Health services administration

To the Editor: The recent supplement to the Journal on clinical process redesign1 is a tepid attempt by NSW Health and their colleagues in South Australia to disguise their own shortcomings. Astute readers need more than fancy jargon, acronyms and pretty diagrams to be convinced that reform of the sort suggested by NSW Health cuts the mustard. Indeed, some of the language (“The process will proceed with or without you”2) provides disturbing insight into the mindset of those at the helm. Also, the ideas exemplified in another section are at clear odds with what I experience daily as a senior clinician. To illustrate, McGrath and colleagues write of “engaging clinical leaders” and that “solutions need to be evidence-based”.3 Regrettably, the opposite is the reality. Senior medical clinicians are sidelined and the decision-making process becomes the domain of a few select individuals, thus making it sclerotic, remote from the clinical interface and, at times, autocratic. Further, some management decisions are implemented without any of the supposed evidence base that McGrath and colleagues3 refer to. Perhaps of greater concern is the notion of “stretch targets”.3 These are considered “essential to stimulate real innovation”, but, translated into plain English, sound like asking staff to work harder with no additional resources. In the past 15–20 years I have witnessed several changes in senior hospital management, each bringing the “latest and greatest” ideas on public hospital reform. Sorry folks, we don’t need more of this nonsense. Rather than yet another futile cycle of reform per se, the community needs to have a debate on the level of health care that it wants, contrasted with how much of the “pie” should be consumed relative to other needs. Until that happens, we are merely pretending that “process redesign” is the answer to our problem.

George Larcos

To the Editor: In regard to your recent supplement dedicated to clinical process redesign in health care,1 we support the need to learn from other industries, but have concerns about an exclusive focus on process redesign to improve the quality and safety of health care for patients. In industry, unlike in health care, outcomes surveillance is almost always feasible. Clinical practice reminds us of the fallibility of surrogate measures of benefit, which, like “processes”, require validation by “hard” outcomes.2 Industry knows when its services or products meet minimum quality standards and satisfy “customer” needs. By contrast, a “lean approach” in health care, while taking a patient-centred perspective of care processes, makes several assumptions. The first is that better flow processes relate directly to improved outcomes. Process redesign focuses on measuring targets such as access block and elective surgery waiting lists, which are subject to confounding and manipulation.3,4 The impact on health care outcomes remains unclear. Furthermore, the studies cited in these supplement articles had no concurrent controls.3,4 The second assumption is the relative values of the process measures chosen. Is a relatively small reduction in time spent in the emergency department more important than use of an appropriate device for relieving pressure ulcers in an older woman with a fracture?5 The third assumption is that there are cause and effect links between process redesign and outcomes, such as fewer episodes of litigation at Flinders Medical Centre.6 Such links cannot be substantiated without a control group, as concurrent changes, such as open disclosure and guideline implementation, may have similar effects. Other literature pertaining to the benefits of lean thinking in process redesign emphasises opportunities to reallocate resources to implementing best practice as a result of the efficiencies and cost savings achieved.7 This assumes that process redesign occurs quickly, and that all cost savings are reallocated. These claims appeal to managers and directors constrained by external demands for meeting efficiency targets. The inevitable consequence is that organisations are likely to focus on simple “fixable” problems rather than more fundamental system-based problems requiring more resources and longer timeframes. Also, it can be argued that the process redesign examples are “micro-reforms” within a “macro-system” that remains unchanged. The hospital sector needs broader redesign wherein existing models and systems of care, and not just internal processes, are subject to critical review and improvement. Process redesign should be viewed as a useful tool, but the primary starting point must continue to be the delivery of evidence-based care, which is known to give patients the best chance of optimal outcomes.

Caroline A Brand · Peter A Cameron · Peter B Greenberg · Ian A Scott

In reply: We agree with Wilson and Collins. Community-based or ambulatory alternatives to admission to an acute facility are essential adjuncts to the redesign and increased bed capacity referred to in our article.1 The capital costs alone will be prohibitive if our only strategy is adding bed capacity. We see a significant shift in capacity from the acute to community sector as eminently amenable to redesign methods: to map current constraints (as the issue is not just inadequate community services), engage clinicians in changing their referral and treatment patterns, improve awareness of alternatives, identify new processes to facilitate use of the community as a viable alternative, and embed these new behaviours through easily accessible redesigned pathways. We chose the case study of the frail older patient deliberately, as it highlights how our current default option, hospitalisation, does not necessarily give these patients the best outcomes. In response to Larcos, we are concerned that the frustrating complexity of our current system for patients and frontline staff alike has produced so many clinicians who, like him, are cynical about improvement. Good redesign activity does engage clinicians, and our best improvements arising from redesigned processes are those that have incorporated clinician and patient input. That is the practical everyday “evidence” on which good redesign is based. Redesign does not ask staff to work harder. Significant leaps in performance can be achieved by redesigning to make an increased throughput easier to deliver. Good redesign eliminates the frustrating and wasteful steps in care that add no value to the staff or patient experience. Finally, in response to Brand and colleagues, both delivery of evidence-based care and process redesign are required to improve access to services and, hence, equity, patient flow, and patient and staff experience, and to reduce wasted effort. There is mounting evidence that better flow processes are associated with better outcomes. An Australian study has shown that delayed progress through Australian emergency departments (EDs) is associated with increased mortality.2 Our own article illustrates a 30% reduction in statewide mortality in New South Wales EDs as flow improved, with a concomitant reduction in statewide hospital standardised mortality rate.1 When patient flow improves because constraints and disconnects are eliminated, then system efficiency improves; it is only when patients are processed with indecent haste that one might expect a deterioration in quality. The improvements reported were not just measured in minutes from initial triage, but also in fewer hours spent in an ED before transfer to a ward, and in fewer days of waiting for tests and consultations as an inpatient before discharge. The results provided in the supplement3 are for an entire state health system, the largest in Australia, illustrating a turnaround in state performance, and they therefore warrant serious consideration.

Tony J O’Connell · David I Ben-Tovim · Brian C McCaughan · Michael G Szwarcbord · Katherine M McGrath

Removing the protection of confidentiality will not help raise standards of care Governments confronting serious adverse health care events feel obliged to be seen to be doing something. They often set up an inquiry or, less commonly but peremptorily, amend legislation, attempting to avoid repetition of the events. The Davies Inquiry, “with particular reference to Dr Jayant Patel.”, was Queensland’s response to adverse incidents in that state.1 By contrast, New South Wales responded to adverse incidents relating to Dr Graeme Reeves2 by amending the Medical Practice Act 1992 (NSW) in the Medical Practice Amendment Act 2008 (NSW), obliging practitioners to notify the NSW Medical Board of “disruptive” or “wayward” colleagues (see Box). The amendments, welcomed by the Board, allow for generally speedier suspension or deregistration of professionally incompetent doctors. These actions can, however, still be delayed by doctors appealing to the Medical Tribunal (customarily, two medical practitioners in the same field of practice as the respondent, a lay person, and a District Court judge as chairman) or the Supreme Court (which has, on legal grounds, stayed the Board’s suspensions of two subsequently deregistered doctors), and by the inclusion of lay persons in these inquiries. In NSW, unlike in other Australian states, the Health Care Complaints Commission, not the Board, investigates and prosecutes breaches of the Act, and the Medical Tribunal, not the Board, strikes off and re-registers doctors. The Board’s jurisdiction covers registration, impairment, performance, and disciplinary breaches that would not warrant de-registration. The amendments to the Medical Practice Act allow the Tribunal to take into account, in a re-registration application, complaints received subsequent to deregistration. Further, the proceedings of the Medical Board’s professional standards committees (PSCs) will no longer be confidential, will be chaired by a legal practitioner, and their findings made public. The mandatory notification included in the amended Act overcomes some of the problems facing whistleblowers who, traditionally, are encouraged to voice their concerns locally — at their hospital or Area Board.5 Already, in many jurisdictions, doctors must report colleagues with health problems that could affect their practice of medicine. Mandatory reporting in the areas of professional standards and competence, however, is a first for Australia. Such reporting is mandated in seven of the United States of America (Arizona, Delaware, Montana, Nebraska, New Jersey, Oregon and Texas). The NSW Board’s much publicised standards of professional care expect doctors to make such notifications6 in accordance with section 86E of the Act: persons may notify the Board of “any matter that the person thinks indicates that the professional performance of a registered medical practitioner is unsatisfactory”. Failure to report concerns has led to serious consequences: the United Kingdom General Medical Council set a precedent when it found a senior anaesthetist guilty of serious professional misconduct for failing to pursue complaints that a locum was endangering patients.7 In 2005, it punished two doctors who had not reported their concerns about a patient of Harold Shipman,8 found guilty of murdering 15 patients and implicated in the deaths of many more. Despite longstanding obligations to report “impaired” colleagues, we know that there is a continuing reluctance among doctors to do so. Will they be any more forthcoming in reporting “incompetent” colleagues? Unless harm to patients is qualified to refer to serious, perhaps life-threatening, harm, as in New Jersey (“conduct which would present an imminent danger to an individual patient or to the public health, safety or welfare”9), the way could now be open for cross-complaints where “turf wars” exist between branches of the profession. Some plastic and reconstructive Fellows of the Royal Australasian College of Surgeons are dismayed by the work of “cosmetic physicians” who lack surgical training; and orthopaedic and neurosurgeons might dispute one another’s spinal surgery techniques. These areas of practice are bedevilled by patients’ complaints. With the amendments now effective, the effects of the “law of unintended consequences” (inevitable unanticipated consequences of the actions of people, and particularly of governments10) remain to be seen. How will the NSW Medical Board, Medical Tribunal and Supreme Court define a flagrant departure from accepted standards? Proof that a doctor ought reasonably to have believed that a colleague warranted being reported will, no doubt, trigger much legal disputation. Over the past two decades, the NSW Medical Board has moved away from seeing all breaches of standards as requiring punishment. Part 5 of the Medical Practice Act enables the Board to help doctors in difficulty continue in practice, with appropriate treatment and monitoring (provided they are no threat to the public). Under Part 5A, the Board has a well established system of performance appraisal. Both procedures are based on confidentiality. A balance needs to be struck between the public interest of raising standards through frank discussion (in confidence) among professional peers, and satisfying individual patients’ or relatives’ desire to know the facts of individual mistakes. Just as the confidentiality of meetings on maternal and perinatal mortality and morbidity and on anaesthetic deaths has led to improvements in standards, so too has the confidentiality of meetings of PSCs. From its inception in 1987, the PSC was understood, and accepted by the NSW Government, as a professional assessment of standards. Cabinet agreed to the trade-off of confidentiality to encourage respondents to be frank and truthful, thus assisting PSCs to improve standards. Respondents are, therefore, not legally represented at these professional hearings. By contrast, serious breaches go to the Medical Tribunal, where respondents have legal representation before a judge, with a right of appeal on points of law to the Supreme Court. Now that PSC findings are no longer confidential, respondents are faced with representing themselves in potentially career-damaging proceedings with publicly available findings. This might make them decline to appear, instead entrusting the defence of their reputation to a barrister before the Medical Tribunal. Such a change, from a discussion with colleagues about techniques or therapies, aimed at improving standards, to a courtroom with a barrister, trying to prove no wrongdoing, is inconsistent with raising standards of care. Are these proposals then simply another example of a government wishing to be seen to be doing something, or are the benefits likely to outweigh the disadvantages? In view of the established policies of the Medical Board, breaches of which are already sufficient to attract disciplinary action, the only gain would seem to be directing whistleblowers to the Board instead of to their local hospital or Area Board.11 This could avoid the futility experienced by nurse Toni Hoffman, in informing her hospital superiors of her concerns about Dr Patel.12 Regrettably, as agreed by complainants’ advocate Terry Stern,13 the abolition of the confidentiality of PSC hearings will hinder the Medical Board’s attempts to improve medical standards. The looming uncertainty, of course, is how these issues will be handled if, when and how the Council of Australian Governments’ proposals for national registration of health care professionals14 are implemented. Reportable misconduct under the Medical Practice Amendment Act 2008 (NSW) (Section 71A) NSW doctors must report if they reasonably believe or ought reasonably to believe that a colleague has: engaged in sexual misconduct in the practice of medicine; practised while intoxicated by drugs or alcohol; or flagrantly departed from accepted standards of professional practice or competence, risking harm to patients.

