Health services administration

If the female perspective is missing, how can true feminisation of the medical workforce occur? Much has been written about the feminisation of the medical workforce. However, this usually refers to the increasing numbers of women entering medicine, rather than to an adaptation of medical theories and practices to incorporate a female perspective. Women and men work differently, and these behavioural differences are attracting attention as the workforce debate brings women’s contribution to medicine, and their place in general practice,1 under an intense spotlight. A number of studies have demonstrated the gendered nature of communication and practice styles,2-6 health care delivery7 and patient care.8 Some have raised the question of whether female work styles contribute to the workforce problem9 — work styles that are often assumed to represent inherent female behavioural attributes.10 The tension generated by increasing numbers of women within a predominantly male-driven medical ethos can be examined using two conceptual models — the “Medusa effect” and the “Mother Teresa effect”. These are used to demonstrate how gender-based stereotyping, plus entrenched assumptions and concepts about gendered behaviour, may be affecting the interpretation of practice styles11 and underpinning the workforce debate. We argue that there is an urgent need to re-think the gendered nature of medicine in order to allow us to explore innovative solutions to the problem of the current workforce shortage in general practice. Exploring female attributes: what is acceptable behaviour? The Mother Teresa effect exemplifies the virtuous in female behaviour. It is based on the famous Roman Catholic nun who worked in the slums of Calcutta, India, for much of the 20th century. Her universally admired behavioural qualities included selflessness; a commitment to vocation above ambition or a personal life; chastity; a willingness to care for the bereft and the destitute; and subservience to a greater authority. Although these behavioural traits are not exclusively female, they do embody socially accepted female behavioural attributes. Medusa, on the other hand, is a mythical goddess whose fate is emblematic of transgressing the boundaries of acceptable female behaviour and highlights the complexities of gender relationships. Medusa emerges in the dawn of history, in many guises and in many civilisations. Her name means sovereign female wisdom, and she possessed powers of foresight, but Medusa paid a gruesome price for her wisdom and her power. Mythology has it that Medusa, a beautiful maiden, so enraged Athena after coupling with Poseidon in Athena’s temple that Athena turned Medusa into a hideous sight, and then assisted the hero Perseus to pursue the pregnant Medusa and behead her. The symbolism of Medusa hints at retribution if female knowledge, wisdom, sexuality and independence overpower the more acceptable female virtues of nurturing and caring. Female behaviour, women doctors and general practiceAn interplay between the Mother Teresa effect and the Medusa effect echoes the complexity of the female presence in medicine across several professional domains, including the doctor–patient relationship (and local care), the societal delivery of health care, and the medical profession itself.12 The doctor–patient relationshipWomen’s presence in medicine has been good for patient care. Studies from Western countries about gender differences in the consultation have produced similar findings — women have an inclusive and democratic style of communication13 that helps foster “collaborative relationships” with patients.12 Women tend to be “information giving”, use a more participatory decision-making model14 and appear less motivated by financial rewards.15 They deal with more complaints, are more patient-centred in their approach, and provide more preventive health care.2,16 These attributes, which could be grouped or labelled as consistent with the Mother Teresa effect, are valued by patients, appear to produce good patient outcomes,17 and have helped shift medical teaching away from a doctor-centred agenda to a patient-centred one.18 On the other hand, in relation to health care delivery, women’s work patterns are seen by some to limit patients’ access to medical services as well as being a contributory cause of workforce shortages. Although acknowledging that “empathy and communication are important”,1 quantitative studies also demonstrate that women work about 13.8 hours less per week than men, tend to work part-time, have longer consultations, and provide less institutional care, emergency services or procedural services.10 However, simply assuming that quantitative studies are evidence of female doctors’ inefficiency or “inability to live with risk”,1 or are a consequence of female doctors preferred working styles7 may confuse cause and effect. Numbers merely describe gendered work patterns — they do not and cannot explain them. Seeking such an explanation may help clarify solutions for some of our workforce problems. Attributing the cause to “women’s behaviour” and in doing so ignoring any other possible factors could reflect an underlying attitude related to the Medusa effect. The importance of these other factors, such as the patient’s gender, the sex match of the doctor–patient duo or the patient’s prior health status,5,19 was highlighted in an Australian study by Britt and colleagues, who established that some of the associations attributed to gendered work styles disappeared after controlling for the influence of age, experience, other practitioners’ characteristics, and patient mix.20 Similarly, a cross-sectional European study into consultation length found that 55% of the variance was due to factors at the patient level and that “the age and sex of the doctor had no impact on the duration of the consultation”.21 Societal delivery of health careThe missing ingredient in contemporary discussions of the effect of women in medicine is the role of sex socialisation, a powerful force for both women and men. The traditions of