Health services administration

To the Editor: “What is the health service for?”1 In essence, this is a question of definition and ownership. What is the definition of quality health care and who decides how it is defined? Who are the recipients of health services, the funders, those who stand to lose or benefit from the way in which health care is delivered? The answer is citizens. When we define quality, we are making a value judgement; we are saying what it is about health care that we consider important and worthy of achieving. In a democratic society, we expect that the values of citizens will be reflected in the definition of health care quality. The United States Institute of Medicine initiative, “Crossing the quality chasm”, emphasises “patient-centered(ness)” and care “customized according to patient needs and values” as system attributes for delivering quality health care to individuals.2 Yet, a broader perspective is suggested in the following statement on the objectives of health care systems from the World Health Organization: The objective of good health itself is really twofold: the best attainable average level — goodness — and the smallest feasible differences among individuals and groups — fairness. Goodness means a health system responding well to what people expect of it; fairness means it responds equally well to everyone, without discrimination.3 Implicit in both definitions is knowing what people expect, need and want from their health service. What do Australians expect, need and want from their health service at an individual, local and national level? How can we engage citizens effectively to answer these questions? We need a process of informed public consultation, a process that is constructive, efficient and representative, to guide the vision and values that form the basis of our health system. Menadue highlights the Canadian Romanow-led Royal Commission as an example of community engagement.1 A similar initiative underlies the United Kingdom’s “Our NHS [National Health Service] our future”, where a process involving consumer consultation has been employed at all levels of health care reform and in the development of an “NHS Constitution”.4 Mooney suggests “citizens’ juries” and a “National Citizens’ Summit”.5 Whatever our Australian national solution, as key stakeholders in the health system, as its patients and its health workforce, citizens need to be given a genuine opportunity to influence and contribute to the future direction of Australian health care.

Amanda E James

Should intrusions by political bodies into personal reproductive decisions be an Australian fact of life? Babies are generally very good news for Australian families, and nationally there is acclaim that our previously declining birth rate has been on a clear rise since 2004 (Box).1 In part, this rise has been a result of welcome government intervention, and several articles and letters in this issue of the Journal relate to reproduction and government subsidy.1-7 Lain and colleagues assessed the effect on New South Wales birth rates of the Howard Government’s cash bonus of $3000 for the birth of a child, introduced on 1 July 2004;1 the then Treasurer, Peter Costello, quipped that a third child could be “for the country”. The Baby Bonus was increased to $5000 on 1 July 2008. Between 1997 and 2006, the proportion of first births in NSW (among a declining total number of births) increased steadily until 2004, after which the proportion of second births, and especially of third and subsequent births, began to rise.1 The timing of the turnaround and the strength of any causal link between the bonus and additional births invites further analysis, using data from the National Perinatal Statistics Unit (Box).8 The $3000 bonus payment to about 272 000 women giving birth nationally during 2005, and 282 000 in 2006, cost about $1.7 billion. We know that in these 2 years over 16 000 of the babies were conceived by in-vitro fertilisation (IVF), and that having an IVF baby most likely indicates reproductive intentions independent of the bonus. If the previous birth-rate trend for non-IVF babies had continued in 2005 and 2006, just over 250 000 babies would have been born in each of these years. This means that about 37 000 of the extra babies born in 2005 and 2006 were attributable to the bonus. The Baby Bonus thus represented a government investment of just over $45 000 for each extra baby. Comparing this figure with the total of $295 million paid out in IVF-related Medicare rebates in the same 2-year period for assisted conception of more than 16 000 IVF babies (an average of less than $20 000 for each baby), it is obvious that, as an ongoing government investment, Medicare funding of IVF is more than twice as productive as the bonus. The Rudd Government has now restricted the bonus to the more disadvantaged in the community by means-testing families. Acknowledging the need to “start in the womb” if we are to close the gap in life expectancy between Indigenous and non-Indigenous Australians,2 de Costa and Wenitong compare Australia’s Baby Bonus with a well established endowment scheme for babies in France that operates with some important differences. An extra payment is recommended for women who commence medically supervised antenatal care before 14 weeks’ gestation; and, instead of a lump sum after the birth, payments are made in instalments linked to positive health practices by the new mothers. The authors make a case for changing the way baby bonuses are delivered in Australia to assist all disadvantaged women to have healthy babies with better life prospects.2 IVF practices, meanwhile, have not stood still.3 When Medicare rebates were introduced for IVF services in 1989, a limit of six treatment cycles was set.9 As IVF practices and outcomes improved during the 1990s,10 including better methods for cryostoring excess early embryos for later transfers, the frequency of multiple pregnancies, with their attendant higher medical and social costs, increased disproportionately.3,10 Since 2000, improved pregnancy rates, the withdrawal of the six-cycle limit for Medicare rebates, and the introduction of the Medicare Safety Net (which decreases out-of-pocket expenses) have worked together to facilitate a fast-increasing practice in Australia of transferring just one IVF embryo at a time. This practice, known as elective single embryo transfer, or eSET, is now the benchmark for best practice. Its effect has been a sharp fall in multiple deliveries after IVF, from a peak of over 22% of confinements in 20008 to now single figures, and better pregnancy outcomes, as Wang et al report3. Improved storage techniques for immature sperm and unfertilised eggs are also pushing the frontiers of what’s possible, biologically and socially. Two such developments are reported in this issue of the Journal.4,5 When a young man is found to be terminally ill or dies suddenly, immature sperm can be collected from a testis before or after death, cryostored, and potentially be available for conceiving a child using IVF — but, if the legal constraint advocated by Middleton and Buist prevails, this will be allowed in Victoria and some other states only if the man has given proven written consent, irrespective of other evidence that this was his wish for his family.4 For women facing sterility from radiotherapy or chemotherapy and who are still to form a permanent relationship, the opportunity to store usable unfertilised eggs has also become technically practicable. Using vitrification, an ultra-rapid freezing method, retrieved mature eggs can be cryostored and, if they survive thawing, can resume a fertilisable physiological state. Given the rise in median maternal age at the birth of a first baby in Australia11 and the increasing physiological sterility of women from their mid 30s,12 this technique can also be used by healthy women to provide what Molloy et al refer to as “reproductive insurance”.5 This is not a development that should disrupt community social order. But governments tend to over-react,13 and can incite indignation. One man has written to the Journal in relation to a statutory limit in Victoria of 10 years for the storage of sperm (in his case his own, for his own use, having survived cancer treatment),6 beyond which each application for continued storage must have the individual approval of Victoria’s Infertility Treatment Authority.7 It seems some parliaments in our country would still subscribe to a 1993 report from Canada’s National Reproductive Technologies Commission, which claimed as paramount the need for “peace, order and good government power”13 and which unintentionally paraphrased Aldous Huxley’s “Community, identity, stability”, the world government’s ruling imperative in Brave new world.14 As Victoria’s statutes stand, a woman seeking “reproductive insurance”5 will likewise need, at a statutorily determined period and presumably regularly thereafter, to justify her decision to store her eggs to an appointed group of people of differing personal views, and she will also need their assent should she wish to take her eggs to another jurisdiction. The power of legislation to destroy individuals’ reproductive futures was demonstrated in the United Kingdom on 1 August 1996.15 Many infertile couples, not able to be contacted over a 3-month period, found out after the event that all UK IVF clinics, to avoid prosecution,16 had been forced by the UK’s Human Fertilisation and Embryology Authority to throw out more than 3000 embryos reaching their 5-year statutory storage limit without a properly formulated request for longer storage. Australia, like most countries, has a long history of government intervention in fertility issues. In 1983, it was the first country to adopt national ethical guidelines for the clinical conduct of IVF. For the safe development of IVF practices, it was considered necessary to do research involving human eggs and sperm (with consent of the providers).17 But (to cut a long story short), a conservative political reaction prevented such research in most states other than NSW until the federal parliament’s passage of the Research Involving Human Embryos Act 2002 (Cwlth). This conservative thinking still finds expression today, with the Australian Health Ethics Committee (a principal committee of the otherwise firmly evidence-based National Health and Medical Research Council [NHMRC]) arguing against research involving human embryos by resting on “an enduring ethical tradition of thought and belief” that has limited community support,18,19 at the expense of outcomes-based ethical principles.13,20 States that legislated to regulate IVF practices in the early 1980s, as Victoria did with its Infertility (Medical Procedures) Act 1984, faced what was then considered radical technology with uncertain social consequences, by applying similar, conservative, non-evidence-based principles. So rapidly were perspectives changing, however, that some parts of this Act were not proclaimed, some parts were later repealed, and, despite a 1996 overhaul of the Act, other parts have come into conflict with Commonwealth legislation.21 The Research Involving Human Embryos Act, which has been mirrored by most state legislatures, legalised embryo research across Australia through special and specific licences administered by the NHMRC. The community clearly recognises and supports the contribution that modern IVF practices make to responsible formation of families in Australia,22 but in Victoria a government authority established under the 1984 Act continues to be responsible for individual, personal decisions affecting all families who have or intend to have their sperm, eggs or embryos exposed in labs. In December 2008, the Assisted Reproductive Treatment Bill 2008, the second rewrite of the legislation in 24 years, and intended to broaden access to assisted reproductive technologies, was passed by the Victorian parliament. Cabinet has apparently over-ridden the advice of the state’s Law Reform Commission and imposed a fitness-to-parent code — compulsory police and child-protection checks — before infertile or childless people can attempt to form families with technological help. The Act also provides for a Patient Review Panel appointed by the Health Minister, with a “primary role” in determining applications for IVF and medically assisted conception.23 For couples with the disability of infertility who need medical help to have children, “the bedroom” is, alas, now a nostalgic metaphor for lost privacy. Intrusions by politically appointed committees into people’s lives and their personal reproductive decisions in Victoria and some other states are real and set to increase. With governments at the bedroom door determined to be part of the detail, too often it’s still two steps in and just a rare step out. Annual IVF and non-IVF births in Australia, 1991–2006 IVF = in-vitro fertilisation. Non-IVF births in 2005 and 2006 above the preceding 4 years’ average (dotted line) are potentially attributable to the Baby Bonus. Data source: Australian Institute of Health and Welfare National Perinatal Statistics Unit.