Peter C Arnold BSc, MB, BA

Objective: To evaluate the feasibility, reliability and acceptability of the mini clinical evaluation exercise (mini-CEX) for performance assessment among international medical graduates (IMGs).Design, setting and participants: Observational study of 209 patient encounters involving 28 IMGs and 35 examiners at three metropolitan teaching hospitals in New South Wales, Victoria and Queensland, September–December 2006.Main outcome measures: The reliability of the mini-CEX was estimated using generalisability (G) analysis, and its acceptability was evaluated by a written survey of the examiners and IMGs.Results: The G coefficient for eight encounters was 0.88, suggesting that the reliability of the mini-CEX was 0.90 for 10 encounters. Almost half of the IMGs (7/16) and most examiners (14/18) were satisfied with the mini-CEX as a learning tool. Most of the IMGs and examiners enjoyed the immediate feedback, which is a strong component of the tool.Conclusion: The mini-CEX is a reliable tool for performance assessment of IMGs, and is acceptable to and well received by both learners and supervisors.

Balakrishnan R Nair FRACP, FRCP · Heather G Alexander PhD · Barry P McGrath MD, FRACP · Mulavana S Parvathy FRACGP · Eve C Kilsby BA(Psych) · Johannes Wenzel MD, FACEM · Ian B Frank BA(Hons) · George S Pachev PhD · Gordon G Page PhD

Ideas abound, but robust evidence from health care services research is still scarce In 2000, 3 years after the election of the Labour Government in Britain, the then Prime Minister, Tony Blair, launched an ambitious reform program for the National Health Service (NHS), which would make it “the healthcare system the world most envies.” The reform was underpinned by the largest ever investment in the NHS, with spending increasing from £23.7 billion in the 2000–01 financial year to £90.2 billion in 2007–08.1 The reform package included not only more medical school places and increased rewards for consultants, but also more specialist registrars, general practitioners and GP trainees. There was also to be a quantum leap in the numbers of nurses and other health care professionals, along with widening of their practising opportunities through task transfer. The Blair NHS plan signalled 7000 more beds in hospitals and 100 new hospitals over 10 years, along with a commitment to modernising general practice premises and opening 500 new one-stop primary care centres.1 It was promised that, by 2005, the maximum waiting time for outpatient appointments would be 3 months; for inpatient admissions, 6 months; and waiting lists for hospital appointments and admissions would be replaced by a booking system, designed to give patients a choice of a convenient time within a guaranteed maximum waiting time. In short, there were to be more doctors, nurses and other health professionals, more hospitals beds as well as improved patient access to GPs and specialists.1 So, what were the outcomes of this radical and incisive reform of a health system? The answers are in the report by the NHS Audit Commission, issued in June this year. The overall verdict was that the NHS system reform has improved management of the health service but needs more time to deliver significant benefits for patients.2 In Australia, there is an expectation that the newly elected Rudd Labor Government might emulate the Blair health reform agenda. But since its election last November, beyond a $423 million commitment to general practice super clinics,3 what we have witnessed is a cavalcade of commissions and taskforces, such as the National Health and Hospitals Reform Commission, the National Preventative Health Taskforce and the National Primary Health Care Strategy. Cynics may well say that the Rudd Government is affected by decision-paralysis, while others might say that it is in the process of gathering evidence to underpin its policies and reforms. In a recent speech, Prime Minister Rudd noted that: “A third element of the Government’s agenda for the public service is to ensure a robust, evidence-based policy making process. Policy design and policy evaluation should be driven by analysis of all the available options, and not by ideology.”4 Furthermore, Sally Redman, Chief Executive Officer of the Sax Institute, a health policy think-tank in Sydney, believes: “Policymakers need timely information that is locally relevant, of high quality and dependable.” (personal communication). But they also need ideas. In this issue of the Journal, we commence a series of articles written by leading proponents of health care reform in Australia, and coordinated by the Series Editor Gavin Mooney, Director of the Social and Public Health Economics Research Group (SPHERe) at Curtin University of Technology in Western Australia (→ The people principle in Australian health care5; → What is the health service for?6). There can be no doubt that Australian health care does indeed need reform, and that there are many ideas upon which to draw. But what is missing from the mix is robust evidence. The National Health and Medical Research Council (NHMRC) is the major powerhouse for health care research in this country. It should be of concern that, in 2000, only $1.7 million was spent on health services research, and this had risen to a mere $23.7 million by 2007.7 Indeed, the funding for new grants for health services research has, on average, scored around less than 3% of total commitments.7 Furthermore, over the same period, successive governments have allocated infrastructure support to a bevy of Australian biomedical research institutes, while fledgling Australian health policy research institutes continue to be poor cousins. This relative poverty in health services research was highlighted in the 2004 Investment review of health and medical research (by the Grant Committee).8 It recommended the development of strategies to improve the impact of research influencing policy and practice, through a dedicated process, NHMRC staffing, an advisory committee and appropriate investment.8 Now, some 4 years later, the NHMRC has announced a package of $108 million over 2 years to support: research — preferably though collaboration between researchers and those responsible for the design and delivery of health services; centres of excellence — undertaking policy research from which a national institute of health research may well emerge; and a program for capacity-building grants for health services research — each of $2.5 million over 5 years (Warwick Anderson, Chief Executive Officer, NHMRC, personal communication). These initiatives are to be welcomed, but there is one missing element — a comprehensive research agenda to guide the gathering of evidence pertinent to health care reform. As the Prime Minister has stressed, health policy formulation and its inherent health care reform should be driven by relevant evidence. The Rudd Government may well consider yet another taskforce that brings together key stakeholders to identify those areas in health care that currently need robust evidence to support future reform. Ideally, establishing this agenda might be an item for consideration at the next Australian Health Care Agreements meeting. After all, health care systems are the responsibilities of all our governments — federal, state and territory. Given the recent highly publicised recommendations to expunge the “blame game” from the Australian Health Care Agreements,9 it could be the seminal test case.

Martin B Van Der Weyden MD, FRACP, FRCPA

We need a set of precise principles to underpin and drive health policy in Australia Key propositions The federal government should outline the principles to inform the work of the National Health and Hospitals Reform Commission and others advising on or implementing national health policy. The federal government should establish an independent and professional “Romanow-type” commission2 to engage widely with the Australian community on the design principles for health care in Australia. That commission should have an ongoing role to consult with the community and report publicly to the government on whether its health programs are consistent with the agreed principles, and on the effectiveness of health departments and health units in implementing these principles. It is hard to find any coherent set of principles that guide health policy in Australia. So much is ad hoc, short term, and seemingly born out of political compromise, designed to placate vested interests. Some services are provided free, while others, like dental, receive little government support. Some services are covered by tax-funded insurance through Medicare, but at the same time there are large incentives for, mainly those on high incomes, to opt out of sharing and into private health insurance. Politicians talk of “universalism” and a “commitment to Medicare” while encouraging the development of a two-tier hospital system. Governments, particularly coalition governments, speak vaguely about the importance of markets, but there are few areas of health care in which there is market competition. Labor politicians sing the praises of bulk-billing while supporting high copayments for pharmaceuticals and maintaining the Medicare safety net, which mainly advantages the wealthy.1 Overall, it would appear that the health debate in Australia focuses on managerialism without first establishing the values that should underpin and drive a national health service. Fragmentation, inefficiency and waste are important issues, but do we want a well managed and efficient system that lacks guiding values? Our values are a statement about who we are and what is important in being an Australian. Our values and our national identity are inseparable. Values such as fairness and equal opportunity are widely shared, but for practical purposes, we need to translate these broad values into more precise principles that guide the development of policy and programs. I believe that there are some key principles, listed below, that should guide health policy design. Having a universal single-payer system accessible to all. Poor and rich should have access to the same high-quality health care services. That does not require subsidising inefficient private health insurance companies — a single payer like Medicare would fund both public and private providers. Further, a universal system does not also imply a “free” system. Promoting private and public health care delivery to ensure efficiency and effectiveness, particularly in hospital services. Designing services around patients’ needs, and not the historic interests of health care providers. Fairness through universal taxpayer funding. Giving priority to disease prevention and keeping people healthy. Actively involving the community in setting priorities (eg, Indigenous health and mental health). Achieving technical efficiency so that we obtain the maximum benefit from our limited health care dollars. Subsidiarity, whereby health care is delivered by the most local health unit (eg, primary care) subject to national policies, national funding and national standards.1 This is not to say that we should be unsympathetic to governments that have to make pragmatic decisions on the basis of perceived or actual public concerns and the self-interest of health care providers. Governments can only build on what we have at the moment. But in health, as in so many areas, we need some clear principles that provide guidance and discipline in the development of health care. I suspect that there is widespread agreement, particularly on the principles of universality and equity, but, in a democracy, the only acceptable way to establish and assert principles is serious and continuing community engagement. Political leadership is important in articulating and shaping principles, but, in the end, it is the community’s values and principles that matter. In Canada a decade ago, the federal government established a Royal Commission to conduct a dialogue with citizens, and to make recommendations to the government on an ideal health care service for Canadians. In Renewing the foundations (of Canadian health), the Commissioner, Roy Romanow, proposed a Canadian Health Covenant that expresses Canadians’ collective vision for health care and that outlines the responsibilities and entitlements of individual citizens, health providers and governments in regard to the system. We need consensus on why the system exists, what it is intended to achieve and how its component parts should fit together. This is vital to restoring the public’s confidence in the system.2 In referring to “consensus on why the system exists, [and] what it is intended to achieve”, Romanow was, in effect, saying that Canadians needed to agree on the principles that should guide the design of the Canadian health care system. His report underlined the wide support among Canadians for the principle of universality. In this series of articles on health care reform, Mooney outlines how community engagement can be effective.3 We must avoid the tokenism which so often is a feature of community consultation or engagement. The Australian Government has not spelled out why the Australian health care system exists and what it is intended to achieve. Principles must come before managerialism.

