Health services administration

To the Editor: Walters and Dawson1 correctly highlight access block (hospital overcrowding) as a whole-of-system problem. Acute medical assessment and admission units (AMAAUs), or other similar incarnations in Australia and New Zealand, are part of the solution, although the evidence presented is low-level non-Australasian data. The reduced length of stay achieved by these units and reported in papers cited by Walters and Dawson would, if replicated in Australasia, produce additional capacity, improving bed availability and patient flow. As has been repeatedly stated: it’s all about available beds!2 However, Walters and Dawson’s article stretches well beyond the evidence in its approach to emergency department (ED) roles and the interactions between AMAAUs and EDs. None of the cited studies suggested that AMAAUs provide better environments than EDs for sick undifferentiated patients. None studied effects that AMAAUs have on ED treatment and none proposed interventions specifically designed to alter ED management. They essentially examined improved patient journeys for front-loaded AMAAU versus standard (slower) general medical inpatient care. In addition, Walters and Dawson imply that these changes related to introduction of the United Kingdom’s 4-hour rule. However, many references were either non-UK or not specific to the 4-hour rule. Rigorous research in an Australasian context would be required before adopting models from a different system. The authors promote a view that undifferentiated acutely sick patients bypass the ED to be managed by “new” acute-care specialists. No evidence is presented to support this change, and it is difficult to see how this would be a sensible policy for Australia and NZ, which have mature ED systems. Emergency physicians are specialists specifically trained and skilled in early diagnosis, management and disposition of the undifferentiated, unwell patient. What is required is a system that builds on the excellent start made by the ED, removes the blocks to patient care caused by waiting for beds in the ED and then continues to emphasise rapid diagnosis, early management, disposition and flow. This is what AMAAUs can deliver and why they should be effective. Australasian EDs already provide an exemplary service in a difficult, access-blocked environment. What patients need is sufficient hospital capacity — hospitals that provide enough appropriate beds. We look forward to seeing AMAAU staff meet this need in partnership with their emergency physician colleagues. In summary, it’s all about available beds, about having enough overall capacity and optimising patient flow to maximise bed availability.2 The only revolution required is for governments to recognise this fundamental precept.

David Mountain · Daniel M Fatovich · Drew B Richardson · Sally M McCarthy

To the Editor: Although written from a United Kingdom perspective, the recent article by Walters and Dawson1 suggests a change in the clinical culture within hospitals, so that patient care and throughput can be improved. A critical factor in achieving change is the creation of an acute medical assessment and admission unit (AMAAU) within each district hospital. Characteristics of the AMAAU will “depend on local circumstances”: there is no one size that fits all.1 Because of Australia’s unique demography, and the number of communities beyond the reach of tertiary centres, many primary-care physicians (general practitioners and “rural generalists”) provide the continuum of care required by patients, both within the community and within their local hospitals (the acute admission, ongoing inpatient care and discharge planning). Twenty-first-century GPs deal daily with patients needing management of multiple comorbidities and the consequences of polypharmacy (the “sick general” and “complex elderly” clinical streams1). GP training prepares doctors for these responsibilities and could easily be expanded to include an AMAAU role for interested GPs, especially those in outer urban and major rural areas. The advent of AMAAUs is an opportunity to change the mindset in medicine: after 8 to 9 years of primarily hospital-based training, some GPs suddenly have no hospital access! This would seem to be a callous waste of talent and resources.

Frank R Jones

To the Editor: Walters and Dawson1 highlight growing interest in new models of care aimed at ameliorating hospital-bed pressures and access block. They advocate acute medical assessment and admission units (AMAAUs) as a potential solution, and claim, principally based on the United Kingdom’s experience, that these units can significantly improve clinical care and patient outcomes. A recent systematic review confirms that these units (which have attracted several different synonyms) have promise, although controlled trials have yet to be performed, and publication bias remains a potential confounder.2 Experience with such units in Australia and New Zealand is growing, with more than 30 units in operation, and up to another 15 due to open over the next few years. Several national workshops conducted during the past 12 months have allowed staff of the units to share lessons and insights, and to debate how to balance service needs with resource availability. Operating standards for AMAAUs have been developed by the Internal Medicine Society of Australia and New Zealand (IMSANZ),3 which represents consultant general physicians. A recent survey shows the operations of Australasian units concord, in the most part, with these standards.4 We caution against Walters and Dawson’s suggested separation of AMAAU physicians into two streams — acute physicians working shifts, and ward-based general physicians responsible for patients requiring transfer from the AMAAU. Given that at least half of AMAAU patients will require transfer to inpatient wards, and many may warrant ongoing outpatient care even if discharged from the AMAAU, the need for continuity of care is paramount at the interface between the AMAAU and ward or clinic. To minimise the number of handovers and their attendant hazards and inefficiency, the medical team assessing and managing the patient in the AMAAU should ideally be the same team that provides ongoing inpatient (and indeed subsequent outpatient) care. This practice also eliminates any confusion around who is ultimately responsible for decisions about individual patient care, particularly for patients who remain in the AMAAU for any length of time. General physicians can acquire and maintain skills in acute medicine by making use of professional development programs sponsored by the IMSANZ. Clinical directors are needed in AMAAUs to oversee unit operations, develop policies and procedures, and provide capacity for rapid consultant response if on-call consultants are temporarily unavailable. The real challenge, to which Walters and Dawson refer, is the need for health care professionals to recognise that whole-of-hospital redesign solutions — which include AMAAUs — are needed, if access block in emergency departments is to be successfully overcome.