Western medicine have been forged in a male-centric work model. In this model, vocational commitment is demonstrated by long hours of work and dedication to the profession.18 This could be seen as the male version of the Mother Teresa effect, except that it is predicated on a personal life that is provided by a full-time “invisible” other. That invisible other is traditionally female. It would seem that little has changed. Many female medical students still see their gender as a disadvantage for their careers and expect that they will be required to sacrifice their professional lives to have a personal life, even if they are in a dual career relationship.22 This persistence of “gendered schemas” within the medical profession means that “men are consistently over-rated and women under-rated” in relation to competence and performance.23 Invisible barriers such as the classic glass ceiling24,25 — or other hidden forms of the Medusa effect — may often stymie women’s attempts at assertiveness or leadership. Overcoming the constraints of such a “discriminatory environment”18 may be having an adverse effect on female doctors’ health and wellbeing,26 especially if the effects of gendered behavioural expectations are not given a place at the “workforce patterns” discussion table. In any debate that draws on quantitative data, women are likely to “fall foul” for biological reasons. In a male-centric environment, periods of peak career building coincide with the time of establishing a family. Both are time hungry, and gendered socialising still sees women expected to take the prime responsibility for both children and domestic requirements.27 Gjerberg, from the Norway Work Research Institute, has pointed out that any discussion of medical workforce patterns that does not factor this expectation in ignores the fact that, while women work shorter hours in paid work, compared with their male colleagues, they work longer hours in total.28 The medical profession Women are here to stay, and we believe that trying to dance to the Henry Higgins refrain of “why can’t a woman be more like a man?” will not help us find workable and practical solutions to help shape the profession’s future. Women now account for about 37% of the Australian general practice workforce overall and half the workforce among general practitioners younger than 45 years. These trends appear set to continue, as two-thirds of all GP registrars younger than 35 years are female.29 As the medical workforce races toward a gender balance, to what extent is the female perspective influencing major decision making within the profession? Evidence suggests this is limited, as gender still appears to have a filtering effect in terms of leadership roles, choice of specialty, and academic advancement for women within the profession.30 Embracing gendered health careIf the female perspective is absent from medical decision making, how is it possible for true feminisation of the medical workforce to occur? Real feminisation implies an adaptation of medicine’s epistemology to include a female perspective and female ways of knowing, which are then expressed ontologically through its workforce. If the female voice is missing, so is the female perspective. As the number of female doctors continues to grow, their perspective is vital for finding workable and realistic solutions that meet society’s needs and expectations for adequate health care. An obsessive focus on women’s behaviour, whether it be on the Mother Teresa or the Medusa traits, in a gender “blame game” is unlikely to accomplish this perspective. As Australian researchers Joyce and colleagues have said, it is indeed “time for a new approach to workforce planning”.31 Are we mature enough then, as a profession, to explore assumptions about gendered social and professional roles and responsibilities? In laying these bare, are we ready to truly “feminise” the medical workforce and embrace new possibilities in workplace patterns that do not sacrifice ourselves, our children, our personal relationships or our responsibilities to our community to provide medical care? The implications for medical education, clinical practice and health care policy will be considerable (for some examples, see Box). A tall order certainly, but in the spirit of the recent Australia 2020 Summit, a think tank is urgently needed that has the gendered basis of medicine firmly at its centre, with a vision focused on the need for medical theory and practice to be inclusive of all the factors that are currently moulding medical workforce styles and health care delivery. Placing gendered workplace solutions on the agenda — some suggestions Medical education All students applying for medicine should be able to attend information sessions about the personal and social expectations of being a doctor. Medical students need to understand how sex socialisation and sexual stereotyping can affect self-expectations, patient expectations and society’s expectations of being a doctor. Vocational educational perspectives could address how the gender of the doctor (and the gender of the patient) can sculpt clinical practice. Clinical practice Alternative models of health care delivery could be explored, such as including childcare subsidies in practice incentive payments. This could, for example, help support practices to provide childcare facilities on site to enable doctors to have access to their children, while their patients have access to the doctors. Job-sharing rosters could address peak times for both practice and families; split (rather than continuous) shifts may help to better match supply and demand. Enhanced electronic communication could ensure appropriate patient handover and follow up. Health care policy There should be a decreased reliance on “proxy” workforce measures such as consultation times (if not controlled for patient gender, conditions managed, and health promotion). Patient health outcomes should be included in workforce modelling. The new opportunity provided by the GP Super Clinics could be used to trial gender-friendly workplace models of health care.