John Menadue AO, BEc

As we are dealing with the people’s health, the people’s voice needs to drive the principles underpinning our health care system Key propositions In seeking to establish the principles to underpin the Australian health care system, the people to ask are informed citizens, and this is best done through citizens’ juries. Evidence to date suggests that, compared with the existing implicit principles, citizens are much more supportive of equity of access and of public health and preventive medicine. A consultative process to establish a health service “constitution” should be set up with 20 citizens’ juries across the country, each with 15 randomly selected members (“20.15”), to be followed by a “National Citizens’ Summit”. In the wake of Menadue’s call for setting principles to underpin our health care system,1 one key principle that members of “citizens’ juries” advocate is that the appropriate group to set the principles are citizens! Health services are first and foremost social institutions — that is, not just there for the people, but to be based on the values of the people. I have facilitated a number of these citizens’ juries.3 They are a form of deliberative democracy.4 They bring together randomly selected citizens; and it is crucial that they are randomly selected, not hand-picked or self-selected. It is emphasised to the members of these juries that they are there as citizens, not consumers, and if the focus is, say, the Western Australian health service, that they are there as citizens of Western Australia, and not just of their home towns of Bunbury or Broome. They are given good information by experts whom they can quiz about health, health care services and resource availability. They are then asked to deliberate on what sorts of principles they want to guide their health services. It seems difficult to argue against this idea of “the people” setting these principles. The issues involved are not technical ones. These principles might include value for money (efficiency); equity (and how this is defined and how important it is); transparency in decision making; prevention and its relative importance compared with treatment; and so on.3 Interestingly, in my experience, the people on these juries just love to act as citizens! They act responsibly and with pride in the role. Two things are clear on the basis of the results of six juries in which I have been a facilitator.3 First, the citizens’ values and the relative weights they attach to them are broadly consistent across different juries. They want better access to services, especially a reduction of the barriers caused by a lack of awareness of where and how to get services; improved equity, particularly for Aboriginal people; and more emphasis on public health and prevention. Second, if built on the principles arising from these six juries, the health care service would be rather different. For example, the citizens place less weight on hospital care and more on equity than the health service does currently. Care needs to be exercised when choosing the issues about which citizens’ values are elicited. Citizens appear to feel comfortable when they are asked to consider principles and broad priorities. They argue that anything more detailed or at a more operational level is better left to others. For the nation as a whole, I propose that there be 20 juries, each with 15 members (“20.15”), each covering a metropolitan, rural or remote geographical area and ensuring a good mix of these. Having just 15 members allows “a conversation” to be conducted within each jury, which is the ideal. These juries might be followed by a “National Citizens’ Summit” (NCS) at which one representative from each jury would present his or her jury’s findings; the NCS would then seek to achieve a consensus at a national level. Metropolitan, rural and remote juries may not be able to agree, but that is to be expected — what people in these different areas want from their health services is quite likely to be different. The other advantage of establishing these principles — or a “constitution” (as I, along with my colleague, health economist Virginia Wiseman, have called these5) — is that this provides a base, indeed an incentive, to establish a more rational and systematic priority-setting system.6 Sadly, one of the most serious methodological failings of the Australian health service is the lack of such a system. This needs to be put to rights and to be based on what Australian health economist Stephen Jan has called long-term “credible commitment”.7 What is needed in setting these values and the subsequent priorities is to ensure that whoever sets them has a genuine long-term credible interest in wanting the system as a whole to function well. Citizens are the only stakeholders who fit this description. There may be opposition to citizens’ juries. The former Health Minister, Tony Abbott, opposed citizens’ juries, believing, wrongly, that they would take power away from politicians and government.8 When I called for a citizens’ jury to look at the funding of aged care, the then President of the Western Australian branch of the Australian Medical Association was quoted as saying: “I don’t think a focus group [sic] debating it is the way you make big decisions.”9 However, these juries are not intended to be decision-making bodies; their role is to set the constitution. The idea will, however, have to be sold to those suspicious of using the lay public’s values in this way. The approach has been adopted in other countries, most notably Canada10 and the United Kingdom.4 Menadue has argued that we badly need principles to guide our health care system.1 I endorse that view. Ethically and politically there is no group that is better placed to do this than the (informed) citizens whose health is at stake. Citizens’ juries provide a tried and tested way to elicit these values. Let’s get on with them — and soon!

Gavin H Mooney MA

To the Editor: A 26-year-old woman presented with 24 hours of severe constant epigastric pain and vomiting. She had no history of similar pains, alcohol consumption or gallstones. Four days before presentation she had received her first dose of human papillomavirus (HPV) vaccine. Two days after vaccination she developed a fever and self-limiting rash of 3 days’ duration. Examination revealed marked epigastric tenderness and temperature of 40°C. Other physical parameters were within normal limits. Biochemical investigations showed normal liver function, moderate leukocytosis, a serum amylase level of 1900 U/L (reference range [RR], 23–85 U/L) and lipase level of 3400 U/L (RR, 0–160 U/L). An upper abdominal ultrasonography showed a non-dilated biliary tree and no evidence of gallstones. Computed tomography showed an oedematous pancreas with peripancreatic fat stranding and arterial enhancement of the pancreatic parenchyma, consistent with pancreatitis without necrosis (Box). Other investigations showed normal serum levels of calcium, triglycerides and parathyroid hormone. Serological tests were negative for acute infection with coxsackie A9, coxsackie B1–6, echo, mumps, herpes simplex, hepatitis and varicella zoster viruses. The patient was diagnosed with pancreatitis and treated conservatively with intravenous fluids and analgesia. Pain, symptoms and biochemical abnormalities settled after 10 days. She was discharged and remains well. Magnetic resonance cholangiopancreatography performed after discharge showed no pancreatic parenchymal or ductal abnormality. Acute pancreatitis is common, with an incidence of 5.4–80 per 100 000.1 Gallstones and alcohol use account for 70%–85% of cases; other causes include drugs, viral infections, tumours, hyperlipidaemia, hypercalcaemia, trauma, iatrogenic injury and pancreatic ductal anomalies. The cause is unidentified in up to 10% of cases.1,2 Viral pancreatitis is well recognised, with cytomegalovirus and mumps, coxsackie, hepatitis, herpes simplex, and varicella viruses all known causes.3 Vaccines have been implicated, with pancreatitis associated with measles–mumps–rubella and hepatitis A and B vaccines.4,5 To date, there has been no report linking HPV vaccination with pancreatitis. The pathophysiology linking vaccination with pancreatitis is unclear. It has been postulated that viral replication in immunodeficient hosts receiving live attenuated viral vaccines can cause pancreatitis. Alternatively, “molecular mimicry” could stimulate production of auto-antibodies, which react with host antigens and cause autoimmunity.5 The HPV vaccine is a quadrivalent, recombinant, non-infectious formulation, eliminating viral replication as a mechanism of pancreatitis. Therefore, an autoimmune mechanism is possible. Extensive clinical testing has demonstrated the safety of HPV vaccine in the general population. In our patient, intensive history taking and investigation failed to identify another cause for pancreatitis, and the close temporal relation of the HPV vaccination, the development of a prodromal illness, and fever without evidence of sepsis led us to postulate that pancreatitis was secondary to vaccination. A coincidental illness causing pancreatitis cannot be ruled out, but neither can HPV vaccination be excluded as a potential cause. We therefore suggest that pancreatitis be considered in cases of abdominal pain following HPV vaccination and if proven, notified to the Adverse Drug Reactions Advisory Committee. Computed tomography scan of the abdomen in a patient with pancreatitis Portal venous computed tomography images showing oedematous enlargement of the pancreas, with surrounding fat stranding and ascites. The pancreas (arrows) appears fully enhanced with contrast, suggesting there was no necrosis. A: Pancreatic head. B: Pancreatic body and tail.

Amitabha Das · David Chang · Andrew V Biankin · Neil D Merrett

To the Editor: Court, Bergh and Södersten raise the issue of why and how some therapies with prima facie evidence for their efficacy have a significant take-up by medical practitioners, while others are allowed to languish, sometimes for decades.1 It is 6 years since Bergh and colleagues conducted their Swedish trial on eating disorders, with significant encouraging results.2 Again they report — albeit this time with a non-randomised but local sample — above-average outcomes.1 Again, the fact that their patients had had previous treatments that failed renders the results compelling. We have to ask why no one has found the time, money or inclination to attempt to reproduce their findings or examine which elements of their intervention are successful. It would be ironic if the answer is that medical researchers are afraid of the unusual. While Australian medical research and public health ignore this mandometer treatment, some private health funds have been prepared to contribute up to $60 000 per patient for it, suggesting that they view it as better value for money than alternative therapies.

Phillip Gray

To the Editor: More than 2000 graduates of South African medical schools have migrated to Australia since 1948. Unlike many immigrants from Europe before and after World War II, all were fluent in English and most were able to start practising almost immediately. In chronicling this unique migration and its contribution to Australian health care, I am trying to contact, by email, as many as possible of the 1800 South African doctors now practising here, as well as surviving spouses or children of the 100 or so who have died since arrival. As a 1961 graduate of the University of the Witwatersrand in Johannesburg, I have a particular personal interest in this migration. Assisted by a sociologist and a statistician, I have prepared an email questionnaire. Responses will be de-identified before analysis. I would be grateful if graduates of South African medical schools would contact me by email.