Robert P S Jansen MD, FRACP, FRANZCOG · Sandra K Dill AM, BComm, MLS

Objective: To assess the change in birth rates, both overall and in age, parity, socioeconomic and geographical subgroups of the population, after the introduction of the Baby Bonus payment in Australia on 1 July 2004.Design and setting: Population-based study using New South Wales birth records and Australian Bureau of Statistics population estimates for the period 1 January 1997 – 31 December 2006.Participants: All 853 606 women aged 15–44 years with a pregnancy resulting in a birth at ≥ 20 weeks’ gestation or a baby ≥ 400 g birthweight.Main outcome measure: Change in birth rate in 2005 and 2006 compared with the trend in birth rates before the introduction of the Baby Bonus.Results: The crude annual birth rate showed a downward trend from 1997 to 2004; after 2004 this trend reversed with a sharp increase in 2005 and a further increase in 2006. All age-specific birth rates increased after 2004, with the greatest increase in birth rate, relative to the trend before the Baby Bonus, being seen in teenagers. Rates of first births were not significantly affected by the bonus; however, rates of third or subsequent births increased across all age, socioeconomic and geographical subgroups.Conclusions: In the first 2 years after the introduction of the Baby Bonus, birth rates increased, especially among women having a third or subsequent birth. This could represent an increase in family size and/or a change in the timing of births.

Samantha J Lain BComm, BHlthSci(Hons), MPH · Jane B Ford BA(Hons), PhD · Camille H Raynes-Greenow BA, MPH, PhD · Ruth M Hadfield BSc, DPhil(Oxon), GCBiostat · Judy M Simpson BSc, PhD · Jonathan M Morris MB ChB, FRANZCOG, PhD · Christine L Roberts MB BS, MPH, DrPH

Health systems can be improved appreciably by making them more efficient and accountable, and enhancing the quality of care, without necessarily requiring additional resources. Australia, like other nations, cannot escape making difficult health care choices in the context of resource scarcity, and the challenge of delivering quality care, informed by best available evidence, to an ageing population with multiple comorbidities. An opportunity exists for a cost-saving or cost-neutral agenda of reallocation of resources within the existing health budget, through reducing the use of existing health care interventions that offer little or no benefit relative to the cost of their public subsidy. This would allow reallocation of funding towards interventions that are more cost-effective, maximising health gain. Criteria based on those developed for health technology assessment (HTA) might facilitate the systematic and transparent identification of existing, potentially ineffective practices on which to prioritise candidates for assessment as to their cost-effectiveness. The process could be jointly funded by all relevant stakeholders but centrally administered, with HTA groups resourced to undertake identification and assessment and to liaise with clinicians, consumers and funding stakeholders.

