Health services administration

Integration of research and education into health care delivery leads to improved outcomes and facilitates rapid translation of results into policy and practice. Australia is at great risk of losing the important contribution of clinical research conducted in our public hospital system. This risk is increasing as research and educational training are targeted for expenditure reduction in the current business models of health service delivery, which focus only on short-term outcomes. The Centres of Clinical Research Excellence Scheme — initiated by the National Health and Medical Research Council (NHMRC) — is an excellent step towards redressing this problem, but it cannot succeed in isolation. We must improve and optimise care through promotion of attractive sustainable career pathways to provide strong clinical and translational research capabilities in hospital settings that address current health priorities and new disciplines. Targeted investment in talented people is the greatest long-term contribution that governments can make to guarantee quality in national systems of health.

Graham V Brown PhD, FRACP, MPH · Tania C Sorrell MD BS, FRACP

Objective: To describe the integration of whiteboards into ward routines in one Queensland health service district (HSD).Design and setting: Case study involving placement of whiteboards in three inpatient wards (two medical, one surgical) in a university-affiliated regional teaching hospital and in a day clinic in the same health service district. Data collection methods included 45 hours of observation of four whiteboards and 62 staff over 2 months, 11 in-depth interviews with nursing and allied health staff, and photographs of the whiteboards taken at intervals. The study was conducted from March to August 2008.Main outcome measures: Structures, processes and perceived outcomes of the use of whiteboards.Results: The physical configuration of the whiteboards did not vary, but their content and usage by various professional groups fluctuated. Whiteboards were most successfully integrated in the clinic, where they became an integral part of multidisciplinary rounds, and were updated and referred to several times each day. They were partially integrated into the two medical wards, with various health professionals updating and referring to the whiteboard. In the surgical ward, a nursing assistant updated the whiteboard, but it was not referred to by others. Staff in the clinic and on the medical wards perceived that whiteboards facilitated timely referrals, improved patient flow and enabled timely and better discharge planning, but surgical nursing staff described them as an imposition and a cause of conflict among clinical team members.Conclusions: Whiteboards have the potential to improve patient flow, but a planned approach to their use is required. Issues relating to the use of whiteboards, including staff buy-in, discharge planning and patient privacy, need to be addressed.

Wendy Chaboyer RN, PhD · Karen Wallen MN · Marianne Wallis RN, PhD · Anne M McMurray AM, RN, PhD

Objective: To evaluate the appropriateness and acceptability of five standardised tools for shift-to-shift clinical handover (CH).Setting and participants: In July 2007, a pilot project was conducted in four Victorian public health services. Five standardised tools developed by the Victorian Quality Council were trialled at night medical handover: an organisational readiness checklist, a suggested organisational policy, a recommended organisational protocol, a CH template containing a minimum dataset to be collected, and a set of key performance indicators. Baseline and post-trial data and observational data were collected, and participating medical staff completed questionnaires before and after project implementation to gauge their opinions on the usefulness of the tools.Results: The tools considered most useful were the organisational readiness checklist, the suggested organisational policy, the protocol for CH, and the CH template. Using the number of medical emergency team calls and incident reports as key performance indicators was not considered appropriate.Conclusions: The project highlighted that organisational support and commitment and stakeholder engagement and involvement are essential for implementing and sustaining changes in CH.

Diana M Quin BA(Hons), MPH · Annie L Moulden MB BS, FRACP · Simon H Fraser MB BS, FRACP, MPPM · Olive K E Lee BN(Hons), MN · Patricia McGarrity BAppSc(Physio), MHumBioeth

Objectives: To develop and test a standardised clinical handover discharge strategy for improving information transfer between private mental health hospitals and community practitioners.Design, setting and participants: A quality improvement intervention using collaborative, iterative methods to develop a standardised discharge and outcome assessment strategy. 150 patient participants were consecutively recruited from two private mental health care hospitals in New South Wales between April and September 2008. Opinions of community practitioners and patients on the discharge process and discharge documentation were solicited by written questionnaires and telephone interviews.Main outcome measures: Community practitioner satisfaction; patient satisfaction; documentation of discharge date at least 48 hours before discharge; faxing of discharge summaries to community practitioners within 48 hours of discharge; proportion of patients receiving a follow-up telephone call within 7 days or 14 days of discharge.Results: Both community practitioners and patients believed the intervention was positive. Between Cycle 2 and Cycle 3, documentation of the discharge date at least 48 hours before discharge remained unchanged at 50%; the proportion of discharge summaries faxed within 48 hours of discharge went from 0 to 82% in Cycle 2 and fell to 65% in Cycle 3. Telephone follow-up of patients within 7 days and within 14 days improved by 10% and 6%, respectively, between Cycle 2 and Cycle 3.Conclusions: A standardised discharge communication strategy improved the timeliness, content, and format of information provided to community practitioners. The intervention was well accepted by patients and providers.

