Health services administration

To the Editor: We welcome the thoughtful analysis from Elkin and Studdert on international students missing out on internship places.1 Given the impending shortage of available internships in Australia, this is of considerable interest to the over 500 international students who graduate each year. Sydney Medical School (University of Sydney) should be commended for explicitly discouraging international students’ expectations of internship.2 Sadly, this is an isolated example. We agree with the authors that universities have an ethical obligation to ensure this information is adequately conveyed to current and prospective international students. Education policymakers and medical school administrators should be forthcoming with vital information on the future of training for international students in Australia. The Australian Medical Students’ Association is currently developing a comprehensive information booklet, which we will distribute to prospective international students. Among other details, this will clearly outline the issue. However, the issues raised by Elkin and Studdert are not confined to international students. The authors observe that the recent health ministers’ communiqué only guaranteed internship to students in Commonwealth-supported places.3 This not only excludes international students, but also local fee-paying students at private universities and those in state-funded places. The authors argue that international students have no legitimate expectation that they will be provided with an intern place on graduation, given the “clear” statements from the federal government. However, there has been no similar guidance for local private university or state-funded students. Do these students have a legitimate expectation of internship? One could argue that state-funded students do, given the funding bodies are the same ones that will also provide their internships. While Australian permanent residents and citizens currently have first or second priority for internships, depending on their state of study and the state to which they are applying, it seems that in the future these students may miss out in favour of Commonwealth-supported students covered by the health ministers’ guarantee. Elkin and Studdert concluded that Australian courts would be unlikely to find that international students hold a legitimate expectation of internship. It is less certain whether this conclusion might apply to state-funded students or Australian permanent residents and citizens at private universities. At a minimum, these applicants too deserve “full and frank information” about their internship prospects.

Christopher X J Wong · Samuel J Whitehouse · Thomas D Crowhurst · Ross L Roberts-Thomson

Concerns have been raised about the capacity of the health workforce to meet increasing future health care demands. Strategies aimed at improving workforce supply, at least in Australia, are focused heavily on education (ie, increasing the number of training places in key health professions) and recruitment (ie, recruiting overseas-trained health care professionals). Data from the 2006 Australian Bureau of Statistics census of population and housing indicate that while many Australians hold health professional qualifications, many are either not in the workforce or not employed within the health occupation they hold qualifications for. Some immediate solutions for increasing the health workforce are to attract qualified health professionals who are either not in the workforce or are working outside the health occupation back into their occupational role; to increase worker retention for those still working within the occupations they trained for; and to explore strategies for better retention of new graduates.

Matthew J Leach BN(Hons), ND, PhD · Leonie Segal BEc(Hons), MEc, PhD · Esther May BAppSc(OT), PhD

To the Editor: The current political debate on health reform has made no mention of the 300 000 people who were identified by the National Health and Hospitals Reform Commission as facing “stark health inequalities”.1 We refer to people with intellectual disability, who face a life expectancy 5–20 years shorter than people in the general population, substantial unmet health needs and significant barriers to getting these needs met. A recent review of health inequalities in England states: To reduce the steepness of the social gradient in health, actions must be universal, but with a scale and intensity that is proportionate to the level of disadvantage. We call this proportionate universalism.2 In its health reform initiatives, the federal government has quite rightly included specific funding for the health of Indigenous people and residents of aged care facilities, and for rural health and mental health. Many of these measures are just a start, but they are direct acknowledgement of specific disadvantage. However, the government has taken no such action on the health of people with intellectual disability. In fact, recent changes to Medicare (in May 2010)3 include a step backwards for people with intellectual disability. The merging of intellectual disability health assessment items into four new time-based items means that data are no longer kept on the uptake of intellectual disability assessments. This was the one piece of information on the health of people with intellectual disability that the government collected. Many of the government’s health reforms will have wide community benefit. However, we are long used to people with intellectual disability missing out on the benefits of generic programs. To give one example, funding hospitals on the basis of the “efficient price” of services may create a disincentive to treat people with intellectual disabilities, who need much more time than other patients. To avoid this disincentive, the government needs to create a price-loading for people with intellectual disability, which in turn will require the government to redress the absence of data on hospitalisations of people with intellectual disability. With each plank of its reform, the government at least needs to ask: “What adjustments are needed to make this work for people with intellectual disability?” We are happy to provide the answers.

Nicholas G Lennox · James C Simpson

To the Editor: Although Clarke and Fitzgerald’s claim that prices for generic medicines in Australia are high compared with prices in other countries1 is valid, their claim that the Pharmaceutical Benefits Scheme expenditure on statins could be reduced by up to $9.31 billion, by increasing the proportion of generic prescriptions to 100% and paying equivalent prices to those in England, is problematic. For the proportion of generic prescriptions to be increased to 100%, the available generic statins would need to be directly substitutable for currently available statins, including those whose patents have not yet expired (eg, atorvastatin and rosuvastatin). Nicholls and colleagues present the results of a meta-analysis of various doses of atorvastatin, rosuvastatin and simvastatin.2 The findings of the Pharmaceutical Benefits Advisory Committee (PBAC) on the comparative effectiveness of the various statins can be summarised as follows:3 Simvastatin is the benchmark statin; the maximum recommended dose is 80 mg/day. Pravastatin is equivalent to simvastatin on a milligram-for-milligram basis: pravastatin 10 mg is equivalent to simvastatin 10 mg. The maximum recommended dose of pravastatin is 80 mg/day. Atorvastatin 1 mg is equivalent to simvastatin 2 mg: atorvastatin 10 mg is equivalent to simvastatin 20 mg. The maximum recommended dose of atorvastatin is 80 mg/day. It is notable that a simvastatin dose equivalent to atorvastatin 80 mg (ie, simvastatin 160 mg) is beyond the maximum recommended dose of simvastatin. Rosuvastatin 1 mg is equivalent to atorvastatin 3 mg, which would be equivalent to simvastatin 6 mg (ie, rosuvastatin 10 mg is equivalent to atorvastatin 30 mg, which would be equivalent to simvastatin 60 mg). The maximum recommended dose of rosuvastatin is 40 mg/day. It is notable that a simvastatin dose equivalent to rosuvastatin 40 mg (ie, simvastatin 240 mg) is beyond the maximum recommended dose of simvastatin. By applying the therapeutic relativities accepted by the PBAC to the results reported by Nicholls and colleagues, the dose–response curves for rosuvastatin, atorvastatin and simvastatin, all expressed in simvastatin mg equivalents, can be generated as shown in the Box. As seen in the graph, simvastatin (available as a generic) may not be substitutable for atorvastatin or rosuvastatin in patients who need a reduction in low-density lipoprotein cholesterol level of > 45 mg/dL (> 1.15 mmol/L). Although having patients switch to generic prescriptions would reduce expenditure on statins, the possibility that such a switch might be associated with inferior outcomes needs to be considered. Dose–response curves for rosuvastatin, atorvastatin and simvastatin LDL-C = low-density lipoprotein cholesterol.

