Health services administration

Objective: To examine the association between long-term health conditions and being out of the labour force among older Australians.Design, setting and participants: Retrospective analysis of cross-sectional data from the Australian Bureau of Statistics 2003 Survey of Disability, Ageing and Carers for people aged 45–64 years.Main outcome measures: Rates of premature retirement associated with ill health; odds ratios of being out of the labour force associated with each long-term health condition and number of conditions; weighted population estimates; estimates of gross domestic product lost as a result.Results: 9198 people surveyed were aged 45–64 years, 3010 of whom were not in the labour force. Of these, 1373 (45.6%) had retired because of a chronic health condition, most commonly a back problem (10.4%), or arthritis and related disorders (8.6%). When adjusted for age and sex, all conditions studied except diseases of the ear and mastoid process, other endocrine/nutritional and metabolic disorders, noise-induced deafness or hearing loss, and high cholesterol were significantly associated with being out of the labour force. Extrapolating from these results, an estimated 663 235 older Australians were not working because of ill health, reducing Australia’s gross domestic product by around $14.7 billion per annum.Conclusion: Prevention of long-term health conditions may help older Australians remain in the labour force longer, thereby increasing revenue to fund health care for the ageing population.

Deborah J Schofield BSpPath, GradDipComp · Rupendra N Shrestha BSc, MSc(Statistics) · Megan E Passey BMed(Hons), MPH, MSc · Arul Earnest DLSHTM, MSc · Susan L Fletcher BAppSc(Psych), PGDipPsych

Objective: To determine if a robust clinical review process can influence an organisation’s response to adverse patient outcomes.Design and setting: Retrospective analysis of the activity and outputs of the Clinical Review Committee (CRC) of a university-affiliated tertiary hospital from 1 September 2002 to 30 June 2006.Main outcome measures: Engagement of clinicians (number on CRC, number interviewed for the clinical review process, number of specific referrals from clinicians); and numbers of cases reviewed, system issues identified, recommendations made to the hospital board, and ensuing actions.Results: A multidisciplinary CRC with 34 members established a robust clinical review process and identified 5925 cases for initial case review. Of these, 2776 (46.8%) fulfilled one or more of the specified criteria for adverse events and progressed to detailed review; 342 of these (12.3%) were classed as serious or major. A total of 317 staff (11%) were interviewed, and 881 system issues were identified, resulting in 98 specific recommendations being made to the Clinical Board and implementation of 81 practice changes (including seven hospital-wide projects) to improve patient care.Conclusion: A robust, multidisciplinary clinical review process with strong links to managers and policymakers can influence an organisation’s response to adverse patient outcomes and underpin a clinical governance framework.

Imogen A Mitchell FRACP, FJFICM · Bobby Antoniou RN, GradDipCritCare · Judith L Gosper RN, RM · John Mollett · Mark D Hurwitz FRACP, FCP(SA) · Tracey L Bessell BPharm, MPH, PhD

To the Editor: Thank you for the opportunity to reply to Sondergaard’s article.1 The Australian health care system is highly complex, involving both federal and state jurisdictions. The Council of Australian Governments, consisting of representatives of national, state and territory governments, makes decisions that have an impact on the respective health ministers and their health departments, state/territory medical boards, and the Australian Medical Council (AMC). The Australian and New Zealand College of Anaesthetists (ANZCA), one of 12 medical colleges accredited by the AMC, is acknowledged by all of these entities as the body responsible for education, training, and standard-setting in anaesthesia. ANZCA’s policies and processes relating to overseas-trained specialists (OTSs) have been scrutinised by the AMC, which requires annual reports from the College; by the Australian Health Workforce Officials Committee (AHWOC); and by the Australian Competition and Consumer Commission (ACCC), in their review of all colleges. ANZCA is progressively altering its OTS processes, as agreed with these authorities. In accordance with AMC guidelines, OTSs are assessed against published criteria, based on their training, qualifications, skills and experience. Anaesthetists from Scandinavia, like those from many other developed countries, are usually assessed as being “partially comparable” to Australian-trained anaesthetists and require 12–24 months’ supervised practice and a performance assessment under Australian conditions before being eligible for Fellowship of ANZCA. It is possible for applicants to be considered “substantially comparable”, providing they are judged to have similar qualifications by training and examination (suitable applicants from the United Kingdom would come under this category). It is worth noting that there are no reciprocal arrangements in the field of anaesthesia between Australia and any other countries. All applicants must be assessed under the same agreed processes as governed by the AMC and the federal government. In relation to Sondergaard’s article, there are some errors that need to be corrected. The AMC is not responsible for “full registration” of doctors — that is the prerogative of the state and territory medical boards, each of which has its own legislative requirements. It is worth noting that, in South Australia, only Fellows of ANZCA can practise as specialist anaesthetists. “Physician assistants”, who in any event are fully supervised by specialists, are currently performing pilot roles in some hospitals to determine the feasibility of assistant anaesthetist roles. This does not have anything to do with “circumventing” the College’s regulations. The quotes in Sondergaard’s Box 1 are extracts from the AMC’s 2002 accreditation report on ANZCA and relate to more flexible methods of recognising the qualifications and training of OTSs. ANZCA has reported annually to the AMC on progress in this matter. With guidance from the AMC and regulatory authorities, changes are continually being made to bring all medical colleges into line with each other. The quote in Box 2 is an extract from the 2005 ACCC/AHWOC review of Australian specialist medical colleges. It refers to all the colleges, and all are working with federal, state and territory regulatory authorities and the AMC to address the issues raised. As the registering authorities, state and territory medical boards act independently (as in the Bundaberg Hospital case2) and do not necessarily accept the advice of any college. The Editor of the Medical Journal of Australia has published a number of editorials that have dealt very fairly with a range of relevant difficult issues, including OTSs,3 task transfer4 and the need for change.5 In conclusion, Sondergaard requested and was granted an interview with ANZCA’s OTS Interview Panel, and his application was dealt with according to the College’s usual processes, following guidelines laid down by the AMC and medical boards. He has lodged an appeal with ANZCA.

Leona F Wilson

To the Editor: Two studies1,2 and an editorial3 on the vexed issue of medication errors in hospitals have recently appeared in the Journal. Yet none of them have mentioned patients, except as the passive victims of error, and all three have focused exclusively on public hospitals. This is unfortunate as, arguably, the public hospital system is evolving predominantly into a way station along the chronic illness journey within the wider health care system. To quote an 86-year-old patient of mine: “I’ve been taking the same tablets for 30 years, but as soon as I come to hospital they take them away and give me other ones, as if I’m incapable.” Indeed. Could patients continue taking their own regular medications (patients’ own drugs [PODs]) themselves? This would eliminate many errors of transcription and administration and eradicate in-hospital dispensing errors altogether. Although it might seem risky for patients to be given free rein with their medications, this is precisely what they are doing at home, and generally with no supervision whatsoever. Furthermore, if patients do make errors, they are more likely to omit some medications than to take toxic doses, and the consequences of such errors of omission are likely to be minor. If a self-administration system for PODs were to be implemented — including newly prescribed drugs that patients were expected to continue using on discharge, as well as medication strategies used in the home (eg, dosette boxes) — then any errors could be noted and corrected, just as a patient’s mobility is assessed before discharge. On the other hand, it is pertinent to note that many hospital admissions arise from medication errors, with one study demonstrating that up to 30% of admissions in patients aged 75 years and over are medication-related and up to 75% are preventable.4 Clearly, certain groups of patients and certain drugs should be excluded from a POD system. A sample protocol is available from the author on request. Would a POD self-administration system be cost-effective? Such a system has been used successfully in at least one Australian private hospital (in which I have worked) and in several hospitals in the United Kingdom.5 A systematic review has also been undertaken to examine the risks and benefits of the use of PODs, but it did not discuss the issue of self-administration.6 A MEDLINE search from 1996 onwards for patients’ own drugs/medications and self-administration yielded no results. As always, further research is required. What my patient’s comment highlights is that patients do have autonomy and some competence, and that these factors should be taken into account in any strategies aimed at reducing medication errors.