Lyn E Clearihan MB BS, MD, FRACGP, GradDipFM, MFM(Clin) · Jan Y Coles MB BS, PhD, MMed(Women’s Health), DCH, GCHPE

The two rural workforce strategies of rural clinical schools and deployment of international medical graduates (IMGs) geographically overlap in Australia’s large expanse of under-served rural and remote areas. We used the Rural Clinical School of Western Australia (RCSWA) as a model to examine the relative numbers of IMG clinical academics, and the contribution of IMGs to rural clinical school development and education. IMGs have established six of 10 rural clinical school sites, maintained an academic presence, and continue to staff the RCSWA in high proportions. In a fragile rural work ecology, WA’s IMGs are contributing to both meeting current workforce needs and the education of future rural doctors. The “double debt” Australia owes to IMGs, stemming from the rich cross-fertilisation of these two workforce strategies, should be acknowledged.

Denese E Playford PhD · Moira A L Maley PhD, PGCertMedEd

Policies need more than development — they need implementation, and continuous reform In his historic Gettysburg Address, President Abraham Lincoln described the core of democracy as “government of the people, by the people, for the people.”1 We were reminded of these words when we witnessed the Rudd Labor Government vigorously emulating this ideal during the recent Australia 2020 Summit.2 In April this year, a thousand Australians gathered in the Great Hall of Parliament House in Canberra to debate 10 national challenges. These included the future of the Australian economy; future directions for rural industries and rural communities; strengthening communities, supporting families and social inclusion; options for the future of Indigenous Australia; and a long-term national health strategy.2 In the challenging area of health, key ideas that were advanced included creating a Health Equalities Commission; creating a National Preventive Health Agency; initiatives for making healthy food choices easy in schools and regional areas; and, finally, the creation of a self-sufficient and flexible health workforce.3 In short, the Summit endorsed the expectation of healthy and long life for all Australians, and the equitable means to achieve this. Before the Summit, the Rudd Labor Government had already set in motion other consultative processes, such as the Preventative Health Taskforce to tackle the health challenges of tobacco, alcohol and obesity, and come up with a national preventative health strategy.4 This body was to be joined by the National Health and Hospitals Reform Commission (NHHRC), created to develop a long-term health reform plan for modern Australia.5 Its brief was to produce a blueprint for tackling future challenges in the Australian health system, such as the burden of chronic diseases and the ageing of the population as well as the rising costs of health care, which have been exacerbated by cost shifting and the “blame game”. In the recent federal budget, the Rudd Government included provisions for another national taskforce to address mental health. In this issue of the Journal, Bennett, Chair of the NHHRC, presents an outline of the Commission’s first report,6 Beyond the blame game: accountability and performance for the next Australian Health Care Agreements.7 At the heart of this report lies the need for the federal and state governments to stop playing the pernicious blame game, and the report advances a raft of relevant performance indicators to govern the Australian Health Care Agreement processes. Also in this issue of the Journal, Southby recounts the workings and achievements of the Hospitals and Health Services Commission, established by the Whitlam Labor Government in the 1970s.8 Its success as a harbinger of change lay in its dual responsibility for both comprehensive development and implementation of policy. In addition, its work was underpinned by an extensive analysis of relevant data, accompanied by consultation with all levels of government, professional bodies, universities and non-government organisations. And this highlights a significant danger for the efficacy of the current health taskforce and commissions — they are advisory only. A government can always ignore or merely cherrypick recommendations and, more worryingly, there need be no real political commitment to developing or implementing policy. Recommendations may well end up gathering dust in ministerial offices in Canberra, or being savaged by the leagues of advisors who prowl those offices. Witness the innumerable reports on health reform emanating from the Productivity Commission, the Council of Australian Governments, the Australian Healthcare Reform Alliance, the Australian Healthcare and Hospitals Association, Consumers’ Health Forum of Australia, and so on . . .9 Most seem to fall on deaf political ears. And yet, we continue to tolerate a health care system whose capacity to deliver is faltering in the face of increasing community demand. What Australia desperately needs is a continuous health reform agenda. We need to abandon the episodic and ad-hoc response to public disquiet and discontent, followed by the inevitable political quick fix. To ensure that this becomes a reality, the NHHRC needs to become a body with similar functions and status to those of the Whitlam era’s Hospitals and Health Services Commission, with a brief for wide involvement. Effectively, it needs to be responsible for driving reform, mirroring President Lincoln’s democratic dictum “by the people, for the people”. We also need to keep the government honest and up to the task of reform through an overarching body, perhaps the “Australian Health Council”, which would promote greater accountability of governments in driving reform effectively. The Council would also need to meet regularly in a different location each time, to have its members discuss health issues with Australian communities in open forums. The time has come to stop the reform rhetoric and political gamesmanship and acknowledge that good health is a right for all Australians. Indeed “the health of the people is the highest law”.10 But we can only achieve this most basic of human rights by making a sincere commitment to implementing meaningful reform of the health care systems we now have.

Martin B Van Der Weyden MD, FRACP, FRCPA

Objectives: To use community pharmacy medication records to identify patients whose asthma may not be well managed and then implement and evaluate a multidisciplinary educational intervention to improve asthma management.Design, setting and participants: We used a multisite controlled study design. Forty-two pharmacies throughout Tasmania ran a software application that “data-mined” medication records, generating a list of patients who had received three or more canisters of inhaled short-acting β2-agonists in the preceding 6 months. The patients identified were allocated to an intervention or control group. Pre-intervention data were collected for the period May to November 2006 and post-intervention data for the period December 2006 to May 2007.Intervention: Intervention patients were contacted by the community pharmacist via mail, and were sent educational material and a letter encouraging them to see their general practitioner for an asthma management review. Pharmacists were blinded to the control patients’ identities until the end of the post-intervention period.Main outcome measure: Dispensing ratio of preventer medication (inhaled corticosteroids [ICSs]) to reliever medication (inhaled short-acting β2-agonists).Results: Thirty-five pharmacies completed the study, providing 702 intervention and 849 control patients. The intervention resulted in a threefold increase in the preventer-to-reliever ratio in the intervention group compared with the control group (P < 0.01) and a higher proportion of patients in the intervention group using ICS therapy than in the control group (P < 0.01).Conclusions: Community pharmacy medication records can be effectively used to identify patients with suboptimal asthma management, who can then be referred to their GP for review. The intervention should be trialled on a national scale to determine the effects on clinical, social, emotional and economic outcomes for people in the Australian community, with a longer follow-up to determine sustainability of the improvements noted.

Bonnie J Bereznicki BPharm(Hons) · Gregory M Peterson BPharm(Hons), PhD, MBA · Shane L Jackson BPharm(Hons), PhD · E Haydn Walters DM, FRCP, FRACP · Kimbra D Fitzmaurice BPharm · Peter R Gee BPharm(Hons)

The federal government announced the establishment of the National Health and Hospitals Reform Commission (NHHRC) in February 2008 to advise on future directions of health care delivery in Australia. In late April, the NHHRC issued its first report, Beyond the blame game, giving its views on key issues for the proper function of the Australian Health Care Agreements. In this report, the NHHRC has proposed 44 benchmarks to be met by both federal and state governments, where performance should have clear consequences for the accountable party.

Christine C Bennett MB BS, FRACP, MPaed

Health was a prominent policy issue in the 1972 Australian federal government elections, and the policy of the new Labor Government at that time emphasised the regional approach to health service delivery, including community-based services and preventive health programs, in close cooperation with the states. The Hospitals and Health Services Commission Act 1973 (Cwlth) was passed in December 1973 and members of the new Commission were appointed in April 1974. The Commission had broad-ranging functions and powers that had major influences on national health policy development in Australia. Major accomplishments of the Commission included the Community Health Program, which incorporated: the Hospitals Development Program, health services planning and research, a review of the School of Public Health and Tropical Medicine at the University of Sydney, diagnostic services, rehabilitation, Aboriginal health, rural health, health transport, nursing personnel, health careers and occupational health, many of which were long-neglected areas of public health. The National Health and Hospitals Reform Commission established by the Rudd Labor Government in February, 2008, while welcome, is an investigative body, whereas the Hospitals and Health Services Commission was responsible for both health policy development and implementation.

