Health services administration

Vulnerability to data manipulation is only one of many problems compromising the use of elective surgery waiting times to assess health system performance The recent controversy in Victoria over the manipulation of waiting lists in a number of public hospitals has focused attention again on the problems associated with a performance management system that is not underpinned by the collection and reporting of sound data. An independent audit of Melbourne’s Royal Women’s Hospital found that patients awaiting urgent or semi-urgent elective surgery whose waiting times were approaching the target for their category (30 days and 90 days, respectively [Box]) were reclassified as “not ready for care — patient initiated”. The reclassification ensured that category waiting time targets were not exceeded and that the hospital met elective surgery key performance indicators.1 Although at the time of the audit the hospital did not participate in the bonus scheme designed to reward hospitals for achieving targets, the state Minister for Health has since scrapped the bonus scheme.2 During the ensuing public debate, the Victorian Auditor-General and the Australian Institute of Health and Welfare (AIHW) both released reports highlighting the limitations of waiting times and clinical urgency categories as indicators of patient access to elective surgery and hospital performance.3,4 Taken at face value, waiting times for elective surgery appear to be a simple measure that can provide information about patient access to services, as well as hospital performance. However, the measurement of waiting times and interpretation of waiting times data are inherently complex. Because we currently measure only the period from the date of entry to the waiting list until provision of surgery, improvements in waiting times do not reflect the entire patient journey and may be negated by increases in the time spent waiting for primary care, diagnostic testing or specialist outpatient appointments. And although waiting times may tell us how long it takes for patients to move through one part of the care pathway, they tell us nothing about the quality of care received. Additionally, their use as performance indicators may provide a motive for data manipulation.5 The clinical urgency categories that have been used as part of the waiting-list management process also have important limitations. Patients are classified into three broad urgency categories (Box) by a largely subjective process with poor reproducibility between clinicians and across health services.6 While the intensity of clinical symptoms such as pain has been fundamental to assigning urgency categories, clinicians vary in how they assess these symptoms. In assigning urgency, clinicians may also consider non-clinical factors, but this occurs informally. Further, each urgency category is aligned with recommended waiting times that are not evidence-based.3 In recognition of the problems with jurisdictional variability, the AIHW has excluded urgency categories from its national reporting since 1999. These limitations make the current elective surgery categorisation system unsuited for one of its main purposes — stimulating improvement through benchmarking and the use of performance targets. Lack of reproducibility and vulnerability to manipulation, which are characteristics of some of the system’s access and performance indicators, limit the value of the information collected. This is one of an increasing number of instances where inadequate attention to data quality has compromised the important function of providing accurate information to guide service provision. If waiting times are to be a sound basis for the routine reporting of patient access to elective surgery or other health services, then they should be explicitly defined to provide a valid assessment of the time spent waiting for surgery, and measured in a standardised and unambiguous way. This approach has been advocated in Canada, where there has been a concerted attempt over the past 5 years to establish evidence-based waiting time benchmarks for specific procedures.7 Likewise, the categorisation of urgency needs to be underpinned by an explicit and standardised way of taking into account all factors relevant to a patient’s requirement for elective surgery. This has already occurred to varying extents in New South Wales, New Zealand and Canada. In NSW, recommendations for assigning specific surgical procedures to urgency categories have been developed and set in policy.8 NZ and Canada have both developed explicit, practical tools that help clinicians systematically prioritise patients for a range of specific procedures, such as joint replacement and cataract surgery.9,10 A clinical priority access system, while not without its controversies, has been used throughout NZ since the early 1990s. Some of the prioritisation tools developed by the Western Canada Waiting List Project have been used in elective surgery programs in several Canadian provinces. The challenges in finding reliable measures of health system performance are not unique to waiting lists. In every area of the health care system, problems result when data used to assess access, quality of care and safety are not based on appropriate measurements. The cornerstones of epidemiologically sound data are validity and reproducibility. The identification of measures able to produce valid, reproducible data is essential for credible assessment of health system performance and to drive long-term improvements. Current Victorian urgency categories for elective surgery Urgency category Desirable treatment time Category 1 Urgent: Has the potential to deteriorate quickly to the point where it may become an emergency Admission within 30 days Category 2 Semi-urgent: Causes some pain, dysfunction or disability Unlikely to deteriorate quickly Unlikely to become an emergency Admission within 90 days Category 3 Non-urgent: Causes minimal or no pain, dysfunction or disability Unlikely to deteriorate quickly Unlikely to become an emergency Admission some time in future (within 365 days)

Andrea J Curtis BSc(Hons), PhD · Johannes U Stoelwinder MD, FRACMA, FACHSE · John J McNeil PhD, FRACP, FAFPHM

Junior doctors face specific pressures related to their professional stage and development and can be at risk of poor health. A confidential survey conducted in 2008 by the Australian Medical Association Council of Doctors in Training investigated the health and wellbeing of junior doctors. There were 914 completed surveys: 71% of junior doctors were concerned about their own health, and 63% about the health of a colleague. A majority of junior doctors met well established criteria for low job satisfaction (71%), burnout (69%) and compassion fatigue (54%). The early stages of a medical career are demanding, and the health and wellbeing of junior doctors must be a personal priority, as well as the responsibility of the medical profession in general, to ensure a healthy medical workforce in the future.