Ian A Scott · John W Henley

To the Editor: The Journal took a significant step forward in publishing the three articles on access block in the 6 April 2009 issue.1-4 Walters and Dawson’s viewpoint article,4 in a later issue, touches on some ideas that will be useful in finding solutions to access block — ideas that some hospitals are implementing. However, I am not sure a microsolution aimed purely at acute medical patients can be called a whole-of-hospital revolution. The acute medical assessment and admission unit (AMAAU) is potentially a good idea. Fortunately, many hospitals all over Australia already have units that are highly efficient at the role that is proposed for it — they are called emergency departments (EDs). Most acute medical patients can be identified as needing admission after a few seconds in the ED by experienced emergency physicians. The remaining patients need some basic pathology or imaging service before a decision can be made, which should take an hour at the most. Having secondary inpatient units providing this role to the community via direct general practitioner referrals, as well as having some patients bypassing the ED by being cherry-picked by inpatient teams, may generate inefficient duplications of service. The AMAAU has merit, streaming patients to the right specialty and the right inpatient bed early in their presentation. Emergency physicians have largely known this for over a decade and these kinds of units have already been introduced in hospitals all over the country. Nepean Hospital, in western Sydney, has the PECC (Psychiatric Emergency Care Centre), AGS (Acute Gynaecological Service), MAU (Medical Assessment Unit), EDMAU (ED Medical Assessment Unit), EMU (Emergency Medical Unit) and ASU (Acute Surgical Unit), to name just a few acronyms. Unfortunately, this does not deal with the 20 patients in the ED, already admitted and sorted, waiting for an inpatient bed at 8 am on a Monday. Increased inpatient bed numbers to cope with the predicted acute ED admissions and the planned elective surgical workload must be the number-one priority. Once we have bed numbers to cope with demand, then we can plan how to use them. I propose my own revolution. We need to provide a true 7-day-a-week service to our hospital inpatients. Ward rounds should be conducted 7 days a week. All inpatient consults, including those of allied health practitioners, should be completed on the same day, including weekends. All complex imaging should be completed on the day it is ordered, not the next working day, with formal reports available the same day. Once we acknowledge that acute hospital medicine does not fit in with the 38-hour working week, then we can truly start acting as patient advocates.

James L Mallows

Objective: To assess and compare health care costs for normal-weight, overweight and obese Australians.Design, setting and participants: Analysis of 5-year follow-up data from the Australian Diabetes, Obesity and Lifestyle study, collected in 2004–2005. Data were available for 6140 participants aged ≥ 25 years at baseline.Main outcome measures: Direct health care cost, direct non-health care cost and government subsidies associated with overweight and obesity, defined by both body mass index (BMI) and waist circumference (WC).Results: The annual total direct cost (health care and non-health care) per person increased from $1472 (95% CI, $1204–$1740) for those of normal weight to $2788 (95% CI, $2542–$3035) for the obese, however defined (by BMI, WC or both). In 2005, the total direct cost for Australians aged ≥ 30 years was $6.5 billion (95% CI, $5.8–$7.3 billion) for overweight and $14.5 billion (95% CI, $13.2–$15.7 billion) for obesity. The total excess annual direct cost due to overweight and obesity (above the cost for normal-weight individuals) was $10.7 billion. Overweight and obese individuals also received $35.6 billion (95% CI, $33.4–$38.0 billion) in government subsidies. Comparing costs by weight change since 1999–2000, those who remained obese in 2004–2005 had the highest annual total direct cost. Cost was lower in overweight or obese people who lost weight or reduced WC compared with those who progressed to becoming, or remained, obese.Conclusion: The total annual direct cost of overweight and obesity in Australia in 2005 was $21 billion, substantially higher than previous estimates. There is financial incentive at both individual and societal levels for overweight and obese people to lose weight and/or reduce WC.

Stephen Colagiuri MB BS, FRACP · Crystal M Y Lee BMedSc(Hons), MIPH, PhD · Ruth Colagiuri BEd, GradCertHlthPol · Dianna Magliano BAppSci(Hons), MPH, PhD · Jonathan E Shaw MD, MRCP, FRACP · Paul Z Zimmet AO, MD, PhD, FRACP · Ian D Caterson MB BS, PhD, FRACP

Australia’s health care system is at a crossroads. It is recognised that the fragmentation of health services, largely caused by the split between Commonwealth and state government funding responsibilities, is undermining patient care. The National Health and Hospitals Reform Commission (NHHRC) has advanced two models of health-system governance to redress this situation — neither incorporating the regional approach so prominent in submissions to the NHHRC and included in Option B of the NHHRC interim report. A regional governance framework such as that described in this paper could keep faith with the importance widely given to local engagement during the consultation process; sit neatly within the NHHRC’s Healthy Australia Accord option; make regions responsible for funding allocation and service delivery; eliminate major weaknesses in our current system; and provide stability to the system at a time of significant reform.

Claire L Jackson MB BS, FRACGP, MD · Caroline Nicholson MBA, GradDipPhty, GAICD · Eugene P McAteer MBA, BSSc, GAICD

Objective: To determine why more than 2000 doctors have migrated from South Africa to Australia since 1948.Design, setting and participants: South African-trained doctors living in Australia and the spouses or adult children of deceased practitioners who had emigrated from South Africa were contacted by email between August 2008 and February 2009. The sample of doctors was gathered and expanded by an email “snowball” technique and through advertising in alumni and professional journals and newsletters. A questionnaire was emailed to 653 contacts.Main outcome measure: Primary reason given for migration.Results: Responses were received from 469 of the 653 email contacts (72%), from a population of about 2200 South African doctors in Australia. Of the 469 respondents, 434 (93%) had been motivated to emigrate by a wish to leave South Africa, rather than by Australian inducements. The primary reason for emigration before 1990 was opposition to apartheid (142/205 [69%]); the primary reason for emigration after 1990 was the level of violent crime (including “safety” issues) (116/264 [44%]).Conclusion: Most South African doctors who migrated to Australia were impelled to emigrate by South African issues, rather than attracted by Australia.