Liliana Bulfone

In reply: Our recent study1 estimates pharmaceutical expenditure from 2009 to 2019 for various levels of use of off-patent statins, ranging from 25% (close to the current proportion) to 100%. We also show that England has much higher use of generic statins and consequently much lower pharmaceutical expenditure. However, our study does not advocate a particular level of generic use and so it is unclear why Bulfone has chosen to focus on only one of the cases (100% use of generics) presented in our study. We agree with Bulfone’s view that it is important to consider whether the greater use of generic statins has an impact on health outcomes in addition to examining the implications for pharmaceutical expenditure. This is one of the points we have already made: “The key question is whether the health benefits resulting from using statins under patent or combination therapies justify the substantially higher subsidies from the [Pharmaceutical Benefits Scheme].”1 The appropriate framework to use to consider this question would be to examine incremental cost-effectiveness of those statins still under patent (atorvastatin and rosuvastatin) compared with off-patent alternatives (simvastatin and pravastatin). Such an evaluation would be timely, as Australia faces billions of dollars of extra pharmaceutical expenditure over the next decade if we continue to prescribe patented statin formulations at current levels.

Philip M Clarke · Edmund M FitzGerald

It may be time to invest more in primary care research, including research on clinical conditions Here is a simple exercise: in the PubMed website (http://www.ncbi.nlm.nih.gov/pubmed), type “The New England Journal of Medicine[Jour] AND Australia[All Fields]”, and you will see that the journal has published about 90 Australian articles since 2000. Scanning through them, you will find that just one includes an Australian general practitioner as an author (Professor John Marley, in 10th author position), for an article describing the large blood pressure trial ANBP2.1 Repeating this exercise for JAMA (the journal of the American Medical Association) yields one Australian GP author in one of 79 Australian papers (Professor Chris Silagy as first author), in an analysis of protocols of published systematic reviews and reports.2 But what should we expect in the way of research from just one discipline — general practice — in one country? Should we conclude that general practice is not a glittering performer among the medical and health disciplines in Australia, or that it is holding its own? On one hand, it could be argued that general practice is not likely to be the area for such revolutionary discoveries as will command attention from the two most-cited medical journals. We could, instead, think of general practice as the final common pathway for best practice, honed in specialty clinical practice and research. On the other hand, general practice could be described as not only an obvious but perhaps even an indispensable place for research in the areas of health services (ways of delivering care better) and clinical research into diseases encountered in primary care. It may even be a place for basic science research. General practice is where about three-quarters of all medical consultations in Australia take place. The gaps between practice and the best evidence are as wide there as anywhere, and our need for information is urgent.3 On the basis of the numbers of clinicians in the discipline who need information, primary care research output should be the highest compared with the other (smaller) disciplines. But this was not the case a decade ago and is still not the case today, although the situation has improved. A 2001 study, using clinician numbers in the discipline as a denominator, showed that research in the area of internal medicine and surgery in Australia was 60–100 times more productive than that of general practice.4 In addition, general practice research is usually published in journals that are considerably less cited than specialty journals (although a citation index is an imperfect way of measuring research quality).5 The stimulus for a surge in Australian primary care research came from an unexpected quarter. In 1989, the proposal to form a register of GPs, championed by the Royal Australian College of General Practitioners (RACGP), was met with opposition from some non-RACGP-aligned GPs and the Australian Medical Association. The Australian Government referred this political hot potato to the Senate Select Committee on Health Legislation and Health Insurance, which took submissions around the country.6 The Committee noted that little information was available about Australian general practice, and made two recommendations. One recommendation approved the proposed GP register (registration then requiring vocational GP training); the other was for a program of evaluative research to be established, the General Practice Evaluation Program (GPEP).7 This was the predecessor of the current Primary Health Care Research Evaluation and Development (PHCRED) program and, between them, these programs have since been the major sources of funding for Australian general practice research.8,9 Early general practice research was over-reliant on surveys and descriptive studies.7 Intervention studies started soon afterwards, although they were bemoaned as still too few and insufficiently rigorous.10 The subject matter for research has been heavily biased towards health services research at the expense of clinical illnesses, as might be expected from the historical origins of the funding.11 The investment has certainly paid off, lifting the average from one to three publications per 1000 Australian GPs per year over the past decade, with physicians now being “only” 50 times more productive than GPs.12 Primary care research has been criticised for being too “soft” (using qualitative rather than quantitative methods), and it may be true that too many nascent researchers think that qualitative research, or even survey research, will be easier than quantitative research; neither is. However, this is to confuse the mode of research with its purpose, that is, to answer the type of question that is being asked. One must use the right tools for the job. For example, questions about interventions need randomised trials; questions about diagnosis need consecutively enrolled cohort studies; and questions about aetiology need case–control studies. But sometimes a question, particularly in relation to implementation of multistranded interventions, can only be answered by using several methods — “mixed methods” research — to allow for some of the complexities of primary care.13 More important is the question of what to research. It may be time to invest more in primary care research on clinical conditions (Box). There is more uncertainty about clinical conditions managed in primary care than about many conditions managed by specialists, and there is much research to conduct. A useful leaf that we, as GP researchers, should take from the specialists’ book is to work more collaboratively with basic science researchers. A good example of a successful collaboration of this sort is a study about the prevalence of whooping cough in children, which has changed the way we think about persistent cough after apparently trivial acute respiratory infections — might it be due to pertussis? In this study, bench-top scientists worked with GP researchers to generate a rapid and reliable diagnostic test for infection with Bordetella pertussis.15 Now is the time for more investment in primary care research — of any kind. Australian primary care research funding 2000–2010: clinical research items compared with total items14 Funding body Total items funded Clinical research items funded Primary Health Care Research Evaluation and Development* 46 0 National Health and Medical Research Council 166 27 Pharmacy Guild 82 0 Total 294 27 * Since 2003.