Alexandra L Markwell MB BS(Hons), BSc · Zoe Wainer BM BS, BHSc

Our public hospitals need medical leadership, and partnerships with medical schools can provide it There have been huge changes in medical practice over the past 20 years, including advances in the fields of cardiovascular disease, orthopaedics and cancer. Many of these were introduced through major teaching hospitals, before going on to influence associated hospitals and private practice. Continuing advances in medical research and technology (including information technology) in coming years will offer yet further opportunities to improve patients’ survival and quality of life. Recurring events with mismanagement of patients have undermined confidence in public hospitals — well publicised incidents in Bundaberg and Royal North Shore Hospital are recent examples. Before the 2007 election, Kevin Rudd promised that public hospitals would be taken over by the federal government if they were not “fixed” by the state governments within 12 months. The community has a right to expect health care with a commitment to excellence and safety. Would transferring responsibility for public hospitals to the federal government, as is now foreshadowed by the National Health and Hospitals Reform Commission (NHHRC), solve anything? The final report of the NHHRC,1 with its 292 pages and 123 recommendations, warrants careful analysis, but the big issues are lost in the detail. I applaud its proposed initiatives to strengthen primary care, mental health care, dental care, preventive strategies and Indigenous health. The big gap is the lack of realistic proposals to “rescue” public hospitals. Despite delivering constantly evolving services, our hospitals have been required to deliver more and more with their existing resources (except for some recent increase in federal funds), with their performance measured against metrics relating to diagnosis-related-group-adjusted “patient separations”, waiting list numbers and emergency waiting times. Quality of care, in which professionals take pride, has become a low priority. Clinical academics and other medical leaders with a commitment to evaluation of quality, and to research and innovation, have been pushed to one side. Statements by the NHHRC that quality, safety, research and innovation should be encouraged have no meaning if management of hospitals continues in the current mode. Are the problems really understood? Garling concluded in 2008 that the New South Wales health system is in a state of crisis — “It is the breakdown of good working relations between clinicians and management which is very detrimental to patients”.2 To varying degrees, the same applies in state after state, although Victoria’s situation is better, with hospital boards overseeing chief executive officers who are expected to make decisions and work with professional teams, rather than detailed management responsibility resting with health bureaucrats and their delegates, as is the case in many other states. In the 1970s and 1980s, Australia had some great university hospitals doing excellent work. The Austin Hospital in Victoria was, in 1966, the first to be established with academic leadership. From 1974, the Flinders Medical Centre in Adelaide was a model “joint” university hospital, but now functions largely as a community hospital. The fine Westmead complex in NSW, developed under guidance from the University of Sydney (from 1976) now suffers state bureaucratic interference. For all that, the medical schools of the University of Melbourne and the University of Sydney were rated among the world’s top 300 medical schools for research in clinical medicine in 2009, being ranked 37th and 59th, respectively3 — both higher than Cambridge University and the University of Manchester, two of the five medical schools in the United Kingdom recently recognised as leading academic health science centres overseeing large groups of hospitals. Four other Australian schools are in the top 200. The interim report of the NHHRC dismissed the concept of “university hospitals”4 as old-fashioned.5 The National Health and Medical Research Council, in its Draft Strategic Plan for 2010–2012, ignores the strong recommendation of its own international strategic review (the Zerhouni Review) that the government should ensure that at least a few competitively selected hospitals have sufficient funds and a mission statement that also supports patient-based research rather than minimising current costs at the expense of long term transformation of health.6,7 This recommendation reflects the pattern so well developed in the United States, Sweden, Finland, the Netherlands, Belgium, Singapore and, more recently, the UK. Despite generalities in the NHHRC final report about the importance of research, university medical schools are now to relate to their teaching hospitals through a new “competency-based” National Health Workforce Agency, and teaching hospitals are to respond to external advice from the National Institute of Clinical Studies (NICS) as to how to treat their patients.1 Valuable though NICS is, its currency is “evidence-based medicine” derived from past clinical trials, usually performed by teaching hospitals, that reflects previous experience rather than advancing knowledge. “Competencies”, the proposed basis for education, can also only be defined by looking at current patterns. Further, clinical governance, so central to the culture of clinical academics, is to be developed through “‘Clinical Senates’ at national, regional and local levels”.1 External control is seen as the answer! Surely we should by now have escaped the tyranny of distance and can learn from the experience of other countries tackling similar problems. Britain’s National Health Service (NHS) was, for years, centrally controlled by bureaucracies. Public disquiet grew as it became clear that the NHS was falling behind international standards of health care. Gordon Brown, as then Chancellor of the Exchequer, intervened over the Department of Health. The Cooksey review8 called for major redevelopment of clinical research to safeguard and advance the quality of services. An outstanding academic surgeon, Lord Darzi, was then appointed a life peer, becoming the Parliamentary Under-Secretary of State for Health, to review the entire NHS. His reforms secured medical leadership of the system at every level, with groups of hospitals led by medical schools.9 The changes have rapidly turned around the morale, culture and quality of services in British public hospitals. In 2009, only the fourth year of the reforms that began with the Cooksey review, an international panel recognised five large hospital groups led by medical schools — Imperial College London, University College London, King’s College London, Cambridge and Manchester — as exemplary in their health care delivery, deployment and education of health professionals, and commitment to quality, clinical research and innovation. The key to reform has been medical partnership in managing services for patients at every level jointly with health service managers, all accountable to medical school leadership. Clinical research with constant evaluation of health care10 is seen as the key to quality of services. Cost savings are now being realised with improved resource allocation, despite also meeting emerging challenges (E Byrne, formerly Vice Provost, University College London Medical School, personal communication, Aug 2009). Australia’s public hospitals should come under a new partnership between federal and state governments and the nation’s medical schools, following British and other international patterns. Each group of hospitals would be led by an appropriate Executive Dean working jointly with a senior health administrator, with hospitals being grouped on current patterns of association for teaching and intern and registrar rotations. Some hospital groupings in the UK are large (including up to 60 hospitals), but clearly work well. Governance and management are devolved in the joint clinician–hospital administrator pattern, with accountability to university leadership, safeguarding appropriate medical involvement. Kevin Rudd may choose to intervene over the “health establishment”, as Gordon Brown did. We stand ready to work with him in rapidly turning around a system in disarray.

David G Penington AC, DM(Oxon), LLD(Hon), FRACP

The National Health and Hospitals Reform Commission (NHHRC) report attempts to deal in the short term with hospital access block by funding more beds in emergency departments, while, over the longer term, reforms aim to improve hospital efficiency, transfer care of patients to non-hospital settings, optimise use of outpatient clinics, fund hospital activities on the basis of efficient cost, and improve governance and accountability. The single most potentially effective recommendation is the considerable investment in and expansion of subacute and non-acute services, which will free up acute-care hospital beds for urgent cases. Population-based chronic disease management driven by Primary Health Care Organisations can also reduce future hospitalisations considerably. What the NHHRC could have dealt with more fully is the need to: (i) prioritise clinical interventions and the need for hospitalisation using evidence of cost-effectiveness obtained from clinical trials and longitudinal patient data; and (ii) move quickly towards funding of all health care by one level of government. Even the most effective reforms will not have a significant impact on future bed demand if professional and public expectations remain unsustainably high and do not acknowledge the need to change the role of hospitals within a reconfigured health care system.

Ian A Scott FRACP, MHA, MEd

The release for public consultation of the draft Health Practitioner Regulation National Law 2009 represents a once-in-a-generation opportunity to ensure best practice in medical regulation. The draft law fails to build on the best aspects of existing state and territory legislation, particularly in regard to how allegations of misconduct, poor performance or impairment are to be handled. If adopted, this legislation has the potential to set back important improvements to professional regulation that have been implemented in Australia in the past 20 years. There are also legitimate concerns about mandatory reporting provisions and the likely increased cost of regulation. More time and more work are needed to get this new scheme right.