Frank T Formby

To the Editor: In May 2007, I began working in an Australian public hospital as a permanent consultant endocrinologist and physician. There are many differences between the health systems of Australia and Sweden, where I previously worked. In particular, there are striking differences in on-call work for the rostered consultant. In Sweden, the compensation (usually taken as leave) for every phone call, whether it was 1 minute or 30 minutes long, was half an hour during weekday hours of 4.30–9 pm and 7–8 am, and 1 hour during nights and weekends. Compensation also applied to ward rounds on weekends. I also received an on-call allowance of 6 minutes per hour during weekdays and 12 minutes per hour during weekends. During public holidays, rates were tripled. Every year, I earned 5–7 extra weeks on top of my normal 5 weeks of annual leave, some of which was used for well paid locum work, as private practice is almost non-existent in Sweden. Compensation could also be taken as payment; each department had its own agreement with staff on the preferred format, depending on staff levels and budget. The on-call frequency was usually 1 in 10, and the physician on call was responsible for all general internal medicine patients. For most of my career I worked in a large tertiary referral centre,1 but the rostering and compensation were similar in local general hospitals, with the only difference being fewer subspecialties with their own on-call roster. The surgical specialties had the same system. As in Australia, I was rarely called to attend the hospital, although contact during an on-call session was more frequent in Sweden (2–10 v 0–2 phone calls). Junior doctors in Sweden were more inclined to discuss patients and, in some wards, the nurses were instructed to call the physician on call first if the matter could be solved by phone. I was happy for every call, as I received extra compensation, but I never received any further phone calls once the on-call session finished. In Sweden, I did ward rounds on weekends, either of all medical wards in the local general hospitals or only the general medical wards in the tertiary centre when I was physician on call. Before seeing patients, I did a paper round with the nurses, when we decided which patients I needed to see. Patients were not admitted directly under me, but under the specialists responsible for the wards during office hours. However, I was temporarily responsible for all medical patients in the hospital. In Australia, at least in my current hospital, I have “my patients” in the wards (usually spread out over the entire hospital). If something suddenly happens to one of them, the intern, resident medical officer or medical registrar will phone me, even in the middle of the night or if I am away on leave. As the compensation is the same whether phone calls are received or not, and most medical patients are admitted under the physician on call, there is little incentive for the physician to volunteer for extra on-call sessions or to encourage junior doctors to phone.

Henrik Falhammar

The future viability of general surgery may depend on combining subspecialty elective surgery with full-scope acute practice in both public and private settings Subspecialisation in surgery is an irresistible and irreversible force. It improves standards of patient care1 but tends to be accompanied by an erosion of competence in the broad scope of the major specialty. For example, many major hospitals in Australia have had difficulty retaining subspecialty breast surgeons on the on-call roster because these surgeons feel that their competence to manage the full range of general surgical emergencies has been diminished by their day-to-day practice involving primarily the breast and axilla and rarely the abdomen. Nevertheless, the community needs surgeons willing and able to provide acute surgical care in the major specialties, including general surgery. Is it possible to have a model of care that satisfies both of these apparently divergent scopes of practice? A century ago, there was a single broad field of surgery. During the 20th century, specialties within surgery developed, many of these arising from general surgery, which continues to be the largest specialty. The Royal Australasian College of Surgeons (RACS) currently recognises nine specialty disciplines, by training and examination: general surgery; orthopaedic surgery; otolaryngology, head and neck surgery; plastic and reconstructive surgery; cardiothoracic surgery; neurosurgery; paediatric surgery; urology; and vascular surgery.2 Recognition as a surgical specialty has required definition of a discrete area of knowledge and skills, and a group of practitioners dedicated to the practice, teaching and advancement of the specialty. Subspecialisation within each specialty continues this development, driven by surgeons’ motivation to increase their knowledge and improve patient care. However, it may also have professional and personal benefits for the surgeon, including a more regulated lifestyle and enhanced prestige and remuneration. Examples of subspecialisation within the specialty of general surgery are breast, endocrine, upper gastrointestinal, hepato-pancreatico-biliary, and colorectal surgery. Of particular concern is that general surgery — comprising the largest specialty group of surgeons and those most likely to be required to treat emergencies — is now attracting proportionally fewer applicants for training. In 2007, general surgery offered 51% of available training posts but attracted only 30% of applications.2 Until recently, a third of trainees transferred to another specialty during their training. Although it is hoped that the new Surgical Education and Training (SET) program3 will bring improvements for all surgical specialties, attraction to and retention in general surgery training is likely to be a continuing challenge. Despite the best efforts of the RACS and public hospitals, the number of training positions in general surgery of sufficient quality to meet accreditation standards has increased only gradually from 266 in 2004 to 304 in 2008.2 These factors at the supply end, combined with the fact that 40% of active general surgeons are aged over 60,2 are creating serious workforce pressures. Very few surgeons remain on the on-call roster after age 60. The situation seen in Australia is similar in other developed countries and is particularly concerning in the United States, where Fischer has warned of the impending disappearance of the general surgeon.4 General surgical specialists have been trained to a competent level in the full range of the specialty, including trauma and the acute abdomen. However, as subspecialisation develops, surgeons may become de-skilled in the requirements of emergency surgery. Thirty years ago, general surgeons practised the full range of the specialty, taking pride in the breadth and depth of their knowledge and skills. This has changed significantly. In a 2003 survey,5 the practice patterns of members of General Surgeons Australia were: general surgery with subspecialty, 45% general surgery with more than 90% subspecialty, 23% “general” general surgery, 18% subspecialty only, 14% Nevertheless, 83% felt an obligation to stay on emergency rosters out of duty to the community, trainees and professional colleagues. But for how long will this goodwill continue? Emergency work is demanding, and reliance on a diminishing pool of “general” general surgeons will not be sustainable. Indeed, the future viability of the specialty of general surgery may depend on the development of a model of practice that combines subspecialty elective surgery and full-scope acute practice in both public and private settings. What is required to encourage surgeons to continue to work on emergency rosters? First, we need a review of these rosters. The tradition of ongoing responsibility for the care of patients taken in during an on-call period being maintained by visiting surgeons — who make up most of the workforce and who are in private practice outside the public hospital for most of their working week — should be reconsidered. The Australian Medical Association has promulgated safe-hours principles,6 and these depend, in part, on the acceptance of safe-handover principles.7 The RACS supports both these professional workplace ideals.8 Rosters have been successfully trialled where a consultant-led surgical team is on call exclusively for emergencies, with no scheduled elective duties, for a defined time period such as 24 hours, or longer. At the end of this time, the team completely hands over care of patients with unresolved problems to the next team.9 Second, we need a review of the efficient use of operating theatres for emergency and elective surgery. Lack of access to beds and operating theatres for elective surgery is a continuing source of frustration for patients, surgeons and trainees, and may be solved by separating the services.10 This can be achieved by establishing a separate hospital for elective surgery, at least for surgery of minor or moderate complexity, or by effective quarantining of services within a major hospital complex. Third, surgeons need to maintain competence in emergency surgery relevant to their major surgical specialty. It is possible to identify the requirements of emergency surgery as a defined scope of practice within each of the nine major specialties. This set of knowledge and skills could be formalised in a curriculum for continuing professional development and delivered in an adult learning format, including online modules and hands-on technical skills laboratories. Surgeons would then have the confidence to continue to serve on on-call emergency rosters, thereby acting as mentors and role models for trainee surgeons, while also continuing to practise a subspecialty interest in elective surgical practice. Finally, hospitals should value their surgeons and provide appropriate incentives and conditions of service, including adequate remuneration and tangible support for continuing professional development. This will require cultural and organisational reform, but hospitals could then reasonably expect surgeons to provide emergency services as a condition of their employment. My emphasis here has been on general surgery, where the problems are so obvious. However, service issues also apply to other surgical specialties with developed and developing subspecialisation (notably orthopaedics and otolaryngology) and are also relevant to other medical specialties. Problems particularly occur in the public sector; while provision of acute care in the private sector is also problematic, motivations and incentives in private sector settings appear to be more effective in maintaining services. In rural and remote areas, the provision of elective and emergency services is also threatened by workforce pressures beyond the issue of subspecialisation. The RACS has recently responded to concerns about the increasing difficulties in providing adequate emergency and trauma care by publishing a position statement outlining guidelines for the sustainability of emergency surgery services.10 To continue to provide emergency surgical care to the Australian community, it is apparent that models of coexistence must be found, and that solutions will include effective rostering and practice models, the certainty of availability of facilities for care, and the appropriate valuation of surgeons, as well as ongoing support for the maintenance of professional competence.

Ian R Gough MD, FRACS

Leading international health organisations are concerned about high use of artificial tanning services and the associated risk of skin cancer. Similar concerns exist about the growing Australian solarium industry. Pre-teens appear to be ignoring sun safety messages in their desire to tan and use solaria. A significantly elevated risk of melanoma exists among people exposed to artificial ultraviolet radiation; the risk is higher for those younger than 35 years at first solarium use. For all users, the risk of squamous cell carcinoma is more than doubled compared with non-users. We estimated the numbers of new melanoma cases and melanoma-related deaths attributable to solarium use by younger people in the five most populous Australian states and indirectly quantified potential costs to the health system that could be saved by effective regulation of the solarium industry. Annually, 281 new melanoma cases, 43 melanoma-related deaths and 2572 new cases of squamous cell carcinoma were estimated to be attributable to solarium use. The annual cost to the health system — predominantly Medicare Australia — for these avoidable skin cancer cases and deaths is about $3 million. By successfully enforcing solarium regulations that ban use by people younger than 18 years or with fair skin, favourable health and cost benefits could be expected.

