and medical research. This is due to the interplay of a number of factors — a critical mass of researchers, a certain spirit of genuine collaboration and a generally intellectual climate. I once heard Gus Nossal (previously, Director of the Walter and Eliza Hall Institute of Medical Research) offer an additional reason — that science was so strong in Melbourne because of the weather, which meant that inside activities were favoured over outdoor ones — while Michael Wooldridge (previously, Minister for Health) put it to me, that it was a legacy of Melbourne’s Scottish enlightenment founding fathers. Of course, Melbourne is not all about intellectual life. No other city in Australia, and perhaps anywhere, supports sporting events so much. For me, as a supporter of the Melbourne Demons, that has been mainly painful. Paul Korner’s time as Director of the Baker Institute, working with Jim Angus, Garry Jennings, Murray Esler and many others (some pictured in Box 3), building the Baker from a small, obscure institution to a major cardiovascular institute with highest quality research, was simply exhilarating. Not everyone warmed to Paul, who could be a fierce critic, but we all learnt so much from him and progressed so far under his guidance. The Baker years for me were the 7-day-a-week years, with dogs to look after that were chronically implanted with catheters and flowmeters; these were large animals that could very readily be trained to participate in experiments without stress. To understand blood pressure control, we need to study two systems that are both dynamic and that interact dynamically; the circulation of blood and filtration and reabsorption in the kidney. Using animals, particularly dogs and domestic animals in research, is controversial. For me, it was essential that we always thought about the welfare of the dogs, and this required a 24/7 commitment. Medical research is team research and I have been so fortunate over many years to have had such colleagues as Kate Denton and Roger Evans (pictured in Box 4; now both National Health and Medical Research Council [NHMRC] Research Fellows themselves), Michelle Kett, Robyn Woods and many others, as well as wonderful, dedicated research assistants and animal technicians. Monash and physiologyI left the Baker Institute in 1996 to become Professor of Physiology at Monash University. The Monash Department of Physiology has had an outstanding record in research and teaching since its inception. I felt that physiology as a discipline was changing, and many were challenging its relevance. The starkest demonstration came when the Harvard Department of Physiology was abolished in the 1980s. I believed then (and I still believe) that an understanding of how things work is physiology’s main game, and that this occurs both at the molecular level and at the integrative, whole human (or animal) level. The molecular bioscience revolution of the last 30 years or more continues to provide astounding insights into the way things work at the cellular and subcellular level. Now, the integrative sciences are resurgent, as we understand that in biology it is rare that “one plus one equals two” and that the answer changes anyhow, with time and environment! First work for the NHMRCMy first contact with the NHMRC came in the late 1980s, and began one morning before dawn when my home phone rang and the conversation went something like this: “It’s John Chalmers here, you old £&£$^&%$. I am just about to get on a plane in Adelaide for Canberra. It’s an NHMRC Medical Research Committee meeting today. I am going to set up an animal ethics committee, you’re going to be the Chair, and I want you to nominate who should be on the committee by the time of the meeting”. Well, like everyone else in medical research in the 1980s, I did what Chalmers (then Chair of the Council of the NHMRC) asked. I went on to serve for more than 7 years as Chair of the NHMRC’s Animal Experimentation Ethics Committee. I am proud of that work. The Australian code of practice for the care and use of animals for scientific purposes8 that we developed and introduced has stood the test of time, and we had excellent engagement with the animal welfare and rights movements. Although there were, of course, differences in our fundamental positions, I thank Hugh Wirth and Glenys Oogjees and their colleagues because it taught me that in public policy, engaging properly with those with different views is much better than not doing so. It provides better outcomes because it considers more diverse views, and is better in general because it builds human relationships. In Australia, there is now deep engagement between researchers who use animals and animal welfare and rights representatives. This benefits laboratory animals, researchers and society through better policies. I found myself debating Peter Singer, philosopher and bioethicist, on television, and occasionally running into pictures of myself labelled as an ogre at Melbourne street markets! Opportunity to reform NHMRC’s research approachesSoon after moving to Monash, Michael Wooldridge, who had recently become Minister for Health, asked me to be Chair of the new NHMRC Research Committee, amalgamated from the two previous NHMRC funding committees (the Public Health Research and Development Committee and the Medical Research Committee). He appointed an outstanding group of people to this new committee (pictured in Box 5). Despite some simmering concerns outside the NHMRC that either “soft science” would somehow take over decision making or that those “gene jocks” would get all the money, the newly merged Research Committee itself worked very well, as did the outstanding membership of the Council (Box 6). I would especially like to thank my two deputies Kerin O’Dea and Sally Redman for their guidance and support. As Research Committee Chair, I tried to be guided by what was best for all health and medical research, not any particular field or group. Some of the reforms we introduced included: The abolition of block funding of the big medical research institutes. Block funding of the biggest institutes had been a very successful policy during a building phase of Australian health and medical research, but I thought it had reached the end of its usefulness and was not well suited to where health and medical research was moving. Research was becoming more dynamic, more team-based and multidisciplinary. I felt that this required moving beyond the administrative constraints that block funding brought, and this also would provide a more open, transparent and competitive environment. Despite initial misgivings, the best institutes have since flourished, and it is encouraging to see the multitude of collaborations between these institutes, universities and hospital-based researchers. A more level playing field in NHMRC Research Fellow appointments; this has seen this scheme become stronger than ever, offering internationally outstanding researchers an opportunity to conduct full-time research in any area and appointments made on merit. A move away from the regional basis of funding, which had been managed through the Regional Grants Interview Committee (RGIC) system. This also involved the end of our interviewing system for grants, which I had personally enjoyed as an RGIC member. Many researchers were worried about the ending of interviews and the feedback that these could offer. On the other hand, one of the NHMRC’s supported outstanding social scientists remarked to me that the committee had been selecting grants on the basis of “performance art”, rather than science. Making NHMRC funding policies explicit. Until then, many policies were really case histories. The benefit of developing explicit written policies was that it led to the Research Committee thinking hard about all aspects of the funding schemes. Introduction of “one-line” grants, consisting of funding for support of both salaries and the direct costs of research, providing researchers and institutions with more flexibility in our system of support for the direct costs of research only. Introduction of the Program Grant Scheme; under this scheme, grants are awarded mainly as a record of achievement of the applicants, and are provided as large