Kerry J Breen AM, MB BS, MD, FRACP

Mandatory reporting and public sharing of information would likely lead to improved health care practices and save lives Staphylococcus aureus bacteraemia (SAB) is common, and it causes serious morbidity and mortality. In Australia, it is estimated that there are over 6000 episodes per year, most of which are health care-associated.1 SAB is also a major problem internationally, and this problem is compounded by antibiotic resistance. Methicillin-resistant S. aureus (MRSA) infections are common in most countries, and MRSA bacteraemia has reached epidemic proportions in some areas of the United States.2,3 The study by Turnidge and colleagues on behalf of the Australia New Zealand Cooperative on Outcomes in Staphylococcal Sepsis in this issue of the Journal4 highlights again how frequently these infections occur, their association with health care (particularly with intravascular catheters), and the high mortality rate associated with them (over 20% by 30 days). It also illustrates our rapidly growing problem with community MRSA strains, which caused over 6% of all the SABs in the period June 2007 to May 2008, during which Turnidge et al collected data. Currently, we have only very patchy measurements of this problem in Australia in comparison with New Zealand, Denmark and the United Kingdom,2 where all SABs are measured. Despite probably causing more deaths in Australia than occur on our roads, there is very little investigation into the causes and the preventable factors of individual episodes of bacteraemia. Most of these infections are preventable. Numerous interventions (such as compliance with hand hygiene and improved care of intravenous catheters) have been shown to lead to major reductions in rates of bacteraemia.2,5,6 The current National Hand Hygiene Initiative7 should also achieve a significant reduction. The Australian Commission on Safety and Quality in Health Care has noted how significant these infections are, and the importance of surveillance.2 It has also taken this matter to the Australian Health Ministers’ Conference, which then endorsed the reporting of SABs in each jurisdiction and nationally. It is time that all health care facilities started collecting and acting on information about SABs. However, this probably won’t happen effectively unless all SABs (based on pathology laboratory results) are made “reportable”. After mandatory reporting was introduced in the UK, the number of documented cases increased by 50%.2,8 It is important that we do more than just collect these data. We need to ensure that, in each hospital, every case is looked at to try to determine why it occurred. Then health care professionals need to intervene at their own local level to make sure that appropriate policies are adhered to (or, where necessary, changed). Nearly all people with SABs are either in hospital already, or will be admitted. Thus, it should be possible to see them at or near the time of their infection. This will usually mean that either a physician or an infection control practitioner would look at every case to determine whether it was the result of a health care-associated procedure, and also look into other issues, such as the likely cause (eg, intravascular catheter) and outcomes.2 This would then also allow timely feedback to the teams responsible for the patients’ current and previous medical care about potential preventable factors.9 Many episodes of SAB, even though they are health care-associated, have their onset in the community. Thus, all cases of SAB will need to be looked at, and not just those with their onset in hospitals.1,2,9 While this will seem arduous to some, at the Canberra and Austin Hospitals, it takes between 30 and 60 minutes to see each affected patient and review each case.2,9,10 Even our largest hospitals are unlikely to have more than a couple of hundred SAB episodes per year. As these episodes have a mortality of more than 20%, this is not an undue task to expect hospitals to perform. They need to devote resources to doing this, and make it part of the core duties of any infection control team. It is important that the data be analysed, reported and acted on in a timely fashion, and this process must involve those at the hospital executive level. The success and benefits of doing this at a local level are highlighted in the study reported by Dendle and colleagues in this issue of the Journal.10 The study by Turnidge et al shows how data can be analysed and reported efficiently at a national (and international) level, with relatively few extra resources being supplied, through the use of a web-based tool.4 Such a system allows summaries to be sent back to the individual hospitals so that they can look at their own data in a timely fashion. It also allows some external auditing of the data to ensure they are accurate. Importantly, it will allow hospitals of similar types to benchmark themselves nationally. This is important because we already know that hospitals in Perth have much lower rates of health care-acquired MRSA than those in the eastern states,11 and we should learn from them. Most Australian states do not have sufficiently large populations to make many comparisons internally, especially of their largest hospitals, where most cases of SAB occur. By using national comparisons, institutions with higher rates of infections should be able to learn from those that have lower rates of infections. There are always arguments that looking at these data and having them publicly available does not help. However, the experience in the UK suggests otherwise. Amid controversy, SAB rates have been published on the web for many years, and this type of benchmarking, when coupled with funded infection control interventions, has led to a 50% reduction in the number of MRSA bacteraemias.2,8 This has not only resulted in substantial monetary savings, but, more importantly, has saved many hundreds of lives each year. Internationally, we are seeing rising levels of SAB. This is principally the result of complications of health care, and most of these infections are preventable. It is time we measured these life-threatening episodes much more accurately, examined each case, and intervened to stop further cases occurring.

Peter J Collignon FASM, FRCPA, FRACP · Marilyn Cruickshank RN, PhD, FRCNA

Time to debate the recommendations of the National Health and Hospitals Reform Commission is slipping away When the history of the Rudd Labor Government is written, undoubtedly a chapter will be devoted to its penchant for summits, inquiries and reports. Health has not escaped this inquisitorial focus. There have been, among others, inquiries and reports regarding preventive health,1 primary care,2 and health care delivery in general.3 The latter was the remit of the National Health and Hospitals Reform Commission (NHHRC), and its final report, A healthier future for all Australians, was released in June this year.3 If the NHHRC’s 123 recommendations are enacted, they have the capacity to change Australian health care in a manner reminiscent of the establishment of Medibank. Despite the report’s length (292 pages) and its prolific list of recommendations, common themes emerge: shared responsibility for care; increased responsibility by the federal government for existing and new health services; consolidation and integration of services, with an emphasis on non-institutional care; shifting care towards being more patient- and person-responsive than provider-convenient; better intrasectoral communication through the use of information technology; extracting greater efficiencies from hospitals; relating remuneration to outcomes and performance targets; and, finally, fundamental changes in the provision of health insurance. In short, if implemented, the report will mean a time of uncertainty, inherent in change. Despite this, the report has not yet been widely debated within the profession. In this issue of the Journal, we commence a series of articles (National health reform: it’s time for a decision, A healthier future for all Australians: an overview of the final report of the National Health and Hospitals Reform Commission and Final report of the National Health and Hospitals Reform Commission: will we get the health care governance reform we need?) exploring the social, health and professional impact of the recommendations of A healthier future for all Australians. Prime Minister Rudd is currently engaged in a whirlwind “getting to know you” tour of selected Australian hospitals, before the federal government’s response to the report is further massaged by the Council of Australian Governments into a united policy and a possible implementation plan. If the profession seeks to influence these outcomes, now is the time to present our views and recommendations. If we do not accept this challenge, change will be imposed from on high and may well be uncomfortable or even intolerable! Although it is important to “talk the talk”, this should not excessively delay “walking the walk”.