Louisa G Gordon MPH, PhD · Nicholas G Hirst BComm, BEc · Peter H F Gies PhD · Adèle C Green MB BS, PhD

Objective: To describe the quality of postoperative documentation of vital signs and of medical and nursing review and to identify the patient and hospital factors associated with incomplete documentation.Design, setting and participants: Retrospective audit of medical records of 211 adult patients following major surgery in five Australian hospitals, August 2003 – July 2005.Main outcome measures: Proportion of patients with complete documentation of medical review (each day) and nursing review and vital signs (heart rate, blood pressure, respiratory rate, temperature and oxygen saturation) (each nursing shift), and the proportion of available opportunities for medical and nursing review where documentation was incomplete. Univariate and multivariate odds ratios for the association between incomplete documentation and hospital and patient factors.Results: During the first 3 postoperative ward days, 17% of medical records had complete documentation of vital signs and medical and nursing review. During the first 7 postoperative ward days, nursing review was undocumented for 5.6% of available shifts and medical review for 14.9% of available days. Respiratory rate was the most commonly undocumented observation (15.4% undocumented). Certain hospitals were significantly associated with incomplete documentation. Vital signs were more commonly undocumented in patients without epidural or patient-controlled (PC) analgesia, during evening nursing shifts, and during successive postoperative ward days. Nursing review was more commonly undocumented in the evening and for patients without epidural or PC analgesia. Medical review was more commonly undocumented on weekends.Conclusion: Hospital and patient factors are associated with incomplete documentation of clinical review and vital signs after major surgery.

Forbes McGain FANZCA, FJFICM · Michelle A Cretikos MB BS, PhD, MPH · Daryl Jones FRACP, FJFICM · Susan Van Dyk RN · Michael D Buist FRACP, FJFICM, MD · Helen Opdam FRACP, FJFICM · Vincent Pellegrino FRACP, FJFICM · Megan S Robertson FRACP, FANZCA, FJFICM · Rinaldo Bellomo MD, FRACP, FJFICM

Vested interests are the main obstacles to reform, and the voice of the community is the main force for change Implementation of health care reform is difficult because serious redesign of health care runs immediately into the power of vested interests. I personally witnessed this at the birth of Medicare in the 1970s, when I was Head of the Department of the Prime Minister and Cabinet. Government archives, both federal and state, are full of health reform proposals that have never been effectively implemented because of the power of these vested interests (see the article by Leeder and Lewis in this series1). The exercise of power in health is reflected in many ways: in the vested interests of bodies like the Australian Medical Association, Medicines Australia and the private health insurance companies, whose lobbying activities make union power look feeble in comparison; in the way the public debate is invariably between the health minister and vested interest groups, while the community is excluded; in the inertia of health bureaucracies that are inward-looking and very beholden to vested interests; in the way some ministers, particularly state ministers, are easily dominated by their departments because of the complexity of the health portfolio; in the way the system is always under pressure and in crisis mode because ministers will never publicly admit that we cannot have all that we want in health care, making planning for long-term change difficult; in the very hospital-centric nature of our health care, which has come about because many vested interests are congregated around hospitals; and in the way states’ rights get in the way of the community’s rights. Lack of political will to contest vested interests is the major cause of failed reform. Australia is not unique — just ask Hillary Clinton, and witness the debacle in American health care today. In light of the way power is exercised in the health sector, what can be done in implementation? The federal Health Minister should stand back from day-to-day crisis management and focus on longer-term redesign of health services, including strategies for improving population health and developing a whole-of-government approach that embraces the social determinants of health. The main cause of poor health is poverty. The Minister should, wherever possible, be prepared to devolve and delegate greater responsibility and decision making to professional and independent organisations (eg, Medicare, the Pharmaceutical Benefits Advisory Committee) and people, and let them explain and defend what they are doing on behalf of the Minister. The Minister should avoid the media loop in which vested interests try to dominate with their own agendas. The Minister should have a clear role in government in all decisions affecting health, such as housing, jobs, transport and education. She is the Minister for Health, and not only for health services. The Australian Government Department of Health and Ageing should be reshaped as a priority to enhance its economic expertise and ensure that it focuses on the community’s interests. Programs should be output-focused rather than input-focused (as they are now, around inputs of hospitals, pharmaceuticals and medical services). The Department is not presently equipped to be the administrative driver of reform. The government should elicit from the Australian community the principles that should drive health reform and thereby establish a constitution or covenant for health care (see my earlier article in this series on principles,2 and another by Mooney on community consultation3). A small, external, professional and independent Australian Health Commission should be established to monitor and advise the Minister on the implementation of its health principles and its health plan following decisions made in response to the National Health and Hospitals Reform Commission report and the national Preventative Health Taskforce. The Australian Health Commission should report to Parliament twice a year. An important role of this Commission would be public education to challenge the views of vested interests and, hopefully, to persuade the community about the case for reform. A supportive community will make political decisions easier, and the case for health reform must be won in the community. A joint federal–state Health Commission should be established in any state where the federal and state governments can agree. The Commission would jointly fund and plan the delivery of health services in that state. Implementation would be relatively easy if there were the political will.4 The federal government should: wind back the $6 billion per annum taxpayer subsidy to private health insurance companies and pay the money directly to public and private hospitals; expand the role of Treasury, Finance and the Prime Minister and Cabinet in the health reform process. They can bring greater rigour, an “outsider’s view” and a whole-of-government approach; cease providing money without reform. For example, the increased funding of state hospitals should be conditional on significant governance and workforce reforms; make primary care the priority area for implementation and funding, with the rollout of 200 multidisciplinary primary health care clinics across Australia;5 involve clinicians, but not organisations of clinicians, in the reform process; and urgently support the recruitment and training of good health managers. The major issue in implementing health reform is political will to break the political paralysis that is cultivated by vested interests. Other issues are much easier to resolve. Good health policy and good health politics require the Australian Government to skilfully and resolutely reduce the power of vested interests in favour of community interests.

John Menadue AO, BEc

Objective: To present a descriptive overview of the quality and recommendations of clinical practice guidelines (CPGs) on diagnosis or management of osteoarthritis (OA) of the hip and/or knee.Data sources: CPGs were identified from several research databases (MEDLINE, EMBASE and The Cochrane Library) and guideline-specific databases from 1966 to August 2005.Guideline retrieval: Thirty-four relevant CPGs were identified.Data extraction: Recommendations were extracted from CPGs and categorised into: assessment and diagnosis, pharmacological management, nonpharmacological management, complementary/alternative therapy, or surgery. The quality of the CPGs were assessed by two appraisers using the Appraisal of Guidelines Research and Evaluation (AGREE) instrument.Data synthesis: Most recommendations for aspects of diagnosis and treatment of OA of the hip and/or knee were consistent among the CPGs included in this study. However, quality varied considerably, with few CPGs being “strongly recommended” according to the AGREE quality appraisal instrument.Conclusions: Given the number of CPGs available relevant to OA, and the consistency of recommendations within them, and considering the time and resources required for CPG development, future efforts to guide management of OA of the hip and/or knee may be better directed towards adapting existing CPGs to the local context, implementing practices known to be effective, and facilitating research to answer important questions where there is little evidence.