Susan K Wood RN, GradCertHEc · Allison K Campbell RN, BHSc(Nurs) · Judith D Marden BPharm · Lavinia Schmidtman MB BS, FRANZCP · George H Blundell RN, BHSc(Nurs) · Noella J Sheerin RN, BAppSc(HMvt), GradCertE-Health(HI) · Patricia M Davidson RN, MEd, PhD

Midwives and visiting medical officers have a unique relationship within private hospital maternity settings. The effective exchange of accurate information between them is a fundamental element of patient safety and is vital to the success of the clinical handover process. The SHARED (situation, history, assessment, risk, expectation, documentation) project developed, implemented and evaluated a framework and support tools for improving clinical handover in two private maternity hospitals. The project included a pre- and post-study design using clinician surveys, chart audits, patient satisfaction surveys and a review of clinical incident data. A standardised approach to handover, using the SHARED framework with a standardised minimum dataset, improves the accuracy and appropriateness of information.

Sara J Hatten-Masterson BN, RN · Marnie L Griffiths BHlthSc, MMidPract

Effective communication at clinical handover is important for improving patient safety and reducing adverse outcomes. In consultation with doctors, nurses and allied health staff in the Western Australian Country Health Service, we developed a clinical handover checklist, adapted from an existing tool for standardising communication. The acronym “iSoBAR” (identify–situation–observations–background–agreed plan–read back) summarises the components of the checklist. We designed a comprehensive iSoBAR handover form to reduce the number of existing clinical handover forms. The new form, with an accompanying toolkit, was initially trialled in the Kimberley region, but is now being adopted more widely. Early adoption of the new form has been attributed to extensive clinician involvement and leadership. There is a need for further research to assess whether the use of handover checklists improves patient outcomes.

Jill M Porteous BHlthSc, GradDip Public Sector Management · Edward G Stewart-Wynne MB ChB, FRACP · Madeleine Connolly RN, GradDipEd · Pauline F Crommelin RN, GradCert Leadership and Management

Threats to patient safety during clinical handover have been identified as an ongoing problem in health care delivery. In complex handover situations, organisational, cultural, behavioural and environmental factors associated with team performance can affect patient safety by undermining the stability of team functioning and the effectiveness of interprofessional communication. We present a practical framework for promoting systematic, comprehensive measurement of the factors involved in clinical handover. The framework can be used to develop viable solutions to the problems of clinical handover. The framework was devised and used in a recent project examining interprofessional communication and team performance during clinical handover in post-anaesthetic care units. The framework combines five key concepts: clinical governance, clinician engagement, ecological validity, safety culture and team climate, and sustainability. We believe that use of this framework will help overcome the limitations of previous research that has not taken into account the complex and multifaceted influences on clinical handover and interprofessional communication.

Mari Botti RN, PhD · Tracey Bucknall RN, PhD · Peter Cameron MB BS, MD · Megan-Jane Johnstone RN, PhD · Bernice Redley BN(Hons), PhD · Sue Evans GradDipClinEpid, PhD · Shelly Jeffcott BSc(Hons), PhD

Objectives: To analyse rates of avoidable hospitalisations in Aboriginal and non-Aboriginal residents of the Northern Territory, 1998–99 to 2005–06, and to consider the implications for primary care interventions.Design and setting: Retrospective descriptive analysis of inpatient discharge data from NT public hospitals.Main outcome measures: Avoidable hospitalisations by age, sex, Aboriginality and condition, with annual time trends.Results: Between 1998–99 and 2005–06, Aboriginal people in the NT had an avoidable hospitalisation rate of 11 090 per 100 000 population, nearly four times higher than the Australian rate of 2848 per 100 000. The rate for non-Aboriginal NT residents was 2779 per 100 000. During this period, the average annual increase in avoidable hospitalisations was 11.6% (95% CI, 11.0%–12.1%) in the NT Aboriginal population and 3.9% (95% CI, 3.3%–4.5%) in the non-Aboriginal population. The greatest increase occurred in those aged ≥ 45 years, and was primarily attributable to diabetes complications.Conclusions: The significantly higher rates of avoidable hospitalisations in NT Aboriginal people reflect the emerging epidemic of chronic disease in this population, highlight barriers to Aboriginal people accessing effective primary care, and emphasise the extent of potential health gains with appropriate interventions.

Shu Q Li MPH, MB, BNursing · Natalie J Gray MIPH(Hons), MB BS(Hons), BSc/LLB(Hons) · Steve L Guthridge MB BS, MPH, FAFPHM · Sabine L M Pircher MPH, BNutrDiet

The goal of “closing the gap” in life expectancy between Indigenous and non-Indigenous people by 2030 is probably unattainable. Despite our best efforts, it is implausible that, within 21 years, preventive strategies, social or medical, will extinguish all excess expression and risk of chronic disease, the greatest contributor to excess Indigenous deaths. Developing systems to supply optimal primary care, as we currently know it, will take time. In addition, we have an incomplete understanding of the nature of excess risk, and lack remedies to totally contain it. Furthermore, vertical imprinting of excess risk will take some generations to ameliorate. To avoid failure by specifying unattainable goals, emphasis should be given to process measures that will lead to better outcomes. It is self-evident that sustained change requires better education, nutrition, employment opportunities and infrastructure. Within the health system, access to good quality, integrated primary care, needs-based health services funding, and an urgent and intensified focus on areas with the highest mortality rates, are top priorities.