Adam G Elshaug BSc(Hons), MPH, PhD · John R Moss MSocSci, FCHSE, FPHAA · Peter Littlejohns MD, FFPH, FRCP · Jonathan Karnon BA(Hons), MSc, PhD · Tracy L Merlin BA(Hons), MPH · Janet E Hiller MPH, PhD, FPHAA

To the Editor: The recent article by Penington, highlighting the apparent neglect by Australian hospitals of actively participating in research over the past two decades,1 is both timely and concerning. During this time, many of our hospitals have seen themselves increasingly as clinical service providers, with teaching and research perceived as additional costs rather than contributions to their status, to the quality of patient care and to clinical and scientific discovery. My point is not simply to add weight to Penington’s eloquent historical, contemporary and strategic analysis of the nexus between hospitals and universities, but to explore areas that he touched on that need more detailed examination. I refer to the potential link between hospitals and community-based primary care. As Penington points out, “health care is increasingly provided outside hospitals”, yet this vital link between hospitals and primary care is often defunct, particularly when it comes to general practice. When Penington refers to hospitals working with “general practice networks” to meet the demands of an ageing population and chronic disease, we need to ask: which hospitals and which networks? In Melbourne, we have health networks that include groups of hospitals with extended primary care and community facilities and responsibilities. Driven by casemix funding, the hospitals or health networks have a vested interest in primary care to ensure short patient stays. However, not all states are the same and not all hospitals have similar links with the community. The other issue of concern is that general practice networks are often politicised and factionalised. Divisions of General Practice do not speak with a single voice, and their state-based organisations and national body do not always represent the views of regional Divisions. Added to the mix of 120 Divisions, we have 22 regional general practice training providers, the colleges (Royal Australian College of General Practitioners, Australian College of Rural and Remote Medicine), the Rural Doctors Association, the Australian Association for Academic General Practice, the Australian Medical Association, etc. Integration of the research, teaching and training activities of general practice or primary health care with hospital networks can only be achieved at a regional level. We need to think globally, but act regionally. This calls for the formation of new regional consortia including universities, health networks (hospitals), Divisions and regional training providers (responsible for general practice registrar training) to work together on national clinical and health service research agendas in large and well defined geographic regions. If the National Health and Hospitals Reform Commission is to take its role seriously, it will need to move beyond the confines of traditional hospital settings and explore opportunities in the community.

Leon Piterman

To the Editor: Penington identifies the appointment of a National Health and Hospitals Reform Commission (NHHRC) and the suspension of 5-year Australian Health Care Agreements as a “once in a generation” opportunity to rediscover university teaching hospitals for Australia.1 He identifies changes to health funding in Australia since 1975, the growth of “cost shifting” between federal and state governments, and reduced funding for university functions in hospitals as important contributors to the decline of university teaching hospitals in Australia.1 We agree with this analysis, but propose that the privatisation of many outpatient clinics as a result of cost shifting has had a disastrous effect on the clinical training of medical students, residents and registrars. Moreover, the reduced funding of university functions in hospitals has been replaced in “teaching” and community hospitals by industry funding, and the perception that industry has “bought” patients for their “research” agenda by providing data management services through per capita payments and gifts or perks for clinicians. The infrastructure sustaining clinical research should not be so reliant on industry. Funding from the federal government (in partnership with state governments) is needed to nurture independent research in university teaching hospitals. Penington highlights the fact that the key element of the university teaching hospital model was leadership of all units by academic clinicians with questioning minds. Since 1975, we believe leadership of units in “teaching” hospitals has changed such that very few are now led by academic clinicians. We recently experienced a lack of interest by medical specialists in supporting clinical research that had been approved and funded by the National Health and Medical Research Council (NHMRC). The project will evaluate doctor–patient communication about treatment options in oncology, including clinical trials. Participating doctors were required to post letters of invitation to patients and audio-record one consultation per patient recruited (20 per doctor). Specialists in all major teaching hospitals in New South Wales and Victoria were contacted; 17 of 41 specialists contacted in NSW (41%) and 15 of 52 contacted in Victoria (29%) have agreed to participate. The most common reasons doctors gave for not participating was that they were too busy or that there was no reward for participation. It is notable that no specialist from two major teaching hospitals — one in Sydney (3 contacted) and one in Melbourne (6 contacted) — agreed to participate. A concerning theme is that the motivation to participate in trials is driven by financial incentives rather than the importance of the question being addressed or interest in supporting novel investigator-initiated clinical research. A starting point for improving the quantum and calibre of “independent” clinical research in university teaching hospitals would be to support clinical research infrastructure by providing per capita payments for recruited patients — a model used by industry. Rebuilding independent research capacity in university hospitals will improve the standard of research in this country, and foster clinical research training. We believe reviving the university teaching hospital model in Australia is an important task for the NHHRC.