Peter C Arnold BSc, MB BCh BA · David E Lewinsohn DipAppChem, GDipDP, PGDipPDM

To the Editor: Having been closely involved with the initiation of the practitioner impairment and performance processes of the New South Wales Medical Board, I appreciate Breen’s generous remarks about the efficiency and fairness of the existing medical boards’ processes.1 In addition to wholeheartedly endorsing his concerns about the proposed medical regulation legislation, I consider that the profession should not lose sight of the origin of these “reforms” — the Productivity Commission’s report on the health workforce.2 This government “workforce” initiative is far removed from the concerns of any registration body — namely, “standards”. Our medical boards have hitherto rightly divorced themselves from workforce considerations. The profession should be concerned that an inquiry into the health workforce has resulted in a national standards body. This mismatch suggests a hidden agenda behind the new legislation to be adopted by all states and territories. Can our governments, Labor or Coalition, be trusted not to combine their powers over the new registration authority and over Medicare to exercise ham-fisted controls over doctors? Australians have already suffered the disastrous Wooldridge reduction in Medicare provider numbers in 19963 — resulting in today’s scramble to train more doctors. Breen says that most doctors have not opposed the proposed scheme.1 As one of the minority who do, I claim that the Emperor has no clothes. The devil is not in the detail, but in the principles. Breen correctly identifies the only valid, but weak, argument for national registration — that “the existing regulatory system [is] somewhat inefficient in terms of interstate mobility”.1 Australia’s health care problems relate primarily to lack of coordination between governments,2 not to standards. There is little regarding standards that could not have been ironed out by the state and territory medical boards and the Australian Medical Council. We are about to witness a horrendous waste of public money by governments whose primary goal, I suspect, is control over our profession — over our numbers, over our education, over our registration, over our postgraduate training, over our standards, and over the nature and location of our eventual practice of medicine. Today’s and tomorrow’s doctors have my sympathies.

Peter C Arnold

To the Editor: We read with some dismay the article by Winch and Henderson1 critically reviewing the introduction into health care of process improvement methods pioneered in manufacturing and service industries. We take issue with the article at several points. While the article is titled a “critical review”, it has more of the character of a personal view. For instance, the authors single out “lean thinking” for particular criticism, but the examples cited are in fact a mixture of business process re-engineering, hospital or health system restructuring, and total quality management. These differ substantially from lean thinking, but this is not acknowledged in the text. Then the authors claim that lean thinking has been accepted “somewhat uncritically”, but this is not so. The current peer-reviewed literature contains a number of articles critical of lean health care that have not been referenced by Winch and Henderson (for example, an article by Young and McClean2). The authors’ principal argument is that fragmentation of health care delivery reduces the quality of care provided. We agree. They then argue that process redesign increases the fragmentation and impairs quality of care, but we reject this view. The process redesign programs we have been involved with have been aimed at increasing the time that staff can spend with patients. They explicitly involve staff in designing systems that will deliver this. Rather than trying to “[reduce] the richness of professional health care practice to impoverished snippets of work”,1 we are trying to put broken care processes back together. The authors close by implying that process redesign may “add to the problems of hospital misadventure . . . rather than solve them”, but they provide no evidence for this assertion. In fact, the existing evidence points the opposite way. For example, a recent report from the ThedaCare group in the United States showed a reduction in mortality after coronary artery bypass grafting from 4% to effectively zero as a result of process improvement.3 Here in Australia, the Flinders Medical Centre in Adelaide has seen a striking reduction in serious adverse events after implementing a process redesign program based on lean thinking.4 Interest in process redesign is increasing in health care. All improvement methods benefit from critical discussion, but critiques that are also well supported by evidence are likely to be the most influential.

David I Ben-Tovim · Duncan Stuart · Maarten Kamp · Paul Cullen

To the Editor: As one who works in paediatrics and sees parents bringing their children to hospital for day surgery, and then taking them home again a few hours later, I concur with Winch and Henderson in their critique of “lean thinking” ways of delivering health care.1 Nowhere is this more obvious, and nowhere is it applied with less critical assessment, than in day admissions. This process, which we are told is best for families, may not be. It is best for the hospital, of course, as it means that care can be delivered for a fraction of the cost of keeping people in for several days. But is it best for families? What are we doing to parents when we send them home with a child fresh from surgery? While we might give them some education about what to do if the child has an adverse event, there is not enough time to make sure the parents have understood, are able to read effectively, and have taken any information on board (with their ability to do so potentially hampered by their state of anxiety). How do we know what the infection rates are after surgery? If the child develops an infection, the parents are likely to take the child to a general practitioner rather than return to the hospital, and busy GPs may not report back to the hospital on the child’s visit and the need for treatment. We do not ask parents what financial burden we are placing on them. Have they taken days off work or used their holiday time to look after the child? Does that mean financial hardship for the family? Do we ask them what emotional burden it is placing on them? As a highly educated health professional who knows the ropes, I can only imagine how anxious young parents must be with a child who has just had an operation and for whom there is no health care support at home. Of course, my comments about children are just as salient for adult day surgery admissions. I believe that lean thinking and its penultimate expression in health delivery, the day admission, should be critically re-examined, and there needs to be much more research on the immediate and long-term effects on patients and their families.

Linda E Shields

To the Editor: It is pleasing to see the acknowledgement by contributors of the fundamental premise that the fragmentation of health care may reduce the quality provided, which was a key argument of our article.1 Our aim was to provide space for critical appraisal of “lean thinking” and its application to health care, by questioning the assumed theoretical basis from which this approach is derived and enquiring about the evidence for long-term benefits relating to patient outcomes. We wished to engender discussion and debate rather than provide a systematic review of existing literature. To this end, we think our aim has been achieved. Returning to the central thesis of our article, we argue that the notion of quality is rapidly being subsumed by quantity (understood as patient throughput and the number of measurable errors). This is reflected in the focus of Ben-Tovim and colleagues on process rather than practice.2 We believe that medicine is grounded in the human condition,3 and thus ideas of quality must relate to patient experience, including harms that are not readily measurable. We acknowledge that health care is becoming more and more complex, and increasingly requires the exercise of practical wisdom that informs clinical reasoning.4 Individual differences between patients mean that each situation has to be considered in its own context. Recognition of this difference provides the opportunity for some of the richness and satisfaction inherent in medicine. Finally, medicine and health care are far from immune to adopting and repeating the mistakes of other professions and industries. It has been suggested that the continued rationalisation of health care, such as occurs with “lean” approaches, may contribute to the deprofessionalisation of medicine over time.5 In turn, this may promote the “McDonaldization”6 of health care, whereby efficient turnaround becomes the primary goal. We suspect that, while meeting a need at one level, this would provide little long-term satisfaction for health care providers or patients.