Richard F Southby PhD, FCHSE, FFPH

Objective: To identify patient safety measurement tools in use in Australian public hospitals and to determine barriers to their use.Design: Structured survey, conducted between 4 March and 19 May 2005, designed to identify tools, and to assess current use of, levels of satisfaction with, and barriers to use of tools for measuring the domains and subdomains of: organisational capacity to provide safe health care; patient safety incidents; and clinical performance.Participants and setting: Hospital executives, managers and clinicians from a nationwide random sample of Australian public hospitals stratified by state and hospital peer grouping.Main outcome measures: Tools used by hospitals within the three domains and their subdomains; patient safety tools and processes identified by individuals at these hospitals; satisfaction with the tools; and barriers to their use. Results: Eighty-two of 167 invited hospitals (49%) responded. The survey ascertained a comprehensive list of patient safety measurement tools that are in current use for measuring all patient safety domains. Overall, there was a focus on use of processes rather than quantitative measurement tools. Approximately half the 182 individual respondents from participating hospitals reported satisfaction with existing tools. The main reported barriers were lack of integrated supportive systems, resource constraints and inadequate access to robust measurement tools validated in the Australian context. Measurement of organisational capacity was reported by 50 (61%), of patient safety incidents by 81 (99%) and of clinical performance by 81 (99%).Conclusion: Australian public hospitals are measuring the safety of their health care, with some variation in measurement of patient safety domains and their subdomains. Improved access to robust tools may support future standardisation of measurement for improvement.

Caroline A Brand BA, MPH, FRACP · Joanne Tropea BPhysio, MPH · Joseph E Ibrahim PhD, FRACP · Shaymaa O Elkadi BA, GradDipAppPsych · Christopher A Bain MB BS, MInfoTech, MACS(Prov) · David I Ben-Tovim PhD, MRCPsych, FRANZCP · Tracey K Bucknall BN, GradDipAdvNurs, PhD · Peter B Greenberg MD, PhD, FRACP · Allan D Spigelman MD, FRACS, FRCS

Objective: To describe the impact of invasive management on 12-month survival among patients with suspected acute coronary syndrome (ACS) in Australia.Design and setting: Prospective nationwide multicentre registry.Patients: Patients presenting to 24 metropolitan and 15 non-metropolitan hospitals with ST-segment-elevation myocardial infarction (STEMI), and high-risk and intermediate-risk non-ST-segment-elevation ACS (NSTEACS) between 1 November 2005 and 31 July 2007.Main outcome measures: Death, myocardial infarction (MI) or recurrent MI, revascularisation and stroke at 12 months.Results: Among 3402 patients originally enrolled, vital status at 12 months was available for 3393 (99.7%). Patients from non-metropolitan areas (810) constituted 23.9% of patients. Early invasive management was more commonly undertaken among patients with STEMI (STEMI, 89.7% v non-STEMI, 70.8% v unstable angina, 44.8% v stable angina, 35.8%; P < 0.001). Factors most associated with receiving invasive management included admission with suspected STEMI or high-risk NSTEACS, being male and the hospital having an onsite cardiac surgical service. Overall mortality by 12 months among patients with STEMI, non-STEMI, unstable angina and stable angina was 8.0%, 10.5%, 3.3%, and 3.7% (P < 0.001), respectively. After adjusting for a propensity model predicting early invasive management and other known confounders, early invasive management was associated with a 12-month mortality hazard ratio of 0.53 (95% CI, 0.34–0.84, P = 0.007).Conclusions: A substantial burden of late morbidity and mortality persists among patients with ACS within contemporary Australian clinical practice. Under-use of invasive management may be associated with an excess in 12-month mortality, suggesting the need for more use of invasive management among these patients.

on behalf of the ACACIA investigators

To the Editor: The Rural Doctors Association (RDA) of New South Wales, of which I am President, has been involved in desperately trying to keep maternity units close to people’s homes. The conclusion formed by Ford and colleagues in their recent report,1 that women with a previous postpartum haemorrhage should only deliver in units with a blood transfusion service, appears extraordinary and contradictory to their own findings. The authors based this conclusion on their finding that 5.8% of women had a postpartum haemorrhage in their first pregnancy, even though their definition of this was remarkably subjective and largely unscientific. They recognised in their study that the incidence of postpartum haemorrhage requiring transfusion is only 0.7%. Therefore, 88% of women defined as having a postpartum haemorrhage do not require a blood transfusion. I am bemused why the authors think 88% of women who did not require a blood transfusion but had a “postpartum haemorrhage” should only deliver in a unit with blood transfusion services. I doubt any of my colleagues would wish to deliver women who required a blood transfusion for a previous postpartum haemorrhage in a small unit. I refer Ford and colleagues, and readers, to a study by Tracy et al reported in January 2006.2 This was a much larger study of 750 491 women giving birth during 1999–2001. This study concluded that “In Australia lower hospital volume is not associated with increased adverse outcomes for low risk women”. In the past 10 years, we have seen the loss of 50% of our maternity units in NSW, and the rest are under severe stress due to the lack of staffing. I doubt that the sort of extraordinary conclusion made by Ford and colleagues will help us maintain services in rural NSW.