Rachel F Dear · Martin H N Tattersall

UK initiatives to increase clinical research capacity hold lessons for Australia The historically unmatched boom in medical science knowledge in the past few decades has steadily increased the opportunities for clinical research. Examples include research into biomarkers and diagnostics, evaluation of potential therapies, and particularly translation of breakthroughs in basic medical science into clinical medicine. Traditionally, it has taken many years to evaluate and validate new treatments, and there is a global need to improve both the capacity and efficiency of clinical research to ensure maximum community benefits in a reasonable timeframe.1 In the United States, several senators have proposed developing a new umbrella organisation that links pharmaceutical and health care industries — a centre for clinical cure.2 A program to support clinical and translational science awards has also been launched. In Canada, there is a proposal to develop a taskforce to review the mission and mandate of the country’s academic hospitals.3 One of the most ambitious responses to the need for increased clinical research capacity has occurred in the United Kingdom. Like Australia, the UK has a splendid tradition in basic medical research, but has been much less successful than the US in translating this work into clinical advances or in building an environment within the National Health Service (NHS) that attracts major clinical trials. The UK Government’s 10-year framework on science and innovation investment includes an ambition to turn the NHS into a world-class collaborative research engine and a preferred host for multicentre trials with and for industry.4 A recent publication, Best Research for Best Health: a new national health research strategy, set out the potential NHS contribution to health research in England.5 The document that largely drove change in the UK was a report by businessman David Cooksey, which looked at the best structure for publicly funded medical research in the UK, with a clear aim of improving translational outcomes and clinical research capacity.6 It is one of the most influential documents in the UK medical research scene to be published in the 60-year history of the NHS, and it led to the transformation of the NHS research and development division into a new National Institute for Health Research (NIHR). Its recommendations, now implemented, include: ring fencing the NHS research budget of almost £1 billion for audited research programs, many of them new; closely aligning the new NIHR (which is responsible for clinical research) with the Medical Research Council (MRC; which is responsible for basic research), and giving both agencies shared responsibility for translational research; and creating a new overseeing office to coordinate publicly funded medical research, focused on outcomes, around major areas of national need — the Office for Strategic Coordination of Health Research, chaired by Professor Sir John Bell, Regius Professor of Medicine at the University of Oxford.7 An early example of this cross-agency collaboration is the development of the new Efficacy and Mechanisms Evaluation Programme, which is funded by the MRC but managed by NIHR. This program has the specific remit of supporting clinical trials that have a major innovative component aimed at gaining new biological insights, elucidating new scientific principles or developing new methodologies.8 A broad series of initiatives has been set in train by NIHR, with major investment in hospital- and community-based clinical research. This includes the establishment of a small number of comprehensive and specialist biomedical research centres, selected after evaluation by an international jury, at which world-class translational and clinical programs are planned or in place. These centres will be the UK equivalents of the Mayo Clinic and Johns Hopkins. A new NHS program is now underway to consolidate some of these centres into university/hospital trust consortia, where research and teaching functions are jointly owned and developed to create academic health science centres, similar to those in North America.9 Although several models are evolving, they have two common principles. First, the university and affiliated hospital sector will jointly own and plan research and teaching. Second, clinical programs will be academically aligned, with the belief that research and teaching excellence will underpin better clinical outcomes for both hospital patients and communities. This might be a good approach for some partnerships between Australian universities and teaching hospitals. Other initiatives developed by NIHR include the development of an extensive clinical research network.10 The aim of this is to ensure that health care professionals and patients throughout England can participate in and benefit from clinical research. Programs established within the clinical research network include an extensive primary care research network; six topic-specific networks, covering cancer, mental health, child health, diabetes, stroke, and dementia and neurodegeneration; and several other comprehensive clinical research networks. Another program is devoted to national technology platforms, the first being centred on imaging technologies.11 In addition, a number of biomedical research units have been established, covering cardiovascular disease, deafness, gastrointestinal and liver disease, musculoskeletal disease, nutrition, and respiratory disease.12 Resourcing to develop or extend similar national networks and centres would be a sensible step for Australia. Total UK funding for basic and clinical research will increase from £1 billion (about A$2.4 billion) in 2006 to £1.7 billion by 2010.13 Basic medical research in the UK was recently given a major boost through the institution of full economic costing for research council funded projects, which meets true infrastructure costs, and the ambitious and well funded programs discussed here are on the way to establishing world-class infrastructure for clinical research. A national structure has been set in place to ensure that the UK takes a leading role in the development of effective new therapies over the next decade. Australia, like the UK, has separate funding streams for clinical care and for research and innovation, and clinical research has been under long-term pressure. The National Health and Medical Research Council (NHMRC) introduced schemes in the early 2000s to fill the gap, such as the Centres of Clinical Research Excellence Scheme, Practitioner Fellowships, and Fellowships for both the early research career stage (eg, the Peter Doherty Australian Biomedical Fellowship and the Neil Hamilton Fairley Overseas Clinical Fellowship) and the more senior postdoctoral years (Career Development Awards) (Professor Warwick Anderson, Chief Executive Officer, NHMRC, Canberra, personal communication). However, what is currently lacking in Australia is a significant new research and development funding stream from the national health budget to fully develop translational clinical research capacity. Such funding would ensure that patients receive the newest treatments, developed in the most beneficial way.

Edward Byrne MD, FRACP

The Council of Australian Governments revitalised national mental health reform in 2006. Unfortunately, evidence-based models of collaborative care have not yet been supported. Previous attempts at national reform have lacked a strategic vision. We continue to rely on arrangements that are fragmented between different levels of government, poorly resourced community services, and an embattled public hospital sector. Our persisting unwillingness to record or publicly report key measures of health, social or economic outcomes undermines community confidence in the mental health system. Six priority areas for urgent national action are proposed and linked to key measures of improved health system performance. In Australia, we recognise special groups (such as war veterans) and organise and fund services to meet their specific health needs. Such systems could be readily adapted to meet the needs of people with psychosis.

Sebastian Rosenberg MPAdmin, BA · Ian B Hickie MD, FRANZCP · John Mendoza BEd, GradDipHlthEd

In preparation for a national medical registration system, the Australian Medical Council has proposed a code of conduct (“the Code”) that provides a comprehensive description of how doctors should behave. While containing much that will be widely acceptable to doctors, the Code has some major weaknesses: Many of its provisions focus on values and aspirations of a very general nature and will be impossible to enforce. It is based on a narrow, culturally specific view of medicine and ethics that does not reflect the multicultural diversity of Australian society. It confuses the roles of ethics and law in medicine, leading to inappropriate and mistaken injunctions about decision making and responsibilities. In place of the existing, effective, democratic and devolved (if imperfect) system of ethical and professional decision making, it threatens to establish a centralised, authoritarian regime. Because of its limited, ideological view of medicine, its implementation would impoverish medical practice and erode the ability to respond to individual circumstances and needs.

Paul A Komesaroff MB BS, PhD, FRACP · Ian H Kerridge FRACP, FRCPA, MPhil

To the Editor: In their recent article, Chen and colleagues argued for an increase in the number of Australians being treated with lipid-lowering drugs.1 It would appear pertinent to question the economic and therapeutic value of such an increase. The daily number of doses of statins in Australia increased by 1218% over the decade to 2005.2 Australia has considerably greater use of serum lipid-lowering agents than other Organisation for Economic Co-operation and Development countries, with annual costs in 2004 of $1.61 billion.2 Four years later, following the introduction of rosuvastatin and recent media reports regarding reductions in heart attacks and strokes, this figure must have escalated. Of necessity, the recommendation for the use of lipid-lowering therapy is largely based on extrapolation from tightly controlled clinical trials to clinical practice. This postulate has been questioned by a number of authorities, essentially due to eligibility requirements of trials excluding 40% of men and 80% of women,3 or, more importantly, because of failure to reach target levels, ranging in the world literature from 21% to 73% (references available from the author). This failure may be due to inadequate dosing or poor compliance, with non-compliance noted to be in the order of 35% at 2 years.2 In a submission to the Australian Government’s inquiry into health funding, I posed the hypothesis that if patients were required to undertake appropriate lifestyle changes before initiation of pharmaceutical intervention, annual savings of $130 million could be anticipated.4 Such an activity would also show benefits in reducing hypertension and obesity and improving glucose control in diabetic patients. Low high-density lipoprotein (HDL) levels and moderate elevation of triglycerides (to an extent that the triglyceride–HDL ratio is greater than 2) are associated with a preponderance of type B low-density lipoprotein (LDL) particles, which are known to be highly atherogenic. High-intensity interval training over a 6-week period increases the HDL levels in patients with initial levels < 1 mmol/L and reduces triglyceride levels, to the extent that the triglyceride–HDL ratio is significantly reduced to less than 2.5 Frequent requests to pharmaceutical companies for data regarding the effect of their preparations on elevating HDL levels in patients with levels < 1 mmol/L have been fruitless. In Australia, the incidence of coronary heart disease events decreased from 1994 to 2005, by 32% for men and 34% for women.6 Similar trends were observed for deaths from coronary heart disease and stroke.6 Year-by-year analysis of these trends fails to demonstrate any particular response in any one year. During the period 1997–2005, the increase in defined daily doses of statins rose from 20 per 1000 population per day in 1997 to nearly 180 per 1000 per day in 2005.2 One might have thought that this increase in statin therapy would have resulted in a far greater reduction in the incidence of cardiovascular disease and deaths than previously. However, this was not so — the trend continued unchanged in the “post-statin era” and of similar magnitude to the “pre-statin era”. In the words of the late Professor Julius Sumner Miller, “Why is it so?”