one-line grants. Introduction of Centres of Clinical Research Excellence, a one-line grant to clinical teams to develop careers and capacity in clinical research. Introduction of a special fellowship (the “Practitioner Fellowship”) for those who wish to keep on providing clinical care, but also to undertake clinical research. This is another rather unique scheme that continues to support some of our most outstanding clinicians in performing outstanding research. Introduction of a capacity-building one-line grant for public health and health services researchers. We realised that one of the problems with our health research sector was that these two fields had not had the opportunity to put teams together, unlike the biomedical sector, through the previous block funding system and the Medical Research Committee’s Program Grant system. Amendment and development of the Statement on Research, which aimed to address integrity in research. This statement would eventually become the Australian code for the responsible conduct of research,9 developed in the mid 2000s by a joint NHMRC, Australian Research Council and Universities Australia group that I chaired, and which was finally adopted in 2007. Being CEOI was appointed CEO of the NHMRC in mid-2006, at a time when the organisation became an independent statutory agency, separate from the Department of Health and Ageing, but still within the portfolio of the Australian Government Minister for Health and Ageing. Major tasks included establishing the organisation with its own support mechanisms (information technology, human resources, finance, etc), finding new premises (where we can conduct peer review, instead of in hotel rooms) and, with the support of the Minister, having a greater involvement in clinical and preventive matters through the establishment of a Health Care Committee and a Prevention and Community Health Committee reporting to the Council of the NHMRC (pictured in Box 7). We have also merged the previous National Institute of Clinical Studies into the NHMRC and are repositioning it as a major entity for the transfer, translation and implementation of clinical research knowledge. The NHMRC supports about 16 different funding mechanisms. Like our sister medical research funding bodies around the world, the NHMRC is buffeted by competing interests and views on how it should operate and what it should fund. Perhaps the most frequent argument is whether we should fund mainly basic discovery research, or only applied research with a clear benefit. The answer in my mind is “both”. Two Nobel Prizes by Australians are good examples of why. Nothing could have been more basic than Elizabeth Blackburn’s work on telomerase 30 years ago. Not only has this opened our understanding to one of the fundamentals of life, but our understanding of telomeres now seems set to help in cancer and in stress-related illnesses, among other areas of ill health. And then there are the Western Australians, Robin Warren and Barry Marshall, who undertook a brilliant piece of very applied research that provided not only a fundamental change in how we understand gastric disease, but resulted in rapid changes in how we treat it, both reducing patient suffering and cost to the system. The NHMRC is a body to both create knowledge and promote its uptake to improve health.10 I am very passionate about bridging that gap between the creation of knowledge and what happens in our health system — a system that too often is not based on science, and not based on evidence from research on what is best. I recognise that clinical judgment and experience are crucial parts of great health care. But science (and compassion!) should be the basis of how the system develops in the future. It is surprising how often science is able to be pushed to one side in all our society, if it is inconvenient. Or, indeed, subverted, as shown in the recent book Merchants of doubt: how a handful of scientists obscured the truth on issues from tobacco smoke to global warming.11 The NHMRC and the futureHealth and medical research is a great career for anyone who believes in the value of science in improving health, who maintains a life-long curiosity about biology and human biology, and who can handle the life-long uncertainty that comes with a research career — where will the next grant come from, will I be able to maintain creativity, am I using the best technique, where will my research take me intellectually? In Australia, health and medical researchers are well regarded. The public trusts that improvements in health will depend to a major degree on research. It looks up to the strong role models that some of our health research leaders have become through their research and through their activities in the public domain — people like Ian Frazer, Sir Gustav Nossal, Fiona Stanley, Stephen Leeder, Richard Larkins, and the many leaders of the Australian Society for Medical Research. The NHMRC will be 75 years old next year. I am proud to have been given the opportunity to contribute to its growth and to have helped in any small way for the NHMRC to achieve its dual role in discovery and application. This was spelled out neatly by Minister for Health, Billy Hughes, when, in delineating the NHMRC’s task, he told the inaugural Council meeting in 1936 that: “Research must be actively pursued and developed and as fast as new knowledge is acquired it must be applied”.12 The NHMRC will need to keep changing to serve the people of Australia and to ensure that what we offer patients improves, that how we prevent disease becomes more evidence based, and that we progress in research to push back the frontiers of knowledge to reveal the biology of health, and ill-health. For myself, I will be content if I have contributed new knowledge through my research and have helped ensure that the NHMRC is better able to do its job as a 21st century funding organisation. 1 On the farm Me (Warwick Anderson; back row, left), my father (front row, left) and Anderson uncles and cousins from Warregah. 2 Renal haemodynamic responses to renal artery stenosis in dogs Error bars on Day 2 show standard error of the mean change in aortic pressure, renal artery pressure and renal blood flow, over the 3 days of stenosis. The arrows indicate the beginning of stenosis. 3 Colleagues from the Baker Institute Left to right back row: Rosemary and Murray Esler, me (Warwick Anderson), Garry and Jan Jennings. Left to right front row: Judith Whitworth, Gavin Lambert, Heather and James Angus and Daine Alcorn. 4 Medical research is team research; the Monash Physiology and Baker Institute cardiovascular team, 1996 Left to right: Chiharu Tomodo, Katrina Worthy, Michael Stevenson, Kathleen Stevenson, Roger Evans, me (Warwick Anderson), Gary Ablett senior (Australian rules footballer, cardboard), Sharyn Fitzgerald, Jan Morrisson, Amanda Edgley, Amany Abdelkader, Simon Malpas, Fumihiro Tomoda and Goran Bergstrom. 5 The first National Health and Medical Research Council Research Committee, 1997 Left to right back row: Terry Nolan, Steven Holdsworth, George Van Der Heide, Robert Baxter, Ron Trent, Fred Mendelsohn, David Roder and John Finlay-Jones. Left to right front row: Nicos Nicola, Sally Redman, me (Warwick Anderson), Kerin O’Dea and Tania Sorrell. 6 The National Health and Medical Research Council of 1997–1999 Left to right back row: Geoff Duggin, Prue Ford, Celia Kemp, Richard Russell, Margaret Guilfoyle, John Delaney, Michele Kosky, Doris Zonta, David Adler, Lesley Barclay, John Catford, Michael Cousins, Bruce Armstrong, Ann Woolcock and John (Jack) Sparrow. Left to right front row: Don Chalmers, Stephen Leeder, James (Jack) Best, Judith Whitworth, Richard Larkins, Robert Wells, me (Warwick Anderson), Stella Clark and Andrew Wilson. 7 Current National Health and Medical Research Council members Left to right back row: Paddy Phillips, John Carnie, Ron Trent, Charles Guest, Jim Bishop, Rosemary Bryant, Anne Cahill Lambert and Aaron Geddes (for Jeanette Young). Left to right front row: Kerin O’Dea, Andrew Cuthbertson, Craig White, Sandra Hacker, me (Warwick Anderson), Barbara Patterson, Michael Good, Simon Towler and John Horvath. Absent: Jeanette Young, Cindy Shannon, Kerry Chant and James Best.