Wendy E Hoy BScMed, MB BS, FRACP

In 1994, only 12 Indigenous people attended the mainstream general practice in Inala, south-western Brisbane, Queensland. An Indigenous community focus group and telephone interviews revealed deficits such as: few items (eg, artwork) that Indigenous people could identify with; lack of Indigenous staff; staff perceived as unfriendly; inflexibility regarding time; and intolerance of Indigenous children’s behaviour. Access to the Inala Indigenous Health Service by Indigenous people improved when these issues were addressed, and has grown significantly every year from 1995 to 2008. Other important factors in improving access include: energetic Indigenous leadership; enabling bulk billing to increase funding; moving to a stand-alone clinic; and engaging with teaching, research and community programs. A Centre of Excellence in Indigenous Primary Health Care is envisaged as the next innovation required to improve access and quality of service, and to close the gap between Indigenous and non-Indigenous health outcomes.

Noel E Hayman MB BS, FAFPHM, FRACGP · Nola E White RN · Geoffrey K Spurling MB BS, DTM

Objective: To investigate sociodemographic variation in antidepressant utilisation.Design and setting: Cross-sectional analysis of antidepressant prescription under the Pharmaceutical Benefits Scheme in Australia, 2003–2005.Main outcome measures: Antidepressant utilisation (defined daily dose/1000/day) by sex, age, socioeconomic status (SES) and geographichal area.Results: Total antidepressant utilisation increased with age. Among those aged ≥ 15 years, female utilisation was about double that of males. About half of antidepressant utilisation was accounted for by sertraline, venlafaxine, citalopram, and paroxetine. SES differentials in antidepressant utilisation changed across age groups for males and females: among those aged ≤ 19 years, total antidepressant utilisation was significantly less in lower SES groups (P < 0.001); there was no relationship to SES among 20–29-year-olds; and among those aged ≥ 30 years, antidepressant utilisation was significantly higher in lower SES groups (P < 0.001). SES differences were attenuated after adjusting for urban or rural residence, but remained statistically significant. Antidepressant utilisation rates were highest in regional centres.Conclusion: Antidepressant utilisation in Australia partially reflects sociodemographic differences in the prevalence of affective disorder. Discrepancies between treatment provision and treatment need suggest that not all social strata in Australia have equal access to these treatments.

Andrew N Page BA(Psych)(Hons), PhD · Sarah Swannell BPsych(Hons), GradCertBiostat · Graham Martin MD, FRANZCP, DPM · Samantha Hollingworth BSc, MPH, PhD · Ian B Hickie MB BS, FRANZCP, MD · Wayne D Hall BSc, PhD

Objectives: To identify the incidence of self-reported harmful adverse events in the health care of community-dwelling adults, and to examine attitudes about safety in the health system.Design: Cross-sectional, population-based survey.Participants and setting: Analysis of data from 3522 adults participating in Stage 2 of the North West Adelaide Health Study, who were surveyed in 2004 and 2005.Main outcome measures: Self-reported adverse events causing harm in the past year; attitudes to safety in health care, including adequacy of current measures for preventing adverse events, and the effect of groups like patients themselves, doctors and governments on patient safety.Results: The annual incidence of self-reported harmful adverse events was 4.2%. The main types were medication error (45.5%) and misdiagnosis or wrong treatment (25.6%). Multiple logistic regression showed that self-reported harmful adverse events were more likely in people who had been hospitalised in the past 12 months (odds ratio [OR], 2.5; 95% CI, 1.9–3.4), those who had low annual income (< $12 000), those who completed higher education to the level of Bachelor degree or higher (OR, 3.0; 95% CI, 1.0–9.4), and those who had some level of dissatisfaction with their recent health care; and less likely in those more risk-averse rather than those with a tendency to risk-taking behaviour (OR, 0.6; 95% CI, 0.4–0.9). People were more likely to believe that individual health care professionals had a positive effect on safety than professional groups or government, and that more resources were the key to improving the safety of health care.Conclusion: We found an incidence of self-reported harmful adverse events that was significantly lower than that found by a 2002 Australian survey (4.2% v 6.5%; P = 0.009). Better communication to help patients acquire more realistic risk perception may help reduce harm. Better communication could also increase public advocacy for systems improvement in safety to counter persisting community beliefs that individual action alone can redress the situation.

Robert J Adams MD, FRACP · Graeme Tucker BSc · Kay Price RN, MA, PhD · Catherine L Hill MB BS, BS(Epid), FRACP · Sarah L Appleton BSc · David H Wilson BEd, MPH, PhD · Anne W Taylor MPH, PhD · Richard E Ruffin MB BS, MD, FRACP

The aim of the National Health Priority Area (NHPA) initiative is to promote cooperation between government and non-government organisations to monitor, report on and develop strategies to improve health outcomes for Australians. The seven existing NHPAs (cancer control, injury prevention and control, cardiovascular health, mental health, diabetes mellitus, asthma and musculoskeletal conditions) were selected on the basis of their profound burden on the health of Australians. Up to eighty per cent of Australians will experience back pain at some point in their lives and 10% will experience significant disability as a result. Back pain disrupts individuals’ quality of life and accounts for an enormous cost to the community. Integrating back pain into the NHPA framework has many potential benefits, including more systematic development and implementation of programs aimed at minimising back pain-related disability by providing a focus for policy, legislation and public awareness; and promotion of best-practice management of the condition. A disadvantage of making back pain an NHPA is the risk that back pain management could become further medicalised and ineffective interventions could become more accepted. Coordinated action on back pain is needed, and integrating back pain into the NHPA framework is one solution. Informed decision making through consultation with key stakeholders is a necessary first step towards ensuring that favourable outcomes are achieved.