Christopher B Del Mar MB BChir, FRACGP, MD · Mieke L van Driel MD, PhD

Will it bring about real behavioural change in general practice? Achieving high-quality and cost-effective care for those with chronic disease requires changes in the behaviour of both doctors and patients. In the past, fragmented policy has led to fragmented management of chronic disease, and there is now an opportunity for change. A new payment scheme for the care of people with diabetes, proposed as part of the federal government’s National Health and Hospitals Network, is centred on patients voluntarily enrolling with a practice and general practitioners being paid in a way that changes their behaviour.1 The proposal is worth $449.2 million over 4 years or up to $10 800 annually per practice, and includes a sign-up payment of $1500 per practice, voluntary patient enrolment, capitation payments ($100 per patient) and annual payments of up to $950 per patient linked to “keeping . . . patients healthy and out of hospital”. Although there is evidence that changing the way doctors are paid can influence their clinical decisions, evidence of how such a change affects patients’ health outcomes and quality of care is scarce. Systematic reviews reveal only a handful of well designed studies that provide reasonable evidence of effects of changes to payment systems on both doctors’ behaviour and clinical outcomes, although recent evaluation of the Service Incentive Payment (SIP) for care of patients with diabetes showed positive outcomes, including an impressive improvement in the appropriate use of glycated haemoglobin (HbA1c) testing.2,3 The first challenge to the supremacy of fee-for-service in general practice remuneration for patient care came with the introduction of the Practice Incentive Program (PIP) in 1998. The PIP has always involved a form of capitation payment and, since 2001, has included “pay for performance” for diabetes and asthma management, cervical screening and (until 2005) mental health care. PIP payments take the form of SIPs and, for treatment of diabetes, are based on completing cycles of care for at least 20% of the practice’s patients with diabetes. So how might these changes in payment affect the way GPs deliver diabetes care and the outcomes achieved? How will the new payments relate to existing programs and will the scheme extend the role of practice nurses? First, patient registration has the potential to strengthen the relationship between doctors and the populations they serve. There is good evidence that continuity of care improves patient outcomes,4 especially for those with diabetes. However, limiting registration to specific groups of patients is a piecemeal approach and inefficient. Voluntary registration for all chronic diseases that require longitudinal care would seem a better way forward. Other questions remain to be resolved. What is in it for patients? Will they appreciate the benefits of more intensive diabetes care? For GPs, participation is limited to accredited practices. Presumably, those already claiming payment through the cycles of care program for diabetes will participate — but will their behaviour actually change? Will new doctors be drawn into this scheme? A key concern is the role of capitation payment. Payments based on patient counts could induce general practices to include in the scheme only those patients whose diabetes is already well controlled, and practices with disadvantaged populations, where treatment is more difficult, may be less likely to participate. However, given that the scheme’s capitation payment of $100 per patient is provided in addition to existing fee-for-service and pay for performance, then incentives for opportunistic selection of patients may be less (depending on the relative size of the performance payments). Care must be taken to avoid opportunities for gaming and other unintended consequences. Second, the scheme’s authors have not detailed the role of pay for performance. The scheme provides an opportunity to pay for outcomes rather than inputs. Paying for improvements in outcomes, rather than for meeting a specified threshold, should be a key element to encourage participation of practices with currently low outcomes of care for diabetes. But how should performance be measured? The cycles of care programs have the advantage of using Medicare data and not adding to GPs’ burden of data reporting. However, the new scheme, by requiring improvements in HbA1c, blood pressure or serum lipid levels to be measured, will rely on practice-level data. The reporting of data by GPs has proved to be feasible through the Australian Primary Care Collaboratives Program and in standard general practice, but often requires further investment in information technology.5 Third, is the $449.2 million new money or a re-use of the diabetes SIP money? If the latter, and if those currently claiming SIPs move over to the new scheme, then behaviour may not change and quality of care may not improve. There are multiple sources of financing, such as the Enhanced Primary Care items for chronic disease and team-care arrangements. Will these be discontinued and funding redirected into this new scheme? Multiple funding sources create red tape and confusion, further limiting the likelihood of behaviour change. Fourth, team-based care and the role of nurses have been given a boost with $390 million for the direct employment of 4600 practice nurses. Although the numbers of practice nurses have been growing rapidly,6 their roles have been limited to existing Medicare items. Direct salary support will enable practices to use their nurses’ skills flexibly and fully, including skills in diabetes care.7,8 However, nurses should also be given equitable shares of performance pay, if teams are to function effectively.9 Using management of diabetes as a test case for this new model of funding patient care is welcome, but as with all test cases, careful evaluation is required before the model is expanded. Evaluation should be a priority from the time the scheme is introduced. The most important question is whether the new scheme will be able to drive real behavioural change among primary care teams and patients, rather than being just another way of delivering funding to those already doing a good job.

Doris Young MB BS, MD, FRACGP · Anthony Scott BA(Hons), MSc, PhD · James D Best MD, FRACP, FRCPath