Peter C Arnold

Australia’s GPs are meeting the challenges of change, while maintaining some constancies A few short years ago, the death of general practice as we knew it was reported.1 However, as suggested by our cover image of the mythical phoenix (Box), with its reference to Ovid’s poem Metamorphoses — “what is called birth is change from what we were, and death the shape of being left behind” — there is another explanation. This perceived “death” may, in fact, have been the preface to a significant cycle of change now manifesting in general practice in many countries around the world, including Australia. These changes, reflected in the articles in this general practice theme issue of the Journal, are many. They include already evolving pandemics of chronic illnesses, including cancer (see Weller and Harris, "Cancer care: what role for the general practitioner?"; Jiwa et al, "Timely cancer diagnosis and management as a chronic condition: opportunities for primary care"), accompanied by the increasing realisation that patients with chronic illness often have multiple morbidities (see Knox et al, "Estimating prevalence of common chronic morbidities in Australia"; Britt et al, "Prevalence and patterns of multimorbidity in Australia"). Parallel with changes in the epidemiology of disease, there have also been changes in health care policy and funding, including a wide array of systems for remunerating practices for their services, all of which need to be acknowledged and some of which could do with a degree of rethinking (see Ashworth and Jones, "Pay for performance systems in general practice: experience in the United Kingdom"; Kirby et al, "Sharing or shuffling — realities of chronic disease care in general practice"). Much discussion and debate about the possibilities for further change have followed the election of the Rudd federal Labor government, particularly the proposed introduction of GP Super Clinics2 (see Kidd, "What impact will the change of federal government have on Australian general practice?"). The announcement that a National Primary Health Care Strategy is to be developed, with strong general practice input into the committee formed to steer the process, is a welcome indication of government interest.3 On the other hand, recent budget cuts to general practice programs such as after-hours services and e-health, and changes to the immunisation incentives program, send a contradictory message.4 Undoubtedly, major challenges surround the issues of general practice workforce and changing roles for general practitioners in clinical practice (see Thistlethwaite et al, Addressing general practice workforce shortages: policy options; Willcock, "Getting back into the emergency department: diversifying general practice while relieving emergency medicine workforce shortages"). Interesting and challenging questions are being asked about what sort of clinician might be best equipped to provide health care for patients with several complex, chronic illnesses. In a world of increasing specialisation and subspecialisation, including within general practice, it is paradoxical that the role of the generalist will become more important in providing comprehensive, coordinated and accessible care for all (see Gunn et al, "The promise and pitfalls of generalism in achieving the Alma-Ata vision of health for all"). This same need underpinned an earlier rebirth of general practice in the 1950s.5 Though much has changed in the world and in general practice, some constancies remain. As highlighted by Professor Trisha Greenhalgh in her keynote address at this year’s General Practice and Primary Health Care Research Conference in Hobart (http://www.phcris.org.au/conference/browse.php?confID=758), people in the community continue to want a knowledgeable, skilled and altruistic family doctor who understands evidence, but who also knows how to apply it with understanding and humanity. We believe this to be an apt description of a typical Australian GP. The phoenix — “and all things change” “The themes of rebirth and renewal of the phoenix legend are universal; the fire can represent illness, death of course, or perhaps another kind of adversity from which, with courage, we might emerge changed by the experience, perhaps stronger.” Dr Kate Hansford, General Practitioner, Hobart, Tasmania. Artworks by other GPs are also featured in this issue.

Ann T Gregory MB BS, GradDipPopHealth · Nicholas A Zwar MPH, PhD, FRACGP

General practice is still somewhat adrift in the complex world of cancer services General practice has not traditionally had a central role in cancer care. Typically, general practitioners have had the task of identifying and referring patients to specialists in a timely manner, but have stayed on the periphery of cancer care until patients reach the palliative stage. But the climate is changing — driven partly by the growing burden of cancer and the need to expand and diversify the workforce. The prevalence of cancer has increased substantially in Western countries,1,2 largely due to the ageing of the population: in Australia, by the age of 75 years, the risk of cancer is 1 in 3 in men and 1 in 4 in women.1 There is now an explicit recognition that GPs should be involved in all stages of the cancer journey, from first presentation to palliative care, and that service reforms must incorporate more significant roles for primary care.3 This has found its way into policy and practice in the United Kingdom and Australia, where service guidance emphasises integration of services and urges all those involved in delivering cancer services to better connect the various stages of the cancer journey and to provide care that is accessible and convenient — all predicated upon significant primary care input.4,5 Management of cancer is complex. It requires specialised skills and knowledge, access to sophisticated diagnostic and treatment facilities, and often long-term management of symptoms and recurrences. Despite this complexity, when cancer patients are asked about how their care could be improved, their requests are often simple: they want to know who is in charge of their overall care, they want ready access to care that is convenient and non-threatening, and they want reassurance that they will have access to specialised services if needed.6 A diagnosis of cancer has a profound psychosocial impact, and those who care for cancer patients need to address a range of complex and often rapidly changing needs. Ideally, cancer care should be provided by teams, supported by a network of services. The concepts of multidisciplinary teams and managed clinical cancer networks have been widely advocated,7 but the place of primary care within these teams has remained poorly defined and highly variable.8 This variability is demonstrated by urban–rural differences: in Australia, rural GPs tend to play a more active role in treating cancer patients than their urban counterparts. General practice is still somewhat adrift in the complex world of cancer services. In this issue of the Journal, Jiwa and colleagues describe the many challenges faced by general practice in providing cancer care that is truly integrated with other parts of the health care sector.9 They emphasise that integrated care is required at all stages of the cancer journey. Just as cancer screening should link public health and clinical perspectives, post-diagnosis treatment needs a range of health care providers, including GPs, to be part of the team effort. Effective communication between specialist and primary care services is an essential component of this integration. There is growing emphasis on the concept of survivorship in cancer patients — rightly so, as cancer has taken on the characteristics of other chronic illnesses such as diabetes and coronary heart disease. Increasing numbers of patients have very prolonged periods of survival after cancer diagnosis, and die with their illness rather than of it. Survivorship is a very positive concept, and general practice, with its capacity for multidimensional care, is well placed to play a leading role in improving services for people living with cancer, providing follow-up that addresses patient priorities, and developing more personalised care for cancer survivors.10 This typically involves “survivorship care plans”, which include a range of tools for health care providers and users. It features heavily in the UK’s Cancer Reform Strategy.5 A challenge for primary care is to recognise its unrealised potential for promoting survivorship and to develop new models of care that allow it to do so.11 Primary care must be able to respond to rapidly changing health care needs of cancer patients in an appropriate and flexible manner. If we are to develop and test new models with enhanced roles for primary care, we need to better define and understand current patterns of care. Do GPs and primary care teams provide the kinds of services that cancer patients need? How well do they detect and manage recurrence of disease and toxicity from treatments? Do they provide the kinds of psychosocial support cancer patients need, and do they help or hinder truly integrated care? How well do they address issues of patient choice, and how good are they at providing education and support? The experiences and needs of cancer patients and their carers vary tremendously. We have perhaps been slow, in general practice, to respond to the needs expressed by our cancer patients. But if we take time to listen to our patients, from the time of diagnosis to death and bereavement, many ideas emerge about how the services we provide could be improved. Cancer patients have a range of illness and social trajectories, their patterns of wellbeing fluctuate, and they often perceive a lack of integration in the services they receive.12 GPs also need to maximise their contribution to primary prevention of cancer, especially in relation to smoking cessation and lifestyle risk factor management — despite the challenges of time constraints, practice systems and patients’ reluctance to change.13-15 To meet the challenges of the future and to adapt to changing health service environments, general practice must be prepared to evolve.16 A better understanding of the role of primary care in cancer management is vital if we are to improve outcomes and quality of life in our cancer patients.3,17 We need to know how primary care can contribute to new models of care. At present, there is little evidence on which to base service design and innovation. We need to develop new, genuinely integrated models of care that address important priorities for cancer patients, such as the availability of care close to home, timely management of symptoms, early detection of recurrences, and comprehensive psychosocial support. Until we have done so, GPs will remain at the periphery of cancer management, and there will be ongoing confusion over how we can make our most effective contribution.

David P Weller FRACGP, FAFPHM, PhD · Mark F Harris FRACGP, MD

P4P has raised the quality of primary care in the UK, but broader performance indicators are needed to accurately reflect the scope of general practice Pay for performance, or “P4P” as it is often known, is now centre-stage in primary care in the United Kingdom. P4P promotes change in clinical behaviour by offering financial rewards in return for achieving certain predefined targets. Both sides of the P4P “equation” are currently the subject of much debate: how generous should the financial reward be (the first “P”); and which performance indicators (the second “P”) should be used as the basis for calculating eligibility for the reward? From the foundation of the UK National Health Service (NHS) in 1948, general practitioners derived their income largely from capitation. Income was related more to the quantity than the quality of care. In 1990, and against much resistance from within the profession, the first performance targets were introduced into primary care. There were just two: rates of cervical smears and childhood vaccines. All this changed in 2004, when GPs accepted a new contract that radically promoted the role of P4P. This new contract tied about 25% of GP income to the achievement of a panoply of performance indicators. Large financial rewards were within reach for GPs able to achieve targets set for 147 performance indicators (subsequently revised to 135 indicators in 2006 and further revised to 128 in 2008). Details of the original 147 performance indicators and the mechanism for tying them to financial rewards have been well documented.1 The overall structure is known as the “Quality and Outcomes Framework” (QOF). In essence, the indicators are a mix of clinical indicators covering the management of 10 long-term conditions (eg, diabetes, coronary heart disease, hypothyroidism) and a series of indicators covering managerial, organisational, educational, prescribing and “patient experience” aspects (eg, undertaking an approved patient survey each year) of primary care. The clinical indicators are a mix of process indicators (such as creating a disease register or conducting a specific investigation), intermediate, or proxy, outcome measures (such as reduced cholesterol levels), and true outcome measures (such as improved epilepsy control). Achievement of an indicator is converted into “quality points”, which are weighted according to the perceived workload required to attain the target set for each indicator. Each quality point attracts a fee — currently set at £126 (A$260) for the average-sized general practice (5891 patients) — and the maximum attainable score is currently 1000 points. Since 2004, the components of the QOF have been revised twice. New indicators for an additional nine long-term conditions (eg, chronic kidney disease) were added in 2006, and in its latest 2008 incarnation, there are 80 clinical and 48 non-clinical indicators. What have been the positive consequences of P4P in UK primary care? The introduction of the QOF has demonstrated that GPs in the UK have achieved far higher quality standards than expected — at least, as budgeted for by government pay negotiators. In 2007, 5% of practices achieved the highest possible score, and the mean achievement of all practices in England was 95.5% of the available points.2 Such a demonstration of success has the potential to both affirm professional pride and to provide some evidence to the general public to justify the additional taxation that has been required to fund P4P. As with most systems of P4P, there is evidence that rewarded activity has increased. Substantial increases have been documented in some of the intermediate outcomes, such as blood pressure, cholesterol and glycosylated haemoglobin control, and also in the proportions of heart attack and stroke patients treated with aspirin.2 The overall rise in standards has been accompanied by a narrowing of the health inequality gap (as measured by the QOF) between least- and most-deprived neighbourhoods. Taken together, these achievements should translate into substantial national public health gains. What have been the unintended consequences of P4P in UK primary care? The success of P4P has been challenged from several perspectives. First, in the case of several QOF indicators, the achievement gains pre-dated the introduction of the QOF and, since then, the improvement rate has continued at a similar pace. For example, evidence has accumulated that overall cholesterol control was improving long before 2004.4 Second, high achievement may be interpreted as targets that were too easy to attain. For example, maximum QOF points are awarded for achieving target blood pressure control in just 60% of patients with diabetes, and the target blood pressure was set at 145/85 mmHg, which is above the value given in most guidelines. Third, GPs may indulge in “gaming” to boost their tally of QOF points — either by under-counting the number of patients on each disease register (only including those for whom target achievement is more readily accomplished) or by using the process of “exception reporting”, whereby GPs can decide whether it is “unsuitable” for a patient to be considered for a given clinical target on grounds such as “maximum tolerated therapy”, extreme frailty, or not responding to three letters inviting them to an appointment.5 More fundamentally, P4P has divided GPs on issues of professionalism. For some GPs, the electronic QOF prompts that accompany a consultation with a patient act as useful reminders and allow the GP to give more thought to deeper issues during the consultation. For others, these prompts represent the intrusion of a reductionist, points-driven approach to patient care that undermines professional autonomy.6 Furthermore, it is readily apparent that measures of patient satisfaction, patient enablement, listening skills, continuity of care, and many of the aspects of general practice that give GPs their greatest professional satisfaction lie outside the scope of any of the performance indicators. There are no measures of the psychosocial problems so common in primary care, nor of many medical conditions (such as any of the chronic gastrointestinal diseases). Indeed, even the advocates of the QOF would concede that probably only a quarter of all registered patients have any of the conditions for which QOF points are available. It is thus clear that P4P in its current form only rewards a small proportion of the overall work of a GP. Finally, the QOF has proven costly. Should such a large proportion of GP income be determined by these indicators, many of which lack a robust evidence base? Since its introduction, a vigorous debate has continued on balancing the “pay” component of P4P with the “performance” component. The higher than expected performance resulted in higher than expected costs, which contributed to NHS overspending in the early years of the new contract (although spending has now been reined in). What are the lessons for Australia? In the UK, the QOF was introduced as a “big bang” solution, without prior piloting. From our perspective as UK-based researchers and practising GPs, we think that perhaps the single greatest lesson from this experience is that piloting might have avoided many of the unintended consequences of P4P in primary care. Although P4P focuses attention on the quality of care, the definition of quality should be multifaceted and derived from evidence-based guidelines and the collective views of GPs, public health specialists and, importantly, patients. Performance indicators undoubtedly need to change over time, either because the evidence base has changed or because the original indicator has become redundant, and a transparent and robust system needs to be devised for regular updating of indicators and targets. An evolving QOF can act as a means to translate research evidence into practice. Simply put, the QOF has the capacity to “cut the implementation corner”. Although contentious, P4P represents a bold attempt to redefine the quality standards of primary care, such that best-practice targets quickly become the norm, expected by patients, health service planners and doctors alike. Beyond this, the next challenge is how P4P can evolve into rewarding a broader, more pluralist definition of quality and not merely the narrow focus of those things that are easy to measure.