Marie L Misso BSc(Hons), PhD · Veronica J Pitt BSc(Hons), PhD · Kay M Jones BSW, MT · Hayley N Barnes BBiomedSc(Hons) · Leon Piterman MMed, MEdSt, FRACGP · Sally E Green GradDip(MT), BAppSc(Physio), PhD

To the Editor: The study by Nichols and colleagues1 and the associated editorial by Hughes2 struck a chord of familiarity for me, as patient safety issues are currently high on the political agenda in the United Kingdom. An estimated 850 000 incidents of harm or near harm affect National Health Service (NHS) hospital patients in the UK each year.3 In April 2004, the Health Foundation (an independent charity that aims to improve the quality of UK health care), together with the Institute for Healthcare Improvement, launched the Safer Patients Initiative (SPI). The four hospitals initially chosen to participate conducted hospital-wide programs to radically improve patient safety, with the aim of reducing adverse events by 50% by October 2006. In November 2006, Phase 2 was launched, adding 20 more sites.3 These hospitals meet regularly to report on progress and exchange ideas. Discrete projects focus on medicines reconciliation, ward-based care, critical care, and perioperative care. The overall aim of the SPI is to improve the patient safety culture within each organisation. Specific targets for all participating hospitals include a 15% reduction in mortality of in-hospital patients; 300 days between central line bloodstream infections in critical care units; 80% of blood sugar levels in diabetic patients falling within their target treatment range; a 30% reduction in cardiac arrest calls; and 50% reductions in methicillin-resistant Staphylococcus aureus bloodstream infections, harm from anticoagulation, and surgical site infections. In my intensive care unit, hand hygiene compliance among medical staff has been regularly audited and has improved from a range of 20%–90% per day to 60%–100%. This compares favourably with a recent Australian hand hygiene initiative.4 When practice improvements are shown in one location, the project team takes on the responsibility of spreading these across the hospital. Initial scepticism from senior clinicians and nurses in my hospital has generally been replaced by cooperation and, in many cases, ideas for other ways to improve delivery of safer clinical care. Large multisite evidence-based trials in intensive care units in the United States showed that, with focused effort on sterile technique and catheter care and by rectifying lapses in standard procedures, a reduction of 66% in catheter-related bloodstream infections was possible.5 The SPI is trying to replicate results such as these within a relatively short period. My intensive care unit has now gone 190 days without a line-related bacteraemia; previously, we had infections almost every month. The SPI Phase 2 completion date is November 2008, with full national reporting due at that time. It is intended that practice improvements will then be spread across the NHS. The experience in my hospital has been that sharing experiences both within the hospital and externally has led to tangible progress in this area.

Peter J Shirley

In a now diverse range of teaching hospitals striving to excel, excellence in research should be prioritised Mention Johns Hopkins Hospital or the Massachusetts General Hospital, and most doctors will recognise these as leading teaching hospitals of the Johns Hopkins School of Medicine and the Harvard Medical School — both consistently ranked in the top 10 medical schools in the United States.1 Both hospitals are exemplars of excellence in the teaching hospital’s functions of patient care, medical education and clinical research. While Australia’s teaching hospitals may not have the same international status, the best of our teaching hospitals are recognised as providers of complex and high-quality care, suppliers of the nation’s medical and health professionals, and leaders in clinical research. Indeed, a recent review of the status of medical research in Australia acknowledged both its high quality and international standing.2 However, it appears that the standing of this research in Australia’s teaching hospitals is under threat. In this issue of the Journal, Penington, a leading academic and Chairman of the not-for-profit company Bio21, which links the University of Melbourne with its teaching hospitals and research institutes, argues that Australia’s teaching hospitals are in danger of slipping behind other nations such as the US, Canada and the United Kingdom in the calibre of their clinical research.3 The immediate concern is that the prevailing administrative emphasis in our teaching hospitals now revolves around service delivery and quantitative performance indices that ignore quality of services. Cecil Helman, general practitioner and social commentator, wrote: . . . hospitals have become factories, yet another form of industrial mass-production in our society . . . Many hospitals have become businesses, dedicated solely to production . . . but without considering the other types of cost that result from this approach . . . They have become businesses run by managers, primarily for the benefit of other managers, accountants and of other executives higher up in the food chain.4 In this environment, the importance of research and its supporting frameworks have dropped below the bureaucratic radar. Furthermore, Penington argues that support for research in teaching hospitals has fallen victim to “cost shifting” and “buck passing” of responsibilities between bureaucracies as to who is responsible for the infrastructure sustaining research and development (R&D) in teaching hospitals.3 A new channel or dedicated funding is needed. The UK has recently witnessed an orderly series of inquiries that have culminated in the UK Government corralling the National Health Service research budget of around £1 billion and forming a new funding body — the National Institute for Health Research — for translational (aiming to connect research to actual patient care) and clinical research programs. An international panel has awarded comprehensive biomedical research centre status with major funding to five major medical research centres — University College London, Imperial and Kings Colleges, and Oxford and Cambridge universities. These are the super medical research universities in the UK, and will be internationally highly competitive in translational research done in a clinical setting (Edward Byrne, Executive Dean, Faculty of Biomedical Sciences and Head of Medical School, University College London, personal communication). The overarching vision is for health research to be performed by the best people, in the best facilities, and focused on the immediate needs of patients and the public. Paramount in this vision are partnerships with industry, and the central roles of universities, granting bodies and research charities.5 An example of this vision in action is the partnership of the Medical Research Council, the Wellcome Trust and Cancer Research UK in a new institute in central London with a building cost of about US$1.5 billion. This institute will perform mainly basic research, but there is a firm requirement that there be clinical research links to the large hospitals in its proximity, particularly those affiliated with University College London (Edward Byrne, personal communication) The issues raised by Penington3 are just part of the story. With the recent increase in the number of Australian medical schools and in medical student numbers, there is also a pressing need for more teaching hospitals, ideally linked in a “hub and spoke” configuration with general practice, which has now been given a greater role in medical education.6 If this is to be achieved with the best possible outcome, it is important that there be specific guidelines and a quantifiable framework for what actually constitutes a teaching hospital, and what may be acknowledged as acceptable variability within this framework. Teaching hospitals have one common characteristic — a commitment to medical education in partnership with university medical schools and clinical colleges. But they can differ in many other ways.7 These include: the size and scope of resident staff; the number of fellowships or advanced training positions; the standing of R&D in the hospital; the facilities and infrastructure to support R&D; the level of integration of university staff in the hospital; the number of academic staff as heads of services; the mix of special clinical services offered; the extent and depth of diagnostic laboratory services; the mix and complexity of clinical care; and so on. The organisational structures of university presence in our teaching hospitals also vary, borrowing extensively from either UK or US models.8,9 It is a given that descriptors like the ones outlined above need to be refined and quantified so that teaching hospitals can be stratified, and key performance indicators can be developed and measured. These parameters might then be the basis of evidence-based and comprehensive remuneration schemes by state and federal agencies, allowing for rigorous accountability of the flow of money. The Australian community needs access to the best health care, benefiting from advances in medical science and technology. The way forward is to borrow from the UK experience of independent and focused inquiries that have resulted in clear expositions and recommendations for action. It is time to confidently answer the question of whether or not our teaching hospitals perform to the level of their international counterparts, and to prevent the deterioration in clinical research capacity signalled by Penington.3

Martin B Van Der Weyden MD, FRACP, FRCPA

Partnership between research and health services has a long history in other countries, but has been relatively recent in Australia, with several models arising in the 1960s and 1970s as research-based specialties developed. Since the implementation of Medibank, which became Medicare, Australian Health Care Agreements have been primarily crafted on the basis of transactional numbers, ignoring the need for links with teaching and research and the need to implement new developments. Education and research have been seen as the responsibility of the federal government, and hospitals are progressively less recognised or funded for these functions by the states. Australia’s teaching hospitals are in danger of falling seriously behind those in other countries and losing their capacity to monitor quality, to innovate and to branch into new strategies in partnership with primary care services. We should look at initiatives in other countries such as the United Kingdom and Canada, which are making big strides in tackling similar issues. University hospitals hold the key, if appropriately linked with other services. The current Australian Health Care Agreements are on hold. A new agency is needed to support clinical and service-related research, with a new structure and track for federal government funding, and providing oversight of research and development, of clinical governance and quality of outcomes in health care, linked with new strategies for prevention and treatment. A component of the foreshadowed additional federal government funding for health should be sequestered to set up such an agency.

David G Penington AC

Strategies for managing increasing health system demand have focused on the acute sector and chronic disease management in the community, with little attention on the role of rehabilitation. There were over 53 000 inpatient rehabilitation episodes in Australia in 2006. We argue that rehabilitation can improve patient flow and outcomes in acute care if engaged early. The effectiveness of rehabilitation can be enhanced by increasing the intensity of therapy and developing models of rehabilitation that provide alternatives to inpatient care. Factors that reduce the efficiency of rehabilitation services include the location of many services in small, stand-alone hospitals without acute support; the lack of options for managing younger people with acquired disability in the community; and deficiencies in government programs for the supply of aids, equipment and home modifications. Improving the organisation of rehabilitation services should improve access to acute and rehabilitation inpatient beds, improve patient outcomes and reduce costs.