Martin B Van Der Weyden MD, FRACP, FRCPA

A national system financed and governed by the Australian Government would open up access to the widest range of health services After 18 months of summits, taskforces, and work by the National Health and Hospitals Reform Commission (NHHRC),1 it is still unclear whether Australia’s health system stands on the threshold of major change. Despite Prime Minister Kevin Rudd’s bold statements during the 2007 election campaign, we do not know the real shape, scope or timetable for health reform. Why the delay? First, the government was elected without a detailed health reform plan. Second, substantive change requires a national leadership group with the confidence and technical expertise to confront the vested professional, business and political interests that will resist change. Importantly, the general public and most clinicians still support the view that the national government should take overall responsibility and lead the reform agenda. Inevitably, the Rudd Government has faced a choice between two contrasting paths. The first is to “talk tough, but do little”. This path characterises Australians as enjoying both excellent health and access to one of the world’s best health care systems. Consequently, new initiatives are limited in scope and largely reactive to the “crises” of the day. To date, the new government’s big actions — financial commitments to the 2009–2014 Australian Health Care Agreements, new hospital-based infrastructure, and reduction of surgical waiting lists — have continued down this conservative road. The alternative is the “road less travelled”. This alternative characterises the current system as chronically stressed and dysfunctional, and is well summarised by the NHHRC.1,2 It recognises daily failures in clinical care and systemic neglect of Indigenous health, mental health, dental care and aged care. Most importantly, it states that our current “hospital-centric” system will not cope with the coming tsunami of chronic disease. This alternative path demands new operating principles that prioritise equity of access, reduce out-of-pocket costs, promote consumer-responsiveness, value collaborative and out-of-hospital care, incorporate new technologies, and build systems to support clinical and system-level accountability. Although the conceptual basis for this approach was established internationally,3,4 it is rarely implemented. If this is the season for radical reform, what should the Australian Government do in the next 6 months? Most importantly, it must decide swiftly on a preferred model for finance and governance. In February 2009, the NHHRC set out three options.2 The conservative option (Option A) is that the federal government assumes financial responsibility for all out-of-hospital care. Sadly, this would leave public hospital funding to the states alone. Even if Option A were combined with partial federal funding of state hospitals,1 we would still retain many of the worst features of our current divided system. Instead, a bold move to a national system that reduces the service gaps is urgently required. The government could adopt the NHHRC’s Option B (regional health authorities) and Option C (national social insurance).2 A public financing system that originates in one level of government, supplemented by private health insurance, would start to open up access for all Australians to the widest range of health services. Unfortunately, in its final report, the NHHRC repackaged and watered down its three original options into two: building a “Healthy Australia Accord”; and then, possible development of “Medicare Select”.1 These are nice names but serve to obscure the real political choices and delay the implementation of change. I believe new national financing arrangements are also the best way to support regional health providers. That is, only a nationally coordinated system can work effectively to reduce health inequities and utilise all clinicians fully. The additional goals of reducing out-of-pocket expenses and containing overall national health expenditure (currently below 10% of gross domestic product1) can be built into a national framework. As in other countries such as the Netherlands, this financing option may work best if implemented by more than one national insurer.5 Its viability may well depend on revising the current level of taxation support for private health insurance. Any new financing options must be linked with active development of a vibrant new breed of health service providers. Although these providers must deliver high-quality, evidence-based clinical care, they also need to develop collaborative care packages for those with complex or chronic needs. Here, Australia needs to learn from overseas experience.3,4,6 Real innovation and the development of consumer-responsive care rely on the existence of genuine competition between providers. Our rigid state-based systems offer no real choice to the users or alternative options for those who require services that the states cannot provide. A government committed to reform of the health system must move away from sole reliance on both federal and state bureaucracies. An independent implementation authority with sufficient resources and legislative power, and a timetable for delivery has a greater chance of achieving real change. Within such an authority, there is the need to embed strong clinical leadership alongside the requisite management and health system expertise.3,4 Together, these actions would start to drag our 19th century hospital-centric system into a 21st century framework that could deliver dynamic and responsive health care. These actions do not require another round of hollow consultations, a national plebiscite or another election campaign. They require political decisions.

Ian B Hickie MD, FRANZCP

After extensive community and health industry consultation, the final report of the National Health and Hospitals Reform Commission, A healthier future for all Australians, was presented to the Australian Government on 30 June 2009. The reform agenda aims to tackle major access and equity issues that affect health outcomes for people now; redesign our health system so that it is better positioned to respond to emerging challenges; and create an agile, responsive and self-improving health system for long-term sustainability. The 123 recommendations are grouped in four themes: Taking responsibility: supporting greater individual and collective action to build good health and wellbeing. Connecting care: delivering comprehensive care for people over their lifetime, by strengthening primary health care, reshaping hospitals, improving subacute care, and opening up greater consumer choice and competition in aged care services. Facing inequities: taking action to tackle the causes and impact of health inequities, focusing on Aboriginal and Torres Strait Islander people, people in rural and remote areas, and access to mental health and dental services. Driving quality performance: having leadership and systems to achieve the best use of people, resources and knowledge, including “one health system” with national leadership and local delivery, revised funding arrangements, and changes to health workforce education, training and practice.

Christine C Bennett MB BS, FRACP, MPaed

The National Health and Hospitals Reform Commission (NHHRC) has recommended that Australia develop a “single health system”, governed by the federal government. Steps to achieving this include: a “Healthy Australia Accord” to agree on the reform framework; the progressive takeover of funding of public hospitals by the federal government; and the possible implementation of a consumer-choice health funding model, called “Medicare Select”. These proposals face significant implementation issues, and the final solution needs to deal with both financial and political sustainability. If the federal and state governments cannot agree on a reform plan, the Prime Minister may need to go to the electorate for a mandate, which may be shaped by other economic issues such as tax reform and intergenerational challenges.

Johannes U Stoelwinder MD, FRACMA, FACHSE

To the Editor: Duckett rightly points out that community knowledge and expectations of the delivery of medical services have increased in recent years, and that the “baby boomers” of today will not accept the hospitals of yesteryear.1 He claims that the Australian health system has responded to technological change, but not to sociological change. Although the introduction of new medical technologies — a process largely driven by clinicians — has helped ensure that Australians still have access to quality health care, the same claim can not be made for the other kinds of technologies necessary to support delivery and review of good-quality care; notably, health information technology lags lamentably behind other sectors. In addition, we have not been “adept in responding to technological change”, because we have not figured out how we are to pay for it. The sociological changes that Duckett is concerned with are well recognised by many working in the public health sector. He states that macro- and provider-level reforms set the context for the interaction between the patient and clinician. He seems inclined to view this interaction as the final frontier — resistant to change and responsible for what he characterises as an ongoing lack of responsiveness in hospitals and health facilities. However, his outdated and stereotypical characterisation of doctors working in the public health sector must call into question his knowledge of what actually goes on in modern health care settings, in addition to pointing to a tendency to underestimate the difficulties of working in these austere and pressured environments. The conversation that privileged baby boomers actually need to have is one that forms part of a public debate about how much health care costs and how we should be thinking about rationing its delivery, or else paying more for it, as Queensland Health has perhaps finally learned. It is disappointing that, despite Duckett’s long years of experience in the public health sector, he fails to address the real implications of the changes, both technological and sociological, to which he alludes in his opening paragraph — how exactly are we going to manage the ever-increasing demand for increasingly expensive treatments by an ageing population?