Andrew M Briggs BSc(PT)Hons, PhD · Rachelle Buchbinder MB BS(Hons), PhD, FRACP

To the Editor: Although the Garling report1 is the latest (and longest, at 1195 pages) in a long line of reports on the state of public hospitals to be commissioned by state and territory governments, the three articles in the Journal commenting on this report are timely and have brought out the fundamental problems with public hospitals Australia-wide, not just in New South Wales.2-4 These problems were highlighted by Van Der Weyden in pointing out the “pervasive sense of loss — loss of control, loss of direction, and loss of ownership by the hospitals’ serving health professionals, politicians, and the community”;2 by Skinner and colleagues commenting on “the progressive centralisation . . . and disempowerment of both clinicians and the community” and the failure of this approach;3 and by Stewart and Dwyer with their comments on resourcing, and the seriousness of the divide between clinicians and managers.4 These remarks in particular are entirely consistent with my own observations from my work in a number of hospitals throughout Australia in the course of doing consultancies or accreditation surveys in recent years. It is now time to stop “resort[ing] to conducting inquiries”2 and for the federal and state governments to work cooperatively to implement the three main solutions that clearly emerge from the issues raised by Garling and the MJA commentators, which are: appropriately resourcing public hospitals, including opening and staffing sufficient numbers of additional beds (to replace the many shut by economic rationalists); re-establishing community boards for individual hospitals or small related groups of hospitals in those states in which they have been abolished. These boards must have members chosen for their skills and experience, not their politics, and be accountable to the communities they serve; and reversing the alienation of clinicians by engaging them in all levels of governance, not only by consulting them but by ensuring that they are actively involved and part of the whole decision-making process. Offering Executive Clinical Director posts1 is necessary but not sufficient to achieve these aims, and must not amount to tokenism. Despite the huge number of recommendations in Garling’s and other reports, addressing these three matters would go a long way toward fixing the problems in public hospitals across jurisdictions. This would help to restore the faith of doctors in the public hospital system, help give communities and clinicians a sense of ownership and pride in their hospitals, and boost morale, so that hospitals can once again become centres of excellence in a re-energised health system.

Michael (Taffy) R Jones

To the Editor: It is easy to contemplate redesigning the medical wheel in the face of grossly dysfunctional health services. Garling’s scholarly report1 is unlikely to be adopted to any significant extent by a government that has already sent negative signals. Menadue’s suggestions for new and reassigned responsibilities2 are counsels of perfection for systems that are not capable of making radical changes. Indeed, as illustrated by Van Der Weyden,3 there is a general perception that all informed action has been replaced by ignorance, inertia and an appalling loss of morale. A superficial scan of the Internet reveals some remarkable information. In December 2008, the federal government approved the distribution of $580 million to 11 universities for various education-investment projects in science, research and health.4 The University of Adelaide Library lists more than 70 public health organisations in Australia.5 The Australian Health Economics Society advertises 33 sources of teaching and research available from local and international teams of 35 to 60 experts.6 These represent only a small sample of many similar sites. Clearly, there are a vast number of enterprises in Australia that are considered — by themselves or reputable others — to be capable of advising on research and development. Of course, their credentials cannot be taken for granted, but a majority seem to be supported by distinguished institutions and personnel with expertise in health management, economics, research and policy. Despite this, we keep seeking new minds, commissions and inquiries to reshape what has long since become a square wheel. I suspect that we might already have much more expertise than we need or could ever use. The cast-aside opinions of long-established groups should be disinterred and urgently re-examined before directing new funds and more time to destructively unproductive and ill-informed bureaucracies. It may be that crucial medical decisions should only be made by those who at some time have worked — and wept — in busy emergency or intensive care wards late at night. Equally, the remarkable organisation and expertise of military hospitals in Iraq and Afghanistan clearly show that miracles can be accomplished when a mix of workers, will and wisdom7 is applied to supreme demands. Can we not learn from that?

John S Wright

To the Editor: The Garling report highlights gaps in the New South Wales health system and establishes a framework for change.1 We support Garling’s view that there is a need for greater measurement of the health system to assess quality of care, and we believe that clinical networks have an important role to play in establishing, interpreting and actioning quality indicator data.2 But the statement that “There is already a great reservoir of information available within NSW Health from which data are available to measure the quality of patient care ...”1 is unhelpful in moving this work forward. While it is true that vast amounts of data are collected and classified using the ICD (International classification of diseases) coding system, in their current state these data have limited ability to accurately measure quality and drive change at a clinical level, for a number of reasons. First, data are not recorded in the medical record in a planned and systematic manner using agreed definitions, making findings susceptible to reporting bias. Second, the coding system fails to accurately account for differences in patient casemix, which is needed to enable appropriate risk adjustment to occur. This was recently highlighted in the United Kingdom when administrative data were compared with registry data to assess outcomes after cardiac surgery: admitted episode data underestimated the number of patients receiving treatment by approximately 20%, and captured only between 27% and 78% of deaths at 30 days in nine of the 11 centres undertaking cardiac surgery.3 Others have gone down the path of investing huge sums of money to measure quality using administrative data and reward high performers, with moderate success at best.4 To emulate this approach in the absence of further investigation would be premature. To measure quality of care we need to: invest in developing high-quality clinical registries across a broad range of high-cost, high-impact diseases and procedures. Where these have been introduced, they have had demonstrable impact on improving patient outcomes.5 These registries may be populated in part by data elements from existing data sources, where these are of high quality. develop data fields for the electronic medical record to ensure that data are epidemiologically sound. This work must include the adoption of unique identifiers to enable monitoring of treatment across care boundaries. validate and test proposed indicators, which might be collected from existing data sources. It is only through assuring clinicians that the data used to measure quality of care are reliable and clinically relevant that they will have any positive impact on changing practice.