Warwick P Anderson

Independent advice continues to be vital for maintaining standards in medical training Many younger doctors may have trouble believing it was only 25 years ago that the assessment of Australian medical schools (for the purpose of medical registration in Australia) changed from assessment by the General Medical Council of the United Kingdom to assessment by a local independent authority. In 1985, the accreditation process was transferred to Australia, and the Australian Medical Council (AMC) was established. The AMC recently marked its first 25 years by publishing its history, Assuring medical standards: the Australian Medical Council 1985–2010.1 The book catalogues many impressive achievements and also describes in detail some significant obstacles in the Council’s progress. Australia now has an almost seamless accreditation process for all phases of medical education (medical student education, postgraduate training and, through the medical colleges, continuing medical education) that is envied by other nations. In addition, the AMC has established a reputation internationally as a leader in the assessment of international medical graduates and for its work in supporting them in preparing for assessment. The release of the AMC history coincides with the most significant change in the regulation of the health professions since laws for registration were first enacted in the mid 19th century.2 It is timely to consider the lessons from the AMC’s experience as we enter this new era of national registration, and to reflect on the importance of independence in setting standards for the profession in the future. Medical education and medical practice are moving into uncertain territory. Several critical issues are likely to engage the AMC and others involved in medical education in the immediate future. First and foremost is securing appropriate clinical training for the rapidly increasing numbers of medical students and graduates, and ensuring sustainable funding for that training through the state and national bodies that have responsibility for the health workforce and clinical training. There is also an urgent need to consolidate state-based standards for early graduate training (the first two postgraduate years) and to align them with those for medical schools and specialty training. The present interest in the ill-defined “competency-based training” is stimulating attempts to define competencies more precisely. If this leads to job redesign and task substitution (as envisaged by the Productivity Commission),3 then that will need to be done in a measured and intelligent manner which does not diminish existing standards of medical care. There is an urgent need to rethink teaching about patient safety throughout medical education.4 If we are ultimately to ensure that preventable harm to patients becomes negligible, then the new science of patient safety must have a high priority in the training and professional development of all doctors.5 The AMC is considering whether this will require strengthening of its accreditation standards. These matters all rest on the underlying responsibility of medical educators to develop good students into competent doctors who will maintain their knowledge, skills and professionalism throughout their careers. Regulation of the medical profession was originally intended to protect the community by defining a legally qualified medical practitioner, but health workforce supply now occupies a pre-eminent place in the new national regulatory structure. Sections 11(3)(d) and 11(4)(a) of the Health Practitioner Regulation National Law Act 2009 (Qld) provide for the Ministerial Council to intervene in an accreditation standard when that standard might impact on the recruitment or supply of medical practitioners. Before the legislation was passed, a caveat was added by way of section 11(4)(b) requiring the Ministerial Council to consider the impact of any such intervention on the quality and safety of health care. While the national law thus incorporates the tension between workforce considerations and standards of medical education, this represents potential future conflict. The concurrent reforms in funding of clinical training have the potential for a more immediate impact on medical education. The need to account for the appropriate expenditure of funds may see a push towards standardisation of clinical training — “one size fits all” thinking — supported by an education model built on “tick box” competencies. Comprehensive, thorough clinical training is essential for developing an effective, flexible and safe medical workforce, and for producing practitioners able to adapt to changes in medical sciences and clinical practice throughout their careers. It would be reassuring for the medical profession if we could confidently predict that the AMC will still be here after the next 25 years, but this is by no means certain. For medicine, it is vital that the AMC commits itself to working closely with the bodies whose responsibilities will influence standards of medical education and medical practice, including the Medical Board of Australia, Australian Health Practitioner Regulation Agency, and Health Workforce Australia. It is equally important, given the policy focus on health workforce reform, that the AMC continues to provide strongly independent, evidence-based advice and guidance on standards of medical training and assessment.

Richard A Smallwood AO, FRACP, FRCP · Ian Frank BA · Theanne Walters BA

Objectives: To explore the perceived impact of medicolegal concerns on how Australian doctors practise medicine and to compare doctors who have experienced a medicolegal matter with those who have not.Design and setting: Cross-sectional survey (posted in September 2007, with reminder 4 weeks later) of Australian doctors from all major specialty groups, trainees and a sample of general practitioners who were insured with a medical insurance company.Participants: 2999 respondents of 8360 who were sent the survey.Main outcome measures: Perceived practice changes due to concerns about medicolegal issues, beliefs about medicolegal issues, and the influence of medicolegal issues on both career choices and how doctors relate to their patients.Results: Respondents reported changes in practice behaviour due to medicolegal concerns, with 43% of doctors stating that they referred patients more than usual, 55% stating that they ordered tests more than usual, and 11% stating that they prescribed medications more than usual. Respondents also reported improved communication of risk (66%), increased disclosure of uncertainty (44%), developed better systems for tracking results (48%) and better methods for identifying non-attenders (39%) and for auditing clinical practice (35%). Concerns about medicolegal issues led to 33% considering giving up medicine, 32% considering reducing their working hours and 40% considering retiring early. These proportions were all significantly greater for doctors who had previously experienced a medicolegal matter compared with those who had not.Conclusions: This Australian study, like international studies, confirms that doctors’ concerns about medicolegal issues impact on their practice in a variety of ways. There is a greater perceived impact on those doctors who have previously experienced a medicolegal matter.

Louise M Nash MB BS(Hons), BA, FRANZCP · Merrilyn M Walton BA, MSW, PhD · Michele G Daly BSc(Hons), MSc · Patrick J Kelly BMath(Hons), PhD · Garry Walter BMedSc, PhD, FRANZCP · Elizabeth H van Ekert BA, DipEd, MMedHum · Simon M Willcock MB BS, PhD · Christopher C Tennant MD, MPH, FRANZCP

The Victorian Department of Health reviewed its Hospital in the Home (HIH) program in 2009, for the first time in a decade. Annual reimbursements to all Victorian hospitals for HIH care had reached $110 million. Nearly all Victorian hospitals have an HIH program. Collectively, these units recorded 32 462 inpatient admissions in 2008–09, representing 2.5% of all inpatient admissions, 5.3% of multiday admissions and 5% of all bed-days in Victoria. If HIH were a single entity, it would be a 500-bed hospital. Treatment of many patients with acute community- and hospital-acquired infections or venous thromboembolism has moved into HIH. There is still capacity for growth in clinical conditions that can be appropriately managed at home. The review found evidence of gaming by hospitals through deliberate blurring of boundaries between acute HIH care and postacute care. The Victorian HIH program is a remarkable success that has significantly expanded the overall capacity of the hospital system, with lower capital resources. It suggests HIH with access to equivalent hospital remuneration is necessary for a successful HIH policy. Hospitals should invest in HIH medical leadership and supervision to expand their HIH services, including teaching. HIH is a challenge to the traditional vision of a hospital. Greater community awareness of HIH could assist in its continued growth.

Michael Montalto MB BS, PhD, FRACGP

Objectives: To review the literature on different models of clinical governance and to explore their relevance to Australian primary health care, and their potential contributions on quality and safety.Data sources: 25 electronic databases, scanning reference lists of articles and consultation with experts in the field. We searched publications in English after 1999, but a search of the German language literature for a specific model type was also undertaken. The grey literature was explored through a hand search of the medical trade press and websites of relevant national and international clearing houses and professional or industry bodies. 11 software packages commonly used in Australian general practice were reviewed for any potential contribution to clinical governance.Study selection: 19 high-quality studies that assessed outcomes were included.Data extraction: All abstracts were screened by one researcher, and 10% were screened by a second researcher to crosscheck screening quality. Studies were reviewed and coded by four reviewers, with all studies being rated using standard critical appraisal tools such as the Strengthening the Reporting of Observational Studies in Epidemiology checklist. Two researchers reviewed the Australian general practice software. Interviews were conducted with 16 informants representing service, regional primary health care, national and international perspectives.Data synthesis: Most evidence supports governance models which use targeted, peer-led feedback on the clinician’s own practice. Strategies most used in clinical governance models were audit, performance against indicators, and peer-led reflection on evidence or performance.Conclusions: The evidence base for clinical governance is fragmented, and focuses mainly on process rather than outcomes. Few publications address models that enhance safety, efficiency, sustainability and the economics of primary health care. Locally relevant clinical indicators, the use of computerised medical record systems, regional primary health care organisations that have the capacity to support the uptake of clinical governance at the practice level, and learning from the Aboriginal community-controlled sector will help integrate clinical governance into primary care.