Heather J Cleland

To the Editor: The next challenge for medicine in Australia, in Duckett’s opinion, will be the need to provide for the “very different expectations . . . and a greater sense of entitlement” of baby boomers, as they reach old age and have more need for health services, in and out of hospital.1 They will not meekly wait for care — but how will waiting lists for appointments and elective surgery be abolished? They will not accept “cattle class” in outpatient departments — but who will pay for the replacement of wooden benches with easy chairs? They will not accept whatever is on offer — but who will provide what is not on offer at a time of need? They will expect frank discussion of choices, risks and outcomes — but which cardiac surgeon or registrar will have the time to go into the 40 different possible complications of coronary artery bypass, an operation with usually excellent results? And if nurse practitioners or podiatrists become leaders of the medical team, will they be professionally and legally responsible when outcomes are unsatisfactory or disastrous? People with visions of the ideal medical service should keep in mind a basic principle, expressed by Enoch Powell 42 years ago.2 Even in prosperous times, limited resources (trained staff, facilities and money) will never meet unlimited demands. Duckett’s baby boomers may have expectations, but they must be measured against reality. With the unceasing growth of knowledge, technology and pharmacology, medicine is not about to become cheaper.

Derek H Meyers

In reply: Notwithstanding the differences in tone, Cleland and Meyers make the same substantive point: that a challenge I ignored in my short piece was the costs of meeting the different expectations of baby boomers. Regardless of the changed expectations I discussed in my article, health costs over the next few decades are predicted to increase from just over 9% of gross domestic product to over 12%.1 Economists recognise that societies appear willing to devote more spending to health care as they get wealthier, perhaps to avoid confronting the difficult choices involved in some rationing decisions.2 But should we immediately jump to the conclusion that more rationing is inevitable? What other choices are there? First, we — policymakers and clinicians alike — need to address the waste and inefficiency inherent in the current system;3 and, second, change the health system so that it is better suited to respond to changing needs4 and potentially “bend the trend” of health cost projections. Third, we need to recognise that rationing — or, to use a less emotive term, priority setting — is already part of our health system. Australia leads the world in terms of formal processes before listing new drugs on the Pharmaceutical Benefits Scheme or items on the Medicare Benefits Schedule, but here too, improvements are needed. Clinicians are already involved in rationing choices, but different clinicians appear to have different thresholds of when (and what) treatment should be recommended. These differences may be cultural,5 and addressing these unexplained variations in practice patterns remains a policy work in progress. Thus, we in the health system have a lot of work to do in putting our house in order so that any rationing debate can occur knowing that alternative strategies have already been pursued.

Stephen J Duckett

To the Editor: The authors of the recent MJA article “Making cars and making health care: a critical review”1 have misunderstood the importance of process design in a service as complex as health care delivery. They state that the Toyota “lean thinking” model has been “accepted somewhat uncritically” in health.1 In fact, the opposite is true. Work practices and roles in conservative institutions such as public hospitals have changed minimally over many years. Cutting-edge medical technology is delivered within an archaic work practice model that fosters inefficiency, frustration and unnecessary expense. Inefficient work practices give skilled clinicians less time with their patients — not more. Like Winch and Henderson, let’s take an example from the surgical field. Years ago, when public hospital beds were relatively accessible, many patients were admitted for “work-up” and spent days in their pyjamas in hospital before planned surgery. The application of the “just in time” principle has led to the huge turnaround to day-of-surgery and day-only admissions — freeing up beds and saving enormous cost as well as many unproductive days for patients. This is only one small example. Lean thinking is just one model for improving the way in which complex processes are coordinated.2 Far from being “highly stylised and simplistic”, lean thinking is about removing redundant steps and reducing duplication, waiting times and errors. It’s about investing in the talent and skill of trained staff, by maximising the value they add to whatever process they are working on and minimising the extraneous tasks they have to do.3 Managed properly, this can result in faster and better care delivered by happier staff, with more time to “cure and comfort”.1

Susan Ieraci

In reply: Our article highlighted issues with the uncritical adoption of car-making processes into health care planning — specifically, the regulation and splintering of the human element of a care pathway. While day-of-surgery admission speeds patients through the system, the capacity for error remains and relates to our original arguments. For example, one assumption commonly made is that the patient or carer has the literacy level to understand the presurgical procedures, such as fasting, taking particular preparations or completing health history forms. Yet the Australian Bureau of Statistics reported in 2003 that 37% of the population met only the minimum literacy standard (Level 3) required to function in a complex society such as ours in Australia.1 Forty-six per cent fell below this benchmark. For health literacy specifically, 35% of the population met only Level 3 standard, with about 60% falling below this standard. This indicates that some of the work we have happily “outsourced” to the patient may be poorly understood and cause problems further down the line. It also highlights another key difference between cars and people: baseline control of the beginning raw material is difficult to achieve.

Sarah Winch · Amanda J Henderson

Everybody thinks that if everybody used common sense, the problems in health care would go away — but common sense isn’t that common, and health care is more complex than it seems. However, MJA Books’ latest publication provides a simple, clear guide to effective clinical risk management. So said Professor Bruce Barraclough, President of the International Society for Quality in Health Care, at the official launch of Enhancing patient care: a practical guide to improving quality and safety in hospitals, authored by Alan Wolff and Sally Taylor. The Hon Daniel Andrews, Victorian Minister for Health, officially launched the book on 31 August 2009 at the Victorian Department of Human Services. The book summarises extensive, confusing literature and shows results that can reasonably be expected to be achieved. It provides a logical, simple and effective model, along with summaries and checklists to help put the model in place; and outlines what does and does not work in the real world. Associate Professor Alan Wolff is Director of Medical Services for the Wimmera Health Care Group. He credits the success of the Group’s risk management program (on which the book is based) to five factors: the hospital’s intermediate size; its dedicated, long-serving staff; commitment from those at the top of the organisation; an innovative, flexible and cooperative hospital culture that does not “blame and shame”; and using simple improvement strategies. “We open high-risk medical records on a daily basis, run checklist programs, and have the clinical risk management team located in the wards, not as a separate function”, he said. Mr Andrews praised the book’s authors for taking their own successful project and providing it for others to use. “We can never eliminate errors, but we can have a shared commitment to learn from each error. This is a roadmap of a framework to always make sure health care is about care”, he said. Enhancing patient care is published by MJA Books and is available from the MJA BookShop at <http://shop.mja.com.au> Above Left to right: Sally Taylor, Associate Professor Alan Wolff, the Hon Daniel Andrews and Professor Bruce Barraclough. Below Left to right: Sally Taylor, Alan Wolff and Rivqa Berger.

Rivqa Berger

Our public health system, addicted to increasing centralisation and regulation, is pushing our everyday work environment beyond the point of sustainability — it has become too complex. Like an ecosystem grown too complex to resist sudden environmental change, public health organisations have become “brittle”, unable to respond to changing conditions. Another bureaucratic restructuring, such as recommended by the Garling report, can only be self-defeating. It is time for us to design systems small enough, and therefore resilient enough, to meet tomorrow’s challenges.