Sue M Evans · Peter A Cameron · John J McNeil

To the Editor: The Garling report,1 reviewed by Van Der Weyden2 and others in the Journal, yet again brings to our attention the problem of bullying within our health care system. New South Wales is not alone in having this problem, as it has been highlighted across many systems throughout Australia and the rest of the world over the past 10 years.3 Garling acknowledges that the current guidelines in NSW are robust and comprehensive, but that there are serious deficiencies in their implementation. His report then goes on to suggest implementing the “Just Culture” program within the NSW health system.1 I would hold that if the policies and procedures already laid down are adequate, there is little point in reinventing the wheel and expending a large amount of time and energy, not to mention fiscal resources, in developing new guidelines, which, in all probability, will not be followed either. To minimise bullying in the workplace, one must be aware of the root causes of the problem — these include improperly trained managers, financial pressures, and a resultant “survival” culture within stressed environments. Many Australian public hospitals operate in a resources-limited, highly pressurised environment, where the culture is often adversarial — as pressure on the system grows, so does bullying. Garling correctly suggests that there must be zero tolerance for bullying behaviour within the workforce. This, however, needs to be more than just window dressing and must be rigorously enforced throughout the organisation, from the top down. Positive reinforcement of good interpersonal relationships, rather than the constant negative feedback that health care workers have come to expect, will reap rewards and aid the cultural change required. Training of people in management roles is essential, and all staff within the organisation must be aware of the expectation that they will work together in a collaborative and respectful relationship for the benefit of the patient. In the final analysis, in workplaces where a culture of openness and respect is present, bullying is likely to be minimised. In public hospitals in NSW and in most other Australian states where bullying is an ongoing problem within the workplace, the solution is not to institute yet another program to combat the issue, but to properly implement the policies and procedures that are already in place, and to develop an open, non-adversarial environment in which excellence in health care can flourish.

Alan E O’Connor

To the Editor: Three articles in a recent issue of the Journal1-3 call for implementing the changes recommended in the Garling report.4 One recommendation is that the appalling practice of placing male and female patients in the same room in general wards, and sometimes in adjoining beds, “must stop immediately”.4 This practice, and the sharing of toilets and showers associated with it, exemplifies a disregard for the human dignity of patients and lack of respect for the principles underpinning consent at the level of hospital and ward management. Trialled in the United Kingdom for reasons of economy and later banned on the grounds of patient welfare,5 the practice is not evidence-based and has been objected to in New South Wales through letters to the Minister for Health, in occasional newspaper articles, and through patient complaints to the NSW health consumer watchdog body. The responses to date point to the practice being considered acceptable by the powers that be on the basis of alleged efficient use of beds and the claim that “a hospital will make every attempt to relocate those who object”.6 Van Der Weyden,1 Stewart and Dwyer,2 and Skinner and colleagues3 cite prioritisation of recommendations, provision of funding, strong leadership, continuing consultation with clinicians and the community, and partnerships between state and federal governments as important ingredients for implementing the recommendations of the Garling report. Implementing the recommendation on mixing the sexes requires no more than an administrative edict to the effect that this practice is no longer permissible. The period of time it takes to issue this edict will be a good index of how serious we are about getting on with fixing what’s wrong in NSW hospitals.

Judith R Kennedy · Michael C Kennedy

To the Editor: At school we were counselled that the most important criterion for passing examinations was to answer the actual questions asked and to avoid adding irrelevant material. The Garling report considered the organisation of New South Wales public hospitals, concluding: If public hospitals are to survive as providers of free care for all, there will have to be some radical changes in the way they do business.1 Stewart and Dwyer’s commentary on Garling’s proposals2 ignores this core theme. Garling recommends many significant changes that would directly affect doctors,1 such as: Within 6 months, NSW Health should redesign rostering systems and practices to ensure an appropriate number of senior clinicians are in hospitals for 16 hours a day, 7 days a week. NSW should require that all ward rounds occur in the early morning, be multidisciplinary, and that accurate and complete notes are taken and approved by the supervising doctor within 24 hours. Rather than discussing the consequences, implications and implementation of Garling’s recommendations, Stewart and Dwyer air opinions on federal–state financial relationships, arguing that: It is time for the Rudd Government to live up to its pre-election rhetoric and work with the states in urgently restoring adequate funding to the public hospital system.2 Stewart and Dwyer’s confused intent is evident in their criticism of federal funding provided to NSW in 2008 “to help divert patients who are not thought to need urgent care away from emergency departments and towards general practice services”. They believe this money “would do much more for emergency departments if it were used to open more beds and reduce access block”. However, later in their article they declare that “looking at a huge hospital system in isolation from other parts of the health care system is a somewhat artificial exercise”.2 Stewart and Dwyer’s views on the practical feasibility and day-to-day implications for doctors of Garling’s proposals would have been of interest. Broader health financing issues, including respective federal and state responsibilities, were not the focus of Garling’s report. In reply: Coote is correct that the true benefits of the Garling recommendations lie in the details of implementation. This was not, however, our brief in our article;1 we were asked to identify the root causes of the current crisis in New South Wales public hospitals and to assess against these the potential for the Garling recommendations2 to pull the system “back from the brink”. From our list of 16 causes, we chose to give particular attention to the federal–state divide and the increasing disengagement of clinicians. The reduction in federal funding to public hospitals over the past decade has been a major driver of clinician dissatisfaction and the widening gap between frontline workers and management, as is well captured in the Garling report.2 Reduced resources, including insufficient hospital beds, have driven the centralisation of authority and underpinned the bullying behaviour of some managers. A sizeable proportion of the much needed reforms recommended by Garling will be difficult to implement without the Australian Government providing its fair share of funding for the public hospital system. In this context, a detailed implementation plan for Garling’s recommendations is essential — but, unfortunately, the recently released response from the NSW Government3 is very weak in this regard. Clinicians appear to have a long, hard struggle ahead to ensure that the road map to recovery laid down by Garling is followed by government and the bureaucracy, and that the changes needed are funded adequately.