Mark Ashworth DM, MRCP, MRCGP · Roger H Jones DM, FRCP, FRCGP

The new government is working hard to keep its promises, but it is too early to tell what long-term impact its new programs will have on health care delivered through general practice On 24 November 2007, the people of Australia elected a new Labor government. In the lead-up to the election, the Labor Party made many health care commitments. Here, I summarise and comment on the new government’s strategies and policies that can be expected to have an impact on general practice. What was promised, what has happened since the election, and what are we still waiting for? National Primary Health Care StrategyOn 17 November 2007, the then Shadow Health Minister, Nicola Roxon, advised that a Rudd Labor government would develop a National Primary Health Care Strategy. Primary care — like GPs [general practitioners] and allied health professionals — is crucial to keeping people healthy and out of hospital. The best way to equip our health system to deal with the challenges of the future is to boost primary care services.1 A promise of long-term planning was made through the development of a “long term strategy for delivering this care into the future”. Elements of the strategy would include: Examining providing incentives for GPs to practise quality preventative health care, including through longer consultations and evidence-based management of chronic disease; An increased focus on multi-disciplinary care from primary care teams; A review of the Medicare Schedule in an effort to alleviate the crippling red tape burden on GPs; $220 million investment in GP Super Clinics, which will be driven by local health professionals, and build upon the great work they are already doing in local communities; [and] Reforming the Rural Medical Infrastructure Fund to ensure funding gets to the communities that need it. The federal 2008–09 Budget papers state that a reference group of stakeholders and experts will be convened to develop the National Primary Health Care Strategy.2 Comment: While such a strategy is welcome, it needs a much wider scope. There is an urgent need to reduce the pressures on the nation’s general practice workforce and increase the number of GP registrars in training, while at the same time increasing the capacity of Australian general practice to train an increasing number of medical students, registrars and practice nurses. Further, the government has made few announcements to date about future roles for Australia’s network of Divisions of General Practice. The need for a more coherent approach to policy and service delivery was a major focus in the discussions of the health stream at the Australia 2020 Summit, held on 19–20 April 2008, which declared an ambition to have “one health system” with “single governance, management and funding” by 2020.3 GP Super ClinicsOn 26 August 2007, the Labor Party released a policy entitled New directions for Australia’s health — delivering GP Super Clinics to local communities.4 This promised to: provide infrastructure funding to establish a greater range of convenient and quality services in local communities — particularly in rural and regional areas and where Medicare has not been utilised to its fullest because of workforce shortages. Implementation of the GP Super Clinics Program is underway — GP Super Clinics have been announced for 31 localities across Australia,5 and “different processes” are being used to select the organisation that will “construct/refurbish and operate” each clinic. Comment: Any initiative to provide new centres of excellence in primary care service delivery and multidisciplinary health professional education and training in areas of need should be welcomed, but this funding only supports 31 such centres. An independent evaluation could be beneficial to determine whether the proposed GP Super Clinics are being planned for the 31 localities of greatest primary care need in Australia, to ensure the plans have the support of the local community and local GPs, and to ensure that there is no unnecessary duplication of existing services. Every primary care clinic in Australia needs the capacity to work within a framework that is relevant, timely and sustainable.6 Preventive health strategyOn 21 February 2007, the then Shadow Health Minister called “for consideration of a national preventative health taskforce ... to evaluate and make recommendations to Government on the basis of the safety, effectiveness and cost-effectiveness of prevention programs”.7 A focus on preventive health continued throughout Labor’s election campaign, including a commitment to an additional $15 million over 3 years for the National Tobacco Strategy.8 On 9 April 2008, the government announced the establishment of the National Preventative Health Taskforce, chaired by a Fellow of the Royal Australian College of General Practitioners. The taskforce, made up of health experts from around Australia, will develop strategies to tackle the health challenges caused by tobacco, alcohol and obesity, and develop a National Preventative Health Strategy by June 2009. The Government also announced that it would take immediate action to ensure preventive health measures become a key part of health funding agreements between the Commonwealth and state and territory governments.9 Prevention also received strong support from the members of the health stream at the Australia 2020 Summit.3 Comment: It remains unclear how the taskforce and the national strategy will involve general practice, in its long established role as a major site for providing preventive health care10 and health promotion advice.11 Given its seemingly strong commitment to prevention, it was surprising that the government announced reduced funding of general practice immunisation incentives in the federal 2008–09 Budget.2 National Health and Hospitals Reform CommissionOn 23 August 2007, the Labor Party made a promise to “establish a $2 billion National Health Reform Plan over four years to improve Australia’s health system and ensure better health services for patients in hospitals”.12 The plan would include: $2 billion in investments to deliver improved health outcomes for patients in Australia’s health care and hospital system [and a] commitment that a Rudd Labor Government [would] seek to take financial control of Australia’s 750 public hospitals if State and Territory Governments have not begun implementing an agreed National Health Reform Plan by mid-2009. [Further,] within the first 100 days of the election, a Rudd Labor Government — through COAG [Council of Australian Governments] — [would] establish a National Health and Hospitals Reform Commission to develop Federal Labor’s National Health Reform Plan.12 On 28 February 2008, federal Cabinet approved the establishment of the National Health and Hospitals Reform Commission.13 The Commission released its initial report, Beyond the blame game: accountability and performance benchmarks for the next Australian Health Care Agreements, on 8 May 2008, outlining 12 health care challenges and a series of proposed performance benchmarks.14 Comment: General practice perspectives are well represented on the National Health and Hospitals Reform Commission. With Labor in government not only nationally but also in each state and territory, there is an unparalleled opportunity to redress barriers and cost-shifting in our health care system that impact on health care delivery, access and equity. From a primary care perspective, the initial set of proposed benchmarks appear limited, but the Commission is welcoming comment and is engaging in an extensive process of consultation with the community and stakeholders. Aboriginal and Torres Strait Islander healthOn 13 February 2008, the Prime Minister, Kevin Rudd, apologised to the Stolen Generations. In his speech to federal parliament, he said: Let us resolve to ... provide proper primary and preventive health care for [Indigenous] children, to begin the task of rolling back the obscenity that we find today in infant mortality rates in remote Indigenous communities — up to four times higher than in other communities.15 This followed the commitment he made on 26 November 2007 to offering such an apology early in the new government’s term.16 Since the election, the Prime Minister has set a goal to halve the gap in infant mortality rates between Indigenous and non-Indigenous children within a decade, and to close the 17-year gap in life expectancy between Indigenous and non-Indigenous Australians within a generation,17 as well as making a commitment to provide an annual progress statement on closing the life-expectancy gap.18 As part of an earlier commitment “to improving Indigenous health, including through [a] $260 million Indigenous early childhood package”,19 an announcement was made on 23 April 2008 that the government would provide more health services for Indigenous families through funding to expand child and maternal health services and to boost primary health care service delivery in areas where health services are lacking.20 An announcement was made in the federal 2008–09 Budget of some funding increases for Indigenous health.2 Comment: Real action is now needed in Indigenous health, but what that action will be and what roles general practice will take are yet to be developed. As one solution, the health stream at the Australia 2020 Summit called for the establishment of a Health Equalities Commission for all Australians, with a focus on Indigenous health and other disadvantaged communities.3 Health care in rural AustraliaOn 12 September 2007, the Labor Party made a commitment to reform the Rural Medical Infrastructure Fund, to improve health infrastructure in rural communities.21 A further list of promises followed on 17 November 2007, including that “GP Super Clinics will be established in areas where there is under-utilisation of Medicare funded services, which will particularly include rural areas” and that the “National Health and Hospitals Reform Commission will be asked to explicitly identify a long-term plan for improving rural health services”.19 A promised audit of Australia’s rural and regional health workforce was released on 30 April 2008.22 Comment: Equity of access to health care services and equity of health care outcomes should be available to all people in Australia, regardless of where they live. Each of the reforms announced by the new government needs to have a specific focus on its impact on people living in rural and remote Australia. Dental healthOn 18 September 2007, the Labor Party made a promise to fund up to one million additional dental consultations for Australians needing dental treatment, by establishing a $290 million Commonwealth Dental Health Program.23 The Rudd government’s First 100 days report advised that negotiations had commenced with state and territory governments on the plan’s implementation.17 In a further development, the government announced on 2 March 2008 that it would “invest up to $360 million over three years in a Teen Dental Plan to make it more affordable for families to keep their kid’s teeth in good health”, and that this plan, assisting a million young Australians, would become operational on 1 July 2008.24 Comment: General practice organisations have long advocated for improvements in access to dental health services, especially for people on low incomes. Healthy Kids CheckOn 10 April 2007, the Labor Party made a commitment to develop a Healthy Kids Check, which would include an assessment of each child’s basic health such as teeth, hearing, balance and sight.25 This check would “ensure all children starting school receive a health and early skills assessment so they get off to the best start in life”. Comment: In the federal 2008–09 Budget, it was announced that new Medicare items would be developed to allow a “GP or a practice nurse [to assess] health indicators such as height, weight, eyesight and hearing”, and that this item would be claimable at the same time as the immunisation for 4-year-old children.2 Climate changeOn 30 May 2007, Kevin Rudd, then Leader of the Opposition, outlined Labor’s Framework for Climate Change. “We must immediately ratify the Kyoto Protocol to show we are serious and want to help forge a global solution”, he said.26 True to this commitment, the first official act of the new government was the ratification of the Kyoto Protocol on 3 December 2007.17 Comment: Global warming remains a concern for many Australian GPs, who have an important role in preparing for and responding to climate change-related threats to human health.27 In the words of one GP, responding to a conference presentation about health care reforms and innovations in general practice: “The rest of this is all very interesting, but if we don’t do something about climate change, it may all be irrelevant”. General practice is at the core of many of the health initiatives of the new government, and GPs need to be engaged in these developments, both as individuals having the opportunity to comment on each program, and through the viewpoints and advocacy of representative organisations. One of the national health initiatives currently under development that was not promised by the Labor Party is the new National E-Health Strategy, which is being developed through the Department of Human Services in Victoria on behalf of the Australian federal, state and territory health departments. E-health will be a crucial component of many of the government’s new health care initiatives. The new Australian Government is working hard to keep its pre-election health promises (see summary in the Box), and many of the programs announced have the potential to improve aspects of primary care. However, it is a shame that the National Primary Health Care Strategy is being developed after several of the initiatives that should be its core components have already been announced. General practice is accustomed to having to respond to piecemeal strategies from government, but it would be better if these programs were integrated in a way that supports the whole system in the delivery of high-quality primary care. Perhaps this is the intent of the new government, but it is too early to determine the likely long-term impact of these programs on the health care delivered to the people of Australia through general practice. Summary of the Rudd government’s health promises and actions to date Date Promise Action taken 21 Feb 2007 National Preventative Health Strategy Taskforce established 9 Apr 2008 30 Mar 2007 Ratify the Kyoto Protocol Protocol ratified 3 Dec 2007 10 Apr 2007 Healthy Kids Check Announced in Budget 13 May 2008 23 Aug 2007 National Health Reform Plan Commission established 28 Feb 2008 26 Aug 2007 GP Super Clinics Under development 18 Sep 2007 Commonwealth Dental Health Program Under development 17 Nov 2007 National Primary Health Care Strategy Under development 26 Nov 2007 Apology to the Stolen Generations Apology made 13 Feb 2008