Sarah Winch · Amanda J Henderson

In the Australian public health system, access to elective surgery is rationed through the use of waiting lists in which patients are assigned to broad urgency categories. Surgeons are principally responsible for referring patients to waiting lists, deciding on the appropriate urgency category, and selecting patients from the waiting list to receive surgery. There are few agreed-upon criteria to help surgeons make these decisions, leading to striking differences between institutions in proportions of patients allocated to urgency categories. In other countries with publicly funded health systems, programs have been developed that aim to make prioritisation more consistent and access to surgery more equitable. As demand for health care increases, similar programs should be established in Australia using relevant clinical and psychosocial factors. Prioritisation methodology adapted for elective surgery may have a role in prioritising high-demand procedures in other areas of health care.

Andrea J Curtis BSc(Hons), PhD · Colin O H Russell MB ChB, FRACS · Johannes U Stoelwinder MD, FRACMA, FACHSE · John J McNeil PhD, FRACP, FAFPHM

Hospital funding based on achieving targets for numerical key performance indicators was implicated in Queensland’s Bundaberg Base Hospital scandal and has driven hospital data fraud in Victoria and New South Wales. Nationally uniform legislation is required to make health service reporting standards consistent and to criminalise public sector data fraud. Urgent action is needed to develop realistic outcome measures that base hospital funding more on the quality and safety of patient care and less on patient throughput numbers.

Antony Nocera FACEM, MSc(Emergency Planning and Disaster)

To the Editor: Two recent publications have described programs of carrier testing for cystic fibrosis (CF) gene mutations.1,2 The authors conclude that CF carrier testing of women in early pregnancy and their partners, as well as couples contemplating pregnancy, can successfully identify those who are at risk of having a child with CF and provide them with reproductive choices. The authors use these proof-of-concept studies, in the absence of Australian economic data, to call for all couples to be offered CF carrier testing that is supported by government funding. Although reproductive choice is clearly an individual’s right, what obligation does the community have regarding government funding of specific services to generate information that might assist such couples? Genetic screening policies have often been determined on the basis of technological capability, rather than through a rigorous evidence-based review process.3 Decision making should also take into account evidence of clinically effective screening programs, ethical principles, and opportunity costs, given the limited resources available in the health sector. A simple economic analysis of these publications highlights some issues that need to be addressed. Massie and colleagues identified nine carrier couples by screening 3200 individuals (3000 females) before conception or during early pregnancy (CF carrier frequency, one in 30). Two of the nine carrier couples had affected pregnancies, which equates to a cost of $300 000 per CF case. In Christie and colleagues’ dataset of 1000 individuals, 73% had no family history of CF; 27 of these individuals carried CF mutations, and two carrier couples but no affected pregnancies were identified. Based on population gene frequency statistics (CF carrier frequency, one in 25; 75% of CF gene mutations being p. F508del),1 Massie et al’s screening model2 would, on average, require 3585 women to be screened to detect one affected pregnancy, costing about $740 000. Christie et al’s expanded one-step model1 would require about 3763 couples to be screened to detect one affected pregnancy, at a cost of more than $430 000. Among the 270 individuals with a family history of CF who were screened in the latter model, 126 were carriers of CF mutations (carrier frequency, one in two). It is clear that cascade screening of those with a family history would be a more effective strategy. There is an ethical argument that projected economic benefits from the termination of affected fetuses should not play a role in decisions to offer testing.4 Nevertheless, technological capability needs to be considered together with evidence of cost-effectiveness and community acceptance before public funding of community CF carrier screening can be justified.

Peter C O’Leary · Susannah J Maxwell · Leanne M Youngs · Kate J Brameld · Ian R Walpole

In reply: Our aims in publishing the outcomes of offering cystic fibrosis (CF) carrier testing to couples were to demonstrate the high acceptability rate and report the reproductive choices made by high-risk couples. Not all decisions resulted in termination. O’Leary and colleagues rightly raise the question of screening costs. Laboratory costs will reduce with economies of scale and centralisation of testing. The recent release of a position paper on population screening for CF by the Human Genetics Society of Australasia1 will influence the demand for testing. It recommends that all couples intending to have children, and women in early pregnancy and their partners, be made aware of the availability of CF carrier testing, and that couples should be offered testing for 10 CF transmembrane conductance regulator gene mutations using an expanded one-step or two-step model. O’Leary and colleagues suggest that cascade testing of those with a family history of CF would be a more effective strategy. However, only 10% of children born with CF have a family history.2 Studies have demonstrated that costs of CF screening are less than the averted medical care costs associated with fewer births of infants with CF.3-5 Although economic considerations are important, these should not form the primary goal of any screening program.

Louise M Christie · Angela J Ingrey · Gillian M Turner · Anne L Proos · Gloria E Watts

To the Editor: The recent letter by Cox, about transfer of pregnant women from remote communities to Cairns for birthing,1 mirrored my experiences while working in general practice and psychiatric community outreach in rural Australia for many years. The removal of people from their familiar surroundings (especially for extended periods) in itself exacerbates health problems, even more so when they are already hindered by impaired socioeconomic status or ethnic disadvantage. Almost always, the security of their attachment and capacity to maintain resilience are strained. Furthermore, this displacement often occurs in emotionally charged or threatening health situations, where it is likely to be most damaging: childbirth, treatment of life-threatening disease caused by malignant neoplasm or cardiovascular disease, and management of mental disorders or substance misuse. The increasing concentration of “expert” treatment centres in fewer and fewer (usually metropolitan) centres, together with the degradation and de-skilling of rural and remote services that I have observed for the nearly 30 years I have worked in Australia, are sad. However, even worse is the failure of government to do anything to reverse the trend, despite repeated hand-wringing and talking about the rural health “problem”.