William Coote · Graeme J Stewart · John M Dwyer

Transparency and open communication are key to a healthy relationship Medical practice these days is influenced to a large extent by clinical practice guidelines. Usually sponsored by professional bodies, these compendia of advice should be produced by groups of experts with broad representation and credibility. These experts are expected to follow clearly defined processes1 to arrive at recommendations that are based on evidence, and which are unadulterated by other influences, such as commercial considerations. Strict adherence to this framework underpins the authority and acceptability of the guideline. But these standards are sometimes not met, and there have been calls for reform to ensure reliability of guidelines, and thereby offer patients protection from treatment based on guidelines whose content may be affected by extraneous influences.2-4 In this issue of the Journal, Millar5 adds to the disquiet regarding guideline formulation with his critique of the Prevention of venous thromboembolism: best practice guidelines for Australia and New Zealand, fourth edition,6 produced by a Working Party of Australian and New Zealand experts. The Guidelines were published in booklet form by a company part-owned by a member of the Working Party, and were supported by a grant from a pharmaceutical company that manufactures enoxaparin, a low molecular weight heparin recommended in the Guidelines for prophylaxis and treatment of venous thromboembolism. In Australia, the National Health and Medical Research Council (NHMRC) has published criteria for developing guidelines,1 and in doing so has set high standards, including standards for commercial sponsorship. In light of the NHMRC criteria, the overall process involved in the Guidelines can be criticised for the: apparent lack of independent peer review, as best exemplified by publication in a recognised medical journal; lack of comprehensive declarations of conflicts of interests in a setting where at least a perception of pecuniary interest is possible; failure to provide levels of evidence or costing for the recommendations; failure to include a full and readily available list of the references on which the evidence for the recommendations are based; failure to divulge the precise writing process and the details of the relationships between the publisher, the Working Party in general, and individual Working Party members and the sponsoring pharmaceutical company; and publication as a booklet that was initially distributed only by the sponsor, and thus not easily or independently accessible. Millar’s article implicitly raises the question of tolerance by the medical profession in general of the involvement of the pharmaceutical industry with these and other guidelines. At the core of this issue lie the opposing aims and philosophies of the pharmaceutical industry and medicine — namely that, although both groups ostensibly work for the benefit of patients, the industry does so to make a return on capital, whereas doctors generally do so altruistically. As stated in a recent commentary in JAMA: By favoring . . . one therapy over another, guidelines often create commercial winners and losers, who cannot be disinterested in the results and who therefore must be separated from the process.2 Nevertheless, it is natural that the pharmaceutical industry has a keen interest in guideline development. Commenting on the interaction of industry and medicine, Sir Iain Chalmers of the James Lind Initiative in the United Kingdom was recently quoted as saying: I do not blame industry for trying to get away with anything that is normally considered to be its primary purpose, which is to make profits and look after its stakeholders’ interests.7 Sponsorship and marketing behaviour is not unlawful (nor should it be), and indeed is at the centre of company philosophy and statute in a capitalist economy. Therefore, the restraint on unbridled marketing effort that can compromise patient care lies squarely with the medical profession. The profession’s individual members are obliged to maintain a respectful distance from the pharmaceutical industry and show some disdain for the apparent benefits of pharmaceutical sponsorship — to avoid being stabbed, one should not waltz too closely with the porcupines! Two senior editors of JAMA recently wrote: The profession of medicine, in every aspect — clinical, education, and research — has been inundated with profound influence from the pharmaceutical and medical device industries. This has occurred because physicians have allowed it to happen, and it is time to stop.9 In Australia, there is no overarching national policy for interactions of Australian doctors and the pharmaceutical industry. We should consider the lead of our colleagues in the UK, where the Royal College of Physicians of London (RCP) recently published a report entitled Innovating for health: patients, physicians, the pharmaceutical industry and the NHS, which extensively defines a framework for proper interaction.10 The Royal Australasian College of Physicians has also commented on this topic.11 There have also been recent multinational calls for the cessation of industry support for continuous medical education directed to individual doctors and institutions.10,12-14 However, the President of the RCP counsels that there is no need to destroy the bridges between industry and the profession. What is required is that the culture between these sectors should be transparent, and governed by open communication and agreed-upon national policy.15 This is sound wisdom to guide national policy deliberations in Australia.