Christine B Phillips MA, MPH, FRACGP · Christopher M Pearce MFM, PhD, FRACGP · Sally Hall RN · Joanne Travaglia BSocWk, PhD · Simon de Lusignan MB BS, MSc, MD(Res) · Tom Love MPH, MSc, PhD · Marjan Kljakovic MB BS, PhD

Objective: To identify the financial costs and benefits associated with teaching in private general practice.Design: Cost–benefit analysis of teaching in private general practice across three levels of training — undergraduate medical training, prevocational training and general practice vocational training — using data from a 2007 survey of general practitioners in South Australia.Setting and participants: GPs and practices teaching in association with the Adelaide to Outback GP Training Program or the Discipline of General Practice at the University of Adelaide.Main outcome measure: Net financial outcome per week.Results: The net financial outcome of teaching varied across the training levels. Practices incurred a net financial cost from teaching medical students that was statistically significantly different from zero. With respect to vocational training and teaching junior doctors, there were small net financial benefits to practices, although the mean estimates were not statistically significantly different from zero.Conclusions: This study shows a net financial cost for practices teaching medical students, while at the prevocational and vocational training levels, adequate levels of subsidies and income generated by the trainees help offset the costs of teaching. Our results suggest that a review of subsidies for undergraduate teaching is necessary, particularly as the demand for teaching practices will increase substantially over the next 5 years.

Caroline O Laurence BA(Hons), MHSM, PhD · Linda E Black BA(Psych), DipAppPsych, MAPS · Jonathan Karnon BSc(Hons), MSc, PhD · Nancy E Briggs BSc, MSc, PhD

CorrectionMissing authors: In “Pathways to the diagnosis of epithelialovarian cancer in Australia” in the 20 September 2010 issue of the Journal (Med J Aust 2010; 193: 326-330), two study groups were omitted from the list of authors. The Australian Cancer Study (Ovarian Cancer) and the Australian Ovarian Cancer Study Group should have been listed as the final two authors, as shown here.

Susan J Jordan MB BS, FRACGP, PhD · Jane E Francis MA, MPH · Anne E Nelson PhD · Helen M Zorbas MB BS, FASBP · Karen A Luxford BSc(Hons), PhD · Penelope M Webb MA, DPhil

Passive surveillance cannot be relied on as the sole means of surveillance On 22 April 2010, use of seasonal trivalent influenza vaccine in children aged 5 years and under was suspended across Australia, pending an investigation into an apparent increase in reports of adverse events following immunisation (AEFI).1 This unprecedented halt to a national immunisation initiative followed Western Australia’s decision to place a moratorium on the use of this vaccine in young children after observing a spike in emergency department presentations for high fever and febrile convulsions after vaccination.2 A subsequent investigation by the Therapeutic Goods Administration indicated that febrile convulsions related to the vaccine were reported from all jurisdictions except the Northern Territory.2 The apparent rate of febrile convulsions following vaccination was 5–9 per 1000 doses administered, about 50 times higher than that reported following measles–mumps–rubella vaccination.2,3 A recent review, requested by the Minister for Health in WA, has highlighted significant deficiencies in AEFI surveillance.4 In Australia, the current mechanism for identifying AEFI nationally is passive surveillance. Passive surveillance relies on health providers and the public recognising and reporting suspected AEFI to state or federal health authorities. The constraints that are inherent to passive surveillance, including under-reporting and biased reporting, are compounded by the diverse approaches to surveillance that are employed throughout Australia, as illustrated by a fourfold difference in AEFI reporting rates per 100 000 population between jurisdictions.5,6 Adding to concerns about variable sensitivity across the state systems is the inevitable delay in collection, aggregation and analysis of AEFI reports forwarded to the national authority. A number of the issues evident during the response to the vaccine-associated reactions were recognised 5 years earlier during the National Vaccine Safety Workshop.7 A clear set of recommendations for improving adverse event surveillance was identified at the time, but many of the recommendations have not been adequately addressed. Robust postmarketing surveillance is vital for influenza vaccines because seasonal trivalent influenza vaccine does not require clinical trial data to demonstrate safety before release — it is assumed that safety is not altered by the annual change in the combination of vaccine strains. While past experience suggests that this is true, history also indicates that future vaccine scares are inevitable and we should plan accordingly.8 Trivalent influenza vaccine, in particular, highlights the need for postmarketing surveillance to be linked with the capacity for rapid review and response, because a large proportion of the vaccine is administered over a short period before the onset of the influenza season each year. The way forward is to establish a coordinated, uniform approach to AEFI reporting, coding, collation and analysis. A standing vaccine safety monitoring group which includes key stakeholders — representing the regulators, state and national immunisation programs and vaccine safety and epidemiology experts — needs to be urgently established. The inability of the existing surveillance systems to detect the early signal of an increased incidence of febrile convulsions, within 24 hours of receiving 2010 seasonal trivalent influenza vaccine, demonstrates that passive surveillance cannot be relied on as the sole means of surveillance. Complementary active surveillance systems which can methodically detect potential AEFI signals, quickly establish rates and establish causality should be developed. The Australian Childhood Immunisation Register is uniquely placed to contribute to vaccine safety surveillance through data linkage with hospital morbidity and emergency department datasets, as demonstrated by a recent study from South Australia.3 Sentinel surveillance in four tertiary care Australian paediatric hospitals has been shown to be an effective mechanism of surveillance for specific AEFI.9 Implementing active AEFI surveillance systems will require sustainable funding, but this will be a small fraction of the cost expended on vaccines and vaccine delivery and could be resourced by levying a surcharge per vaccine dose sold, similar to methods adopted elsewhere to support compensation for vaccine-associated injuries.10 Central to any system of vaccine safety monitoring are issues of governance; specifically, transparency in decision making. Other countries currently provide full disclosure and web access to de-identified AEFI reports and open access to the deliberations of expert committees.11,12 This engenders public trust in immunisation programs, and similar strategies should be considered in Australia. The vast majority of Australian parents, vaccine recipients and health care providers trust public health authorities to assess and monitor vaccine safety. This is critical to ensure that the benefits of vaccination outweigh any potential risks. In the aftermath of the 2010 seasonal trivalent influenza vaccine experience, maintaining the public’s trust requires that we get started on building the fully functional, standard-of-care AEFI surveillance system that Australia deserves. Vaccine safety should be an integral component of the National Immunisation Strategy, which should include strategies for comprehensive and complementary passive and active systems of surveillance.