Robert D Craig

Two phenomena are shaping physician assistants and their futures: change in human societies and change in health care delivery The physician assistant (PA) is a global phenomenon: a product of medicine that enjoys unparalleled success within the health profession in many societies. Born in the 1960s, nurtured in the 1970s, and grown in the 1980s, the PA proved to be a capable player in American health policy in the 1990s. By 2000, the PA had emerged in a handful of countries, and by 2015, PAs will surpass 100 000 worldwide.1 Various explanations regarding why this profession is growing have been advanced. Clearly, PAs fit well in the entrepreneurial American health care system; economic advantages, clinical flexibility and dependence on doctors are factors that contribute to their success. But it is other countries that are building on the original model. With a worldwide shortage of 4.5 million doctors and an inadequate number of medical schools, the sheer weight of population growth demands more medical personnel and resources.2 In addition, improvements in childhood survival and the control of archaic diseases (eg, malaria, tuberculosis, dengue fever, smallpox, polio) have resulted in people living longer and more comfortably than their parents. Technological advancements are limited only by the logistics of delivery to populations, both urban and remote.3 The increasing years of productivity of individuals indicates the need for an unprecedented cadre of health workers. Without more doctors and nurses, the next group of providers to look to is PAs. Canada, the United Kingdom, South Africa and the Netherlands are examining not only their present workforces, but also what will be needed in decades to come. The alternative to not growing their own workforces is recruiting overseas-trained doctors — a strategy with its own ethical considerations.4,5 A sociological explanation for the emergence of PAs is an evolution in the division of medical labour, not a loss of autonomy for doctors. Medicine has become infinitely more complex over the past several decades and the information base required to practise medicine is enormous, leading to greater levels of team-based care. Health care knowledge was once a vaunted supremacy of doctors, but now diagnostic and therapeutic tasks are shared with other health care professionals (in part because modern-day doctors cannot know and do everything in so vast a field). Throughout the 20th century, analytical technologies and therapeutic approaches produced new specialties, and today we have genetics, interventional radiology, robotic surgery and the resurgence of midwifery. Further expansion of medical activities and capabilities will necessitate the inclusion of additional trained personnel who share the domains of doctors but remain dependent on doctors for directing care. Other social forces have had a major influence on the PA movement. Changing lifestyles — doctors’ preferences for greater work–life balance grew during the 1970s. Today, most are eager to work (though not as hard as their predecessors) and desire help. Gender shifting — women have entered the workforce in a major way. They have tried out careers that are traditionally dominated by men, and have found them to their liking. For PAs, the education path is shorter than for medicine but has similar rewards. The opportunity to be engaged in a well respected career and successfully raise a family ranks high with many female applicants. Doctor dependency — the unwavering commitment of the PA profession to remain dependent on doctors bolsters widespread acceptance of PAs by medical professional bodies. National competency — the establishment of program accreditation and an independent national board overseeing the specific skills and competencies of PAs allows states to focus on licensure, roles and supervision. Primary care — for PAs, the emphasis on training in general medical care and obtaining core competencies creates a known entity. Such a model permits more role flexibility and mobility (beneficial characteristics in a changing health care environment) than exists for doctors and nurse practitioners. The PA succeeds, in part, because of the attributes of individuals. Early entrants saw themselves as change agents who wanted to prove that allied health individuals trained in this PA model could benefit society safely and effectively. The PA profession continues to attract those who feel dead-ended in their current health care roles but do not want the burden of a protracted medical school experience or investment. For example, an experienced military medic may seek to use his or her skills in civilian life or an indigenous health care worker who is isolated without options for career progression may wish to upgrade his or her role to enable a return to cultural roots. Looking forward, key questions emerge. What does the future hold for the PA profession? How will the changing faces of various health care systems affect the PA profession? Will a PA trained and certified in Utrecht, the Netherlands, be able to work in Mt Isa, Australia, and be effective? Two phenomena are shaping PAs and their futures: change in human societies and change in health care delivery. These are on convergent paths that predict the growth of PAs for many years to come — at least in many countries. How Australia will fit this new provider into its health care system is contentious for some. For those who want to expand the capacity of its highly skilled workforce, the pace of change leaves few options.6

Roderick S Hooker PhD, PA

Rebecca Nicole Hannah Zajac is not a name two people are likely to have. Yet, my daughter, living in the United States, found that someone with this name and the same birthday as her had opened three bank accounts and overdrawn these accounts substantially. Thus, when Rebecca came to open a bank account in New York City, she was told it was not possible because she already had three accounts on which money was owed at another bank. This is a real and not uncommon scenario in the US where, because of the complexity of the banking system, identity fraud is rife. For Australians visiting or living in the US since the new homeland security laws came into force, it is quite difficult to open a bank account there. On the other hand, having one’s credit card skimmed to duplicate the cardholder’s name, the card’s number and other data is easy. What might surprise you is that medical identity fraud is now becoming a significant issue in the US. An article in the New York Times in July 2009 described a person who discovered, on checking his credit rating, that he owed tens of thousands of dollars for medical bills.1 This included visits to emergency rooms and an air-ambulance flight. According to a 2006 World Privacy Forum report, more than 250 000 Americans were affected by medical identity theft in 2005.2 For us, it is quite difficult to conceive how this process works. An Australian who goes to a public hospital emergency room incurs no cost. In the US, a visit to the emergency room, whether public or private, incurs substantial fees. For uninsured patients, these fees are often payable in advance, unless the patient has a life-threatening illness, in which case the money will be collected later. Using another person’s identity, including his or her name and Social Security number shifts the bill to that unfortunate person. A slight variation on this theme involves patients going to the doctor and using someone else’s name and insurance identification number to get free treatment, including, apparently (according to the New York Times article), major elective surgery. As some forms of US health insurance have a lifetime cap on financial benefits, someone else using your insurance could, in fact, use it all up. Medicare fraud in Australia, which was reported to occur in the early days of Medicare, involved doctors billing patients whom they had not seen, or billing patients for additional and longer visits. If President Obama’s public insurance scheme is passed, it is possible that a similar problem could occur in the US. President Obama stated that a significant goal of his new health policy would be the generation of transportable, up-to-date, reliable electronic medical records. This is a worthwhile goal, and if it comes to pass and develops technology that can be used in Australia, it will have a substantial and positive effect on our health care system. However, in the US, if someone were to get hold of your electronic record and use it as part of a medical insurance identity fraud, their medical information could become entangled with yours. Obviously, for patients with relatively short medical records, regular review would pick this up immediately. However, for many older patients with very complicated medical histories, this may not be readily apparent, and could potentially cause a major health problem. It could lead to incorrect blood transfusion, incorrect drug prescription or incorrect surgery. The possibility of incorrect data within an electronic medical record is a major issue. Anyone used to dealing with large computer files will recognise the problem at once. Misfiling in paper hospital records occurs, but it is usually obvious when a result or history relates to a patient other than the owner of the file. In an electronic record, if the content is divorced from the name, or if fraud is involved, medical staff seeing the patient for the first time might not detect the error. As in many things, future developments in Australia are seen first in the US. It is to our advantage that foresight is a wonderful gift. However, we must remain mindful that, like many clever ideas originating in the US, this one may have a substantial downside if we are not very careful.