Michael R Kidd MD, FRACGP

Objectives: To estimate prevalence of selected diagnosed chronic diseases among patients attending general practice, in the general practice patient population, and in the Australian population, and to compare population estimates with those of the National Health Survey (NHS).Design, setting and participants: In late 2005, 305 general practitioners each provided data for about 30 consecutive patients (total, 9156) as part of the BEACH (Bettering the Evaluation And Care of Health) program, a continuous national study of general practice activity. GPs used their knowledge of the patient, patient self-report, and medical records as sources.Main outcome measures: Crude prevalence of each listed condition currently under management among surveyed patients, and adjusted prevalence for the general practice patient population, and the national population.Results: 39.6% of respondents had none of the listed conditions diagnosed; 30.0% had a cardiovascular problem (uncomplicated hypertension, 17.6%; ischaemic heart disease, 9.5%); 24.8% had a psychological problem (depression, 14.2%; anxiety, 10.7%); 22.8% had arthritis, mostly osteoarthritis (20.0%); 10.7% had asthma; and 8.3% had diabetes, mostly type 2 (7.2%). Adjustment to the population attending general practice resulted in lower estimates for cardiovascular disease, arthritis and diabetes but had little effect on prevalence of asthma and psychological problems. After adjusting for non-attenders, about one in five people in the population had a cardiovascular problem, a similar proportion had a psychological problem, 14.8% had arthritis, and about 10% had asthma, hyperlipidaemia and gastro-oesophageal reflux disease. Estimates were similar to NHS results for any arthritis, asthma, and malignant neoplasms; higher for any cardiovascular problem; far higher for specific cardiovascular diseases, cerebrovascular disease and hyperlipidaemia; and almost twice the NHS estimate for psychological problems (particularly depression and anxiety). Estimates for type 1 diabetes aligned with NHS results, but were far higher for “all diabetes” and type 2 diabetes.Conclusions: This study offers an alternative, perhaps more accurate, approach to measurement of disease prevalence than the NHS approach, which relies on respondent self-report alone. It provides valid prevalence estimates with the help of GPs at a fraction of the cost of the NHS. This study could be repeated annually to augment other data sources and better define existing health needs in the population.

Stephanie A Knox BA(Hons), MPH, BSc · Christopher M Harrison BPsych(Hons), MSocHealth · Helena C Britt BA, PhD · Joan V Henderson BAppSc(HIM)(Hons), PhD

Objectives: To estimate the prevalence and patterns of multimorbidity in a sample of patients attending general practice, in the population who attended general practice in 2005, and in the Australian population.Design, setting and participants: Secondary analyses of data from a study of prevalence of selected conditions (a substudy of the BEACH [Bettering the Evaluation And Care of Health] program); data were provided by 305 general practitioners for 9156 patients seen in July–November 2005, based on knowledge of the patient, patient self-report, and medical records. Listed conditions were classified according to the Cumulative Illness Rating Scale morbidity domains.Main outcome measures: Prevalence of morbidity in each domain; prevalence of specific patterns of multimorbidity (defined as presence of morbidity in two or more domains).Results: Prevalence of multimorbidity was estimated as 37.1% of surveyed patients, 29.0% of people who attended a GP in 2005, and 25.5% of the Australian population. Prevalence and complexity (number of domains present) increased with age: 83.2% of surveyed patients aged 75 years or older had multimorbidity, 58.2% had morbidity in three or more domains, and 33.4% in four or more. Prevalence of multimorbidity did not differ between the sexes. The most common morbidity combinations were arthritis/chronic back pain + vascular disease (15.0% of sample), a psychological problem + vascular disease (10.6%) and arthritis/chronic back pain + a psychological problem (10.6%). We estimate that 10.6% of people attending a GP in 2005 and 9.3% of the population have arthritis/chronic back pain + vascular disease (± other morbidity types studied), and this group accounted for about 15.2 million Medicare-claimed general practice encounters in 2005.Conclusions: This study provides the first insight into prevalence and patterns of multimorbidity in Australia. Knowledge of the common combinations of multimorbidity may help in planning the health services needed in the future by an ageing population with an increasing burden of multimorbidity.

Helena C Britt BA, PhD · Christopher M Harrison BPsych(Hons), MSocHealth · Graeme C Miller PhD, FRACGP · Stephanie A Knox BA(Hons), MPH, BSc

To the Editor: We conducted a qualitative study to explore the perspectives of general practitioners and allied and other health professionals on their interactions in the care of patients with chronic disease, especially where Team Care Arrangements (TCAs) are involved. We interviewed 16 clinicians from urban and rural New South Wales who were involved in the care of patients with type 2 diabetes, ischaemic heart disease and hypertension — four GPs, two practice nurses, two medical specialists and eight allied health clinicians. Interviews took place from late 2006 to early 2007. While all those interviewed felt that a coordinated approach provided optimal management of chronic disease, this did not always seem to translate into smooth working relationships. Allied health clinicians and medical specialists described two types of attitudes of GPs to team care. They perceived some GPs as accepting of the involvement of others in patient care, leading to mutually respectful and highly satisfying working relationships. However, they felt other GPs did not value the opinions of allied health professionals and referred patients to them to fulfil a process (either for TCAs or at the patient’s request), or saw them as competitors. As one urban allied health clinician said, “I think they’ve got to realise that we’re not there to compete, we are there to assist”. TCAs provide financial incentives for GPs to coordinate care.1 We have previously reported that multidisciplinary care plans are associated with improved attendance at allied health services and improved metabolic control for patients with diabetes.2 However, in the present study some respondents felt that TCAs were little more than “paper shuffling” — predominantly a mechanism to attract reimbursement, rather than to facilitate two-way communication. Although TCAs provide an opportunity for communication between health care professionals, they have not overcome all the barriers to communication, especially in cases where an interprofessional relationship based on clear understanding of each other’s roles has not already been established. Our findings suggest that relationship-building and discussions about roles in shared care, including the power differentials between professionals, would improve the functioning of TCAs. Other recent studies have also reported on the lack of effective collaboration between GPs and other health professionals in managing chronic conditions.2,3 Respondents felt that it was uncommon for clinicians to discuss and agree on a plan of care. Optimal management of chronic disease requires a team approach and, consistent with other studies,4,5 we found that all the professional groups interviewed acknowledge the desirability of team care and its potential to improve patient outcomes. With increasing emphasis on team care, it is imperative that policies fund and facilitate a real team approach that is in the best interests of patients — one that places greater emphasis on two-way communication rather than paper shuffling or gatekeeping. This requires working with allied health professionals, medical specialists and GPs to improve communication and trust between clinicians. The Divisions of General Practice must surely be well placed to facilitate this process.

Sue E Kirby · Joyce L Chong · Maureen Frances · Gawaine Powell Davies · David A Perkins · Nicholas A Zwar · Mark F Harris

One in three men and one in four women in Australia will be diagnosed with cancer in the first 75 years of life. The majority will survive the cancer and ultimately die from unrelated causes. Many cancer patients and their families will experience some physical, social, economic and psychological sequelae, regardless of the prognosis. A recurring theme is that patients are disadvantaged by the lack of coordination of care and their needs are not being adequately met. We argue that greater integration of care through a multidisciplinary team of professionals, peer support groups and primary health practitioners functioning within a care hub could offer better practical and psychosocial supportive care for patients and their families.