Peter W New MB BS, MClinEpi, FAFRM(RACP) · Christopher J Poulos MB BS, MSc, FAFRM(RACP)

Recent trials and meta-analyses have raised questions about choice of therapy and use of strict glycaemic targets In August 2006, representatives of the American Diabetes Association (ADA) and European Association for the Study of Diabetes (EASD) published a consensus algorithm for glycaemic management of type 2 diabetes.1 The algorithm provoked debate, but the authors defended their recommendations,2 including the introduction of metformin at diagnosis and the addition of insulin, sulfonylureas or glitazones as second-line therapy if satisfactory glycaemic control is not achieved. The glycaemic target at this and later stages of therapeutic intensification was a glycated haemoglobin (HbA1c) level less than 7.0%. However, based on epidemiological data from studies suggesting no threshold for microvascular or macrovascular benefit, including pooled results from the United Kingdom Prospective Diabetes Study (UKPDS),3 organisations such as the ADA suggested more stringent goals — including a normal HbA1c level (< 6.0%) — if the clinical situation allowed this.4 The first challenge to the applicability of the algorithm came when the results of A Diabetes Outcome Progression Trial (ADOPT) were published at the end of 2006.5 These confirmed the durable glycaemic efficacy of rosiglitazone monotherapy but showed an unexpected increase in distal fractures in women, which was subsequently also reported for pioglitazone,6 the other agent in the class. Then, in May 2007, a meta-analysis of published and unpublished trial data revealed a significant 43% increase in risk of myocardial infarction with rosiglitazone relative to other therapies for type 2 diabetes.7 Although the validity of this analysis is debated,8 pioglitazone appears to have no such deleterious cardiovascular effects and may reduce all-cause mortality.9 The ADA/EASD consensus algorithm was updated in early 2008 to include warnings about the association between rosiglitazone and myocardial infarction, as well as the risk of fracture with both glitazones (Box 1).10 Three recent large-scale randomised controlled trials investigated whether the 7.0% HbA1c threshold recommended in the ADA/EASD algorithm should be lowered. In the glycaemic control arms of the Action to Control Cardiovascular Risk in Diabetes (ACCORD)11 and Action in Diabetes and Vascular disease: preterAx and diamicroN modified release Controlled Evaluation (ADVANCE)12 trials, and in the Veterans Affairs Diabetes Trial (VADT),13 type 2 participants who were at high vascular risk were randomly assigned to either conventional or intensive therapy. The target HbA1c level in the intensive arm was < 6.0% in both ACCORD and VADT, and ≤ 6.5% in ADVANCE. Median HbA1c levels achieved at close of the trials were 6.4%, 6.9%, and 6.5%, respectively, compared with a median ≥ 0.7% greater HbA1c in the respective conventional therapy groups.11-13 Although ADVANCE used sulfonylurea-based intensive treatment,12 other therapies could be added as needed. In ACCORD and VADT, there was no uniform management strategy, but most intensively treated patients were prescribed rosiglitazone and insulin.11,13 Despite differences in the components of the primary endpoints between these trials, intensive therapy was not associated with significant macrovascular benefit. In addition, a 22% increase in all-cause mortality in the ACCORD intensive group, detected 18 months before close of the trial, resulted in all patients being transferred to less intensive glycaemic control for the remainder of the ongoing blood pressure and lipid treatment arms.11 Microvascular endpoint data are not yet available for ACCORD and VADT,11,13 but ADVANCE data show significant reduction in new or worsening nephropathy but no effect on retinopathy with intensive therapy.12 The lack of effect of intensive glycaemic control on cardiovascular disease in these trials appears to be at odds with epidemiological data, especially from the UKPDS.3 It is possible that better contemporary management of non-glycaemic cardiovascular risk factors, with increased use of statins, angiotensin-converting enzyme inhibitors, β-blockers and antiplatelet agents, attenuates the benefits of improved glycaemic control. For example, fewer than 2% of UKPDS patients took lipid-lowering therapy during the trial — which closed in 1997 — compared with more than 50% of ACCORD and ADVANCE patients at the end of these studies.11,12 Although overt hypoglycaemia was not implicated in the increased mortality in ACCORD,11 it was linked to later cardiovascular events in VADT13 and it is also possible that unrecognised low blood glucose concentrations contribute silently to a higher than expected cardiovascular event rate in intensively treated patients. In addition, as suggested by ACCORD subgroup analyses,11 established atherosclerosis may be refractory to glycaemic intervention. A further possibility is that, in contrast to statin studies, in which benefit is evident early, the cardiovascular effects of glycaemic improvement only manifest many years later. This “legacy effect” has been reported in type 1 diabetes14 and may not have been detected in ACCORD, ADVANCE and VADT as average duration of follow-up was ≤ 6 years. What are the lessons from what some might regard as an “annus horribilis” for research into type 2 diabetes management? One is the clear need for carefully designed and adequately powered studies that assess the long-term efficacy and safety of new treatments from both metabolic and cardiovascular standpoints. The Rosiglitazone Evaluated for Cardiac Outcomes and Regulation of Glycaemia in Diabetes (RECORD) study might provide endpoint data that help overcome the limitations of rosiglitazone meta-analyses. However, despite an interim unblinded review of data from the study,15 and post-hoc ACCORD11 and VADT13 analyses that did not suggest increased risk in rosiglitazone-treated patients, it is likely that larger studies will be needed for a valid assessment of the cardiovascular effects of this drug. With new therapies now available in Australia — sitagliptin (a dipeptidyl peptidase-4 inhibitor) and exenatide (a glucagon-like peptide-1 mimetic) — it would be reassuring for prescribers to know that long-term, large-scale safety surveillance of these agents was in progress. It is hoped that such trials will not be viewed as too expensive or logistically difficult, and that the government, pharmaceutical industry, hospitals, academic institutions and consumer organisations will work together to ensure their viability. In the case of glycaemic targets, ACCORD, ADVANCE and VADT were necessary because the relative cost, inconvenience and rates of side effects (including hypoglycaemia) associated with intensive treatment needed to be weighed against cardiovascular and mortality benefit using “gold standard” randomised trial methodology. Their overall findings support the conservative glycaemic target (HbA1c < 7.0%) used in the consensus algorithm10 (Box 2). However, further analyses of their data — especially those relating to microangiopathy, together with post-trial follow-up — could allow a more complex treatment algorithm to be developed, with some well defined patient groups benefiting more from achieving HbA1c levels close to or below 6.0% than others. In the meantime, evidence is emerging of the importance of optimal management of non-glycaemic vascular risk factors in patients with diabetes. For example, the recently published Steno-2 study found short- and long-term morbidity and mortality benefits from multifactorial interventions including multiple drug combinations of renin-angiotensin system blockers, aspirin and lipid-lowering agents in addition to appropriate lifestyle modification.16 Indeed, at present the ADA recommends placing less emphasis on concerted efforts to achieve normal HbA1c levels, and more on optimal management of non-glycaemic vascular risk factors.17 1 Updated algorithm for the metabolic management of type 2 diabetes from the ADA and EASD (2008)10 Reinforce lifestyle intervention at every visit. a Check HbA1c every 3 months until HbA1c is < 7%, and then at least every 6 months. b Associated with increased risk of fluid retention, congestive heart failure and fractures. Rosiglitazone, but probably not pioglitazone, may be associated with an increased risk of myocardial infarction. c Although three oral agents can be used, initiation and intensification of insulin therapy is preferred based on effectiveness and lower expense. ADA = American Diabetes Association. EASD = European Association for the Study of Diabetes. HbA1c = glycated haemoglobin. Source: Nathan DM, Buse JB, Davidson MB, et al. Management of hyperglycaemia in type 2 diabetes mellitus: a consensus algorithm for the initiation and adjustment of therapy: update regarding the thiazolidinediones. Diabetologia 2008; 51: 9 (Figure 1). Reproduced with kind permission of Springer Science+Business Media. 2 Recommendations for glycaemic management of type 2 diabetes based on consensus guidelines and recent trial data A glycated haemoglobin (HbA1c) level < 7.0% remains an appropriate target when using established blood glucose-lowering therapies There are possible deleterious effects of attempting to achieve normoglycaemia (HbA1c level < 6.0%), which may include death due to cardiovascular causes associated with hypoglycaemia Prescribe metformin at diagnosis Add insulin, a sulfonylurea or a glitazone* as second-line therapy (see algorithm to aid choice, Box 1) Use triple therapy if necessary (ie, initiate insulin or add a second oral agent)* Intensify insulin therapy (continue metformin ± glitazone) as the final therapeutic option Use glitazones only when increased risks of osteoporosis, cardiac failure and myocardial infarction (rosiglitazone) have been considered carefully * Pharmaceutical Benefits Scheme restrictions to subsidised glitazone therapy may apply.

Timothy M E Davis DPhil, FRCP, FRACP

Health care workers agree that it is necessary to improve the quality of health care for Australian patients by designing systems to avoid the risk of preventable harm. An important component of such a system is the capacity to measure, monitor and act on health care performance data. This is the current focus of health care reform around the world, including Australia. Health care quality can be measured by a variety of methods. In response to slower than anticipated health care reform, there is increasing interest in the use of nationally defined standards, which could be subject to mandatory external reporting and remedial processes. Here, we consider the issues that are likely to arise if national standards are to be developed and implemented in Australia, and provide a model for developing the standards.