Leslie A Woollard

In reply: Safety and appropriateness are important principles underlying the provision of health care. Maternity care in Australia requires that women are offered care in an environment that is appropriate to their level of risk. Such a risk-management approach requires accurate data to inform the process, including accurate identification of women who may access local services as well as those who may benefit from higher levels of care. The aim of our study was to present risk estimates of recurrent postpartum haemorrhage (PPH) to better inform decision making by both clinicians and women about subsequent pregnancies. While we are aware of the struggles faced by rural maternity units, we estimated that only 0.2% of women giving birth in New South Wales would be affected by our suggestion that women with a history of PPH consider delivering at a hospital with onsite cross-match facilities. The definition of PPH that we used is consistent with that of the International classification of diseases1 and the NSW Department of Health’s PPH policy;2 this policy resulted from a review of hospital PPH policies sparked by a coronial inquest into a maternal death.3 In contrast to Tracy et al’s study, which only considered low-risk women and had no maternal morbidity outcomes,4 our study calculated risk among all women. Women with a PPH are at increased risk of transfusion, intensive care unit admission, unplanned procedure in the operating theatre, hysterectomy and major maternal morbidity.3 Where we have information about an increased risk of a potentially life-threatening event, surely we should communicate and act on this knowledge to achieve the best possible outcome for women and babies. In Canada, which has similar geographical challenges to those in Australia, it is recommended that where risk factors for PPH are identified, additional precautions such as intravenous access, coagulation studies, and availability of anaesthesia should also be considered.5 The key to successful regionalised maternity care is ensuring that women give birth in risk-appropriate settings.

Jane B Ford · Christine L Roberts · Jane C Bell · Charles S Algert · Jonathan M Morris

To the Editor: I wish to comment on Collignon’s recent editorial on methicillin-resistant Staphylococcus aureus (MRSA).1 The crux of the piece is his argument that what we need is interventional studies, not more studies documenting the extent of environmental contamination. This echoes the sentiment held by me and other colleagues working in the areas of infectious disease, microbiology and infection control. We do need more research and we need good data to evaluate interventions. However, we need to go one step further — a step that can and should be taken now, across the country. In 2006, I was part of a small team that reviewed the infection control program of a major teaching hospital in New South Wales. It became very clear that what is needed in infection control is a change in governance. At present, there is little ownership of nosocomial infections by clinicians or hospital administrators. Infection control intervention is perceived as belonging to the infection control practitioners, and not really the business of the doctors, nurses and other health workers who are caring for the individual patient. At worst, this attitude regards the necessary barrier precautions as an annoying, meddlesome burden imposed by some external agency. Clearly, such an attitude is unlikely to result in good compliance with containment measures. Infection control units have a very important role in terms of providing advice, consultancy and monitoring. But as long as there remains a general perception that nosocomial infections are solely the province of these units, progress in control is likely to be slow. One of the recommendations of our review was to change the governance structure as it relates to nosocomial infection. Elements of this included the following: Introducing infection control into the job descriptions of senior hospital executives and heads of departments; Conducting performance appraisals of these personnel to include infection control indicators; Seeking explicit agreement from all senior medical staff regarding compliance with infection control interventions; Requiring all departments to regularly and frequently review infection control indicators; and Requiring all departments to have regular, formal education sessions in infection control for all medical and nursing staff, including junior staff. We need a change in the mindset of clinicians. They must accept responsibility for what happens to their patients, including MRSA infections. These complications are no different from any others their patients may experience during their encounter with the hospital system.

Raymond C Chan

In reply: I heartily endorse Chan’s comments. To control infections in our hospitals, we desperately need not only a change in governance, but also a change in attitude. Chief executives of all hospitals, as well as all clinicians (nurses and doctors), need to take personal responsibility for serious infections that occur frequently in our hospitals. To do so, they also need to know how often these infections occur. We need robust and transparent measures — for example, data on health care-associated Staphylococcus aureus bloodstream infections, including methicillin-resistant S. aureus (MRSA),1 and deep-seated prosthetic joint infections. In recent years, faced with rising numbers of health care-associated infections, especially MRSA infections, the United Kingdom embraced necessary changes in governance. These included the promotion and use of seven key actions,2 with active surveillance and investigation being the first on the list. One of these mandatory surveillance measures was of all bloodstream infections caused by S. aureus (including MRSA)2,3 and the investigation of all episodes caused by MRSA with a “root-cause analysis”.2,4 There are early indications that the changes have successfully reduced the number of MRSA infections: from a peak of 3955 episodes of MRSA bloodstream infection occurring between October 2003 and March 2004, the number had fallen by over 40% to 2376 episodes in the period April 2007 to September 2007.3 Prevention and control of health care-associated infections must be a core part of clinical governance and patient safety programs in all hospitals. Chief executives and all clinical directors need to be aware of the numerous factors that must be given careful attention in order to reduce health care-associated infections. More importantly, they need to ensure that all appropriate steps are taken to prevent infection. This includes basic issues such as making sure that surfaces in clinical areas are adequately cleaned5 and that hand hygiene protocols are complied with — not just some of the time, but all of the time.