Despite significant investment in e-health, practical outcomes are yet to be realised In classical Fabian tradition, the federal Labor government has embarked on a series of reforms that will have an impact on the welfare of “Australian working families”. The rationale for the health reforms1 has been exhaustively detailed in the reports of the National Health and Hospitals Reform Commission2 and the taskforces on the National Preventative Health Strategy3 and National Primary Health Care Strategy.4 A significant and unifying theme in all these blueprints for health reform is the centrality and crucial involvement of general practice in achieving change. Indeed, these reforms would come to nothing without the willing acceptance and widespread cooperation of general practitioners. In this special General Practice issue of the Journal, Kidd summarises the reform schedules for general practice (page 71).5 However, there is mounting evidence that GPs are already experiencing difficulties meeting the constant and ever-changing demands placed on their practices, as illustrated on the cover of this issue. To impose yet another structural reform agenda in an already chaotic environment will be a monumental challenge. Generally speaking, reform is more readily acceptable if it: lessens rather than increases the workload; improves the efficiency and effectiveness of tasks; increases the quality and safety of services; and provides tangible incentives for participants. Without a doubt, a major source of frustration and consternation with the federal government’s reform agenda is the very clear sense that it is essentially a top-down approach, rather than a bottom-up consultative process. In fact, if there were to be a national poll of GPs ranking current health reform initiatives, “e-health” — the use of digital data transmitted, stored and retrieved electronically in support of health care6 — would definitely emerge as a major priority. Such information technology infrastructure is crucial to all health care communication in the 21st century but, to date, all we have achieved in Australia has been to indulge in expensive and time-consuming chatter. We have been talking the talk but not walking the walk! It must be acknowledged that e-health has been on the federal government’s agenda for more than a decade. In 2000–01, the then Health Minister, Michael Wooldridge, announced the planned development of HealthConnect — a national system of e-health records that could be shared over secure networks with strict privacy and consent controls.7,8 The system was trialled in pilot studies across the country and, in March 2004, the government allocated $128 million for national implementation.8 But then, in 2005, Health Minister Tony Abbott (now leader of the federal Opposition) pulled the plug on HealthConnect.7 Around the same time, the federal, state and territory governments established the National E-Health Transition Authority (NEHTA), with a clear purpose: to lead the uptake of e-health systems of national significance; and to coordinate the progression and accelerate the adoption of e-health by delivering urgently needed integration infrastructure and standards for health information.9 Since its inception in July 2005, NEHTA has been spending just under $164 000 a day.7 It is yet to deliver any e-health outcomes beyond a 2009–2012 strategic plan and the development of a national health care identifier system that was recently ratified by the Australian Government.10 In May this year, the federal government allocated NEHTA a further $466.7 million over 2 years, ostensibly to fund development of core national standards and tools that can provide all Australians with access to a personally controlled electronic health record from 2012–13. The federal government will thus spend $639 315 each day on the implementation of personally controlled electronic health records.7 Despite this, vigorous debate is ongoing as to who will actually control the records! Confusion reigns. It must be remembered that the realisation of e-health infrastructure in Australia is underpinned by taxpayers. Whether it will ever produce a functional electronic communication and record system, which actually improves health care delivery, is the million-dollar question.

Martin B Van Der Weyden MD, FRACP, FRCPA

Divisions of General Practice are a significant part of Australia’s health care sector. The Australian Government intends to establish “Medicare Locals” (MLs), which will assume many of the roles currently undertaken by Divisions. MLs will, on average, be larger than Divisions and are likely to have different ownership, governance and accountability arrangements. While some Divisions may find transformation into an ML an appealing and relatively straightforward option, others may wish to follow alternative paths that allow them to maintain many of their current characteristics. Evidence suggests that the move to MLs might jeopardise the level of clinical involvement attained by Divisions.

Philip K Davies MSc, GAICD

In 2008, the Australian Government established three major health reform initiatives — the National Health and Hospitals Reform Commission, the first National Primary Health Care Strategy working group, and the Preventative Health Taskforce. We examined which journals were most frequently cited in the publicly available discussion papers, commissioned papers, submissions and final reports of these initiatives. Journal articles were cited most in discussion papers, commissioned papers and submissions, followed by reports and other publications from Australian organisations and governments. The Medical Journal of Australia was the most cited journal, with 392 references to its articles (11.8% of all journal articles cited) in discussion papers, commissioned papers, submissions and an interim report, and 58 references to its articles (13.7% of total journal articles) in the three final reports. Our findings demonstrate the importance of credible, local, accessible, peer-reviewed evidence in reforming the national health system, including hospitals, primary health care and preventive health care.

Elizabeth C Kalucy BSc, MSc, Dip Ed · Eleanor M Jackson Bowers BA(Soc Sci), MNurs, GradDipInfoStud

Objective: To determine changes in the pattern of use of standard general practice consultations, and the degree to which any changes are offset by the use of special Medicare Benefits Schedule (MBS) items.Design, participants and setting: Population-based retrospective analysis of age- and sex-standardised Medicare claims data (1994–2009) on the utilisation of general practice standard consultations (Levels A, B, C and D) alone and in combination with health assessments and care plans and other special MBS items.Results: Utilisation rates of Level C and D (long) consultations increased consistently from 1994 to 2004, but by 2009 a considerable decline had occurred. A reverse of this pattern was observed for Level A (short) consultations. When utilisation rates for special items and long consultations were combined, the combined utilisation rate followed an upward trend until 2007, but also declined in 2008 and 2009.Conclusions: The decline in the use of Level C and D consultations in recent years has been dramatic and accompanied by an increase in use of Level A consultations. While the use of special items has offset the decline in long consultations, this compensating effect has weakened in the past 2 years. This pattern is at odds with health policy objectives that rely on long consultations to provide preventive care and chronic disease management. Given the current situation, the recently introduced Medicare reforms (May 2010), including changes to Levels B, C and D consultation item descriptors, may not be sufficient to change consultation patterns.

Michael J Taylor BPharm(Hons), LLB(Hons), PhD · Dell Horey BAppSc(Chem), MMedSc(Clin Epi), PhD · Charles Livingstone BA, MEc, PhD · Hal Swerissen BA(Hons), GradDipPsych, MAppPsych