Caroline A Brand MB BS, FRACP · Joseph E Ibrahim MB BS, PhD · Peter A Cameron MB BS, MD · Ian A Scott MB BS, FRACP

We won’t make progress on preventing disease if we don’t try. It’s time to try! Key propositions Develop a national charter for health that identifies targets for key risk factors and the determinants of improved health, to be endorsed by federal, state and territory governments and, where appropriate, also by local government and community agencies. Have Health Ministers report progress against the national charter every 3 years. Increase funding for prevention to 10% of the national health budget by 2015. Establish a nationally coordinated preventive health agency to be responsible for evidence synthesis, nationwide campaigns, program coordination, and evaluation of effectiveness, efficiency and equity outcomes. Australia’s health care system has performed quite well in international comparisons. However, health outcomes for many Australians, most notably Australia’s Indigenous people, are still poor. Our health system was never designed to meet the challenges presented by the ageing, burgeoning obesity, disability, substantial health inequalities and chronic illness in the Australian population today. There is now compelling evidence that Australia will reap considerable health, social and economic benefits from making disease prevention and the promotion of lifelong social, mental and physical health and wellbeing a much higher priority. A recent Australian Institute of Health and Welfare report has estimated that Australia’s total investment in “public health” by all Australian health jurisdictions is currently 1.8% of recurrent health expenditure, unchanged in almost a decade.1 This is low compared with an average of about 3% (which is still inadequate) for “prevention” among countries belonging to the Organisation for Economic Co-operation and Development.2 A reorientation of Australia’s health system towards primary prevention (which Australians want3) and health promotion would lead to a considerable reduction in the personal and community burden of avoidable disease, injury and disability. It would also lead to a more efficient use of resources, and generate substantial economic benefits over time, as Australia’s economic performance and productivity would also be improved by having a healthier workforce. Chronic disease accounts for about 80% of the total disease burden, and trying to manage it accounts for 70% of all current health expenditure in Australia.4 About a third of the current disease burden could be prevented by controlling risk factors like smoking, low fruit and vegetable consumption, alcohol misuse and physical inactivity.5 Social and economic marginalisation is also associated with each of these, which in turn has led to a significant rise in health inequalities in Australia. Quite clearly, focusing only on reducing hospital waiting lists and on correcting the current inadequacies of the health system cannot solve the chronic disease and other health problems facing Australia. As discussed at the National Prevention Summit held in Melbourne in early April this year, there are two major components to a nationally coordinated prevention agenda.6 These are (i) a prevention-oriented health care system and (ii) a whole-of-system for health approach. The first requires a health care system that provides leadership and delivers quality preventive care and health promotion. For example, all hospitals and the primary health care sector should be required to develop and implement a prevention strategy, and Australia’s jurisdictions should be required to achieve appropriate benchmarks. The second and more challenging requirement is the creation of a whole-of-society approach that enables disease prevention and health promotion strategies to operate effectively and sustainably across all levels and sectors of Australian society. Such an approach will involve all portfolios and levels of government, as well as the non-government sector, business and the broader community. Clearly, the current challenges confronting the health care system, such as the obesity epidemic, are not going to be solved by focusing only on “downstream” solutions within health services. For example, Australia’s obesity epidemic is associated with unhealthy diet and large reductions in physical activity, resulting from significant changes to the food supply, lack of public transport and the design of our communities and cities. Australia needs a whole-of-society approach that embraces prevention and acknowledges the crucial importance of cultural, social, economic and environmental factors for the health of all individuals and communities. This will only come about if prevention is elevated to a national priority, reflected in targets for key prevention outcomes identified and agreed to by all governments, and if prevention measures to achieve these targets, are appropriately financed. Australia needs a national charter that identifies all of the agreed key targets for improved health. This charter needs to be formally agreed to by all jurisdictions and levels of government in Australia, and Health Ministers should formally report on progress towards it at least every 3 years. This approach needs to build on Australia’s past successes with tobacco control, reducing the incidence of road traffic trauma, control of HIV/AIDS, prevention of heart disease and many others that have shown that long-term planning and coordinated effort over many years are hallmarks of successful and cost-effective prevention programs.7,8 Australia requires an approach to prevention that is accountable, targets the causes of poor health and that is financially supported and rigorously evaluated. We propose a series of health targets, agreed to by all governments, which tackle the causes of poor health, such as smoking, poor nutrition, excessive alcohol consumption and insufficient physical activity. These targets could inform the distribution of an increased pool of funding for primary prevention. Targets should also be set for some of the socioeconomic influences that are fundamental to better health (including housing, community cohesion and social inclusion, and education), and for population groups who experience the worst health outcomes. A substantial additional investment of at least 10% of the national health budget will be required for this new approach. In the 2005–06 financial year, just over $250 million was spent on health promotion in Australia, out of an inadequate $1.4 billion spent on all of public health. The impact of this additional investment should be accompanied by rigorous research and evaluation so that, over time, the evidence base for health promotion can begin to resemble that of more clinical areas of medicine. This prevention approach will require commitment from government portfolios beyond health, engagement from the three levels of government, and partnerships with the non-government and business sectors. Shared targets, accountability, greater investment, evaluation and mutual responsibility are the keys. However, to reach these achievements, Australia will require a new statutory authority or national preventive health agency to provide the leadership, technical support and program delivery capabilities, while working in partnership with all jurisdictions and relevant sectors of society.

Brian F Oldenburg PhD, MPsychol · Todd A Harper BEc, PGDipHealthProm, MHEcon

History doesn’t repeat itself; at best it sometimes rhymes — learning from the past to secure future success Key propositions If the two new commissions established by the federal government are to have lasting impact, their recommendations will require appropriate and sustained funding. Political leadership and commitment are essential. Professional capability and adequate expertise, both on a commission and available to it through its secretariat, are necessary for bringing about meaningful outcomes. Non-government and civil society networks must be consulted — a commission’s recommendations need to strongly reflect prevailing community understanding and values. In the light of Australia’s current health challenges,1 the new Labor federal government has established two commissions to review existing health services and advise about reform — one expressly to concentrate on what might be achieved through prevention. Two former national commissions deserve attention to see what lessons can be learned that could help ensure the success of the new initiatives. Before 1972, the Australian federal government’s role in health had essentially been to subsidise private health care services. During the Whitlam era, the Hospitals and Health Services Commission (HHSC), created under legislation passed in late 1973, produced a wide range of initiatives with its most important innovation being the Community Health Program, which was intended to make primary care more accessible, and prevention more popular, across Australia.2 The HHSC was inextricably connected with the policy ideas and political skills of the chair, Sidney Sax, former Director of Research and Planning in the New South Wales Department of Health. The HHSC was well resourced, with three full-time and six part-time Commissioners, but faced several familiar but serious constraints.3 The difficulties arising from the fast pace at which policy development was pursued were compounded by the division of responsibilities between Medibank and the Ministry of Health. However, the HHSC was able to pursue a deliberately conciliatory course. It emphasised primary health care and established the Community Health Program, which included the Family Medicine Program, the Hospitals Development Program, health services planning and research, a review of the School of Public Health and Tropical Medicine at the University of Sydney, diagnostic services, rehabilitation, Aboriginal health, rural health, health transport, nursing personnel, health careers, and occupational health.3 The legacy of the HHSC is mixed. Not only was it unclear whether prevention should be emphasised at the individual or population level, but many general practitioners were uneasy about the multidisciplinary, team-based approach of the community health centres and use of salaried doctors. However, a national corps of health professionals was imbued with the idea that community-based health interventions were achievable, while health promotion received unprecedented recognition.4 Another step for the nation away from the “sickness” model of health was the Better Health Commission (BHC), established by federal Health Minister Blewett in 1985. Noting the nationwide failure to advance prevention, it committed adherents to reorient their systems towards health promotion, and urged the creation of a national health promotion body. In 1987, after receiving the report of the BHC, the Australian Health Ministers’ Conference set up the Health Targets and Implementation (Health for All) Committee (HTIC), chaired by one of us (S R L).5 The HTIC produced a comprehensive set of eight national health goals and 65 targets in the proposed National Better Health Program (NBHP), with priority given to prevention. In 1988, the Australian Health Ministers accepted the NBHP and approved 3-year federal–state funding of $40 million for its implementation. This was the first national plan employing health promotion to be endorsed at such an elevated political level. Evaluators of the NBHP in the 1992–93 financial year noted observable progress in the HTIC’s priority areas, although major progress would clearly require efforts beyond a limited-life initiative like the NBHP.6 The BHC’s approach of using measurable outcomes, health priorities and cooperative leadership at the national level enjoyed a degree of popularity, and this has persisted, with current interest in measurable accountability owing something to this parentage. Notably, this includes renewed interest through the recent proposal for a National Prevention Agency.1 What can we learn from these commissions? First, both the HHSC and the BHC enjoyed considerable influence, though some sceptics judge that neither made any lasting impact. Such a dismal view of history overlooks incremental change, especially in the domain of political and social attitudes.7 By comparison with other commissions and inquiries whose recommendations go absolutely nowhere and whose reports are never read, at least these two were taken seriously, received multimillion-dollar funding and had an impact that lasted over several years. Second, the commissions enjoyed the patronage of competent federal ministers. Without strong political leadership,8 and political commitment, nothing happens. If the minister (or prime minister or premier) does not want a commission to do anything, it won’t. Consequently, a wise commission will keep in mind the political risk that the minister has taken in establishing it. This is “Politics 101”, but commissions have been known to be so dazzled by the brilliance of their recommendations that they lose this critical insight. Third, the commissions were led by individuals with professional status, congenial temperaments and political capability. Dull, politically inept people appointed to positions of leadership lead nowhere. Fourth, a commission needs to be well resourced to work. Finally, both commissions had strong links to non-government and civil society networks. A commission detached from the people will fail.