Michael S Gold MB ChB, MD, FRACP · Paul Effler MD, MPH · Heath Kelly BSc, MB BS, MPH · Peter C Richmond MB BS, MRCP, FRACP · Jim P Buttery MB BS, FRACP, MSc

To the Editor: I applaud Leach and colleagues for their recent article examining lost opportunities with Australia’s health workforce.1 There are many lost opportunities in the area of rural health. National and international studies have documented that a health professional with rural origins is more likely to return to a rural area to work than a colleague who grew up in the city.2,3 My research over the past 4 years looks predominantly at primary school students and their parents, teachers and governesses who reside over 800 000 km2 of outback Australia and study by distance education. My research is mainly into primary school-aged students because it is generally agreed among career development theorists that students start to shape ideas about occupations long before they reach high school.4 The students I studied initially had little knowledge or interest in health careers (relevant educational activities were subsequently provided to the school community in 2008). I identified five main factors inhibiting their knowledge and interest in health careers: the severe chronic shortage of health professionals in rural and remote Australia (and therefore a shortage of positive health professional role models); the limited career pool of their parents (most of whom are involved in the agricultural industry); the isolation in which they live; the limited information about the health professions provided by the school (their window to the outside world, which did not make up for their environmental shortfall); and parental perceptions. Two factors influencing parental perceptions deserve mention: awareness of the unhealthy workloads and the high degree of burnout among rural medical practitioners (they didn’t want this for their children); and the negative images portrayed in the media (eg, reports about health workers’ pay). My research focused solely on developing an awareness of the health professions as possible career options for these students.5 However, other factors also prevent students who live in rural and remote Australia becoming health professionals: inequality of primary and secondary educational opportunities;6 falling access, participation, retention and success rates in tertiary education;7 and the financial, emotional, family and social costs of attending tertiary courses a long way from home.8 We are all aware of the hardships of urban-raised health professionals undertaking rural medical placements, but do we understand equally the hardships of rural and remote students studying in the city? If Australia is genuine about wishing to solve the rural health workforce crisis, students from rural and remote areas must be provided with real opportunities to become rural health professionals, because the evidence suggests that the long-term survival of rural health services may depend on the recruitment of rural students.

Susan M Gorton

Currently available data can be used to focus clinical quality, patient centredness and safety of care in hospitals Australia has traditionally focused its public reporting efforts concerning hospital care on indicators of volume, costs, length of stay and efficiency at state, territory and national levels. Curiously, there is much less nationally consistent hospital-level reporting on other dimensions of care such as appropriateness, effectiveness, patient-centredness and safety across Australia. There are two major reasons for measuring, monitoring and reporting on these dimensions of quality of hospital care. First, hospital-level reporting stimulates and focuses quality improvement initiatives that support better care and better health. Quality improvement techniques such as benchmarking, Six Sigma, “lean” programs, collaboratives and process re-engineering all depend on measurement and reporting to monitor impact. There is evidence, for example, that confidential, hospital- and physician-level reporting can substantially reduce 30-day mortality after cardiac surgery.1 A review of international evidence indicates that there is “strong and consistent evidence that public reporting stimulates quality improvement in hospitals” and “the majority of studies show significant positive impact of public reporting on clinical outcomes”.2 Second, hospital-level reporting is necessary for accountability and transparency as governments, insurers and the public reasonably expect to understand how effectively care is being delivered. Public reporting is also necessary for transparency if ready access to information is expected to influence patient choice. A recent review of international evidence indicated that public reporting “may be able to make significant and policy-important changes in consumers’ decisions in choosing hospitals in some settings”.1 This Supplement features articles that describe how currently available data can be used to focus quality improvement and to support accountability and transparency through the creation and use of timely and accurate information on clinical quality, patient centredness and safety of care in hospitals. The article by Sketcher-Baker and colleagues on the use of variable life-adjusted displays (VLADs) describes how inpatient data in Queensland have been used to support quality improvement, accountability and transparency.3 Data collation, calculation of VLADs, and feedback inform a clinical improvement program and support accountability while delivering transparency through public reporting of outcomes. Other important elements of this program are the commitment to ongoing review and consultation around the indicators, and the clinical governance model that underpins the VLAD review and response cycle. The article by Clarke and colleagues on the AusPSI program describes how inpatient data have been used to support routine reporting to the Patient Safety Monitoring Initiative in Victoria.4 This initiative involves the use of risk-adjusted outcome measures that build on patient safety indicator work established by the Agency for Healthcare Research and Quality.5 The main questions to ask in assessing data collections that report on quality of care include: Are we asking the right questions — will each data collection accurately describe significant variance in practice and outcomes? Is the data collection feasible and efficient, or unrealistically burdensome? Is there high-quality data scrutiny — of accuracy and reliability? Is there high-quality interpretation and clinical review of reported compliance and variance? Is the risk adjustment fair? Reid and colleagues describe the Australian Cardiac Procedures Registry (ACPR).6 The ACPR includes patient, procedure and outcome data from 21 participating facilities, generating and feeding back risk-adjusted outcome measures against local and international benchmarks. In a previous issue of the Journal, McNeil and colleagues recommended the establishment of clinical quality registries for high-cost, high-volume interventions where there is variation in practice and where practice modification can improve outcomes.7 The successes of the National Joint Replacement Registry,8 the National Breast Cancer Audit,9 the Australian and New Zealand Intensive Care Society Centre for Outcome and Resource Evaluation patient databases,10 and the Australia and New Zealand Dialysis and Transplant Registry11 suggest that clinicians are prepared to trade off the burden of submitting a succinct dataset — that they themselves have developed — in return for routine reports showing their own performance, risk-adjusted, against their peers. Ben-Tovim and colleagues describe their efforts to measure standardised, in-hospital death rates.12 The authors, in collaboration with the Australian Institute for Health and Welfare (AIHW), have led national analyses of hospital mortality data, and refined the Canadian risk adjustment through detailed analyses of the National Hospital Morbidity Database. The calculation, monitoring and reporting of hospital-standardised mortality ratios (HSMRs) is not without controversy.13,14 The Australian Commission on Safety and Quality in Health Care, however, has recommended that hospitals routinely review HSMRs, deaths in low-mortality diagnosis-related groups and condition-specific inhospital mortality rates to identify opportunities to improve hospital care.15 Kennedy and colleagues describe the importance of clinical practice guidelines, and the need to identify and respond to variations in practice, in the context of the rapid escalation of the comparative effectiveness agenda in the United States.16 Leathley and colleagues summarise the results of a forum, convened by the Clinical Excellence Commission in New South Wales, on measuring hospital performance.17 The authors outline key principles for the design of hospital performance measures, and identify measures with the highest potential. McNeil and colleagues describe the National Antimicrobial Utilisation Surveillance Program approach to measure, monitor and identify significant variance and trends in antibiotic usage.18 They demonstrate how antibiotic usage data from 28 principal referral hospitals and one private hospital have generated interventions and real change in antibiotic prescribing practice. Current health care reportingAt the national level, the AIHW and the Australian Government Productivity Commission take seriously their charters to “provide information on Australia’s health and welfare, through statistics and data development”19 and “promote public understanding of matters related to industry and productivity”20 on health services. On 20 April 2010, the Council of Australian Governments agreed (with the exception of Western Australia) to sign the National Health and Hospitals Network Agreement, including the establishment of a National Performance Authority, and there are plans to launch a public website with hospital-level information.21 At the state and territory level, several governments release information on the performance of public hospitals, including Victoria,22 Queensland23 and NSW.24 NSW publishes information including waiting lists for elective surgery, health care-associated infections and current safety notices, and hosts a health service website.25 The NSW Bureau of Health Information was recently established to publicly report on the performance of the state’s health system. The Bureau’s first report provided comparative, hospital-level information on patient-centred care in 38 large hospitals.26 Its hospital quarterly reports will provide information on inpatient services, surgical care and emergency departments every 3 months. The first issue expanded the scope of hospital-level information previously reported to include new measures of accessibility and patient-centred care and increased the number of hospital emergency departments reported on from 40 to 66.27 The way forwardIf we accept the premise that timely, accurate and comparable information about the performance of hospitals is “a good thing”, the most important question remains: “What measures are meaningful and useful?” If the purpose of reporting is better care, selection of measures should be driven by the priorities of clinicians and health care management and policy communities. If the purpose of reporting is accountability, selection of measures depends on the aim of investments. If the purpose is transparency about the performance of hospitals, a broad and balanced portfolio of measures is important. Authors of articles in this Supplement highlight how current information systems in Australia can be used to gather meaningful, useful information for clinical, management and policy communities. It’s up to the rest of us to build on these initiatives to create and use timely, accurate and comparable information about the performance of hospitals in Australia to support better care.