Delegation to practice nurses may be the main reason for an increase in Level A consultations In their analysis of Medicare claims data for general practice consultations published in this issue of the Journal, Taylor and colleagues report a recent decline in Level C and D (long) consultations and an increase in Level A (short) consultations — a pattern they consider to be “at odds with health policy objectives that rely on long consultations to provide preventive care and chronic disease management”.1 They hypothesise that the increased use of Level A consultations may reflect: the administrative burden created by the complexity of Medicare Benefits Schedule (MBS) special items; an increase in encounters for “vaccinations, prescriptions, medical certificates or test results”; or greater use of practice nurses.1 Data from the BEACH (Bettering the Evaluation and Care of Health) program2 suggest that the third option — greater use of practice nurses — explains most of the increase in claims for short (Level A) consultations. The introduction of MBS items for practice nurses in May 20043,4 had a significant impact on the use of Level A consultations. Trends in utilisation of short consultations can be followed in BEACH data, with the lowest proportional use occurring in April 2004 to March 2006, when 1.0% of all claimable consultations (Medicare or the Department of Veterans’ Affairs [DVA]) were short consultations. By 2008–09, short consultations accounted for 1.5% of all consultations.5 However, the mean duration of measured consultations (claimable from Medicare or the DVA) did not change over this period (average, 15 minutes; median, 13 minutes).5 This suggests that the increase in shorter-duration consultations has been offset by an increase in longer-duration consultations. Short consultations in 2008–09 included a large number of procedures, and practice nurses were involved in 24% of these consultations, a much greater proportion than the average for all consultations (6.4%).2 This led us to compare consultations for 2008–09 with those for 2003–04,6 just before the introduction of MBS items for practice nurses. In both years, short consultations were relatively straightforward, involving, on average, 1.2 patient reasons for the encounter (fewer than the average for all consultations of 1.5–1.6 reasons) and management of fewer problems (single-problem consultations represented 89% of consultations in 2003–04 and 87% in 2008–09). However, in 2003–04, 26% of the problems managed were chronic conditions, while in 2008–09 this proportion had increased to 36%. Prescriptions, referrals and counselling were provided at low levels in both 2003–04 and 2008–09. However, procedures increased 3.4-fold, from 112 per 1000 short consultations in 2003–04 to 385 per 1000 in 2008–09 when practice nurses undertook almost two-thirds of all recorded procedures. More specifically, there was a fourfold increase in the categories “dressings” (from 20 to 78 per 1000 short consultations) and “excisions” (commonly cauterisation) (7 to 26 per 1000 short consultations), and a threefold increase in “incisions” (venesection and ear syringing being the most common) (5 to 14 per 1000 short consultations). There was no point-of-care INR (international normalised ratio) testing in 2003–04 but, in 2008–09, 31 INR tests were conducted per 1000 short consultations. Further, the number of vaccinations administered doubled, from 105 to 214 per 1000 short consultations. As regards administrative activities, these almost doubled between 2003–04 and 2008–09, from 19 to 35 per 1000 short consultations; in both years, almost half were for sickness certificates. Other administrative procedures recorded, including those related to health care plans, increased from 10 to 17 per 1000 short consultations. These BEACH study results show an increase of about 45% in claims for short consultations between 2003–04 and 2008–09. Two-thirds of these claims are accounted for by increases in vaccinations (23% of the increase), dressings (25%), INR tests (10%), and excisions (8%). Practice nurse involvement in procedural care accounts for about three-quarters of the increase in short consultations. By contrast, the rise in administrative activities accounted for only 5%–6% of the total. Taylor and colleagues suggest that their findings of an observed rise in Level A consultations1 is directly contradicted by reports from the BEACH study of a decrease in the number of single-problem encounters.5 While this decrease is true for the average of all consultations, it does not apply to short consultations, which are, in the main, single-problem encounters. Finally, Taylor et al propose that the increase in Level A consultations1 means there is an increasing proportion of “obvious” and “straightforward” patient encounters, and this “may support targeted delegation of such consultations to nurse practitioners or physician assistants”.1 As we have shown, assistance from, and delegation to, practice nurses may already be the main reason for the recent increased use of Level A consultations, with administrative activities accounting for only a small proportion. The newly announced enhanced role for practice nurses in primary health care (the federal government’s 2010 Budget),7 planned to commence in 2012, may further influence GPs’ utilisation of short consultations.

Helena C Britt BA, PhD · Salma Fahridin BAppSc(HIM), MHSc · Graeme C Miller MB BS, PhD, FRACGP

The GP Super Clinics Program is a highly topical and controversial initiative with varying levels of support within the policy, consumer and health care communities. Here, we describe the GP super clinic initiative of the University of Queensland (UQ), and how it aims to enhance primary-care capacity in the regions where clinics are based. The UQ GP super clinic model has considered the concerns of general practitioners, patients and other stakeholders, and addresses the needs of these groups while providing an excellent opportunity for the university to be involved in innovative service delivery, community-based education, primary-care service design and evaluation.

Jared M Dart BA, MB BS, PhD · Claire L Jackson MB BS, MPH, MD · Helen J Chenery MSpThy, PhD · Paul N Shaw BSc, PhD, FRPharmS · David Wilkinson MB ChB, PhD, DSc

Much of the rhetoric on interprofessional learning is not underpinned by high-level evidence Interprofessional education (IPE) has been identified as a critical component in the development of a collaborative, practice-ready health care workforce in Australia.1 According to the Centre for the Advancement of Interprofessional Education in the United Kingdom, IPE “occurs when two or more professions learn with, from and about each other to improve collaboration and the quality of care”.2 Its purpose is to improve patient outcomes by providing a learning environment that enables undergraduates (and postgraduates, where appropriate) to gain a better understanding of teamwork, and of how each discipline contributes to team-based care without losing its professional identity. It seems reasonable to assume that IPE is an effective way for professionals to learn how to work in teams. However, it is important to establish whether there is an evidence base that supports the link between IPE, improved interprofessional practice (IPP) and better patient outcomes. The World Health Organization’s Framework for action on interprofessional education and collaborative practice cites research evidence for the benefits of IPE to collaborative practice.3 These benefits include improved access to and coordination of health services, better use of specialist resources, and improved health outcomes for people with chronic disease. They also include improved patient care and safety, reduced patient complications and length of hospital stay, and reduced suicide rates in patients with mental illness. However, evidence for the link between IPE and improvements in collaborative care is tenuous. A Cochrane review of the impact of interprofessional collaboration on professional practice and health care outcomes found only five studies that met randomised controlled trial (RCT) inclusion criteria.4 While the review found that practice-based interprofessional collaboration interventions can improve health care processes and outcomes (eg, patient satisfaction and professional competence), its conclusions were limited by the small number of studies and sample sizes, and because many of the studies were confined to medicine and nursing. The review recommended the need for longitudinal, more rigorous, cluster-based RCTs.4 Advocacy for the introduction of IPE into medical, nursing and health science curricula around Australia is being driven by several factors. These include workforce shortages, concerns about patient safety, the need for team-based care to meet the growing burden of chronic disease associated with ageing, and the pressing need to improve shared care of patients with mental illness. Australia has lagged behind comparable countries in systematically introducing IPE and promoting IPP. There has been a lack of government policy initiatives to fund the development of such programs.5 In contrast, for more than a decade, Sweden has been conducting IPE in clinical environments by establishing hospital wards dedicated to interprofessional learning and practice. Students across medicine, nursing, physiotherapy, occupational therapy and social welfare have been collaboratively managing patients in orthopaedic and geriatric wards, under the supervision of a multidisciplinary team.6 Graduates have indicated increased confidence in working collaboratively following their interprofessional learning experiences.7 A recent Australian initiative is the Health Care Team Challenge, which brings together undergraduates from a range of disciplines to work in interdisciplinary teams to develop a management plan for a clinical case study scenario. The purpose of this program is to increase students’ exposure to, immersion in and mastery of interprofessional practice.8 However, there are barriers to introducing IPE in the clinical environment.9 The most significant are logistic difficulties with timetabling, student recruitment and finding suitable clinical environments such as wards or practices for conducting programs. Student-related barriers include balancing numbers from each discipline, role uncertainty and lack of relevant joint assessment tasks. Other challenges include recruitment, training and workload of staff; structural and policy issues (eg, curriculum development, joint accreditation and validation); and funding. Team-based care is essential to meeting Australia’s growing burden of chronic disease associated with ageing, and the burgeoning health problems of obesity, diabetes and mental health. The government is now encouraging and funding this need through a range of initiatives, particularly in general practice through the Enhanced Primary Care Program and the Better Access to Mental Health Care initiative. The current health care reform proposals place an emphasis on primary health care, and Health Workforce Australia identifies interprofessional learning as a way forward in promoting collaborative practice. The challenge is to ensure that this does not merely become a logistic exercise. It is clear that much successful health professional learning is based on the principle of “learning by doing”, and has occurred in the absence of RCT evidence establishing its efficacy and effectiveness. In this instance, it may prove fruitless and time-wasting to wait for sufficient evidence from RCTs before proceeding with IPE and IPP programs.