Hans Peter Dietz MD, PhD, FRANZCOG

To provide the ongoing robust evidence needed for workforce planning, a national longitudinal study will itself need to be sustained into the future Globally, medical workforce shortages and maldistribution are major impediments to providing accessible, sustainable and safe health care.1,2 Strategic medical workforce planning is essential for resolving this problem. This requires up-to-date, robust data to predict future trends and, most importantly, give sound insights into the underlying determinants of workforce patterns and choices for workforce participation. Many countries have sought to develop appropriate medical workforce data collection mechanisms for tracking practitioners from graduation through employment, with varying degrees of success.3,4 Rural medical workforce shortages have been the impetus for several of these collections. Experience from these highlights the importance of comprehensive, systematic and ongoing quantitative data collection, and the value of establishing a minimum data collection system from the outset of a medical education program.5-9 In Australia and New Zealand, a small number of cross-sectional workforce studies have been undertaken in the past.10 A major limitation in using the disparate research outcomes of these to inform policy directions is the lack of connection between studies of students, current practitioners and past practitioners. Evaluations of government health workforce initiatives in Australia and New Zealand further emphasise the need for a uniform data collection methodology as the basis for tracking the progress of students throughout their training program and beyond.11-13 All of these approaches highlight the fundamental problem — a series of cross-sectional studies and evaluations “stitched together” to answer workforce questions will always provide less robust evidence than a well conducted, purpose-built, ongoing study. Sound medical workforce planning requires longitudinal data. Responding to this need, Medical Deans Australia and New Zealand (MDANZ) established the Medical Schools Outcomes Database (MSOD) and Longitudinal Tracking Project in 2005. This project collects reliable demographic and educational data about medical students across all Australian and New Zealand medical schools. To date, data have been collected on at least 11 200 medical students in Australia over 5 years of their training. Using an agreed national minimum dataset based on consistent definitions, the project targets critical times of medical career decision making — at the commencement of, and exit from, medical school; during the intern year; and during postgraduate training. Demographic information and data on vocational and practice location intentions are collected from surveys of students commencing medical school. Data obtained directly from the medical schools provide information on the nature of the students’ education and clinical experiences; for example, the length and nature of rural exposure, or membership of rural health clubs. Exit surveys of students again collect demographic data, vocational and practice location intentions, data on factors influencing career choices, and future contact details. Initial results from the MSOD show that length of residence in a rural area, generalist practice intention, and financially supported study (but not a bonded arrangement) are the strongest predictors of intention to take up rural medical practice. In addition, changing trends towards intended take-up of specialties are apparent — for example, a steadily increasing proportion of students intending to take up general practice was apparent between 2006 and 2008.14 In short, excellent data now exist to benchmark the impact of medical education and training activities. Success for this project requires more than a strong interest in evaluative medical education research. Other important catalysts have included champions (leading medical education researchers and medical school deans), resources (national funding provided by the Australian Government), a mandate (national auspicing by MDANZ to ensure comprehensive collection of relevant data), and timing (eg, to assess the impact and effectiveness of specific Rural Undergraduate Support and Coordination program funding designed to increase the numbers of students taking up rural practice). Importantly, the process for establishing the MSOD drew on international expertise to identify possible pitfalls and to help realise its potential. Professor Howard Rabinowitz, a rural workforce expert in the United States who played a leading role in a medical school longitudinal study in Pennsylvania, was engaged in an advisory capacity at the outset and continues to have an ongoing role. The MSOD will allow both short- and long-term monitoring and reporting on outcomes of medical education programs, and will inform national workforce policy implementation. It can contribute to evaluating the effectiveness of federally funded medical education initiatives in achieving improved medical workforce recruitment and retention. It complements activities of bodies such as the National Health Workforce Taskforce (NHWT), state and territory medical boards in Australia, and the Medical Council of New Zealand. It has the potential to link with data collected by the NHWT and other similar groups to track graduates after they leave medical school. This will allow further exploration of factors influencing career choice and destination, and continued data collection on the location and types of their clinical experience. Linking the MSOD with the forthcoming national medical registration system has the potential to identify specialty, practice location and changes in patterns of medical practice. In addition, the MSOD project offers a facility for conducting targeted substudies of specific policy or research questions, not unlike other well known longitudinal studies such as the 45 and Up Study.15 The project has access to 100% of the relevant student doctor population, and to date has achieved a student participation rate of around 95%, providing a high-quality sampling frame on which to base any empirical study. MDANZ considers MSOD an essential resource and is fully committed to its success — but is this sufficient to ensure its sustainability? Given the tyranny of distance, the process of bringing diverse groups together has required fostering trust and collegiality among all players around a shared project goal, in order to minimise competition and apprehension. Moreover, longitudinal studies have a long lead time before results become apparent, and convincing funders that outputs will justify the time and resources needed requires good ongoing communication and strong partnership arrangements. The Australian Government Department of Health and Ageing has provided crucial financial support that has produced a solid foundation without which the MSOD project would not have progressed. Several factors have been built into the project with a view to ensuring its sustainability. The database has not been produced by any one individual, university or workforce organisation. Instead, a collective approach that reflects all parties as equal partners is led by the MDANZ steering and management group. The process is underpinned by project officers who liaise with stakeholders. Project objectives, processes and desired outcomes are shared by all parties, and stakeholders are regularly engaged in full and open discussion of any likely sticking points, including ethics, ownership of data, roles and responsibilities. Agreed principles (such as simplicity, necessity, consistency, objectivity, sufficiency and relevance) guide the data collection process and support the intended outcomes. While all medical schools share a belief that the total good is more valuable than the sum of the parts, there is ample opportunity within the MSOD and Longitudinal Tracking Project to conduct rigorous substudies, either by individual medical schools or in partnership with others. Sound medical workforce policy decisions and reforms cannot be made in the absence of quality longitudinal data. The MSOD project is unique, well established and running effectively. With the continued and sustained commitment of MDANZ and the Department of Health and Ageing, the full potential of this resource as a valuable platform for informing a more coordinated approach to medical workforce planning will be realised.

John S Humphreys BA(Hons), DipEd, PhD · David Prideaux BA(Hons), MEd, PhD · Justin J Beilby MB BS, MD, FRACGP · Nicholas J Glasgow MB ChB, MD, FRACGP