Jeffrey D Zajac MB BS, PhD, FRACP

Paying incentives above the baseline Medicare Benefits Schedule to health services for the additional work required to meet the health needs of Aboriginal people or Torres Strait Islanders might mitigate inequalities of care, but evidence supporting this is lacking. The proposed “Indigenous health” incentive payment to reduce Aboriginal health disadvantage, which is largely aimed at increasing the responsiveness of mainstream general practices, provides an opportunity to examine the assumptions behind this and other recent health reform bids. Contentious implementation issues include: the ineligibility of several Aboriginal community controlled health services (ACCHSs) to receive this payment; determining Aboriginality and the potential for misappropriation of payments; the difficulty accounting for practice population diversity and patient mobility; and concerns about the benefits or otherwise to the Aboriginal community. Evaluation of the measure will present problems: to attribute outcomes, an evaluation must disaggregate outcomes by type of service provider (general practice or ACCHS). If these challenges are not addressed, this initiative may end up merely funding coordination of care for those Aboriginal people and Torres Strait Islanders who are already regular users of the health system.

Sophie Couzos FRACGP, FACRRM, FAFPHM · Dea Delaney Thiele PGDipHlthMgt

To the Editor: I note, with a breath of fresh air, your recent column about managing hospital staff rosters1 and, in the same issue, the article by Dietz, calling for a simpler, more resilient health bureaucracy.2 We are stuck in an environment where process seems to be disassociated from outcome and, if the outcome is not what is wanted, then more process is added, thus compounding the problem. Surely it is time to step back a bit and look strategically at bureaucratic processes, and how they work and don’t work? No one would deny that we need good administration — it is one of the very bastions of our way of life. We seem to study most things in an evidence-based manner, or at least try to. Why can’t we have chairs of bureaucratic studies in our universities to rigorously research our bureaucratic processes? Armed with sound evidence, we could develop template systems and other tools to break the nexus in which we find ourselves. Dare I say the spin-off would be greater than just health care. Food for thought.