Peter J Collignon

What will it take to break the funding drought in Australia? Donations to health and medical research have recently made headlines, with mining magnate Clive Palmer pledging $100 million to medical research and Indigenous needs.1 While this amount is an Australian record, it is somewhat eclipsed by “gigaphilanthropists” Bill and Melinda Gates’s multibillion dollar inputs to research and health delivery. The prefix “gigas” is Latin for “giant” and it is worth asking: Where are the giants of Australian giving? As Daniel Petre (an Australian philanthropist and former Microsoft vice-president) recently slammed the lack of generosity of richer Aussies,2 it is timely to consider where health and medical donation stands in Australia. How do we compare with other nations and what is the forecast for the future? Australia is blessed with superb philanthropists — just not enough of them. To borrow from poet Dorothea Mackellar,3 the comparison is in the order of “droughts and flooding rains”, particularly when pitted against the philanthropy-rich landscape in the United States. US philanthropy is a veritable flood. Since the mid 1990s, 2% of the US gross domestic product has been given to charities;4 the percentage in Australia is less than half of this — a relative drought.5 More recently, the prescribed private fund — a new style of private foundation akin to the US family foundation — has burgeoned in Australia, with some 610 formed since this tax-effective structure was instigated in 2001. Many of these were established by people far from the wealth apex. Still, when it comes to health and medical research, as prominent medical research leader and former Chief Medical Officer Professor Judith Whitworth points out, “Australian philanthropic funding — both corporate and private — lags way behind”.6 Australian health and medical research non-profit organisations (eg, the Royal Children’s Hospital Foundation, the Leukaemia Foundation) attract one in seven of all individual donation dollars.5 So the area is popular, ranking second to religious institutions. However, it is not even a close second, as it is a case of many donors but small dollars.5 While three in five donating Australians support health and medical research, the average gift is comparatively low: just $77 per annum (pa) compared with $529 pa to religion, $234 pa to international aid, and $220 pa to arts and culture.5 By contrast, in the US, the average gift to health causes by the most modest households is US$173, ranging to US$92 289 in households with incomes over a million dollars.7 Philanthropy worldwide has been the crucible of fine medical research institutes and the trusts that fund them: consider our Walter and Eliza Hall Institute, the US Howard Hughes Medical Institute and the Wellcome Trust in the United Kingdom. Indeed, through the Wellcome’s input, UK charitable funding matches that of its nation’s Medical Research Council. Where is Australia’s Wellcome equivalent? The possibilities for a luminary local funder to alter the landscape are profound. With mean affluent household income growing by 36% in the decade to 2005, it is concerning that charitable giving by this income band has not kept apace. The most common affluent band of Australians (taxable incomes from $100 000 to $500 000) give less than 0.5% of their income to charitable causes.8 Longitudinal corporate research provides an international benchmark, with an average of 3%–11% of portfolios allocated to giving in some other countries.9 Despite comparable wealth levels, Australian givers trail the US, the UK and Canada. Yet Australia is said to have one of the world’s fastest growing rates of millionaires. Ironically, US philanthropist Chuck Feeney, a founder of the conglomerate Duty Free Shoppers, is thought to be Australia’s most generous philanthropist. His approach of leveraging funding sources through his foundation, Atlantic Philanthropies, has catalysed potent funding partnerships. Atlantic Philanthropies offers a significant amount, providing the recipient organisation can convince governments and others to match the pledge. Consider, for example, the $900 million research program at the University of Queensland generated by leveraging state, federal and other monies from Feeney’s $150 million input.10 People commonly believe medical research is the government’s responsibility. However, as a Nature editorial asserted last year, “In scientific funding, as in agriculture, monoculture is risky”.11 The lithe and flexible philanthropic dollar can trek where more risk-averse government or corporate dollars cannot. Untrammelled by politics, elections, profit, shareholders, disease numbers, or directives not to fund infrastructure, the philanthropic dollar can more readily finance risky ideas, chart cumulative progress over decades, consider orphan diseases, and trial venturesome backing that generates social profit. The future for the US, and most likely Australia, looks set to see more of this “venture philanthropy” model. A growing number of organisations (Box) are using their philanthropic agility to fund promising science through its pre-proof of principle, “Valley of Death” phase — the critical translational funding gap between basic research and later stage drug development. The concept of successful people “investing” donations to move innovative research to the point where venture capital may kick in is an enticing model that is working. For instance, the Alzheimer’s Drug Discovery Foundation reports seeding 22 biotechnology companies and supporting 148 academic international researchers who have created new classes of drugs for Alzheimer’s disease, screened millions of compounds, and are now entering clinical trials of several new drugs. Still, more debate is needed. Is it appropriate that philanthropy influences the research agenda? How valid is “personal whim” funding over majority need? Discovering better treatments sometimes means more expensive medicines, and is this progress for all? Change in the Australian health and medical research philanthropic landscape is needed, and the climate is right. Research Australia Philanthropy now exists to foster contribution to research (http://thankyouday.org/ra/philanthropy.aspx). The National Health and Medical Research Council added philanthropy to its strategic plan in 2006 and is working on fruitful partnerships with health and medical research charities (eg, co-funding with the Junior Diabetes Research Foundation Australia of the Diabetes Vaccine Development Centre). The national peak body, Philanthropy Australia (http://www.philanthropy.org.au/), provides forums for interested existing and potential funders to collaborate and exchange. The challenge is one of communication and culture change: convince philanthropic trusts, companies, individuals and households that funding medical research is not just a job for government, but a task for all Australians to shoulder. With governments increasingly unlikely to meet the spiralling costs of complex medicine for an ever-ageing population, the funding drought needs to be broken. Everyone can — and maybe should — play rainmaker. Organisations exploring “venture philanthropy” for medical research Goldman Philanthropic Partnerships was set up by a former merchant banker and his wife to accelerate the way cures are discovered through a business model of research funding partnerships (http://www.goldmanpartnerships.org) The Alzheimer’s Drug Discovery Foundation was set up by the Lauder family, of cosmetics renown (http://alzdiscovery.org/) The Washington, DC-based think tank, FasterCures (http://www.fastercures.org) The Epilepsy Therapy Development Project acts as a catalyst and a clearing house for innovative research and early commercialisation of new epilepsy therapies (http://www.epilepsy.com/epilepsy_therapy_project) CFF Therapeutics, a non-profit drug discovery and development affiliate of the Cystic Fibrosis Foundation (http://www.cff.org/research/CFFT/) Accelerate Brain Cancer Cure supports researchers and creates collaborations between medical, academic, industry and government partners (http://www.abc2.org)