Don’t just report, respond — inaction injures children Every Australian state has enacted mandatory reporting of child abuse. Child abuse is a ubiquitous problem affecting at least one in 13 children, and among Indigenous Australians, this rate is higher.1 The most important comorbidities for child abuse — poverty, domestic violence, mental ill health and substance misuse2 — are seen by all health professionals on a daily basis. Mandatory reporting of child abuse aims to achieve better outcomes for children and families where abuse is thought to have occurred or has occurred. It arose in the United States out of the correctly perceived need to allow health workers to report concerns about child abuse to statutory child protection agencies without fear of subsequent litigation for breach of confidentiality. The assumption is that the child protection agency will pick up the baton and protect the child. Current research clearly indicates that this is not the case.3 The recent Wood Inquiry into the New South Wales child protection agency (Department of Community Services) has outlined the perils of this false expectation; no child protection agency can cope with all the referrals that it receives.4 Mandatory reporting is not essential to good child protection. However, good communication between agencies and practitioners is essential; when this fails, disaster strikes. There are, sadly, many examples of these failures in Australia (where the case of Daniel Valerio is one of the best known5) and overseas (eg, the cases of Victoria Climbié6 and Baby P7). Management of child abuse does require mandatory responding. There is an obligation on each and every one of us who work in the community as a health professional to respond, and this must involve more than completing a mandatory reporting form. If we are to make a difference to children’s lives, all health professionals must respond when they suspect child abuse. The difficulty for all of us is that, unlike in other areas of medical practice, few patients are either willing or able to outline their suffering in a standard consultation. On many occasions, the parent deliberately sets out to mislead the practitioner in situations where child protection issues exist. This may be done maliciously, out of pride, or out of fear of prosecution. Thus health professionals need to have an index of suspicion, and then act on that suspicion in a way that does not jeopardise further the safety of the child. This suspicion is often outside the comfort zone of many health care practitioners. Of reports made to statutory agencies, substantiation rates vary from 2.4 to 9.3 per 1000 reports.1 Substantiation is not a cure for the child in question; all it does is confirm that the original concerns were correct and that the child needs help. The vast bulk of cases are unable to be substantiated, and this may result in the protection agencies feeling that such cases are no longer a priority; this potentially endangers children even further. The onus is thus on health practitioners, you and me, to respond.8 How can we do this? Responding can take many forms, depending on what is needed. It must never be assumed that someone else will fix it. If a particular case requires major social intervention, and if statutory agencies have not acted or have acted inappropriately, phone/write/fax/email them and alert them to your concerns. On occasion it may entail being more tenacious than you are used to being. If the issue is the mental ill health of a parent or child, ensure that the parent gets help either from you or from someone else. This may require repeated contact with mental health agencies. Mental Health Care Plans are very useful in this setting. Child abuse is a criminal matter that puts children at risk. In such cases, ensure that police are involved and are taking appropriate action. If there are medical matters affecting a parent’s ability to parent, these need to be addressed. If you are in doubt about what you see when a child presents, arrange for the child to be admitted and for the protection issues to be investigated while the child is safe. At a general practice level, responding appropriately in child protection cases may involve reviewing the patient on a number of occasions in order to obtain a clearer picture, and being in contact with your local child protection agency and other health care providers. Doctors often falsely believe that they can do better alone than by involving child protection services.9 Every capital city in Australia has at least one child protection unit at their children’s hospital, from where advice can be obtained. There is often a moral and legal fear that reporting may do more harm than good for the child and his or her family. A groundless report can cause anguish; however, inaction injures many more children than the odd report that should not have occurred. With Australia-wide mandatory reporting, the onus is now on us to provide mandatory responding. Only by responding in an appropriate manner, case by case, will we be able to facilitate better outcomes for children and, in turn, for society at large. Mandatory responding at the individual level and as a public health issue is the universal panacea for child abuse; mandatory reporting is only one tool in that response.

Peter M Winterton BA, MB BS, FRACGP

“Second-generation” clinical trials are refining the use of toxic and expensive drugs, but “silo” regulatory and funding structures prevent Australia participating The development of drugs aimed at new molecular targets exemplifies the power of translational research — “bench to bedside” translation of biomolecular science into clinical practice — to offer both significant clinical outcomes and the opportunity for commercial benefit. Classic examples are the monoclonal antibody trastuzumab for HER-2 receptor-positive breast cancer and the “designer” small-molecule inhibitor imatinib for BCR/ABL-positive chronic myeloid leukaemia.1,2 However, in Australia, there are structural constraints on funding for translational clinical research that prevent us participating fully in its clinical and financial benefits. To understand these constraints, we need to examine the roles of the various regulatory and funding bodies in Australia — the Pharmaceutical Benefits Scheme (PBS), Medical Services Advisory Committee (MSAC), Medicare, and the National Health and Medical Research Council (NHMRC). We also need to consider their different attitudes to “primary” and “second-generation” clinical trials. Pharmaceutical companies devise clinical trial strategies to register their drugs as rapidly as possible. These “primary” trials are conducted by large groups and provide high statistical power;3 the resulting data form the basis for drug marketing and reimbursement in Australia by the PBS. In contrast, “second-generation” trials apply new pathological and radiological technologies to refine treatment schedules and identify patient subgroups in whom new drugs have optimal clinical and cost-effectiveness. Second-generation trials have the potential both to improve clinical outcomes and to reduce costs. In Europe, second-generation studies refining dosage and patient subgroups are emerging through government-funded cooperative trial groups. Such studies require integrated funding of imaging, molecular analysis and pharmaceutics. This is currently not possible in Australia, reflecting “silo”-like structural barriers that prevent the PBS, MSAC and Medicare commissioning research. These regulatory bodies are unable to look beyond primary marketing data submitted by industry. They are unable to commission evaluation of the integration of diagnostic and therapeutic modalities. The optimal indications, schedules and duration of use of expensive pharmaceuticals cannot be effectively investigated in Australia — our superb collaborative clinical trial organisations are structurally limited to first-generation industry-funded studies, unless they can obtain funding through competitive grant systems that are neither pragmatically nor economically orientated. Two examples of second-generation trials that Australian groups have not accessed, reflecting the inability of the regulatory silos to fund such activity, are: Trastuzumab in HER-2 receptor-positive early breast cancer.4 Based on initial trials, current therapy is a 1-year course of the monoclonal antibody trastuzumab, at a cost to the PBS of about $50 000 per course. Separate European groups are currently investigating 3-month and 6-month versus 12-month courses with potential for dramatic cost savings and reduction in toxicity. Oxaliplatin in stage II colorectal cancer.5 Current therapy includes a 6-month course of this expensive and toxic drug at an overall cost of about $20 000. European groups are comparing 3-month versus 6-month courses, which could increase cost effectiveness and reduce toxicity. An application by an Australian group to the NHMRC to fund participation in this cost-neutral study was not ranked highly enough based on “lack of innovation” (Professor J Zalcberg, Peter MacCallum Cancer Institute, Melbourne, VIC, personal communication). A solution to the disconnection between regulation and funding could be to develop relationships between the PBS, MSAC, Medicare and others to address funding of the translation of new diagnostic and therapeutic technologies into practice. The treatment of cancer is an ideal model for this, given its interdependence on imaging, molecular pathology and targeted therapeutics.6 The stakes are high. In the 2005–06 financial year, the PBS cost7 Australia more than $6 billion, and its cost is increasing rapidly. The current Health Technology Assessment review to examine Therapeutic Goods Administration and MSAC procedures may solve some of these problems; it has noted the need to coordinate Pharmaceutical Benefits Advisory Committee and MSAC recommendations.8 One solution could be the creation of an “Emerging Technology Assessment Group”, representing the PBS, MSAC, Medicare, NHMRC and the cooperative clinical trials groups, supported by health economics input. This group could recognise emerging issues and commission appropriate second-generation trials. These would almost certainly be associated with international groups using the European model. These trials would be cost-neutral, reflecting reduced drug usage in the experimental arms. There may even be a place for a “health dollar offset trading scheme” (analogous to carbon emissions trading schemes) between the PBS, MSAC and Medicare. The second-generation trials would represent a new form of postmarketing surveillance, with the emphasis moving from assessing toxicity to optimising clinical and cost outcomes through the application of technology to translate into rational therapeutics. We should not adopt the simplistic solution of using NHMRC funding for these trials, as this would exacerbate the cost-transfer silo problem. The scheme should also recognise the need for Australian Health Care Agreements to appropriately support clinical research and infrastructure funding in teaching hospitals.