Moyez Jiwa MD, MRCGP, FRACGP · Christobel M Saunders FRCS, FRACS · Sandra C Thompson FAFPHM, PhD · Lorna K Rosenwax BAppSc(OT), MSc, PhD · Scott Sargant BPharm, MPS · Eric L Khong MB BS, PGradDipPrimHlthCare, FRACGP · Georgia K B Halkett BMedRad(Hons), FIR, PhD · Gloria Sutherland BAppSc, PGradDipHlthEd · Hooi C Ee MB BS, FRACP, PhD · Tanya L Packer BSc(OT), MSc, PhD · Gareth Merriman BAppSc(Psych) MPsych, PhD · Hayley R Arnet BHSc(Pod), PGradDipHlthInform

To the Editor: General practitioners play an influential role in the improved health care of people with intellectual disability (ID) through assessment, diagnosis, and development and maintenance of health plans. GPs also help patients access specialist health care and community-based services.1 Recent initiatives by the International Association for the Scientific Study of Intellectual Disabilities (IASSID) and Medicare Australia have been introduced to develop a national strategy for GPs and other health practitioners in their contribution to the promotion of health care for people with ID. With the support of the World Health Organization, the IASSID set health targets for people with ID. These in turn contributed to a national strategy for improved health care for people with ID.2,3 Medicare Australia introduced Medicare rebates for people with ID on 1 July 2007 (Medicare Benefits Schedule Items 718 [“Attendance by a medical practitioner . . . at consulting rooms for a patient with an intellectual disability”] and 719 [“Attendance by a medical practitioner . . . not being an attendance at consulting rooms, a hospital or residential aged care facility for a patient with an intellectual disability”]).4 These rebates aim to provide a structured clinical framework, allowing more time for GPs to spend with patients with ID to assess their overall health and plan for their long-term care, thus improving the quality of service through improved decision making in the context of prescribed medication, specialist referrals and hospital admissions.1 GPs can implement a health assessment program aimed at enhancing interactions between the adult with ID, his or her carer and the GP through the systematic gathering of a health history and review and, subsequently, development of a health action plan.2 To assist GPs in their assessment of patients with ID, Lennox and colleagues have developed the Comprehensive Health Assessment Program (CHAP).2 The CHAP is a 21-page booklet, split into two parts. The first part covers the medical history of the patient with ID and is filled out by the patient’s carer and brought to the GP. The second part is the CHAP assessment, completed by the GP. The CHAP assessment involves a review of the medical history, a targeted examination, and assistance for the carer in completing a health action plan. A 1-year post-intervention review has shown a substantial increase in GPs’ attention to the health needs of adults with ID, with concomitantly more disease detection.2 Thus, these initiatives have demonstrated positive clinical outcomes for this group of patients. Comment: The research is clear that people with intellectual disability have been receiving inadequate health care. A seminal population study clearly demonstrated that they experience high levels of unmet health need, with 42% of health conditions persistently undiagnosed and half of the conditions that are diagnosed inadequately managed.1 Their life expectancy is much lower than the general population — about 20 years lower for people with severe disabilities.2 These unmet health needs are partially addressed by the Comprehensive Health Assessment Program (CHAP) one-off health review. In the only randomised controlled trial of the health assessment process, we found a significant increase in health promotion and disease prevention, and greater case finding.3 We believe the CHAP enhances communication between adults with intellectual disability, their carers and their general practitioners. The widespread use of an annual health review now afforded by Medicare Australia provides an example of best practice in the health of this neglected group of Australians. This change was achieved after sustained collaborative lobbying driven by the Australian Association of Developmental Disability Medicine and the National Council on Intellectual Disability (New South Wales branch) — an advocacy organisation — and supported by other national medical organisations. While these changes are welcome, they are not enough, as half a million Australians4 (a population at least as large as the Indigenous population) with intellectual disability continue to experience poor health care while being excluded from most generic research. We call upon the Australian Government to act to regularly monitor and assist in the development of strategies to improve the health of this population. Would any other population of this size and health status receive such scant attention in the national discourse?

Kathryn A Vanny · Michael H Levy · Susan C Hayes · Nicholas G Lennox · Miriam T Taylor

A cold never killed anyone ... did it? I went to work with a cold. My nasty sore throat woke me early, so I spent the time emailing our incoming clinical students: Get your influenza vaccinations before you start your clinical rotations — influenza kills people, vaccinating health care workers decreases mortality in nursing homes, and vaccination reduces other viral infections and days off work or school, and meets duty of care for oneself and others!1,2 Sincerely, your (vaccinated) Clinical Dean Sneezing and miserable, I considered staying home, abandoning the 20 complex, high-admission risk (general medicine) patients scheduled at the Aboriginal Health Centre and the hospital, many of whom had waited 2–3 months for an appointment. I thought of my mother — “Go to school, you’re not dying, you only have a cold!” Memories of my only previous sick day resurfaced: as an on-call intensive care unit senior registrar — feverish, achy, sneezing, nose running like a faucet, I had decided this wasn’t good for anyone. Caving at the prospect of working all night sick, I settled for guiltily calling in a fellow registrar. My “chief” had then rung — “How are you?” — Oh no, they think I’m skiving off! Peer pressure is strong stuff. So, this time, with patients waiting and my past lurking, I took some paracetamol, packed some tissues, and went to work. My first patient, recovering from a lung resection for bronchiectasis after last winter’s viruses almost killed him, is now surviving his first postoperative virus — not a drama. After warning him to stay far away and not shake my hand, I got through the rest of the day constantly apologising to my patients and colleagues, suppressing sneezes, washing my hands, and touching as few things as possible. After clinic, an email explained the coincidental absence of my medical students — “Sick with cough, unable to attend”. A colleague’s voice from the doorway wryly observed, “You’re sending the students mixed messages about getting vaccinated and duty of care while working with a cold yourself, potentially infecting everyone in sight”. I responded blithely, “I’m more dedicated to my work than the students are (different generation), and besides, a cold never killed anyone” ... but then, a moment of evidence-based-medicine horror hit me — That’s true, right? Although my work-despite-a-cold ethic hasn’t done me any harm (misery aside), I salved my skiving-off guilt with my greater desire to “do no harm”, collected kilos of paperwork and my laptop, and retreated home for a day in isolation. A hasty MEDLINE search for “common cold AND mortality” from 1997 to 2007 revealed 68 papers. Of these, the 13 highly relevant papers (gulp) fell into three categories: chronic obstructive pulmonary disease (COPD) or asthma complications (eight); childhood morbidity and deaths, largely related to cold medications (four); and HIV-related deaths (one). I quickly discovered that over 50% of COPD exacerbations are attributed to respiratory viruses — no big surprise.3 More concerningly, rhinoviruses are now well established culprits causing significant morbidity and even mortality.4-6 Indeed, only miniscule amounts of rhinovirus are needed to infect patients who then develop lung function changes typical of COPD exacerbations.7 If COPD causes 4% of all deaths per year in the United States (Australia should be similar)8 and viruses cause half of COPD exacerbations, then about 2% of mortality is potentially attributable to respiratory viruses. I began to worry about my patient with bronchiectasis. On the other hand, at least I hadn’t done any harm by prescribing over-the-counter cold medications with worrying potential for harm for any of my adult patients, let alone any children.9 Hmm ... non-steroidal anti-inflammatory medications seem to have evidence for relief (as long as I don’t have hypertension, stomach ulcer, heart failure, or kidney disease),6 so I think I’ll take some. What about vaccination? Reassuringly, at least for my reputation among my students and staff, several reviews supported influenza vaccination,10,11 especially since influenza viruses account for up to 10% of “common colds”.6 Distressingly, however, vaccination rates among health care workers are less than optimal — 82% of doctors and 40% of nurses had been vaccinated in one emergency department study (the best rates I could find).11 One dilemma remains. I, like 80% of doctors, worked with an illness for which I would have “sick-listed” my patients,12 but given that I care for under-served patients in a rural area with a shortage of doctors, is it worse to stay home and reschedule patients for appointments weeks to months later or to risk exposing them to my virus-laden self? Mortality rates for residents of rural and regional areas in Australia are 10% higher than for city-dwellers13 — largely due to health care access issues. My personal vaccination campaign should decrease the frequency of my own (and my students’ and staffs’) “colds” and, if I’m sick less often, this should increase access to me, thus decreasing my patients’ morbidity and mortality. Sadly, the evidence suggests that if I were working in an intensive care unit or a medical ward with high-risk COPD patients, I could justify staying home, but in my general medicine role and doctor-shortage situation, the mortality trade-offs suggest that I should probably go to work with a cold next time too (sigh). But as for you, dear health care providers: first, do what I say and what I do (get vaccinated against influenza); and second, do what I say and not what I did, and consider staying home with your own cold — because, you never know, it just might kill someone ...

Dawn E DeWitt MD, MSc, FRACP

Objective: To determine the timeliness of access to general practitioner appointments in South Australia.Design and setting: Face-to-face interviews with a random and representative sample of South Australians living in metropolitan Adelaide and country towns with a population of 1000 or more in 2007.Participants: 2507 people aged 15 years and over who had seen a GP in the previous 12 months.Main outcome measures: Waiting times for obtaining an appointment with a GP, patients’ perceptions about appointment waiting times, and waiting times at the GP’s surgery.Results: Most respondents reported that for their last visit with a GP, they were able to be seen on the same day (39%) or within 1 or 2 working days (33%); 20% waited more than 2 working days for their appointment. Nine per cent of respondents (159/1764) reported waiting more than 2 working days because an earlier appointment was not available. Respondents reporting lower levels of household income were more likely to report longer waits for GP appointments. Most respondents (78%) felt that they were able to make a GP appointment as soon as they thought necessary. At the surgery, 46% of respondents were seen within 15 minutes, but 13% waited 45 minutes or longer.Conclusions: In general, access to GPs is timely, and most South Australians reported that for their last GP visit they were able to make an appointment as soon as they thought was necessary.

Richard L Reed MD, MPH · Leigh S Roeger BA(Hons), PhD · Nova Reinfeld-Kirkman BBSc(Hons) · Sara L Howard BHlthSc(Hons), PhD