Neville Board RN, BA, MPH · Diane E Watson PhD, MBA, BScOT

A Clinical Excellence Commission seminar explored how clinical practice variation can be monitored, and identified directions and opportunities in this field The Clinical Excellence Commission (CEC) is a statutory corporation, entrusted with improving patient safety and clinical quality within the New South Wales health system, in collaboration with key partners. In addition to sponsoring several clinical improvement initiatives, the CEC has a reporting, capacity-building and networking role to identify, promote and help spread best practice. In 2008, to meet community and government requirements of transparency, openness, accountability and integrity, the CEC sought to progress the development of a small set of safety and quality measures for NSW hospitals. Related reform initiatives included the Special Commission of Inquiry into Acute Care Services in NSW Public Hospitals1 and outcomes of the 2008 Council of Australian Governments meeting,2 calling for the development of robust, agreed, reliable, readily available and publicly reported measures relating to quality and safety of health care. Cognisant of successful developments overseas and nationally, and of reform initiatives within NSW, the CEC hosted a seminar in Sydney on 13 November 2008, entitled Hospital Performance and How We Can Measure and Report On It. The aim of the seminar was to explore current reporting mechanisms and to engage a range of key stakeholders in discussion regarding the development of critical measures that could best report quality and safety performance in NSW hospitals. Over 50 senior clinical and administrative stakeholders were in attendance. The seminar focused on the experiences of health agencies in Canada and Australia, identifying initiatives for capturing and reducing variation, and highlighting challenges and opportunities related to data collection and reporting. Outcomes from the seminar included identification by the assembled group of agreed key principles, critical measures with the highest potential and the next steps to facilitate progress. PresentationsThe seminar included the following presentations: The Canadian Experience of Performance Measurement and Reporting (Professor G Ross Baker, University of Toronto) shared the experience of developing a balanced scorecard in the Canadian health system in the mid 1990s and of the growing acceptance of public reporting of key indicators. Measures for the Australian Health System (Jenny Hargreaves, Australian Institute of Health and Welfare) outlined a set of proposed performance indicators across the health and aged care system, and the development of national indicators of safety and quality in health care, being undertaken for the Australian Commission on Safety and Quality in Health Care. The Queensland Experience (Professor Michael Ward, Health Quality and Complaints Commission) described the origins and evolution of public hospital performance reporting via variable life-adjusted displays (VLADs). The Overview (Professor Clifford Hughes, CEC) outlined key drivers and developments of developing public hospital performance measures in the NSW health system. DiscussionA plenary discussion after the presentations debated the need for improved measures of safety and quality, the requirement to report these publicly, and the potential role of NSW Health or the CEC in measuring hospital performance. The following key points were identified during the discussion. Improvement and accountability are interlinked. There is value in distinguishing between dimensions of care; for example, low-dimension elements with clear intervention, outcomes and accountabilities, and high-dimension elements, which are more complex and where outcomes, processes and accountabilities are less clear. Community expectations and patient satisfaction measures do not generally correlate with performance outcome measures. There is a need to consider timing correlations between performance reports, reduction in variation and improved quality of care. VLAD data provide immediate feedback with links to process changes relatively evident, whereas mortality-related data take longer to review. Triangulation approaches are likely to assist. Linkage to population health is supported, with development of relevant measures being considered. “Accountability” generally involves elements of blame and responsibility for improvement. A key question to address is: “Accountability to whom?” Accreditation is a useful part of the framework, but is not an end in itself. Mortality is a complex outcome, not simply a “bad” one, and its negative aspects need to be balanced against allowing a patient to die with dignity and respect. Datasets will need to be refined over time, in terms of number and value, rather than trying to get a perfect set first time. The value for hospitals and clinicians is in being able to compare performance with their peers in regard to valid measures. Feedback loops are important for sharing and acting on data — there is a need to link in with broader quality improvement processes and other parts of the system, such as ambulance services. Systematic, regular reporting is seen to be important for the health system (from Minister to clinicians) and consumers, to provide reassurance that the system is performing as it should, and to highlight vulnerabilities to be improved. Quality of data is more important than quantity of data. There was general consensus that the key principles shown in Box 1 should apply to the design of a set of hospital performance measures for safety and quality. Selecting measures with greatest potentialSeven working groups were asked to identify the indicators or measures with the highest potential, in terms of being: relevant; clearly defined; measurable; routinely reportable; robust (high-volume, reliable, clearly defined); evidence-based and/or representative of interventions that will most improve safety and quality; timely; risk-adjusted; consumer- or patient-focused; immune to political influence, “gaming” or manipulation, and perverse incentives; and able to be collected with minimal cost and burden on clinicians. The measures with the highest potential as selected by all groups are shown in Box 2. The group believed that this would be an ambitious, but realistic, initial set of measures, to be refined or developed with experience. Other measures which were considered to have potential, but not to meet all criteria at this time, included: caesarean section and other women’s health intervention rates including hysterectomy and episiotomy; stroke and heart failure best-practice care (bundle of evidence-based interventions as per acute coronary syndromes); mental health (readmissions, number of admissions per annum, follow-up after 7 days); hospital-acquired malnutrition; mortality from conditions considered amenable to health care; hospital standardised mortality rates; staff satisfaction; and open disclosure process. Subsequent directionsSeminar participants endorsed the CEC proceeding in partnership with other key stakeholders in developing and implementing a key set of indicators for reporting safety and quality in NSW hospitals. As part of this process, a summary report of the seminar was distributed to participants and temporarily posted on the CEC website to communicate, lead discussion and increase buy-in. This included acknowledgement of the need to engage more broadly with significant groups within hospitals in the development, collection and reporting of relevant measures. Shortly after the seminar, the final report of the Special Commission of Inquiry into Acute Care Services in NSW Public Hospitals was published.1 A key recommendation of the report was identification, development and publication of patient care measurements as a comprehensive way of seeing how patients in NSW hospitals are being looked after. Key measurements identified by the report were: access to and availability of hospital services; clinical performance; safety and quality of clinical care and hospital attendance and admission; cost of clinical care; patient experience and satisfaction; staff experience and satisfaction; and system impact and sustainability. The report recommended the establishment of a Bureau of Health Information to meet the above reporting requirements. This Bureau (http://www.bhi.nsw.gov.au/) was formally established in 2009, and the CEC will work in close association with the Bureau to support and help promote the development, implementation and reporting of relevant quality and safety measures. The findings of the seminar reported here will be a key factor in this development. 1 Key principles Choose measures based on strategy and intent, not political imperative Identify the core purpose (eg, accountability, improvement, research, consumer/patient knowledge) Choose a limited number of measures Have dual sets of indicators for different purposes: high-level indicators for public reporting more detailed outcome and process measures for quality improvement Engage clinicians in the design and collection of indicators; this is crucial Increase capacity of computerised systems to facilitate access to outcome measures, and to reduce the burden of data collection Recognise that most improvements in indicator data quality usually follow their reporting 2 Selected measures Hospital-acquired infections (bundle of measures including methicillin-resistant Staphylococcus aureus infection, infection with vancomycin-resistant enterococci, central line infections, surgical site infections, Clostridium difficile infection, and ventilator-associated pneumonia) Pressure ulcers Best-practice care for acute coronary syndromes (bundle of evidence-based interventions including provision of medications on discharge) Unplanned return to intensive care unit Unplanned return to operating theatre Medication errors (with associated measures of extent of harm) Patient falls Management of patients with deteriorating conditions Venous thromboembolism 30-day unplanned overnight readmission rate