Michael A Neaverson

Objective: To assess the ability of doctors to calculate drug doses and their workplace prescribing and calculation habits.Design and setting: Prospective, questionnaire-based observational study conducted at a 570-bed teaching hospital in February 2007.Participants: Convenience sample of 190 doctors, representing all acute medical and surgical disciplines and diverse levels of experience.Main outcome measures: Demographic data, self-reported prescribing habits, predicted score on a 12-item test of ability to calculate drug doses, score considered adequate for peers, and actual score.Results: 141 doctors (74%) completed the questionnaire. The mean actual score on the test was 72.5% (95% CI, 67.8%–77.3%), which was similar to the group’s mean predicted score (74.7%; 95% CI, 71.0%–78.5%) but significantly lower than the mean of the score they considered adequate (91.6%; 95% CI, 89.5%–93.8%) (P < 0.001). Subgroup analyses showed that senior doctors and those in critical care specialties (intensive care, emergency medicine and anaesthesia) achieved significantly higher actual scores than junior doctors and those in non-critical care specialties, respectively.Conclusions: Doctors expect their colleagues to perform significantly better in a drug-dose calculation test than they expect to, or can achieve, themselves. Junior staff and those in non-critical care specialties should be targeted for education in the skill of drug-dose calculation to reduce the risk of medication error and its consequences.

Chanelle M Simpson MB BS(Hons), FACEM · Gerben B Keijzers MB BS, MSc(Epidemiology), FACEM · James F Lind MB BS, FACEM, MRCP

The World Health Organization estimates a current global shortage of 4.3 million health workers. Australia and New Zealand compare unfavourably with other Organisation for Economic Co-operation and Development (OECD) countries in respect to doctor numbers. The overall shortage of doctors in Australia and New Zealand is exaggerated by the disciplinary, cultural and demographic maldistribution of the doctors relative to need and utility. Australia and New Zealand are the most reliant of the OECD countries on foreign doctors. An increase in spending on health promotion and disease prevention is essential. However, it is unlikely that the demand for doctors will be significantly reduced by compressions of morbidity in the later years of life or that there will be a substantive increase in either the percentage of the community employed in health services or in the output from the current workforce. Doctor shortages are better addressed by alignment of elements of the education and health systems with each other and with patient care needs, and by innovative health provider training and employment.

Des F Gorman MB ChB, MD, PhD · Peter M Brooks MD, FRACP, FAFPHM

To the Editor: Needlestick injuries are inevitable during surgery, particularly if operating hurriedly by “feel” in blood-obscured fields, such as in Caesarean sections. The risks associated with these injuries were accentuated by the advent of the HIV pandemic. While working in rural Zimbabwe, an article describing Betadine inactivating HIV in an infected cell culture, with the cells surviving, triggered my interest.1 Betadine (Mundipharma, Basel, Switzerland) is povidone–iodine. Povidone is a polymer — polyvinylpyrrolidone, (C6H9NO)n — with many applications, including past usage as a plasma expander. It is hypoallergenic, has lubricating properties, and forms a loose chemical combination (iodophore) with iodine up to about a 10th of its weight.2 Therefore, a 10% solution of Betadine contains about 1% iodine. The iodophore is usually non-staining, although the iodine retains its chemical properties, such as turning starch dark blue. Povidone–iodine is a powerful antiseptic that kills Staphylococcus aureus and saprophyticus, Streptococcus pyogenes and pneumoniae, Neisseria gonorrhoea, Haemophilus vaginalis, Candida albicans and Trichomonas vaginalis within 30 seconds of contact, and Clostridium tetani spores in 30 minutes.2 In also destroying HIV,1 it may thus be regarded as a self-sterilising solution. Betadine can be applied as a simple protectant in surgical gloves. Before donning, 5–10 mL of Betadine are poured into each glove, with the operator inserting his or her hand and massaging the solution around, up to the gusset, ensuring the digits are liberally coated. Digital sensitivity is unaffected. Betadine’s brown colour (blue-black if the gloves were starch-dusted) makes its presence apparent through the semitransparent latex, and any glove perforation is evident by leakage of the solution (Box, A). Although licensed for topical application only, Betadine has for many years been used internally, as in peritoneal douching, so minor leakage from the gloves into body cavities would be of little consequence. On glove removal after prolonged operating, the skin surfaces of the operator’s hands are stained dark brown by the iodine, except, strangely, the dorsal aspect of the thenar muscles, seemingly because the hotter working digits cause exothermic deliquescence (Box, B). This stain is easily washed off, except for discolouration of the nails, which can be removed with scraping or will otherwise disappear in a day or so as the iodine sublimates. Although this technique needs formal evaluation, using Betadine in surgical gloves has several advantages: It is hypoallergenic, inexpensive, readily available and easy to apply. It provides a powerful additional protective barrier to needlestick injury infection transmission from patient to surgeon and vice versa. It can be used as an adjunct to “scrubbing up”, increasing surgical sterility. It obviates clumsy double gloving, pre-gloving hand drying, and dusting with fibromata-inducing talcs. It has an obvious presence that is psychologically reassuring. Glove perforations are easily detectable, allowing rapid intraoperative re-gloving. Betadine solution in surgical gloves A: Note evidence of a small perforation in the glove over the right thumb. B: Postoperative digital iodine staining, with probable heat-induced deliquescence sparing the thumbs and index fingers despite their being awash with Betadine.