Robert N Atkinson

“We cannot stay silent any longer, waiting and watching as more people are harmed in health care.”1 Error in health care remains a significant problem in Australia, despite more than a decade of efforts to remedy it. Since the landmark 1994 Quality in Australian Health Care Study (QAHCS),2 Australian governments, both state and federal, have introduced various clinical governance, health policy and structural reforms to improve the quality of patient care and reduce preventable harm to patients. However, adverse events have not been measurably reduced. Many acknowledge that barriers to change are embedded in the culture and norms of health care. So, 15 years after the QAHCS and 5 years after a follow-up editorial in the Journal by Wilson and Van Der Weyden3 noting that health care was no safer and calling for a more imaginative strategy to improve patient safety, it is necessary to consider new approaches — not just more of the same. One such approach is to enable patients, carers and families who have experienced poor-quality care and preventable health care harm to develop solutions in partnership with clinicians, health providers and policymakers. In July 2009, 40 people who identified themselves as agents of change met in Perth, Western Australia, to take part in the 3-day inaugural Australian Patients for Patient Safety (PFPS) workshop, convened by the Health Consumers Council of WA, the WA Department of Health, Perth’s Curtin University of Technology and the United States organisation, Partnership for Patient Safety. The workshop was the 12th in a series of global workshops supported by the World Health Organization’s PFPS program,4 which was launched in London in November 2005. The workshop adapted an organisational change strategy known as appreciative inquiry (AI). AI builds on meaningful personal experiences that reflect the most positive core of human systems — values, visions, achievements and best practices.5 Participants in an AI process mine their stories to give voice to their most desired future.5 Half the workshop attendees were patients who had suffered preventable harm in health care or lay carers of people who had been harmed. The other half were health care professionals, health system researchers, government officials and non-governmental organisation leaders interested in hearing from and working with patients to bring about change. Participants came from a variety of backgrounds and cultures (fulfilling a workshop planning goal). In an atmosphere of deep mutual respect, they shared their experiences of health system failure and the profound impact this had had, and continues to have, on their lives. Sharing personal experiences, lessons learned and possible ways to make health care safer, participants developed the Perth Declaration for Patient Safety (Box).1 This passionate call to action seeks to ensure that the impact of health care harm is recognised and that patients’ unique experiences inform change. It calls on all who work in and shape the Australian health system to strive, in partnership with patients and their families, to improve health care safety. Participants emerged from the workshop appreciative of one another’s experience and contributions, and dedicated to working collaboratively to advance patient safety in Australia. Through the WHO, they join an international network of PFPS “champions”, whose mission is to help patients be active partners in health care, not passive recipients.6-8 The Australian PFPS workshop and its recommendations are timely indeed, given the current push for reform of the Australian health care system. Authors of recent reports, including the proposed National Safety and Quality Framework of the Australian Commission on Safety and Quality in Health Care9 and the final report of the National Health and Hospitals Reform Commission (NHHRC),10 encouraged conversation with consumers about future directions. Both reports call for action more than words, a call now underscored by the Perth Declaration. The NHHRC final report specifically argues that, to create a self-improving health system, a necessary first lever is to strengthen the engagement and voice of consumers. The PFPS workshop showed that a partnership is readily achievable when stakeholders reach through the invisible walls that separate them. Cooperation among people who are moved to attain what is possible brings new life and confidence to reform efforts. The vision of a safer future embodied in the Perth Declaration and reflected in the workshop participants’ commitment to openness, appreciation for one another’s experiences and learning from patients’ wisdom, must be supported. The opportunity to co-create that future — to stop harm and save lives — is now here. Perth Declaration for Patient Safety1 We, the participants of the inaugural Australian Patients for Patient Safety workshop, convened in July 2009 to share profound health care experiences in our lives and to take forward our call for action to improve patient safety in Australia. We are patients, family members, carers and health professionals — people from all walks of life. Each one of us is a testament to the personal experience of unintended harm in health care and its continuing impact. Much of that harm was preventable. We declare Policies and protocols alone have not made us safer. This problem is systemic, widespread and deep-rooted. The fact that any person or family could one day experience needless devastating harm within the health care system is unacceptable Action must be taken now across all aspects and all levels of health care to prevent more harm occurring to others Our trusted health care workers and managers must recognise that we, your patients and our families, are an invaluable asset and resource for improving patient safety. We offer our stories and experiences. Seek to learn from our hard-won wisdom and partner with us to make lasting change We are the owners and funders of our health care systems and have collective responsibility for them. We ask everyone in the community, including health care providers, administrators and the Government, to join us in making the right to safe health care a priority for all people, especially those who are currently disadvantaged Care has no borders, neither does harm. The journey through all care settings must be better coordinated as too many lives have been lost or grievously harmed on this journey We need to receive care that conforms to the best evidence and practice. Safe practice must be supported by the reporting of and learning from patient safety incidents, education, innovative solutions and information Many barriers exist for Aboriginal and Torres Strait Islander people which limit access to safe health care. Interpreter services, effective communication, transport and accommodation are all integral elements of patient safety Patients know their own bodies better than anybody else. It makes sense to include patients in decisions about their care and treatment. Patients must always be told the options available, the expected outcome of each option including risks and complications, and the likelihood of each outcome occurring Patient safety is a basic human right. When harmed, people have the right to timely apology, explanation, redress and other remedies meaningful to them In accepting that all humans err, we nevertheless dedicate ourselves to ensuring that effective systems are in place to Track and learn from health care errors, adverse events and near misses Minimise the impact of errors on all involved, including the care provider Make changes to prevent the same errors happening again Current reporting arrangements have failed to deliver safe health care for patients. We accept that everyone, including patients, their families and clinicians, needs to safely report patient safety issues and problems. We therefore demand the application of improved patient safety legislation, including sanctions, which enables good clinical practice and provides real safety We cannot stay silent any longer, waiting and watching as more people are harmed in health care. As Australians, we own this problem and will work together with actions that go beyond words. To progress this call for action to improve patient safety, we expect partnership at all stages and at every level of the Australian health care system This Declaration is our kindling. We, the participants of the inaugural Australian Patients for Patient Safety workshop, will use it to ignite the flame of change to advance patient safety for everyone. This is our promise. Perth, Australia August 5, 2009

Stephanie M Newell Cert IV OHS, DipCouns · Dorothy A Jones BM BS, FAIM, MACMQ · Martin J Hatlie JD

Objective: To examine differences in outcomes between planned home births, occurring at home or in hospital, and planned hospital births.Design and setting: Population-based study using South Australian perinatal data on all births and perinatal deaths during the period 1991–2006. Analysis included logistic regression adjusted for predictor variables and standardised perinatal mortality ratios.Main outcome measures: Perinatal death, intrapartum death, death attributed to intrapartum asphyxia, Apgar score < 7 at 5 minutes, use of specialised neonatal care, operative delivery, perineal injury and postpartum haemorrhage.Results: Planned home births accounted for 0.38% of 300 011 births in South Australia. They had a perinatal mortality rate similar to that for planned hospital births (7.9 v 8.2 per 1000 births), but a sevenfold higher risk of intrapartum death (95% CI, 1.53–35.87) and a 27-fold higher risk of death from intrapartum asphyxia (95% CI, 8.02–88.83). Review of perinatal deaths in the planned home births group identified inappropriate inclusion of women with risk factors for home birth and inadequate fetal surveillance during labour. Low Apgar scores were more frequent among planned home births, and use of specialised neonatal care as well as rates of postpartum haemorrhage and severe perineal tears were lower among planned home births, but these differences were not statistically significant. Planned home births had lower caesarean section and instrumental delivery rates, and a seven times lower episiotomy rate than planned hospital births.Conclusions: Perinatal safety of home births may be improved substantially by better adherence to risk assessment, timely transfer to hospital when needed, and closer fetal surveillance.

Robyn M Kennare RM, DipApplSc(Nursing), GradDipPH · Marc J N C Keirse MD, DPhil, FRANZCOG · Graeme R Tucker BSc · Annabelle C Chan MB BS, DPH, FAFPHM

To the Editor: Congratulations on the 21 September 2009 issue of the Journal, highlighting preventive cardiology in Australia. I believe that the “working class man” of the well known Jimmy Barnes song has trouble affording preventive cardiology care in Australia. Assuming that he is currently employed, he will not be entitled to a Health Care Card and will be paying full price for care in general practice. There will be a gap of $20 to $60 between what he pays and the Medicare rebate per visit. He will have to pay about $30 per prescription. Assuming that he is taking antiplatelet agents, statins, and a blood pressure agent such as an angiotensin-converting enzyme inhibitor, he would be paying about $90 per month for medication. On an average income of $1200 per week1 ($800 after tax), and assuming that he visits his general practitioner monthly, preventive cardiology care might cost him about 4% of his disposable income. If our working class man is earning $900 weekly ($600 after tax), then preventive cardiology care would cost him 5% of his disposable income. Of course, the costs are similar for a wealthy man. However, the costs represent a far smaller percentage of his income than for the working class man. In this regard, the costs of preventive medicine are similar to the poll tax imposed in England in the 14th century. This regressive capitation tax was raised to pay for the imperial wars in France. However, the disproportionate burden it imposed on the serfs resulted in such anger that it led to the Peasants’ Revolt in 1381. Until medicine is funded more equitably, there will be a major disincentive to pursue preventive cardiology care for poorer people, who experience cardiovascular disease at an earlier age than their wealthier counterparts.2 The problem is not which model to use for absolute risk assessment,3 but the money to apply it.