Leon Piterman MD, MMed, FRACGP · Jennifer M Newton EdD, BA(Hons), RN · Benedict J Canny BMedSc, MB BS, PhD

Australia’s general practitioners are working fewer hours, and many are leaving medical practice. Little is known about when and why experienced mid- and late-career GPs move away from clinical practice. Although career downsizing is often seen as an abrogation of vocation, it may reflect a desire to broaden work experiences within a constrained set of options. Policy should focus on supporting and enhancing the development of GPs’ careers. This approach should acknowledge that career trajectories for GPs are often relatively flat from mid career onwards, and that a GP’s working life extends beyond clinical work in one general practice.

Lesley M Piko MBA, FCPA, FAICD · Christine B Phillips MB BS, MA, FRACGP, Associate Professor

For effective preventive care, policies and programs are needed that provide incentives, address workforce roles, utilise information systems and empower patients With an ageing population, a stretched health budget, and mounting costs associated with increasing levels of chronic disease, prevention is a priority for all Australian governments. But how effectively is evidence-based preventive care currently being provided in general practice? Rates of cancer screening by general practitioners have improved dramatically,1 but there has been less progress in other aspects of preventive care — for example, fewer than 30% of patients at risk of chronic disease are routinely given advice about diet or physical activity, and only 10% are referred to other health care practitioners for interventions.2 Although some may consider behavioural interventions to be too time-consuming to justify their potential gain, there is evidence that they can be effective in general practice and make a significant contribution to population health.3 Of course, critical drivers to health exist in the social and physical environment, such as socioeconomic status and the availability of safe opportunities for physical activity, and thus preventive care for individuals must complement a population health approach to these problems. The National Primary Health Care Strategy calls for a more systematic approach to implementing preventive care,4 including provision of appropriate and targeted screening services, health checks for specific population groups and at critical stages of life, and preventive interventions consistent with evidence-based guidelines such as the Royal Australian College of General Practitioners (RACGP) Guidelines for preventive activities in general practice.5 The National Primary Health Care Strategy recognises the importance of population groups in greatest need receiving effective interventions. To achieve this, we need a multilevel approach to implementing preventive care, including structural aspects (ie, practice, workforce and financial considerations), contextual aspects (including patient considerations) and practitioner aspects (related to changing professional behaviour). Many of the preventive recommendations in the current reform documents are focused on the structural level, recognising that general practice and primary health care are currently not adequately supported or funded for population health approaches to risk reduction and management across local communities and populations.6 The recent rationalisation of preventive health care item numbers (which occurred on 1 May 2010), into four new time-based items (Box), has reduced their complexity, but they still do not provide support for preventive care throughout a person’s life, or facilitate involvement of the whole practice team in preventive care. There is a need to re-examine workforce roles and responsibilities to determine how the mix of primary health care professionals can best deliver preventive care. In the United Kingdom, for example, practice nurses play a key role in several areas of practice. They identify the patients most suitable for health checks, assess risk factors and combined risk scores (using algorithm tools), provide motivational counselling and health education, negotiate behavioural goals, provide opportunistic brief interventions and arrange referrals and follow-up recalls.8 Also important are information systems to support patient recalls and reminders for preventive health checks, to monitor patients for follow-up, and to audit records to determine population coverage and evaluate the impact of preventive care on risk and outcomes. Decision support systems for patients and providers can help assess risk and instigate guideline recommendations.9 The lack of a robust national framework for funding, prioritising, developing and implementing evidence-based guidelines remains a major stumbling block to effective primary care.10 Current guidelines are predominantly developed by non-government organisations with insufficient funding to support implementation. It is essential that we have appropriate measures and means to evaluate the quality and outcomes of preventive care in general practice. What little information is available suggests significant gaps between evidence-based preventive care guidelines and practice.11 Patients should not be considered passive elements in preventive care. Patient health literacy and engagement are directly correlated with uptake and effectiveness of preventive interventions in general practice.12,13 Developing, promoting and utilising self-assessment tools (including risk-assessment tools) may enhance delivery and uptake of evidence-based preventive care. When risk is personalised, patients gain a better understanding of their health, make more appropriate use of screening tests, and improve their perception of risk.14 A more robust evidence base is necessary to overcome professional and patient barriers to implementing evidence-based preventive health measures, such as lack of compliance with and adherence to lifestyle modification. A theoretical understanding of the processes involved in changing the behaviour of health care professionals enables interventions to be better targeted at barriers to practice change.15,16 For example, an understanding of the fit between practitioner behaviour change and current practice routines can help develop tailored roles for members of the practice team in preventive care. This, along with more rigorous design of interventions,17 may result in more successful implementation of evidence-based changes.18 So what could all this change mean in practice? In future, patients will undertake individualised risk assessment at critical points in their lives. GPs will offer evidence-based preventive interventions tailored to a patient’s level of risk. Practice nurses will facilitate assessments and coordinate access to health education and other interventions as appropriate. Practice systems will follow up at-risk patients and provide reminders and information to support evidence-based interventions. Local primary health care organisations will ensure availability of services to support preventive care at the local level, and deliver health promotion and preventive programs targeting risk factors they have identified using data analysis at the population level. As with all reforms, it is difficult to envisage how such changes can be achieved. Funding targeted at higher-risk groups and people in most need, support for new roles for practice staff, and support from the soon-to-be-established regional primary health care organisations (“Medicare locals”) in providing access to support services and allied health providers, as outlined in the Primary Health Care Strategy, would be a good start. New Medicare preventive health care items7 Time-based health assessment items: brief assessment: < 30 minutes duration ($55.00) standard assessment: 30–45 minutes ($127.80) long assessment: 45–60 minutes ($176.30) prolonged assessment: > 60 minutes ($249.10) Available once only, assessments for: children aged 3–5 years (Healthy Kids Check) patients aged 45–49 years at risk of chronic disease refugees and other humanitarian entrants Available once every 9 months, assessments for: Aboriginal and Torres Strait Islander patients Available annually, assessments for: patients aged 75 years and older permanent residents of residential aged-care facilities patients with an intellectual disability Available once every 3 years, assessments for: patients aged 40–49 years at high risk of diabetes