George D S Turner

Redressing the imbalance between community expectations and the capacity of the hospital system to meet them will require more than recommendations for prescriptive frameworks and practices Should a Martian dispatched to report on the state of Australia’s hospitals happen to land in New South Wales, the nation’s most populous state, his report would be pertinent and predictable: Public hospitals are severely stressed and sick. They are afflicted by bureaucratic inertia, and riven with mistrust, poor communication and bullying. To add to their woes, they are chronically under-resourced and understaffed. To the outsider, they appear to be a collection of islands, with health professionals on one island, and administrators, health boards and bureaucrats on others; all are surrounded by seas of silence. Their political masters are at a loss over what to do or where to turn and, in desperation, they resort to conducting inquiries when media reports of adverse hospital incidents become political millstones. In short, there is a pervasive sense of loss — loss of control, loss of direction, and loss of ownership by the hospitals’ serving health professionals, politicians, and the community they are meant to serve. The Martian is puzzled by this loss and the state of public hospitals. Is this harsh judgement reflective of an extraterrestrial mind, or is it accurate? The tenor of recent hospital-related media headlines or the frequency of high-level hospital inquiries may shed some light on this question. A sample of the former include: Packed hospitals cause 1500 deaths;1 Public hospitals on ‘brink of collapse’;2 Sick opt to walk out of hospitals — long delays in emergency wards;3 Loss of morale driving doctors out;4 Doctors seek cure for bullying;5 Minor cases clog hospitals;6 Longer wait for elective surgery;7 and Westmead doctors seek boss’s removal.8 As to high-level hospital inquiries, there have been no less than three in NSW in the past decade: the Walker Special Commission of Inquiry into Campbelltown and Camden Hospitals in 2003;9 a NSW Parliament Joint Select Committee (chaired by Revd Hon Fred Nile) convened in 2007 to conduct an inquiry into the quality of care of Jana Horska, who had a miscarriage in the emergency department toilets at Sydney’s Royal North Shore Hospital (RNSH);10 and, in 2008, the Special Commission of Inquiry into Acute Care Services in NSW Public Hospitals, led by Peter Garling SC.11,12 This inquiry followed a coronial investigation into the death of Vanessa Anderson, a young patient at RNSH, following a head injury inflicted by a golf ball. In his findings on the Anderson case, NSW Deputy Coroner Carl Milovanovich noted that: There is little doubt that the NSW health system, while certainly staffed by dedicated professionals, is labouring under increased demand and expectations from the general public. Unfortunately, the same issues are invariably identified: not enough doctors, not enough nurses, inexperienced staff, poor communication, poor record keeping and poor management. These are systemic problems that have existed for a number of years and regrettably they all surface in the death of Vanessa Anderson ... it is almost impossible to avoid comment on the unfortunate repetition of the same systemic problems that continue to surface ... the Government of the day has the responsibility to provide adequate resources, training and staff to ensure the delivery of appropriate and timely medical services.13 In short, Coroner Milovanovich poignantly described a system failing because the demands on it exceed its capacity to deliver safe and quality services. On the same day that he delivered his findings, the NSW Labor Government announced the Special Commission of Inquiry into Acute Care Services in NSW Public Hospitals (the Garling inquiry). In this issue of the Journal, Clare Skinner and her colleagues from the Hospital Reform Group provide a synopsis of the main recommendations of this inquiry.14 The Garling report is in desperate need of such a synopsis. In his opening statement, Garling is nothing if not disingenuous, nonchalantly noting that his report is “voluminous and detailed”. My copy of the report weighs nearly 3.5 kg! Leaving aside the 64-page “overview”,12 there are three substantial volumes comprising 1195 pages, accompanied by an incredible 139 recommendations.11 This represents the outcome of reviewing more than 1200 written submissions from more than 900 individuals and organisations, listening to more than 600 citizens in public hearings, making 61 visits to public hospitals, conferring with 27 peak bodies, and holding two conferences — and all in just 10 months.15 Notwithstanding the importance of such activities and the gravity of the resultant report, it provokes issues worth exploring. Inquiries serve multiple complex purposes, including learning, discipline, catharsis and reassurance.16 But an overriding purpose is to establish the truth and to recommend change, seeking to eradicate the shortcomings of the past by creating a more effective and efficient system. In some respects, reports of inquiries are like science. Science seeks the truth, but does not become science unless it is published, widely read, and widely accepted. Important to its reception and wide dissemination are the essential reporting qualities of focus, brevity, clarity and conciseness. These are hardly descriptors of the Garling report! One may well ask who has both the time and the stamina to read a report exceeding 1200 A4 pages. A further complication lies with the very people who are to be instrumental in implementing the recommendations. Hardworking health professionals, including those who have been swept up in the intense scrutiny of the system in which they valiantly try to operate, may be understandably sensitive to criticism and additions to their already burdensome workloads. Furthermore, most health professionals now support the principles of evidence-based medicine, with its taxonomy of levels of evidence. In contrast, the Garling report is based on broad consultation and represents the distillation of a constellation of opinions — the lowest tier in the levels of evidence. As such, it raises the spectre of the ancient Greek philosophical debate as to whether any consensus of opinion is necessarily synonymous with the truth.17 In any event, the report’s lightning rods for change are the 139 recommendations (many with extensive subclauses), and herein lies another problem. The recommendations are presented with no sense of priority and, curiously, are not costed. Finally, while acknowledging that policy formulation is easy and implementation is hard,18 the report is resoundingly silent on the details of implementation, beyond stressing the need for independence and auditing of the process. In this issue of the Journal, Stewart and Dwyer explore some of the conditions that have to be satisfied if the implementation of Garling’s recommendations is to cure the sicknesses of NSW public hospitals and, for that matter, hospitals nationwide.19 The report unearths little that is new in the Australian hospital system that has not been broached by publications in the Medical Journal of Australia over the past decade or so. It aims to increase the efficiency and effectiveness of the current system by way of recommendations directed at optimising health through prescriptive frameworks and practices. It offers little in the way of modifying community and hospital cultures that are trapped in the prevailing imbalance between community demands and expectations and the capacity of the hospital system to satisfy these demands. The Garling recommendations touch ever so briefly on this disconnect; but these cultures can only begin to be addressed more fully by communicating the essence of the report to both the community at large and to all health professionals. Furthermore, we need to move beyond treatment of the symptoms of hospital diseases and determine if there is a commonality of their root causes. This analysis would also inform culture change. For now, Garling’s recommendations need to be prioritised and scrutinised for their ability to actually deliver an improvement in the quality and safety of NSW public hospitals. It is imperative that these recommendations (which are essentially only suggestions) be evidence-based, reality-tested and rigorously debated by health professionals working at the coalface in broad consultative forums, such as the well attended NSW Health Ministerial Forum held in Sydney in December 2008. Will any of this satisfy our observant extraterrestrial Martian? Will the Garling inquiry make a difference to the cultures of health care? We need to know what the state apparatus thinks. As Skinner and colleagues note: “The response from the state government looms as very important, and is eagerly awaited”.14