V Michael Jelinek

If you are interested in health care reform, late 2009 is a fascinating time to be in the United States. An appointment as Visiting Professor in the Department of Family and Community Medicine at the University of California, San Francisco has provided me the opportunity to observe the debate and try to understand its meaning, with the help of US primary care leaders Kevin Grumbach and Tom Bodenheimer. Health care reform is writ large on the political and personal agendas of Americans. The newspapers are full of reports on the progress of President Obama’s proposals for reform, and debate about what needs to be done is a barbecue stopper at any social gathering. Despite massive spending on health care (US$2.5 trillion per year), many Americans have poor access to services and, at a population level, the system is underperforming. Inability to pay for health care is the most common reason for personal bankruptcy. The cost of insurance to employers is also a major issue, as access to an insurance plan is often linked to employment and some corporations therefore carry a huge cost burden — the US automobile industry, for example, spends more per car on health care than it does on steel.1 A contentious feature of Obama’s plan for reform is the “public option” for insurance. Under this proposal, the government would offer health insurance in competition with private insurers. The idea is that this would improve access and drive down costs. The public option is seen by many in the Republican Party and by some Democrats as government interfering with personal choice and as “un-American”. Quite why is not clear, especially as the public option will only apply to a limited group of people and is far from being a single-payer system, but terms such as “big government” and “liberal” (which, in this context, roughly translates to creeping socialism) are used, and the spectre of government-controlled health care decisions is raised. The mythical “death panels” have been the extreme example of this political scaremongering. There are also powerful interests, such as insurance companies and the pharmaceutical industry, who may stand to lose from substantive reform. The stakes are high and so is the money being spent on lobbying politicians — about US$2 million per day according to the Center for Responsive Politics.2 Despite this, the public option has survived as part of the Bill that has passed through the House of Representatives and, in a different form, is also part of the Bill to be debated in the Senate. Primary care would seem to have a lot to offer a country that is struggling with overwhelming health care costs and relatively poor outcomes. The work of Barbara Starfield (University Distinguished Service Professor at Johns Hopkins University) provides evidence that countries with a health care system built on a strong foundation of primary care have better health outcomes and lower health costs.3 So what are the opportunities for primary care in the reform process? Primary care leaders have been invited to meet with the President’s health care reform team and put forward suggestions to revitalise primary care in the US. Key issues for reform are changes to the amount and nature of primary care payment systems, investment in primary care infrastructure and organisation, and strategies to attract more local medical students into family practice as a career.4 Sound familiar? Readers of Australia’s draft National Primary Health Care Strategy will see many parallels.5 In payment reform, addressing the disparity in income for US family physicians versus other specialties is called for through changes in the payments from insurers and through examination of payment systems for care coordination tasks and electronic consultations. Increased funding of family medicine rehsidency programs and debt relief for family practice graduates are also suggested reforms. There is evidence that government is listening. The health reform Bills before Congress include changes to Medicare payments for family practice and funding for local Primary Care Cooperative Extension Services that would support primary care transformation and modernisation. Roles of the Primary Care Cooperative Extension Services would include fostering local learning communities to facilitate change and providing technical assistance in practice transformation — including adoption of information technology and development of primary care teams with the capacity to provide systematic chronic disease care and organised preventive services. Already, the massive US stimulus Bill includes funding for improvements in health information technology, but the amount of this that will go towards improving electronic health records and communication systems in primary care remains to be seen. There are excellent examples in the US of good integration between primary care and secondary and tertiary services through alignment of incentives, high-quality communication and shared resources. These include Kaiser Permanente and the Geisinger Health System. Australia has a lot to learn from these models in its thinking about the roles of local primary care organisations. However, like nearly everything else in the US, these models are not generalised across the country and it is not clear how to make such models available nationwide. It is likely that by early 2010 it will be clear whether the reform process in the US is underway or has stalled again. The proposed reforms will only be a start and, if passed, will take years to implement. But there is hope, including opportunities for improved primary care.

Nicholas A Zwar MPH, PhD, FRACGP

Objective: To assess the feasibility of using a rapid access neurology clinic to assess and manage patients considered safe to discharge home from the emergency department (ED), yet requiring specialist neurology review.Design, setting and participants: The ED Rapid Access Neurology (ED RAN) clinic was trialled at Royal Prince Alfred Hospital, a major tertiary teaching hospital in Sydney, over a 12-month period (23 March 2008 – 22 March 2009). The service uses a new clinic and referral system to offer suitable patients specialist neurology outpatient review within 5 working days of their discharge from the ED.Main outcome measures: Quality of patient care, patient satisfaction, estimated service impact on the hospital system.Results: During the 12-month trial period, 311 patients were referred to the ED RAN clinic. Of these referrals, 222 patients (71%) attended the clinic, where a number of serious neurological diagnoses were made, and eight patients required admission after specialist review. All patients attending the clinic found the visit helpful. Consultant ED physicians believed that the clinic prevented 83 unnecessary admissions and 188 out-of-hours neurology registrar consultations, and saved an estimated 809 hours of ED bed time.Conclusions: The ED RAN clinic provides a viable model for improving the quality of patient care, with high levels of patient satisfaction. This model of care may allow significant cost savings and help to relieve the major access block in Australian EDs.

Rebekah M Ahmed MB BS(Hons) · Timothy Green MB BS(Hons), FACEM · Gabor M Halmagyi MD, FRACP · Simon J G Lewis MB BCh, FRACP, MD