Stephen R Leeder MD, PhD, FFAPHM · Milton J Lewis MA, PhD

Chronic myeloid leukaemia (CML) was the first human cancer linked to an acquired chromosomal abnormality, subsequently shown to be a reciprocal translocation between chromosomes 9 and 22. The resulting fusion gene product, BCR-ABL, was shown to be the causative agent of the disease. CML has an incidence of around 1–2 cases per 100 000; in Australia, there are probably more than 200 new cases per year and more than 1300 prevalent cases. Treatment of CML with imatinib has been a powerful vindication of the concept of rational, gene-targeted drug design. Five-year published experience with imatinib at 400 mg orally daily demonstrates 89% overall survival and an estimated 93% freedom from disease progression. Adverse effects are mostly mild and transient. Higher doses of imatinib may be more efficacious and will be studied in upcoming clinical trials in Australia; however, imatinib is almost certainly not curative. Up to 28% of patients may have to stop imatinib because of intolerance or disease resistance, mostly due to point mutations of BCR-ABL. In this situation, many patients will respond to second- and third-generation tyrosine kinase inhibitors. Management of CML patients should involve close monitoring, especially in the first 2 years, with regular cytogenetics and quantitative polymerase chain reaction to optimise response and identify suboptimal responders as early as possible. Bone marrow transplantation remains the only known cure, but is reserved for patients whose kinase inhibitor therapy has failed, or who have advanced disease (accelerated phase or blastic transformation).

David J L Joske MB BS, FRACP, FRCPA

Worried sick: a prescription for health in an overtreated America. Nortin M Hadler. Chapel Hill: University of North Carolina Press, 2008 (viii + 376 pp). ISBN 978 0 8078 3187 8. Public and professional debate about health services has traditionally been dominated by concerns that needy patients are missing out on helpful care. In recent years, another perspective has been gaining ground: that too many people are having unnecessary, ineffective or even harmful tests and treatments. This argument is strongly and provocatively put by Nortin Hadler, Professor of Medicine and Microbiology/Immunology at the University of North Carolina at Chapel Hill and attending rheumatologist at UNC Hospitals, in his second book examining this issue. Professor Hadler argues that the institution of medicine has become self-serving in its medicalisation of the everyday complaints of life. He describes as “type II medical malpractice” doctors doing the unnecessary, albeit very well, and argues that health insurance should only underwrite interventions with a meaningfully advantageous benefit-to-risk ratio. His critique of the evidence used to back many common interventions is scathing, and he gives particularly short shrift to the claims of interventional cardiologists and cardiac surgeons. Others in his sights include the New England Journal of Medicine’s Editor-in-Chief, Dr Jeffrey Drazen, and epidemiologists involved in such practices as data dredging. Professor Hadler has little respect for holy cows, finding faults with evidence-based medicine, systematic reviews, large randomised controlled trials, and the quality movement. But he is not a nihilist. He wants to bolster people’s resources for coping with the everyday complaints of life, whether they be heartburn, backache, or insomnia. To be well, he points out, is not the same as feeling well. Readers may disagree with Professor Hadler’s interpretation of the literature or philosophical view. But don’t let this put you off. Apart from providing plenty of food for thought, his self-confessed “diatribe against medicalisation” is an engaging read. “We are”, he rails at one point, “a country of obese, hypercholesterolemic, hypertensive, diabetic, osteopenic, depressed, pitiful creatures perched on the edge of a cliff staring at condors: cancer, heart attacks, strokes, dementia, fractures and worse. We fear for our future. We teach our children that they, too, must live in fear for their future.” Something similar might be said of Australians, perhaps.

Melissa Sweet

Objective: To assess public perceptions of Australia’s doctors, hospitals and health care systems.Design and participants: A cross-sectional national telephone survey of a random sample of 800 Australian adults in August 2007.Main outcome measures: Ratings of subjective trust in health care providers, public and private hospitals, private health insurers and Medicare; attitudinal ratings for the current health care system, and public and private health care systems.Results: Australians reported high trust in doctors (general practitioners more than specialists), low trust in alternative practitioners, moderate trust in hospitals (private more than public), and greater trust in Medicare than in private health insurers. Older adults had the greatest trust in physicians, hospitals and Medicare, but all age groups held similar attitudes toward public and private health care systems. Support for the current health care system with its mix of public and private funding was moderately strong, but all respondents reported weak pro-private attitudes and very strong pro-public attitudes.Conclusions: Public perceptions of Australian medical professionals, institutions and systems are generally positive. This sample did not endorse an individual user-pays private health system, but strongly favoured a universal public health system that is collectively funded by the public purse.

Elizabeth A Hardie BA, PhD · Christine R Critchley BA, PhD

Public hospitals need an injection of cash to help reduce demand for hospital services; networking and role delineation among hospitals would immediately increase safety and quality Key propositions Funding — an immediate injection of $1 billion and agreement on equal state and federal funding of hospitals. Institutional — networking and role delineation for metropolitan hospitals, including subclassification of emergency departments to more accurately delineate their capacity; improved inter-hospital transport systems; and development of a mutually beneficial partnership between public and private hospitals. Workforce and staffing — accreditation of the skills of individual doctors who work as locums, restoration of constructive and timely interaction between clinicians and senior management, and a supportive environment to promote staff retention. Demand management — building up out-of-hospital services and preventive care. Community engagement — dialogue with the community to make sure they understand the rationale for the proposed changes. While most patients in our public hospitals receive a very high standard of care, the incidence of misadventure and the inequities that currently exist1 are unacceptable. These problems are a product of a workforce crisis, ever-increasing demand for hospital services from ever-sicker patients, and too many episodes where the clinical needs of a patient are not attended to by suitably skilled staff. This last problem is a feature of a political climate in which warnings by hospital clinicians that a hospital cannot provide a quality service (such as an intensive care unit) are too often ignored for fear of community anger about that service not being available locally! Each evening, many hospitals have staff phoning medical agencies in frantic competition for doctors who might help them out during the coming night. It is a lottery in which the doctor you “win” may not have the experience needed for the tasks required. Hospitals do not function optimally with occupancy rates that exceed 85%, yet many regularly exceed 100%. In very busy, inadequately staffed hospitals, communication breakdowns all too often compromise safety.2 SolutionsRole delineation for every hospital is essential. Too many are expected to provide a broad array of quality services. Each hospital should be an invaluable asset in a “networked” system, offering services based on its ability to guarantee quality and safety, and the overall needs of the network. We need to follow other countries and subclassify our emergency departments, redesignating some as acute care centres, with their capabilities and limitations clearly explained to the public. Poor urban planning has seen the development of smaller hospitals in close proximity to each other. These should act as a single hospital on split sites, offering excellence at each site, but not duplication. Even some of our “principal referral hospitals” could benefit from such an approach. Instituting and, in some cases, improving interhospital transport will be an essential ingredient of such an integrated hospital system. Commonsense changes like these do require political leadership and public understanding (as explored by Mooney in this series3). We would be promising our patients that, wherever they entered the public hospital system, we would ensure that they are given the highest quality care, even if that means moving them to a more appropriate facility. Public hospital clinicians are feeling increasingly disenfranchised as budgetary control dominates the thinking and actions of hospital managers and promotes centralisation that removes clinicians from the frontline environment. This must change. Clinicians are extremely frustrated when their urgent concerns cannot be addressed by inhouse administrators with decision-making power. Decreasing budgetary pressures by instituting hospital funding based on episodes of care rather than fixed historical budgets would see the re-emergence of all-important partnerships between clinicians and managers.4 Clinician governance (medical staff councils, clinical councils, etc) must be revitalised, with clinicians’ influence guaranteed in hospital by-laws. Up-front bonuses may attract some nurses to return to work, but flexible working conditions with support and mentoring replacing bullying and excessive workloads would be more effective. Each state needs an institute for medical education and training, resourced to accredit the practical skills of Australian and overseas-trained doctors who plan to work as locums in our public hospitals. Senior doctors should be encouraged, and financially remunerated, to spend more time in their hospitals helping to improve the quality of decision making. Many inadequately staffed hospitals would benefit by training emergency response teams to provide quality urgent care at all times. We need to develop a long-overdue, mutually beneficial partnership between public and private hospitals. With additional funding, public hospitals that do not have any additional capacity could purchase services for their patients from private hospitals.5 In the medium term, the reforms offered in these articles would provide more health care from current funding levels. However, the public hospital system, as constituted, needs a major and immediate injection of cash. Given the current federal budget surplus, the offer of $2 billion over 4 years for our hospitals could surely be more generous, with at least $1 billion more needed in the next year ($500 million is on offer). The next Australian Health Care Agreements must represent both an instrument for these reforms and a return to the 50/50 funding split for the federal and state governments, as was mandated at the inception of the scheme. Additionally, these reforms must be accompanied by major efforts to reduce demand for hospital services by focusing on disease prevention, the maintenance of wellness, and earlier diagnosis and treatment of potentially chronic diseases. Our health care system needs dollars, reform, public understanding of the rationale for changes needed and, most of all, political courage. These would provide our best chance in a very long time to create the sustainable, fair, quality hospital system we need and can afford.