Martin B Van Der Weyden MD, FRACP, FRCPA

Drugs are expensive in the United States. I am writing, of course, about pharmaceutical agents. In 2006, the US spent $900 per capita on pharmaceuticals — a higher per capita amount than anywhere else in the world, and almost double what Australia spends. Individuals and even state funding bodies often buy their drugs in Canada or Mexico. Apparently, good-quality drugs are available in these countries at a fraction of the cost of the same drugs in the US. Nonetheless, US authors continue to boast about the ready availability of pharmaceutical agents in the US compared with the rest of the world. In December 2008, the New York Times ran an article about a British cancer patient denied access to an expensive new medication1 — the story being that, although there were data to show that the drug worked, the cost–benefit analysis did not favour using it. This is similar to the situation in Australia. The Times crowed with typical US hype: “If the Hardys lived in the United States or just about any European country other than Britain, Mr Hardy would most likely get the drug, although he might have to pay part of the cost”. “Absolute nonsense” is not too strong a description for this statement. Firstly, drugs are expensive in the United States (much more expensive than in Australia), and secondly, the patient would have got the drug only if he could pay for it himself, if his insurance authorised it (assuming he had insurance), or if Medicare or Medicaid accepted it. Thus, if he had been living in the US, he may have had to pay a major part of the cost, and indeed, many patients in a similar position would not have had access to the drug in the US. Most New Yorkers are very well educated about pharmaceuticals, much more so than the average educated Australian. Drugs are advertised on television and in other media. Coupons for free drugs are available in magazines. The patient takes the coupon to the doctor, gets a prescription and then mails in the coupon and script. Free drugs then appear. New Yorkers consider themselves to be discriminating, but they often end up with the latest and most expensive drug rather than the best. Australia’s Pharmaceutical Benefits Scheme (PBS) may not be perfect, but many people think it is the best thing about Australian health care. It ensures that essential drugs are available at a reasonable price for all. The US Medicare system supplies drugs for special categories of people (mostly the elderly), but doesn’t work in the same way as the PBS. US Medicare Part D, which pays for drugs, has the notorious “donut hole” — a gap between the initial coverage limit and the “catastrophic coverage” threshold. This is designed so the government can pretend that it provides pharmaceuticals to needy patients. The patient pays the first $290 of his or her drug costs, after which the plan starts to pay its share. This varies from plan to plan, but the insurance often pays 75% of the cost up to $2700. Once the patient and the plan have spent $2700, the patient has to pay all costs up to $4350. After that, the patient pays only a small proportion of the cost of drugs until the end of the year. Thus, between $2700 and $4350, the patient has to pay 100% of the costs out-of-pocket. I took this example from the official “Medicare and You 2009” booklet put out by the centres for Medicare and Medicaid services. Not only is there a significant gap in coverage above $2700, but the patient also pays a premium to be part of the process. So, in spite of the media hype, drugs are certainly not readily available for the average older person with limited means. On top of this, drugs are restricted, as happens in Australia under the PBS. In fact, Australian doctors may be surprised to know that limits to prescribing in the US may be quite egregious. Thus, a physician may be able to prescribe one statin for one insurance company, but may need to prescribe a different statin for another insurance company. This often involves a phone call from the physician to a non-medical bureaucrat working for the insurance company. Authorisation is required for the drug cost to be reimbursed from insurance. The US drug system is an example of the free market in action. Let us hope this type of free market drug system never arrives in Australia. Speaking of arriving in Australia, this postcard was written shortly after my return to these shores. For those who are interested, working in health care in the United States is a very positive, stimulating, fulfilling experience. But in my opinion, the Australian health care system, for all its faults, is much, much better for doctors and patients.

Jeffrey D Zajac MB BS, FRACP, PhD

Objectives: To measure the prevalence of interventions used to circumvent intensive care access block and to estimate the attributable mortality and additional hospital bed-days associated with them.Design and setting: Retrospective observational study of 11 adult public hospital intensive care units (ICUs) in Melbourne, Victoria, July 2004 – June 2006.Main outcome measures: Prevalence of five interventions in response to access block; attributable fatalities and/or increased length of stay associated with each.Results: 21 896 ICU admissions and 3039 inhospital deaths (13.9%) were screened. All hospitals reported ICU access block. There were 6787 interventions for access block (mean, 9.3/day) — 4070 (18.6% of admissions) instances of after-hours step-down from an ICU to a low-acuity ward; 1115 (5.1%) delays in an emergency department > 8 hours; 895 (4.1%) postponed major surgeries; 487 (2.2%) interhospital transfers; and 220 (1.0%) instances of premature cessation of intensive care. Based on published risk estimates, these interventions may have resulted in 91.1 (95% CI, 34.7–147.2) attributable deaths and 4368 (95% CI, 333–10 050) additional hospital bed-days each year.Conclusions: Intensive care access block is frequent, and measures to circumvent it increase mortality and length of stay. Further study of the health and financial implications of access block are warranted.