Danielle Mazza MD, FRACGP, DRANZCOG · Mark F Harris MD, MB BS, FRACGP

Objective: To model the effect of excluding payment for eight hospital-acquired conditions (HACs) on hospital payments in Victoria, Australia.Design, setting and participants: Retrospective ecological study using the Victorian Admitted Episodes Dataset. The analysis involved all acute inpatient admissions to Victorian public and private hospitals between 1 July 2007 and 30 June 2008.Interventions: Each admission record includes up to 40 diagnosis and procedure codes from which payments are calculated. The model deleted diagnosis codes for eight HACs from all records, then recalculated payments to estimate the impact of a policy of non-payment for HACs.Main outcome measure: The effect on hospital payments of excluding diagnosis codes for eight HACs.Results: 2 047 133 cases with total estimated payments of $4902 million were identified; 994 cases (0.05%) had one or more diagnoses meeting the code definition for a definable HAC, representing total payments of $24.1 million. In-hospital falls and pressure ulcers were the most commonly coded HACs. Applying a model that excluded HAC diagnosis codes changed the diagnosis-related group for 134 cases (13.5%), thereby generating a $448 630 reduction in payments.Conclusions: Introducing a non-payment for HACs policy similar to that introduced by Medicare in the United States would have little direct financial impact in the Australian context, although additional savings would accrue if HAC rates were reduced. Such a policy could add further incentive to current initiatives aimed at reducing HACs.

Peter D McNair BN, MPH, MHS · Terri J Jackson PhD · Daniel J Borovnicar PhD

The Australian Health Technology Assessment Review has the potential to have a major effect on the availability of new medical technology and the listing of associated medical procedures on the Medicare Benefits Schedule. Despite this, only about 15% of submissions to the Review came from “medical associations”. Pharmaceutical and medical technologies are inherently different, and there are a number of difficulties associated with evaluating medical technology using the same process and evidence levels as those used for pharmaceuticals. The current sequential and lengthy processing of new medical technology and procedures is delaying access to beneficial medical technology and could be substantially reduced. There is currently no effective funding process for medical technology classified as capital equipment or consumables and disposables. This has created a perverse incentive in favour of using funded implantable prostheses based on access to funding rather than superior clinical effectiveness. The existing horizon scanning process could be better used to not only identify all potentially cost-effective new and emerging medical technology and procedures as early as possible, but also to identify gaps in the evidence.

Susanne P O’Malley BA, MEc, DipTeach

Bowel cancer kills over 4000 Australians each year. From the late 1980s to October 2005, research evidence guided the development of bowel cancer screening policy proposals, but political, financial and institutional constraints restricted implementation options. Since 2006, the Australian Government has provided a limited bowel cancer screening program, based on what the government deems it can afford, rather than on evidence of what is required to implement a successful population-based screening program. Even a partial program can be implemented in an evidence-based way, and failure to do so threatens to undermine the potential public health gains of a national bowel cancer screening program. To realise the expected public health gains from a national bowel cancer screening program, bowel cancer screening policy should return to its evidence-based beginnings, starting with an analysis of Australian age-specific cost-effectiveness data.

Kathy L Flitcroft BBSc, MA(Govt), GradCertHealthPolicy · Glenn P Salkeld GDipHealthEconomics, MPH, PhD · James A Gillespie PhD · Lyndal J Trevena MB BS(Hons), MPhilPH, PhD · Les M Irwig MB BCh, PhD, FFPHM

To the Editor: The arrival of national registration of health professionals on 1 July 2010, and consequential amendments to state and territory legislation, overcomes registration and recognition complexities currently facing Australian medical practitioners who wish to practise in multiple jurisdictions. However, national registration stops short of removing current inconsistencies among state and territory laws in various areas of medicine — including those that regulate prescription of Schedule 8 (S8) medicines. Despite recognition of S8 restrictions in every part of the country, medical practitioners potentially need to have a working knowledge of up to eight separate sets of controlled substances laws when prescribing S8 medicines. Imagine a general practitioner providing a morphine prescription with repeats to a couple caravanning around Australia for 3 months. That prescription may need to comply with the laws of each jurisdiction as to what details need to be included on the prescription form. Getting it wrong could result in significant delay and inconvenience for the holidaymakers if the pharmacist refused to dispense the prescription because it didn’t comply with local laws. For example, in South Australia a prescription for a drug of dependence must not be dispensed by a pharmacist if the patient’s date of birth is not included on the prescription form1 — yet there is no similar requirement in New South Wales, Tasmania, Victoria or the Australian Capital Territory.2-5 Conceivably, through unawareness or habit, a prescriber in one of the latter jurisdictions might omit a patient’s date of birth from a relevant prescription form, leading to problems for the patient when travelling in other states. Granted, such a situation could be corrected with a few phone calls or faxes, but in a busy practice, who has time to be repeating tasks? National regulation of health practice (achievable through referral of powers or harmonising state and territory laws) — in this case, the prescription of S8 medicines — would logically complement national registration and help maximise anticipated benefits after 1 July 2010.