Martin B Van Der Weyden MD, FRACP, FRCPA

Objective: To explore the experiences of families with a baby with Down syndrome at the time of diagnosis, and their preferences for information and support in the early period after diagnosis.Design, setting and participants: A qualitative, interview-based study of 18 families living in Victoria with a child with Down syndrome born between 2002 and 2004 who had not been diagnosed with the syndrome before birth. Interviews were transcribed verbatim and interpretive content analysis was undertaken.Results: Parental coping with the unexpected diagnosis of Down syndrome in their infant was influenced by the time interval between birth and disclosure of clinical suspicion of Down syndrome, the level of certainty of the attending physician at the time of disclosure, and the time interval between disclosure of clinical suspicion and confirmation of karyotype. Initial uncertainty and a delay in the diagnosis were detrimental to parental coping, as was premature communication of the news. Perinatal complications increased parental anxiety regarding their child’s condition and future. Individual communication style of midwives and physicians was a powerful predictor of parental adaptation. Parental needs for support and information were facilitated through normalising postnatal care, ensuring privacy, and providing early access to peer support and up-to-date written information. Many parents would have appreciated access to a liaison worker.Conclusion: The experiences of parents in this study provide practice points for improving postnatal care with minimal changes to formal service systems.

Evelyne E Muggli MPH · Veronica R Collins PhD · Catherine Marraffa FRACP, FRCPCH

Objective: To seek the views of patients attending general practice about doctors’ interactions with the pharmaceutical industry and their wishes for disclosure of this information.Design, setting and participants: 906 patients attending three general practices in metropolitan Sydney during October –November 2007 completed an 18-item anonymous survey exploring their perceptions of doctors’ competing interests.Results: Most patients (76%) were unaware of any relationship their doctor may have with pharmaceutical companies. Patients wanted to know if their doctor obtained any benefits in cash or kind from the pharmaceutical industry (71%), financial incentives for research participation (69%) or sponsorship to attend conferences (61%). Most agreed that disclosure of competing interests by doctors is important (84%), believing this disclosure would help patients make better informed treatment decisions (78%). Eighty per cent of patients stated that they would have more confidence in their doctor’s decisions if interests were fully disclosed, with strong support for verbal disclosure during the consultation (78%).Conclusions: Patients are currently not aware of their doctors’ competing interests but do want to know of doctors’ interactions with the pharmaceutical industry, indicating that disclosure of competing interests would improve their confidence in doctors’ decisions.

Martin H N Tattersall MD, FRCP, FRACP · Aneta Dimoska PhD · Kevin Gan LLB

Objective: To characterise the demographic and psychosocial circumstances of women contacting Victoria’s largest public pregnancy advisory service (PAS).Design and setting: Audit of PAS electronic records for the 12 months from 1 October 2006 to 30 September 2007. De-identified data were extracted from a comprehensive electronic database used for recording consultations.Main outcome measures: Summary statistics and measures of association.Results: During the 12 months, 5462 women contacted PAS; records were created for 3827 women, and data were available in more than 80% of records for 77% (13/17) of items. Over half of the women receiving pregnancy support from PAS (60%) were 18–29 years old; 12% lived outside the metropolitan area; 51% held a health care card, and smaller percentages faced housing, financial, or drug and alcohol problems; 16% reported violence, but 71% described partners as involved and supportive. Most (79%) made contact within 2 weeks of discovering pregnancy, and 72% were referred by a general practitioner. Later gestation at contact was associated with younger age (P < 0.001), having a health care card (P < 0.001), and living outside the metropolitan area (P < 0.001). The most common reasons for seeking abortion were the desire to delay pregnancy (23%) and family completion (18%); 42% already had at least one child. Twenty-three women reported that the pregnancy was the result of rape. Ten per cent had mental health problems, and smaller numbers faced access barriers and had special needs.Conclusions: This PAS responds to demand from women with diverse social and personal circumstances. Findings provide evidence for policy, prevention and service development.

Heather J Rowe BSc(Hons), PhD, MPHAA · Maggie Kirkman BA(Hons), PhD, MAPS · E Annarella Hardiman BSA, MSW, MAASW(acc) · Shelley Mallett BAppSci, BASoc, PhD · Doreen A Rosenthal BA(Hons), PhD

In this 21st century, we will need to better analyse the outcomes of our spending on newer and more expensive anticancer drugs, particularly through postmarketing assessment, to ensure that these investments are justified. Evidence-based medicine is only as good as the evidence available, and we advocate for more independently designed and funded trials that concentrate on the minimum effective dose and duration of therapies to reduce toxicity to patients and to control costs. There is a place for governments to provide funding for these studies in the public good. Although improving survival over standard care is the gold standard for proving the efficacy of a new therapy, surrogate endpoints such as early biological marker changes, functional imaging changes or earlier measures such as progression-free survival must be investigated to enable drug therapies to be discontinued earlier if they are ineffective. Studies searching for the presence of biological targets must be funded to exploit the potential advantage of targeted therapies. Treatment guidelines are best written by experts who are independent of the pharmaceutical industry. Existing databases should be linked to better monitor the outcomes of new therapies. Privacy safeguards are important, but privacy legislation may need to be modified to serve the greater public good from the information gained from linking databases.

Ian N Olver MD, PhD, FRACP · Ian E Haines MB BS, FRACP, FAChPM

The final report of the Special Commission of Inquiry into Acute Care Services in NSW Public Hospitals was published on 27 November 2008. The report acknowledges the challenges facing the New South Wales health system, including increasing numbers of patients, rising treatment costs, workforce pressures, and the breakdown of working relations between clinicians and management. Many of Commissioner Garling’s 139 recommendations formalise aspects of clinical care that should and could be happening now if the system were better managed, including better supervision and training of junior staff. Commissioner Garling recommends that change should be driven by clinicians “from the bottom up”, but does not adequately describe how this should happen. Implementation of the report’s recommendations that will require strong leadership and continuing consultation with clinicians and the community.