Graeme J Duke MD, FJFICM, FANZCA · Michael D Buist MD, FRACP, FJFICM · David Pilcher FRACP FJFICM, MRCP · Carlos D Scheinkestel FRACP, FJFICM, DipDHM · John D Santamaria MD, FRACP, FJFICM · Geoff A Gutteridge FJFICM, FANZCA · Peter J Cranswick FJFICM, FANZCA · David Ernest FRACP, FJFICM, MHlth · Craig French FJFICM, FANZCA · John A Botha MMed, FRACP, FJFICM

To the Editor: We read with interest the recent editorial by Van Der Weyden on the issue of doctor displacement.1 We agree completely that a transparent and evidence-based approach to health care roles is essential. In proposing a pilot program of physician assistants (PAs) in South Australia to examine the potential of “physician extenders”, we broadly used the model applied to the introduction of new therapies in medicine, including new drugs: Evidence of an unmet need; Evidence of safety and efficacy in another setting; A monitored pilot/trial in practice; Re-evaluation after a defined period with a defined process; and An emphasis on any ongoing utilisation being a consistent and national process. This last point is noted in the Australian and New Zealand College of Anaesthetists’ submission to the National Health and Hospitals Reform Commission.2 We emphasised the need for any proposed future clinical role for PAs to be defined, followed by identification of the required knowledge base, training and education requirements, and certification. Not all new health care roles have followed such a pathway, and this provides potential challenges for ensuring quality, safety, consistency and “trademark definition” (widespread understanding of the role). In the case of PAs, it was evident at a recent International Forum for Physician Assistant Education in the United States that the definition of the term “physician assistant” varies greatly internationally, potentially confusing future debate on this topic in Australia. Hence, to develop a robust Australian model, any proposals for ongoing use and training of PAs would have to be discussed at a national level.

Guy L Ludbrook · Guy J Maddern

To the Editor: The Journal’s Editor is a man of words and we love him for it, but, as Lord Tennyson said: “For words, like Nature, half reveal and half conceal the Soul within” (In memoriam A. H. H., 1850). So what does his Christmas issue editorial1 really reveal about our man of words? He has unfortunately biased the debate about physician assistants and other alternative health care providers with his editorial’s very title: “Doctor displacement”. Doctors will not be displaced — liberated, perhaps, to concentrate on things that interest them, where their advanced skills can be best used and where they can make the most impact. This is not (nor should it be) about maintaining the status quo. The debate should be about how to provide health care to patients and the community, ensuring that they can get appropriate advice from well trained professionals when and where they require it. Most health services are now provided by teams — no longer is it ethical to promote the idea of an autonomous practitioner, be it nurse or doctor. The great strength of the physician assistant is that it is a “delegated model”, dependent on the doctor and not, as the editorial suggests, able to practise independently. Physician assistants will never be able to practise independently; they will always have to practise under supervision and within the scope of practice of their supervisor. Nowhere in Van Der Weyden’s editorial is the issue of preventive health, as an important physician assistant or other health professional role, raised, nor the fact that health professionals might use teleconsulting to link across disciplines and geographical areas. These are aspects that could change workforce requirements dramatically. Australia currently spends a minor fraction (less than 5%) of its $90 billion health budget on trying to prevent illness.2 We must use our health dollars more wisely and effectively. Also absent from the editorial is mention of the current global shortage of 4.5 million health workers. On this point, the MJA should look to the Lancet to see how it has consistently run a global agenda on health services and workforce, pointing out our responsibilities to low- and middle-income countries.3 The world is divided into those with and those without effective health care. Opinions on proposed changes to health care split into those who say “why?” and those who say “why not?” Editor, you have always appeared to us to be in the latter group. Please don’t disappoint us now by becoming a nay-sayer. We want to see this Journal promoting a health system that is patient-focused and health professional-friendly, and not one that just maintains the status quo.

Peter M Brooks · Charles A Mitchell

In reply: I appreciate the comments of Brooks and Mitchell on the importance of words to editors — they are, after all, their tools of trade. Indeed, this is no more so than in the titles of editorials, wherein their succinctness must not only encapsulate the tone and theme of the text but, having captured the readers’ attention, induce them to read on. It seems, however, that the title of my recent editorial “Doctor displacement: a political agenda or a health care imperative?”1 has caused disquiet and prompted the accusation of “bias”. And the offending word? “Displacement”. The Concise Oxford Dictionary defines the verb “displace” as: “shift from its accustomed place”, “remove from office” and “take the place of; oust”. Given the substance of the editorial, it was my intention that all these connotations were relevant in the context of this many-layered debate. In essence, the editorial focused on the urgent need for the profession to address, or at least debate, the increased instances of “task transfer” or “role substitution” occasioned by the escalating numbers of nurse practitioners and physician assistants. Despite Brooks and Mitchell proffering the conventional justification of this recent phenomenon as being “teamwork”, history tells us that this may well be academic double-speak. One precedent was the protracted tussle some 300 years ago between organised medicine and apothecaries, who were to eventually evolve into the progenitors of general practitioners.2 More recently, there have been well documented instances of physician assistants establishing independent practices in the United States.3 One could say that the very title of my editorial seems to have mesmerised Brooks and Mitchell, who have fixated on its seeming bias, ignoring the editorial’s subsequent exploration of current workforce issues in the delivery of quality health care and the urgent plea for the profession to have an evidence-driven debate. On the other hand, it is easy to appreciate their sensitivity to the phrase “doctor displacement”, given their ongoing commitment to the University of Queensland’s postgraduate physician assistant training program.

Martin B Van Der Weyden