Myles McGregor-Lowndes BA/LLB, MAdmin, PhD · Wendy Scaife BBusComm, MBusMgnt, PhD

Objective: To assess the efficacy of a multimodal, centrally coordinated, multisite hand hygiene culture-change program (HHCCP) for reducing rates of methicillin-resistant Staphylococcus aureus (MRSA) bacteraemia and disease in Victorian hospitals.Design, participants and setting: A pilot HHCCP was conducted over a 24-month period (October 2004 to September 2006) in six Victorian health care institutions (4 urban, 2 rural; total beds, 2379). Subsequently, we assessed the efficacy of an identical program implemented throughout Victorian public hospitals over a 12-month period (beginning between March 2006 and July 2006).Main outcome measures: Rates of hand hygiene (HH) compliance; rates of MRSA disease (patients with bacteraemia and number of clinical isolates per 100 patient discharges [PD]).Results: Mean HH compliance improved significantly at all pilot program sites, from 21% (95% CI, 20%–22%) at baseline to 48% (95% CI, 47%–49%) at 12 months and 47% (95% CI, 46%–48%; range, 31%–75%) at 24 months. Mean baseline rates for the number of patients with MRSA bacteraemia and the number of clinical MRSA isolates were 0.05/100 PD per month (range, 0.00–0.13) and 1.39/100 PD per month (range, 0.16–2.39), respectively. These were significantly reduced after 24 months to 0.02/100 PD per month for bacteraemia (P = 0.035 for trend; 65 fewer patients with bacteraemia) and 0.73/100 PD per month for MRSA isolates (P = 0.003; 716 fewer isolates). Similar findings were noted 12 months after the statewide roll-out, with an increase in mean HH compliance (from 20% to 53%; P < 0.001) and reductions in the rates of MRSA isolates (P = 0.043) and bacteraemias (P = 0.09).Conclusions: Pilot and subsequent statewide implementation of a multimodal HHCCP was effective in significantly improving HH compliance and reducing rates of MRSA infection.

M Lindsay Grayson MD, FRACP FAFPHM · Lisa J Jarvie RN · Rhea Martin RN, MPH · Paul D R Johnson PhD, FRACP · Meryanda E Jodoin RN · Celene McMullan RN · Roger H C Gregory RN · Kaye Bellis RN · Katie Cunnington RN · Fiona L Wilson RN · Diana Quin RN, BA, MPH · Anne-Maree Kelly MB BS, FACEM

Objective: To characterise the understanding of good clinical research practice (GCRP) among clinical researchers.Design, participants and setting: Survey of all staff within the largest clinical research group (Critical Care and Neurosciences) of a non-government research institute affiliated with a major children’s hospital, between 1 April and 31 May 2007.Main outcome measures: Staff’s role and research activity; knowledge of relevant guidelines and translation into practice; GCRP training; and experience of research audits.Results: 122 of 154 research staff (79%) responded and were divided into three categories: clinicians (45%); research students/junior researchers (32%); and researchers (23%). While 60% of researchers reported they had read (at least in part) the two key Australian documents (the National statement on ethical conduct in human research and the Australian code for the responsible conduct of research), only 36% of clinicians and 30% of students/junior researchers stated they had done so. GCRP, such as obtaining consent and document storage, was only partially understood. 13% of all respondents had experienced a research project audit and 10% had undertaken formal GCRP training. Reasons given for the lack of GCRP training included insufficient resources, no training provided, and no time. 79% of staff felt that research auditing was important and 74% would like more education in GCRP.Conclusions: Many clinical researchers are unaware of all the responsibilities involved in GCRP. A formal mandatory training program and GCRP auditing would be likely to improve practice.

Franz E Babl MD, MPH, FRACP · Lisa N Sharwood RN, BN, MPH

Objective: To explore the role played by human research ethics committees (HRECs) with regard to the fair inclusion of men and women in Australian clinical research.Design and participants: Semi-structured face-to-face and telephone interviews with 25 chairs (or their nominees) of Australian HRECs between 9 June 2006 and 24 January 2007.Main outcome measures: Chairs’ views about the role of HRECs in identifying sex discrimination, monitoring the inclusion of men and women in clinical research, and interpreting and applying National Health and Medical Research Council (NHMRC) guidelines relating to fair inclusion in research.Results: In general, HRECs do not take an active role in monitoring the sex of research participants. They do not ask for or often receive information about the sex of participants. Most HREC chairs did not believe that sex discrimination in research is currently a significant or widespread problem, and were confident that their committees would be able to identify arbitrary exclusion of either men or women from research. However, many chairs expressed a lack of familiarity with debates about sex equity in research. Most chairs were unaware that anti-sex-discrimination legislation could apply to research. “Fair inclusion” was interpreted in a number of ways by chairs, but most frequently that the sex balance among research participants should reflect the sex distribution in the community of the condition under investigation. Chairs said their committees would be reluctant to reject a research protocol on the grounds that the sex balance among participants was perceived to be unfair.Conclusion: Views about, and expertise on, sex equity in research vary among chairs of HRECs. Many HRECs require further guidance about the appropriate standards for fair inclusion of men and women in Australian clinical research.

on behalf of the Australian Gender Equity in Health Research Group

The level of documentation of vital signs in many hospitals is extremely poor, and respiratory rate, in particular, is often not recorded. There is substantial evidence that an abnormal respiratory rate is a predictor of potentially serious clinical events. Nurses and doctors need to be more aware of the importance of an abnormal respiratory rate as a marker of serious illness. Hospital systems that encourage appropriate responses to an elevated respiratory rate and other abnormal vital signs can be rapidly implemented. Such systems help to raise and sustain awareness of the importance of vital signs.