Clare A Skinner BA(Hons), MB BS, MPH · Jeffrey Braithwaite MIR, MBA, PhD · Brad Frankum BMed(Hons), FRACP · Ross K Kerridge MB BS, FRCA, FANZCA · Kerry J Goulston MD, FRACP

Public hospital clinicians across Australia will relate to the problems described in the Garling report and endorse most of the recommendations to bring the system “back from the brink”. Implementation is feasible but requires substantial culture change, which must re-engage clinicians and stem the flow of desertion to the private sector. It must also address the fundamental causes of the current crisis. Key recommendations involve a substantial change in governance, with a transfer of many areas of the New South Wales Department of Health’s responsibility into four board-governed statutory authorities, where equal partnership between clinicians and managers will exist. Of Garling’s “four pillars of reform”, the greatly expanded role for the current clinician-led Greater Metropolitan Clinical Taskforce is a strong indication of the seriousness with which the Commissioner viewed the clinician–manager divide (which he likened to the Great Schism of 1054). The major omission in implementation is a failure to adequately address the loss of local accountability in hospitals since the abolition of area health service boards. Major change can occur without additional funding, but without substantial new money from the Australian Government, the public hospital system will not be pulled back from the brink. A better opportunity for true partnership of such importance between state and federal governments may not come again before it is too late.

Graeme J Stewart AM, FRACP, PhD, FRCPA · John M Dwyer AO, MB BS, FRACP, PhD

To the Editor: I read with interest the article by Hardie and Critchley, in which the authors attempted to measure attitudes towards both Australia’s current health care system, and shifts to greater public or private funding of health care.1 The article’s finding that pro-public funding attitudes were greatly favoured over pro-private funding attitudes may in fact be more of a reflection of the leading nature of the authors’ pro-private statements than of the true attitudes of the 800 study participants. Most Australians, regardless of their views on public versus private funding of health care, would be unlikely to support the statements “Australia should adopt a private, user-pays system like they have in the [United States]” and “The very best health care should be available only to those who can afford it”.1 The results are certainly not consistent with the findings from the 2007 Ipsos Health Care and Insurance study2 — a survey with more than 5300 participants and a solid 20-year history, which is supported by governments (Commonwealth and state/territory), private providers and industry associations. This study found that just over half of respondents (52%) supported full government funding of Australia’s health care system, while 42% opposed such a funding approach. In fact, more than 20% of respondents “disagreed a lot” with the proposal that “All hospital and medical costs should be met out of government revenue — the taxes we all pay — people should not have to pay anything directly”.2 The Ipsos results suggest there is still significant diversity of views on how Australia’s health care system should be funded and, importantly, these results do not support the conclusion of Hardie and Critchley that Australians “overwhelmingly favour a more socially responsive public health system, funded by the public purse”.

Michael H Armitage

In reply: We are intrigued by the discrepancy between our findings1 and the 2007 Ipsos study results2 noted by Armitage. We took a psychometrically rigorous approach to measuring the public’s preference for health care systems. If our pro-private statements seem “leading”, then the pro-public statements (“Australia should adopt a collective social health system supported by higher taxes as is done in some Scandinavian countries”, “I would be willing to pay higher taxes to improve Australia’s health care services”) could be similarly construed. Armitage reports that 52% of the Ipsos sample supported (and 42% opposed) full public funding of health care. If we apply this support–oppose dichotomy (ie, per cent above and below the scale mid-point) to our own data, a striking 70% of our sample support (and 30% oppose) greater public funding, while just 7% support (and 93% oppose) more private funding. This is consistent with other Australian studies showing a preference for health and medical research being conducted in public, as opposed to private, settings.3-5 We cannot directly compare our methods and results with the Ipsos survey because, ironically, when we tried to access this research supported by “governments ... private providers and industry associations”, we were advised by Ipsos that the report is not publicly available.

Elizabeth A Hardie · Christine R Critchley

To the Editor: Arnold is correct to question whether the New South Wales reportable misconduct legislation will be effective,1 because it relies on doctors making a judgement about whether a colleague has flagrantly departed from accepted standards of professional practice. Doctors have a high threshold for referring to medical boards, in part because they perceive the system to be adversarial rather than recognising that individual and system factors can combine to create poor professional performance. Also, medical boards have no direct ability to modify the workplace circumstances to make them more supportive of a poorly performing doctor. Poor performance has multiple causes, including mental and physical illness, cognitive impairment, substance misuse, professional isolation, and personality disorders.2 Flagrantly poor performance is rare, but research shows that the prevalence of poor performance is about one in a hundred doctors per annum.2 Many of these doctors are amenable to local remediation, provided there are properly promulgated procedures. The United Kingdom and some states in the United States have developed systems for assessing poorly performing doctors that require directors of medical services to manage complaints locally. In the UK, the National Clinical Assessment Service is available to support medical directors in more complicated cases. Consequently, the number of referrals to the General Medical Council has decreased, but the number of doctors being reviewed has increased to the number that would be expected from research.3 Doctors reviewed by medical boards in Australia do not reach the predicted prevalence levels, and boards’ processes seem slow by comparison with what can be done locally. It is a moot point whether Dr Jayant Patel would have been reported under the new NSW legislation, because some of his colleagues appeared not to have thought that he flagrantly departed from accepted standards. The real problems in Bundaberg were that there were no local mechanisms for health professionals to raise their concerns. For almost 2 years, the director of medical services at the hospital took no direct action.4 Queensland Health is developing local processes that will be administered by directors of medical services supported by a clinical performance support service.5 The evidence against relying solely on medical boards and in favour of local procedures for managing poorly performing doctors is now incontrovertible. Currently, many poorly performing doctors are not being identified and offered remediation, and patients are being left at risk. These are important issues for the National Health and Hospitals Reform Commission.

James A Dunbar · Prasuna Reddy

In reply: The opinion expressed by Dunbar and Reddy that: “The real problems in Bundaberg were that there were no local mechanisms for health professionals to raise their concerns” ignores the many real difficulties (canvassed in my editorial)1 confronting any member of staff who tried to raise their concerns within that institution. Local mechanisms cannot play their part if the institution’s senior staff do not wish to implement them. The ability of and, indeed, encouragement for all staff, regardless of seniority, to report their concerns directly to the medical board, bypasses all local deterrents. Our medical boards have the experience needed to sort out the major from the trivial, the genuine from the frivolous, incompetence from impairment. Dunbar and Reddy continue: “The evidence against relying solely on medical boards and in favour of local procedures for managing poorly performing doctors is now incontrovertible.” This is a straw man. No one, to my knowledge, has made any such suggestion. What I support is: (i) a direct avenue for someone local to report to the medical board; (ii) diligent and sensitive enquiry by the medical board; and (iii) if needed, the cooperative implementation of remediation by the local entity and the medical board.

Peter C Arnold

The issue of “equal health” for Aboriginal and Torres Strait Islander peoples involves a broad range of social determinants, in addition to physical health. The formation of an Australian college of Aboriginal and Torres Strait Islander health would allow a continuing authoritative conference of broad expert opinion, including that of Aboriginal health workers, to address health and social inequality.

Robert M Parker BMed, AFACHSE, FRANZCP