Colin M Brown

To the Editor: I agree with the claim by Richardson that “the overlap between [primary care and emergency department (ED)] services is not as important as many have claimed” and that “‘primary care patients’ and ‘ED [Australasian Triage Scale] category 4 and 5’ patients are not interchangeable”.1 A review of the literature — especially from New Zealand — would show there are considerable differences between patients who attend the two types of services. For example, a comparison of patients with asthma attending either a Wellington after-hours medical centre or an ED service located only 800 metres away2 found that the after-hours medical centre was more likely to see younger patients who live further from the service, are given repeat medications, and are referred back to their general practitioner. In contrast, the ED patients were less likely to be referred by a GP and more likely to be admitted to hospital with asthma than patients attending the after-hours centre. Thus, the two services differed in terms of their clinical policies (repeat prescribing and referral) and patients’ demographic characteristics (age, place of residence). I applaud Richardson for highlighting the powerful effects of hospital policies on the behaviour of people outside hospital walls by saying, “it is not the so-called primary care patients who are blocking ambulances from offloading — it is the ‘access block’ patients waiting for beds on the inpatient wards who are inappropriately occupying ED space and staff time”. This claim has nothing to do with the kind of patients who attend primary care services, but more to do with the influence of management policies arising from within hospitals on patient flow from primary care. It confirms research in New Zealand demonstrating how hospital policies (on advertising their services) can have powerful contradictory effects on attendance at EDs. In some cases, people have been subjected to hospitals advertising the clear message that people should attend the ED when they should be seen in primary care instead; and in other cases, people are dissuaded from attending the ED when they are subjected to advertisements about the poor choices people make to attend a hospital. In each case, it is the hospital policy that determines the direction of flow, not the patients in primary care.3-5

Marjan Kljakovic

To the Editor: A recent commentary from the Editor of the Journal1 raises the health-funding dilemma facing current and future Australian governments. All stakeholders in the health industry need to dispassionately scrutinise the role of current models in perpetuating inefficient or socially discriminatory patterns of care. Health care economics is indivisible from the tendency of the broader economy to sustain growth or create disparities, and comparative analysis of systemic economic policies informs the divergent evolution of health systems. The United States, epitomising the free market paradigm, combines a high gross national product with a high poverty rate and significantly unequal income distribution.2 Per capita health care expenditure and its annual rate of increase are comparatively high.3 This is juxtaposed with one of the highest infant mortality rates in the developed world,3 as well as significant racially related variations in health indices. The Scandinavian societies, particularly Sweden, epitomise the benefits of a social welfare model that maintains low unemployment, relatively low income disparity, and advanced technology, while maintaining a healthy private sector.2 The Swedish health care system, which maintains best practice health indices, is characterised by administrative devolution, combined taxation and insurance-based funding, high equity of access, guaranteed maximum primary-care waiting times, and annually capped out-of-pocket expenses.4 Although it had one of the highest per capita health expenditures in the 1980s, its annual rate of increase is one of the lowest in the OECD.3 Since 1975, Australian economic and social policy has increasingly shifted towards a free-market orientated system, comparable with that of the US and United Kingdom rather than the more mixed economies of most European countries or the social welfare economies of Scandinavia. In this context, Medicare is an anomalous relic, which, because of inadequate funding, has struggled to contain patients’ out-of-pocket expenses and maintain equity. The most successful health care systems have a relatively small private sector, limited fee-for-service provisions, and smaller income disparities between health care workers. In contrast, Australia’s hybrid model has a significant private/entrepreneurial component based on a fee-for-service structure that is driven by market forces rather than needs analysis. As Medicare increasingly withers due to neglect, out-of-pocket expenses will continue to rise and health equity will diminish, but sections of private medicine, fuelled by demand from the more affluent, will continue to thrive. As we confront the unpalatable likelihood that the market-driven private sector is a major cause of increasing per capita expenditure, we shall have to justify the viability and equity of the dominant fee-for-service model.

Jeremy W Butler

Objective: To retrospectively review the frequency and adequacy of family histories recorded from patients admitted to a short-stay medical unit in a tertiary teaching hospital.Design, setting and patients: A formal audit of the medical records of 300 randomly selected patients who were admitted to the Royal Perth Hospital short-stay medical unit between July and December 2007.Main outcome measure: Proportion of patient records with family history documents.Results: Of the 300 patient records, 48 (16.0%) contained a family history with specific details about the presence or absence of a medical condition in at least one relative. Overall, 221 records (73.7%) had no family history documented. There was a trend towards more frequent and detailed family histories being recorded from younger patients and those presenting with chest pain.Conclusions: Family history was seldom documented in patients admitted to a short-stay medical unit in a tertiary teaching hospital. An increased focus on family history taking among acutely ill patients offers potential health gains for patients and their high-risk relatives, particularly as preventive or risk-reducing health care strategies are emerging for a growing number of heritable disorders.

Andrew R Langlands MB BS · David A Prentice MB BS, FRACP · David Ravine FRACP, FRCPA

To the Editor: It is a naïve public health physician who predicts ahead of time how many people will die in a disease outbreak. Such doctors have short careers. What Collignon calls the “wrong and exaggerated” expert predictions1 of mortality from the recent influenza pandemic are based on the numbers that the World Health Organization advised governments to use in planning for pandemics.2 They are derived from a sensible calculation: plan for a situation considerably better than the 1918–1919 pandemic but somewhat worse than the 1957 or 1968 pandemics. The problem in Australia is not so much the pandemic plans produced through the time-honoured process of ad-hoc, temporary federal government committees for implementation by multiple, variously organised state and territory authorities. The real problem is producing a consistent, flexible response to any developing national infectious disease emergency. No other nation tries to do that without having a national authority, made up of full-time professionals with a fair degree of independence from the political process. The United States has its Centers for Disease Control and Prevention (http://www.cdc.gov); the United Kingdom its Health Protection Agency (http://www.hpa.org.uk); and, perhaps the most pertinent example, Canada has its Public Health Agency (http://www.phac-aspc.gc.ca), established in the aftermath of the SARS (severe acute respiratory syndrome) outbreak. The European Union has set up a supranational European Centre for Disease Prevention and Control (http://www.ecdc.europa.eu). A plan can only ever hope to put in place all the resources needed for a response, but a flexible, consistent, science-based and targeted national response to infectious and other health emergencies requires a professional national authority.

Rodney C Givney

Incorrect units: In “Impact of income management on store sales in the Northern Territory” in the 17 May 2010 issue of the Journal (Med J Aust 2010; 192: 549-554), there were errors in Box 2 under the column heading “Outcome measures”. The units for “Fruit and vegetable turnover” should have been kg, and the units for “Soft drink turnover” should have been L.

Julie K Brimblecombe · Joseph McDonnell · Adam Barnes · Joanne Garnggulkpuy Dhurrkay · David P Thomas · Ross S Bailie