Colleen M Leathley MSocSc(Hons) · Richard Gilbert BSc(Hons) · Peter J Kennedy MB BS, FRACP · Clifford F Hughes

Although difficult to quantify, there is known widespread variation in the way that best available evidence is applied in clinical practice. The reasons for gaps between evidence and practice are complex, and efforts to improve uptake are unlikely to be successful if they are one-dimensional or focus on individual health professionals. This article provides contextual reference for articles in this Supplement in addressing how and why clinical variation exists, the importance of reducing it and strategies to drive a more streamlined approach to evidence-based care in Australian health care systems.

Peter J Kennedy MB BS, FRACP · Colleen M Leathley MSocSc(Hons) · Clifford F Hughes MB BS, FRACS, FACS

Worldwide, current practice is to report hospital mortality using the hospital standardised mortality ratio (HSMR). An HSMR is generated by comparing an indirectly standardised expected mortality rate against a hospital’s observed mortality rate. A hospital’s HSMR can be compared with the overall outcomes for all hospitals in a population, or with peer hospitals. HSMRs should be used as screening tools that alert institutions to the need for further investigation, rather than as definitive measures of the quality of care provided by individual hospitals. HSMRs are computed from existing hospital administrative data sources, which are fit for such a purpose. The addition of clinical or physiological data does not, at present, add to the discriminative powers of the risk adjustment models used to adjust HSMR values for differences in hospitals’ casemixes. There has been concern that HSMRs may be too variable over time for individual values to be interpretable. A study of HSMR outcomes in Australian hospitals confirmed earlier reports of the stability of the measure. Considerable progress has been made with developing Australian HSMRs for use as routine measures to improve the safety and quality of Australian hospital care.

David I Ben-Tovim PhD, MB BS, FRANZCP · Sophie C Pointer BSc(Hons), PhD · Richard Woodman BSc(Hons), PhD, MBiostat · Paul H Hakendorf BSc, MPH · James E Harrison MB BS, MPH

The variable life-adjusted display is a graphical, statistical methodology used in Queensland to monitor patient outcomes of clinical indicators. The quality improvement cycle is a systematic approach employed by patient safety and quality programs worldwide to improve patient care. The quality improvement cycle is beneficial to the review and refinement of indicator definitions. Indicators with definitional issues that are not subject to the quality improvement cycle may initially prompt quality improvement opportunities, but are more likely to potentially lead to unnecessary chart and clinical reviews, which will disengage coders and clinicians. Queensland recently used the quality improvement cycle to refine the laparoscopic cholecystectomy complications of surgery indicator definition and several maternity definitions.

Kirstine M Sketcher-Baker BAppSc(Maths) · Maarten C Kamp MB BS, MHA · Julia A Connors BNurs, BAppSci(MedSci), BAppSci(Hons) · Don J Martin MB BS, BBus · Justin E Collins GradCertHlthMgt

Routine monitoring of performance in the provision of cardiac services aids quality assurance and enables comparisons of performance to national and international standards. The Australasian Society of Cardiac and Thoracic Surgeons conducts a surgical registry that has grown from six hospitals participating in 2001 to 21 contributing in 2010. Variation in performance is monitored on a quarterly basis through the use of control chart methodology, and a peer-review mechanism and governance process for reporting have been established. Proposed future developments of the registry include its expansion to include interventional cardiology procedures, such as implantation of stents and cardiac devices, and a modular format, with the patient rather than the procedure being the key element of the system. An Australian Cardiac Procedures Registry will provide information to stakeholders, including consumers, clinicians, health funders and policymakers, on performance standards and quality of care of medical services affecting an ever-increasing number of Australians.

Christopher M Reid DipEd, MSc, PhD · Angela L Brennan RN, CCRN · Diem T Dinh BSc(Hons), PhD · Baki Billah PhD, MAS, MSc · Carl B Costolloe BSc(Photonics), MEng · Gilbert C Shardey MD, FRACS · Andrew E Ajani MB BS, MD

Objective: To document diabetes health services use and indices of glycaemic management of young people with type 1 diabetes from the time of their first contact with adult services, for those living in regional areas compared with those using city and state capital services, and compared with clinical guideline targets.Design, setting and subjects: Case note audit of 239 young adults aged 18–28 years with type 1 diabetes accessing five adult diabetes services before 30 June 2008 in three geographical regions of New South Wales: the capital (86), a city (79) and a regional area (74).Main outcome measures: Planned (routine monitoring) and unplanned (hospital admissions and emergency department attendance for hypoglycaemia or hyperglycaemia) service contacts; recorded measures of glycated haemoglobin (HbA1c), body mass index (BMI), and blood pressure (BP).Results: Routine preventive service uptake during the first year of contact with adult services was significantly higher in the capital and city. Fewer regional area patients had records of complications assessment and measurements of HbA1c, BMI and BP across all audited years of contact (HbA1c: 73% v 94% city, 97% capital; P < 0.001). Across all years, regional area patients had the highest proportion of HbA1c values > 8.0% (79% v 62% city, 56% capital) and lowest proportion < 7% (4% v 7%, 22%) (both P < 0.001). Fewer young people made unplanned use of acute services for diabetes crisis management in the capital (24% v 49% city, 50% regional area; P < 0.001). In the regional area, routine review did not occur reliably even annually, with marked attrition of patients from adult services after the first year of contact.Conclusion: Inadequate routine specialist care, poor diabetes self-management and frequent use of acute services for crisis management, particularly in regional areas, suggest service redesign is needed to encourage young people’s engagement.