Defining the ideal generalist medical practitioner is essential to effective primary care It is 30 years since 3000 delegates from 134 governments, 67 international organisations and many non-government organisations gathered in Alma-Ata, Kazakhstan, to agree upon a declaration about how primary health care could achieve “health for all by 2000”.1 The conference was convened by the World Health Organization and the United Nations Children’s Fund (UNICEF) in response to the growing inequality among large sections of the world’s population. The conference was influenced by global political and social change in the preceding decades and a strong desire to move away from medical dominance and elitism,2 to focus on developing countries rather than dominant Western nations, and to propose a model of health as a tool for economic development.1 The leadership of WHO Director-General Halfdan Mahler (1973–1988) was crucial to the direction of the declaration, as he had been impressed by developments in China, India, Africa and Latin America that provided health care via local community-controlled services using lay participation, and he envisioned such programs addressing health inequalities across the world.3 The resulting Declaration of Alma-Ata consisted of 10 sections (Box 1). Anniversaries often prompt reflection, and as the Alma-Ata Declaration reaches its 30th birthday, it is clear that implementing the Declaration has been more difficult than creating the vision.4-7 Many commentators argue that the Alma-Ata experiment failed;5 others say it has never been tried.8 Some highlight the influence of the Declaration on policy agendas in developing countries (eg, Mozambique, Nicaragua) and on the development of community health workers.4 However, many programs that evolved were disease-focused, and critics would say that the community health workers, rather than being agents of change, became civil servants.8 So what is the relevance of a WHO declaration made 30 years ago to the Australian health care system? Some may see the Declaration as applying mainly to developing countries, but on reflection there is much we can gain from considering it in our own context. As a population, we desire health for all, and yet we continue to see health inequities. The rise in chronic disease and the ageing population means that multiple morbidities are the most common reasons for presentation to primary care,9-12 yet Australia, like many countries, continues to focus on single-disease-led health care linked to relative disease burden, often via treatment guidelines.13 This approach encourages specialisation, leads to fragmentation of health care, and affects our ability to deliver the goal of “health for all”. The fragmentation in so many health initiatives goes against the spirit of the Declaration. Perhaps governments, the health professions and wider society did not fully understand or truly value the kind of health care proposed. The Declaration called for a dramatically different approach to health and health care, but it failed to articulate the attributes required of the health care workers. The essential role and inclusion of primary medical care in the conceptualisation of primary health care was poorly articulated. Perhaps the desire to reject medical dominance, combined with a poor understanding of primary care,14-17 explains why there was no definition of what a “suitably trained physician”1,18 would need to be like to deliver the ambitious goals. Even though there was increasing focus on the need for a team of professionals to provide primary health care,19,20 there was little systematic gathering of evidence to inform the roles and values of various team members. What kind of physician could contribute to achieving the Alma-Ata vision?We propose that a generalist primary care medical practitioner is a vital component of primary health care. Australia has a well trained general practitioner workforce, yet most GPs continue to practise mostly reactive, consultation-based medicine with little time for planning, monitoring, teamwork, community involvement, and networking or integration activities. As a nation, we face a medical workforce crisis in that general practice struggles to attract and maintain high-quality graduates. The policy response is to shift the work of GPs to non-medically qualified practitioners and assistants. Interestingly, there has been little public involvement in debate of this issue. Our recent review, commissioned in 2007 by the Australian Primary Health Care Research Institute (APHCRI), provides, for the first time, a conceptual model of a primary care generalist based on a systematic narrative review of the literature (Box 2). A full description of the review methods and findings is available from the APHCRI website.21 The generalist ideal encapsulated in our model can bridge the inclusive vision of who should be involved in promoting health for all, with the much more narrowly and often specialty-focused health care found in many countries, such as the United States. The type of generalist role proposed is sophisticated and requires interpretive skills, a broad approach, excellent networks and supports. We conceptualise generalists as exhibiting compassion, tolerance, trust, empathy and respect (virtues). They reflect carefully on each clinical interaction, recognise its complexity, and acknowledge their prejudices (eg, towards obesity, unsafe sex practices, single parenthood, substance misuse, poverty, violence, religion). By acknowledging and dealing with their feelings (being reflexive), generalists can begin to fully engage with each patient. The generalists spend time gathering information from the biopsychosocial and cultural domains, rather than focusing solely on physical symptoms and signs. Each interaction requires biotechnical expertise, and the generalist needs to use the best available evidence to manage health. This is likely to be facilitated by access to independent evidence-based guidelines and reliable information systems. The generalist knows how to access appropriate technology to achieve health (this will range from familiarity with accessing online evidence to knowing how to access a magnetic resonance imaging scan to being aware of how to get patients from a remote area to a district hospital during the rainy season). In addition, the generalist will exhibit a high index of suspicion for medical, psychological and social “complications” and awareness of the complex interaction of morbidities and social factors. A fundamental role of the generalist is to balance the biotechnical with the biographical. The generalist must know and understand how each life story and social context are constantly influencing and being influenced by physical and emotional health. To achieve the balance between the biotechnical and biographical aspects of each interaction, the generalist must have the skills to reach a mutual understanding of the priorities and challenges that individual patients face when managing their health. The ideal generalist would be easily accessible and knowledgeable about other services to arrange appropriate and timely referral. The generalist would balance individual needs against those of the population, and consider the whole person and what they know about each to provide comprehensive care, dealing with areas such as sexual health with as much knowledge, interest and respect as diabetes. They will be comfortable working with both mental and physical health problems (flexible), and able to negotiate a plan for health care that suits each person (patient centred). This might be as simple as ensuring that single parents can get appointments that suit their work schedule and childcare requirements. The generalists would work in a system that allows them to ensure that each person receives all the health care they need regardless of their ability to pay for it, and the generalists would have the potential to guard against fragmentation in the delivery of care. Such a generalist embodies the medical practitioner role for primary health care that has the potential to deliver health for all. Like the Declaration, it is an ideal, but striving towards this goal is likely to have far-reaching health benefits. Generalism and the Alma-Ata DeclarationThe generalists’ character, reflexive and interpretive ways of being, biographical ways of knowing, and accessible, longitudinal, contextual approach place them at the crux of the social, economic and community sectors that are the focus of the Alma-Ata Declaration. The generalists’ biotechnical focus is the link to medicine, but also a way of bridging the gap between medicine and the personal, social and cultural circumstances of individual patients. This vision of generalism responds to the Alma-Ata Declaration and can inform primary care practice in developed or developing countries. There is a strong synergy between the Declaration and the conceptual model of generalism, especially around the importance of incorporating biopsychosocial aspects in the delivery of health care and the focus on first contact, locally accessible health promotion, prevention, cure and rehabilitation (section VII of the Declaration). The virtuous character in our model is in keeping with the spirit of social justice required in the Declaration (section V). The community focus of the generalist is critical to integrating the social and economic sectors into the promotion of health (section I), to bringing health care as close as possible to where people live and work (section VI), and to getting the kind of work done that the Declaration called for (section VII). The promise of generalismWe have identified a conceptual model of generalism that could underpin a new primary health care approach, building on the bold vision of the Alma-Ata Declaration. We have argued that a major limitation of the Declaration was its failure to consider the kind of physician and the health care relationships needed to deliver health for all. Having control over resources, participating in health care and ensuring communities are equipped and empowered to deal with their health needs are important ideals. But someone must integrate health care within a relationship context, continue that care, and support promotion of health, prevention, diagnosis and treatment. Health for individuals, let alone health for all, cannot happen without access to health care practitioners able to promote health, prevent disease, diagnose, treat, and follow up. This will require more than one health professional, but acknowledgement of the important central role of the generalist is missing from the Declaration. Few studies have explored whether generalist approaches to primary care are cost-effective. No randomised trial of generalism has ever been conducted, nor is it ever likely to be undertaken. But there is observational evidence that generalist primary health care contributes to achieving the goals of Alma-Ata.22 The potential pitfalls in achieving generalismGeneralism alone is not the answer. The issues of sustainability, war, terrorism, well planned cities, public transport, affordable housing, secure employment, quality childcare and education are just as important to health as the common physical and emotional health problems that consume most of the health dollars. The generalist offers a bridge between the biomedical and the social, but within limits. To truly realise the potential that generalism offers will require that generalists work closely with others with an expanded view of health and health care. In Australia, this would require us to reconsider the way GPs work and the infrastructure support required to enable them to undertake preventive, curative and rehabilitative health care as a core component of the primary care team. If this is made possible, generalists may find themselves not only providing physical and mental health care, but playing a role in a team that focuses on keeping individuals in their community safe from harm, finding them work for a living wage, advocating for a child-friendly environment, changing the gaming laws, or introducing a cervical cancer vaccination program. The generalist is a part of the wider health care and social system and the generalist role is inherently adaptable to local needs and grounded in local relationships. To avoid the pitfalls of fragmentation in health care and interprofessional rivalry that may stand in the way of achieving generalism and the ideals of Alma-Ata, this role will increasingly need to pay attention to the broad partnerships called for in the Declaration. ConclusionCritics may argue that our literature-based model encompasses an ideal that is impossible to achieve. But, much like the Declaration, if it is not an aspiration, it will never be achieved. One major challenge remains — whether the community as a whole will value the concepts of generalism and the Declaration made at Alma-Ata 30 years ago over the more seductive promise of specialism and high-tech, high-cost intervention. If health for all is the goal, governments, health care professions and individuals need to carefully consider the central role of generalism and the components set down at Alma-Ata, and will need to invest in making sure that they can happen. 1 Summary of the Declaration of Alma-Ata1 The 1978 Declaration of Alma-Ata formally adopted primary health care as the means for providing a comprehensive, universal, equitable and affordable health care service for all countries. Consisting of 10 sections, in summary it declares: I: health as the state of complete physical, mental and social wellbeing; II: the unacceptability of health inequalities, especially between developed and developing countries; III: the necessity of economic and social development for health; IV: the right and duty for lay participation in planning and implementing health care; V: the responsibility of governments for providing primary health care and for measuring health and social wellbeing; VI: the role of primary health care as the local, universally available, essential, first point of contact with the health system, based on practical, scientifically sound and socially acceptable methods and technology at a cost the community and country can afford; VII: the essential elements of primary health care (culturally relevant; addresses the main health problems; provides preventive, curative and rehabilitative care; provides health education; includes a multisectoral approach; community participation; integrated functional referral systems; consists of physicians, nurses, midwives, auxiliaries, and community workers trained to work as a health team); VIII: the need for government policies on primary health care; IX: the need for international cooperation for health; and X: the need for better use of the world’s resources and a policy for peace and disarmament. 2 A conceptual model: essential dimensions of a primary care generalist medical practitioner Ways of being (ontological frame) Virtuous character: holds ethical character traits of compassion, tolerance, trust, empathy and respect. Reflexive: interdependent; reflects on judgements and biases; lifelong learner. Interpretive: uses processes of interpretation to understand patients, with an emphasis on the contextual factors; use of multiple health systems languages; active listener; autonomous decisionmaker; has good communication skills. Ways of knowing (epistemological frame) Biotechnical: uses scientific and rational evidence; high index of suspicion; biomedically driven; technically focused; uses advanced information systems. Biographical: concentrates on lived experience and life story; family, carers, community and social knowledge all provide evidence. Ways of doing (theoretical frame) Access: accessible; first-contact point; gatekeeper; provides referral. Approach: balances individual versus population needs; consultation-based; holistic; comprehensive; flexible; adaptable; acts across clinical boundaries; provides early diagnosis; interdisciplinary team approach; negotiates and coordinates services; integrates knowledge; promotes health through education; prevents disease; is culturally sensitive; provides patient-centred care; minimises service inequities; reduces service fragmentation. Time: provides continuity of care over whole of life cycle. Context: community-based; uncertain; complex; deals with undifferentiated multiple problems of patients; acute and chronic care.

Jane M Gunn PhD, FRACGP, DRANZCOG · Victoria J Palmer PhD, BA(Hons) · Lucio Naccarella PhD · Renata Kokanovic PhD, BSociol · Catherine J Pope PhD, BA(Hons) · Judith Lathlean DPhil, MA, BSc(Econ) · Kurt C Stange MD, PhD

New medical graduates expect to work in an environment that allows scope for flexibility and change across a career in medicine. Recruitment to general practice is adversely affected by its perceived limited scope of practice. Training in procedural and hospital skills is not difficult to access for general practice trainees, but complex and inconsistent credentialling criteria and protectionist attitudes among some specialist colleges mean that many skilled general practitioners are unable to utilise the full range of their skills in clinical practice. The discipline of emergency medicine is also experiencing difficulty in recruiting trainees. The employment of skilled GPs in emergency departments (including metropolitan departments) could improve vocational satisfaction for GPs and emergency physicians, and possibly also improve patient outcomes and flow through the emergency department.

Simon M Willcock PhD, FRACGP, DipRACOG

There is an ongoing shortage of general practitioners in Australia, accompanied by a decline in the popularity of general practice as a career choice. Many factors influence the career choice of junior doctors and medical students, including role models, the quality of clinical attachments during training, remuneration, and flexibility of training and working hours. Evidence-based strategies that could increase the number of doctors choosing general practice as a career include longer and higher-quality general practice attachments during medical school and the early postgraduate years, and emphasising the positive aspects of general practice, such as flexibility. General practice would become a more attractive choice if remuneration was in line with hospital specialties.

Jill E Thistlethwaite MB BS, PhD, FRACGP · Stephen R Leeder MD, PhD, FRACP · Michael R Kidd MD, FRACGP · Tim Shaw PhD