Richard M Fox MB BS, PhD, FRACP

Traditional health care is fragmented, marred by quality and safety defects, with a failure to provide evidence-based care, and huge and unjustifiable variations in practice. There is abundant evidence that traditional means of delivering health care are obsolete. Concerns are deepening about persistent and widening gaps in health status that health care cannot overcome. Increased spending on health care has never definitively solved the problems of access, quality, or equity. Non-medical determinants of health indicate that the solutions to health problems lie mainly outside health care. The current financial crisis may create the urgency and courage to both eliminate the fundamental problems in health care delivery and reduce health disparities.

Steven J Lewis MA · Stephen R Leeder MD, PhD, FRACP

To the Editor: I have read with interest your recent series of articles on access block.1-3 While access block is clearly bad for patients, it is a measure that is focused on emergency departments and not patients. Access block only measures the first part of the process of admission to hospital. Surely, the best measure of access into a hospital is not the rapidity with which patients get out of the emergency department but how long before patients get into the ward that is most suited for their care. At my hospital, patients are shuffled out of the emergency department into a variety of “holding pens”. By this I mean wards (often temporary) whose sole purpose is to act as an overflow area while the patient is waiting to obtain a bed in the home ward of the medical or surgical unit that is looking after the patient. The purpose is to allow the emergency department to function better, but also to allow the hospital to look good from an “access block” point of view. This is hardly optimal patient care. A recent survey at my institution of 136 medical patients at high risk of delirium showed that over 43% had three or more ward moves during their admission, and 60% had three or more bed moves. No wonder they become confused. Patients who are moved to holding pens have intrinsic disadvantages to their care. They are often seen late in the day by medical teams; the medical and nursing teams are not used to working together; allied health professionals may change from ward to ward, and holding pens often have no allied health staff; patient’s belongings, pathology and radiology requests get lost in the transition to different wards; patient meals can be substandard in holding pens (because they are ordered at short notice); and there are multiple handovers between many different groups of nurses. Medications are missed. So, hospitals should not be allowed to play games with this metric. The time for patients to get into the home ward (or the most appropriate ward) of the admitting medical or surgical team needs to be part of the equation.

Charles P Denaro

To the Editor: Cameron and colleagues are to be congratulated on their article outlining strategies that do and do not help improve the access of emergency medical patients to public hospital ward beds.1 The authors fail to mention one strategy that is particularly relevant to rural hospitals, namely, referring privately insured medical patients who present to emergency departments directly to tertiary medical services at private hospitals. This strategy has the dual benefit of providing a hospital bed for a patient in a rural emergency department who requires hospital admission, and relieving some of the external pressures on metropolitan tertiary referral public hospitals to provide beds. Traditionally, private health insurance has been thought of as providing patients with the ability to obtain treatment from the doctor and hospital of their choice. Increasingly, private health insurance is giving patients the ability to choose between staying on an emergency department trolley and being able to access a hospital bed in a timely manner. It is worth noting that privately insured patients who require services that are not provided at our hospital (such as interventional cardiology, neurosurgery, cardiothoracic surgery and faciomaxillary surgery) can sometimes access a bed in a private hospital about 500 km away sooner than we can find them a bed in our hospital prior to transfer to a tertiary public hospital. A significant impediment to this process for some privately insured patients is the inability of private hospitals to perform insurance fund checks out-of-hours. While most private health insurance funds provide internet authorisations and confirmations of a patient’s insurance status to private hospitals, some do not. In one case, this meant the wife of a patient with unstable angina pectoris had to provide a cash guarantee of $28 000 on a Sunday so that her husband could have an angiogram the next day. Even though they had “top-level” private health insurance cover, the private hospital could not confirm their insurance status and obtain an authorisation from their health insurance fund on a weekend. Patients with private health insurance should be able to use the benefits of their insurance 24 hours a day, 7 days a week. Private health insurance funds that do not provide 24-hour authorisations to private hospitals for hospital admission should state this limitation clearly in their insurance product as a part of their statutory product disclosure statements. Such disclosure would provide relevant information to consumers to enable them to make an informed choice about their private health insurer.

Antony Nocera

A 71-year-old man who presented to hospital with chest pain and a history of cardiovascular disease was repeatedly hospitalised over the course of a month for care that included multiple investigations, intensive care, transfer to and from a metropolitan hospital, discharge, and readmissions for collapse, hemiparesis, and vision change. The medical team excluded underlying disease related to his initial chest pain and subsequent neurological symptoms. A search for (undisclosed) prior hospitalisations revealed multiple previous admissions and invasive investigations at hospitals across Australia, resulting in a diagnosis of Munchausen syndrome. Assuming that, despite interventions, patients with Munchausen syndrome or somatoform disorders often continue to seek care at other hospitals, we discuss the implications of this patient’s behaviour for the health care system, society, and the risk to his own health. In our view, this case highlights conflicts between privacy legislation and doctors’ mandates to protect the patient from harm, as well as their duty to attend to the financial viability of health services by communicating with other potential health care providers. The health care system and similar patients may benefit from efforts to educate doctors about this spectrum of disorders and from considering the implementation of a highly confidential, structured notification system.

Dawn E DeWitt MD, FACP, FRACP · Stephanie A Ward MB BS · Sandeep Prabhu MB BS(Hons), LLB(Hons) · Bruce Warton MB BS, GradDipHealth

Clinical supervision is a vital part of postgraduate medical education. Without it, trainees may not learn effectively from their experiences; this may lead to acceptance by registrars and junior doctors of lower standards of care. Currently, supervision is provided by consultants to registrars and junior doctors, and by registrars to junior doctors. Evidence suggests that the clinical supervision provided to postgraduate doctors is inadequate. Registrars and juniors doctors have the right to expect supervision in the workplace. Impediments to the provision of clinical supervision include competing demands of hospital service provision on trainees and supervisors, lack of clarity of job descriptions, private versus public commitments of supervisors and lack of interest. Supervisors should be trained in the process of supervision and provided with the time and resources to conduct it. Those being supervised should be provided with clear expectations of the process. We need to create and develop systems, environments and cultures that support high standards of conduct and effective clinical supervision. These systems must ensure the right to supervision, feedback, support, decent working conditions and respect for both trainees and their supervisors.

Craig T Hore MB BS, FACEM, FJFICM · William Lancashire MB BS, FRACGP, CCFP · Robert G Fassett MB BS, PhD, FRACP