Lin Perry PhD, MSc, RN · Katharine S Steinbeck MB BS, FRACP, PhD · Janet S Dunbabin BAg(Sc), PhD · Julia M Lowe MB ChB, FRCP, MMedSci

This article reports the experience of the Victorian Department of Health in seeking clinician engagement in the testing of 11 quality-of-care indicators in 20 health services in Victoria. The Department previously developed a suite of 18 core indicators and seven subindicators known as the AusPSI set. We used routinely collected administrative data from the Victorian Admitted Episodes Dataset to produce variable life-adjusted display (VLAD) control charts for 11 selected indicators. The Department recognises that clinicians are responsible for the safety and quality of the care they provide, and therefore the necessity of engaging clinicians in the process of investigating apparent variation in patient care. Although using readily available and inexpensive routinely collected administrative data to measure clinical performance has a certain appeal, the use of administrative data and VLADs to identify apparent variations has posed significant challenges due to concerns about the quality of the data and resource requirements. When clinicians at a major Melbourne hospital were engaged, it resulted in an improvement in clinical practice. Investigating apparent variation in patient care provides an ideal opportunity for emerging clinical leaders to take local ownership and develop expertise in investigating apparent variation in processes of care and implementing change as required.

Andrew L L Clarke RN, BAppSci(Nursing) · William Shearer MB BS, MEdSt, FANZCA · Alison J McMillan RN, BEd, MBA · Paul D Ireland PhD, MSc, BSc(Hons)

The National Antimicrobial Utilisation Surveillance Program (NAUSP) collects aggregate data from hospitals in all Australian states and provides reports of monthly hospital inpatient antimicrobial usage to contributing hospitals. These data provide an Australian peer-group benchmark; hospitals can compare their usage with similar hospitals and identify areas of antimicrobial use that require more indepth analysis. Overall high usage has been used by hospitals and area health services as a stimulus for initiation or expansion of antimicrobial stewardship programs. High use of particular classes of antimicrobials has triggered individual drug audits and been used to tailor interventions. Longitudinal antimicrobial usage data have been used by hospitals to measure the effects of antimicrobial stewardship strategies and provide feedback to prescribers.

Vicki McNeil BPharm, GradDipPharm, GradCertPubHlth · Marilyn Cruickshank RN, PhD · Margaret Duguid BPharm, GradDipAdmin

Aim: Design, setting and participants: Retrospective observational study of patients who were tested for influenza A after being admitted to hospital through emergency departments of the Sydney South West Area Health Service from 15 June to 30 August 2009.Main outcome measures: The association of factors such as age, diagnosis at admission, hospital and week of admission with rates of testing and detection of influenza A.Results: 17 681 patients were admitted through nine emergency departments; 1344 (7.6%) were tested for influenza A, of whom 356 (26.5%) tested positive for pandemic influenza. Testing rates were highest in 0–4-year-old children, in the peak period of the outbreak, and in patients presenting with a febrile or respiratory illness. Positive influenza test results were common across a range of diagnoses, but occurred most frequently in children aged 10–14 years (64.3%) and in patients with a diagnosis at admission of influenza-like illness (59.1%). Using multivariate logistic regression, patients with a diagnosis at admission of fever or a respiratory illness at admission were most likely to be tested (odds ratios [ORs], 15 [95% CI, 11–21] and 17 [95% CI, 15–19], respectively). These diagnoses were stronger predictors of influenza testing than the peak testing week (Week 4; OR, 7.0 [95% CI, 3.8–13]) or any age group. However, diagnosis at admission and age were significant but weak predictors of a positive test result, and the strongest predictor of a positive test result was the peak epidemic week (Week 3; OR, 120 [95% CI, 27–490]).Conclusion: The strongest predictor of a clinician’s decision to test for influenza was the diagnosis at admission, but the strongest predictor of a positive test was the week of admission. A rational approach to influenza testing for patients who are admitted to hospital for acute care could include active tracking of influenza testing and detection rates, testing patients with a strong indication for antiviral treatment, and admitting only those who test negative to “clean” wards during the peak of an outbreak.

Andrew Jardine PhD, MAE · Stephen J Conaty MB BS, MPH, FAFPHM · Michelle A Cretikos MPH, PhD, FAFPHM · Wei-Yuen Su MB BS · Iain B Gosbell MD, FRACP, FRCPA · Sebastiaan J van Hal MB ChB, FRACP, FRCPA

Health systems are increasingly recognised to be complex adaptive systems (CASs), functionally characterised by their continuing and dynamic adaptation in response to core system drivers, or attractors. The core driver for our health system (and for the health reform strategies intended to achieve it) should clearly be the improvement of people’s health — the personal experience of health, regardless of organic abnormalities; we contend that a patient-centred health system requires flexible localised decision making and resource use. The prevailing trend is to use disease protocols, financial management strategies and centralised control of siloed programs to manage our health system. This strategy is suggested to be fatally flawed, as: people’s health and health experience as core system drivers are inevitably pre-empted by centralised and standardised strategies; the context specificity of personal experience and the capacity of local systems are overlooked; and in line with CAS patterns and characteristics, these strategies will lead to “unintended” consequences on all parts of the system. In Australia, there is still the time and opportunity for health system redesign that truly places people and their health at the core of the system.

Joachim P Sturmberg MFM, PhD, FRACGP · Diana M O’Halloran FRACGP, MHPEd, FAICD · Carmel M Martin PhD, FRACGP, FAFPHM

To the Editor: The article in the Journal by Leach and colleagues highlights workforce shortages in the Australian health care sectors.1 The authors identify 12 clinical professions for which data from the 2006 Australian Bureau of Statistics census show poor retention rates, and warn of the implications for the Australian population of these future shortfalls in the health workforce. However, in our opinion, the imminent workforce shortage in the pathology sector (rather than that in the higher profile specialties) is likely to represent the vulnerable point of first failure of the health care system in Australia. Pathology and diagnostic laboratory medicine are major areas in the health system, with about 70% of medical decisions being based on laboratory test results.2 About 13% of Australia’s federal health budget is allocated to pathology testing, and a similar percentage is allocated from state health budgets. Within pathology laboratories, medical scientists form the single largest professional group, although they are usually unrecognised and overlooked in workforce surveys, as is the case in the article by Leach and colleagues. Medical scientists face these same problems of poor retention within the health workforce, leading to the risk of future shortfalls in laboratory capacity and an inability to provide adequate diagnostic support for the medical system. The potential laboratory capacity shortfall has been accelerated by government policies leading to reduced funding for pathology, and the consequent failure to invest in workforce recruitment, training and development. Such an approach may deliver short-term savings, but is leading to an unsustainable environment due to the lack of an appropriately qualified and trained workforce.3 This problem is not restricted to Australia, but highlights the need for a sustainable and long-term approach to ensuring access to relevant health resources for all Australians.

Tony Badrick · Leslie Burnett · Peter E Graham · Peter P Vervaart