John M Dwyer AO, FRACP, PhD

Key propositions Prompt development of an appropriately resourced national primary health care strategy, which includes the flexibility to achieve equity of access and equity of outcomes. Much greater government investment in the primary health care workforce and in capital infrastructure for primary care services. Enhanced models of access to medicines for all Aboriginal and Torres Strait Islander people and the extension of this model to other at-risk groups. Primary health care reform is an important part of the package of health care reform that is required in this country.1 Australia has no current agreed national strategy for primary health care, nor an agreed set of principles on which to base its reform. Without a national strategy, primary care reforms will be disjointed, and inequities and cost shifting will continue. While there is some evidence that strengthening primary care in developed countries will improve their citizens’ health through access to more appropriate services, lower the cost of care and reduce the inequities in a population’s health,2 reform must not be a static process. Australia’s current health reform agenda will allow us to trial new approaches in a meaningful way. The way forward is not all across uncharted waters. We do know that improving equity of access for disadvantaged groups in our population will make a difference.3 Equity in health outcomes must be the main aim of any primary health care reform. Measures such as enhancing the health care workforce are necessary to ensure equity of access to a reasonable range of primary care services by all people. Primary care services must be supported by incentives that focus on meeting the needs of people who are at higher risk or more likely to encounter barriers to access. The needs of Aboriginal and Torres Strait Islander people, people from lower socioeconomic backgrounds, those living in rural locations and those with disability, especially intellectual disability, among other groups at higher risk, must be met. Our primary care system must grow and be nourished. While the nation’s primary care workforce needs to be expanded to meet growing community needs, this workforce, once in place, must be supported so it can continue and thrive.4 Our governments need to boost the status of primary health care practitioners through appropriate levels of recognition, reward and support. Mechanisms are required to maintain training, registration and continuing professional development of all members of the primary care workforce. New models of integrated comprehensive primary care provision need to be viewed as pilots which are evaluated and then either more widely adopted or jettisoned to make way for newer ideas. Developing super clinics in 31 scattered locations is rebadging an old concept, and on its own will not meet the nation’s needs. Every primary care clinic needs the capacity to work within a framework that is relevant, timely and sustainable. This needs to be supported by a national plan for capital investment in primary care. Structural and clinical changes must be based on an infrastructure that is able to adapt to the rapidly changing environments that new technologies, including e-health, bring with them. Ready access to best available evidence to support clinical decision making and to key patient information through shared electronic health records has not yet been fully implemented. These measures are, in any case, now no longer enough. New technologies, such as telemedicine, home monitoring, point-of-care pathology testing and e-consultations, all need to be evaluated. Community engagement and involvement in decision making5 is a core feature of primary health care, and is happening, but we need new ways to move this forward. Members of each local community must be joined by policymakers and local health care providers to ensure appropriate governance of local health services, while ensuring that national standards are achieved. Everyone involved in primary care service delivery needs to be committed to ensuring the quality and safety of primary care services. Again, this must also include an active voice for consumers. National programs to improve health care safety and quality must have a strong focus on primary care. This includes further strengthening of the quality use of medicines, the rational use of pathology testing and the management of complex comorbidities. Primary care services need to meet standards of care through accreditation processes. It takes time and ongoing commitment of resources to deliver and maintain quality care. Funding systems need reform to support both the time and the rapid changes required to provide comprehensive primary care, and to allow the further development of multidisciplinary models of care delivery. The Medicare system needs structural and timely reform to ensure, for example, that payment mechanisms do not result in discrimination. The patchwork nature of private, federal and state/territory funding for primary health care services adds complexity to the reform process. Barriers between parts of our health system which impede quality care and put patients at risk must be removed.6 One practical initiative that can be implemented immediately is to extend the effective program for increasing use of medications among Aboriginal and Torres Strait Islander people living in remote communities. This should be extended through community pharmacies to all Aboriginal and Torres Strait Islander people, and also be considered for other at-risk groups.7 The challenge for the federal government is to ensure that primary health care reforms actually do make a difference to health outcomes for the people of Australia. The National Health and Hospitals Reform Commission and the National Preventative Health Taskforce have been widely welcomed. Whether they will bring the reform needed to optimise the contribution of primary health care is yet to be seen.

Michael R Kidd MD, FRACGP · Ian T Watts BSW, DipSocPlan, MBA(Exec) · Deborah C Saltman AM, MD, FRACGP, Professor

To the Editor: There is a significant shortage of general practitioners in Australia, and many of those in practice are nearing retirement. The government has belatedly realised the need to train more GPs and in the past few years has dramatically increased university places for medical students. Coupled with this increase in numbers is the need for medical students to gain more of their education in general practice, where patients with many of the common medical problems are now managed. This has increased the pressure on universities to place medical students in general practice, and they are having difficulty finding enough willing and capable GPs to train their students. Paying GPs more to teach medical students might help. However, students’ experience of general practice needs to be positive if they are to be persuaded to become GPs themselves in the future, and a positive experience is more likely when the supervising GP is not rushed and can provide students with hands-on practice. Therefore, apart from increasing financial incentives, it is important to reduce “red tape” for training medical students and to free GPs’ time for teaching. A positive step would be to provide an extra payment to the GP on top of the consultation fee for each patient seen by a student under the GP’s supervision, similar to the extra payment for a consultation with a pensioner. This would contrast with the current situation, where a GP who supervises students must fill out forms and wait for a PIP (practice incentive payment) many months later. Another step would be to make accreditation less onerous for GPs who regularly provide clinical experience for students. Adequate continuing medical education (CME) points should be given for providing quality training without the GP needing to “jump through hoops”. If the medical student training crisis is to be resolved, then these issues need urgent attention.

Andrew A Beveridge

To the Editor: The authors of the recent supplement on clinical process redesign have shown that improvement can occur in the efficiency and quality of hospital care.1 They acknowledged that this process was accompanied by an investment in external consultants and a boost to the system of 1800 beds. These interventions were necessary, and have been successful in the short term. However, these measures alone may not be sustainable for hospitals in the long term with the projected needs for the health care of an ageing population.2 The table in the appendix to the supplement showed most hospitals continuing to perform poorly in their response to increasing demands on emergency departments (EDs), with corresponding increases in admissions to hospital.3 It was interesting to note that, of all the hospitals listed, Campbelltown Hospital, with the largest increase in demand (27%), also had the lowest increase in admissions through its ED (6%). A similar phenomenon was noted at Bankstown Hospital, which had a 27% increase in demand and a 13% increase in admissions. Could these have been the result of the community and ambulatory redesign that occurred in these hospitals from 2000 to 2004?4 The common feature of these two hospitals is the linkages developed between ED community nurses and general practitioners, creating a situation whereby increasing demand does not have to rely entirely on hospital beds as a solution.5 The case of an older woman with diabetes, sepsis and heart failure described in one of the supplement articles6 implicates a failure in community chronic disease management, as well as hospital care. Older people will continue coming to EDs, and will continue to be admitted to hospital in increasing numbers. To avert future crises in health care, the success of hospital redesign needs to be matched by an equally well resourced redesign of primary health and community care.

Stephen F Wilson · Nicholas Collins