Michelle A Cretikos MB BS, MPH, PhD · Rinaldo Bellomo MD, FJFICM · Ken Hillman MB BS, FRCA, FJFICM · Jack Chen MB BS, MBA · Simon Finfer MB BS, MRCP, FRCA · Arthas Flabouris MB BS, FANZCA, FJFICM

CorrectionRe: “Are Australian children iodine deficient? Results of the Australian National Iodine Nutrition Study”, by Mu Li, Creswell J Eastman, Kay V Waite, Gary Ma, Margaret R Zacharin, Duncan J Topliss, Philip E Harding, John P Walsh, Lynley C Ward, Robin H Mortimer, Emily J Mackenzie, Karen Byth and Zelda Doyle, in the 20 February 2006 issue of the Journal (Med J Aust 2006; 184: 165-169). The article as originally published did not include unbiased estimates across all mainland states for the statistics presented in Box 1 and Box 4. This omission is corrected in the tables presented here. All data in these tables are the same as in the original article, but an extra row showing estimates for mainland states has been added. The “Total” row refers to the study sample only. The unbiased estimate of the national median urinary iodine excretion (UIE) in the results section of the abstract should read 96 μg/L, not 104 μg/L, showing that children in mainland Australia are mildly iodine deficient according to World Health Organization criteria (mild iodine deficiency, UIE 50–99 μg/L). 1 Summary data on participating schoolchildren by state together with weighted estimates across all mainland states State Students participated/ students targeted M:F ratio Mean (SD) age (years) Mean (SD) weight (kg) Mean (SD) height (cm) Mean (SD) body surface area (m2) Median urinary iodine excretion (μg/L) (interquartile range) NSW 427/400 (106%) 1:1 9.3 ± 0.6 34.9 ± 8.5 138.5 ± 6.7 1.16 ± 0.15 89.0 (65.0–123.5) VIC 348/400 (87%) 1:0.8 9.7 ± 0.5 38.2 ± 8.9 141.0 ± 6.8 1.22 ± 0.15 73.5 (53.0–104.3) SA 317/400 (79%) 1:0.9 9.0 ± 0.5 35.3 ± 7.9 137.3 ± 7.3 1.16 ± 0.15 101.0 (74.0–130.0) WA 323/400 (80%) 1:0.8 8.9 ± 0.6 32.8 ± 7.6 136.9 ± 6.4 1.11 ± 0.14 142.5 (103.5–214.0) QLD 294/400 (73%) 1:1.3 9.1 ± 0.4 32.9 ± 7.2 137.3 ± 6.3 1.12 ± 0.13 136.5 (104.3–183.8) Total for sample 1709/2000 (85%) 1:0.9 9.2 ± 0.6 34.9 ± 8.3 138.3 ± 6.9 1.20 ± 0.10 104.0 (71.0–147.0) Estimates for mainland states* 1:1 9.3 ± 0.6 35.2 ± 8.5 138.7 ± 6.8 1.16 ± 0.15 96.0 (66.0–135.0) M:F = male to female. * Formed by weighting the sample data from each state according to the distribution of all Year-4 schoolchildren by mainland states. 4 Percentage of children with a thyroid volume (mL) greater than the new international standard 50th and 97th percentile values (P50 and P97) Based on body surface area (% [95%CI]) Based on age (% [95%CI]) State Boys Girls Total Boys Girls Total Percentage > international standard P50 NSW 58.1 (51.3–64.9) 57.6 (50.9–64.3) 57.9 (53.1–62.7) 61.3 (54.6–68.0) 63.8 (57.3–70.3) 62.6 (57.9–67.3) VIC 18.0 (12.6–23.4) 18.3 (12.2–24.4) 18.2 (14.1–22.3) 24.9 (18.8–31.0) 26.1 (19.1–33.1) 25.4 (20.8–30.0) SA 41.0 (33.5–48.5) 46.3 (38.3–54.4) 43.5 (38.0–49.0) 50.9 (43.3–58.5) 54.4 (46.4–62.4) 52.5 (47.0–58.0) WA 70.0 (63.1–76.9) 71.6 (64.3–78.9) 70.8 (65.8–75.8) 75.3 (68.8–81.8) 81.1 (74.8–87.4) 78.0 (73.4–82.6) QLD 55.0 (46.4–63.6) 50.0 (42.3–57.7) 52.2 (46.4–58.0) 61.5 (53.1–69.9) 60.6 (53.0–68.2) 61.0 (55.4–66.6) Estimates for mainland states* 47.1 (43.3–50.9) 46.2 (42.5–49.9) 46.6 (44.0–49.2) 52.5 (48.8–56.3) 54.1 (50.4–57.8) 53.3 (50.7–55.9) Percentage > international standard P97 NSW 3.9 (1.2–6.6) 7.1 (3.6–10.6) 5.6 (3.4–7.8) 6.4 (3.0–9.8) 10.0 (5.9–14.1) 8.2 (5.6- 10.8) VIC 0 0 0 0 0.7 (0–2.0) 0.3 (0–0.9) SA 4.8 (1.5–8.1) 10.1 (5.3–14.9) 7.3 (4.4–10.2) 6.6 (2.8–10.4) 10.7 (5.7–15.7) 8.5 (5.4–11.6) WA 11.2 (6.5–15.9) 14.9 (9.2–20.6) 12.9 (9.2–16.6) 11.8 (7.0–16.6) 19.6 (13.2–26.0) 15.4 (11.4–19.4) QLD 2.3 (0–4.9) 3.1 (0.4–5.8) 2.8 (0.9–4.7) 3.1 (0.1–6.1) 5.6 (2.0- 9.2) 4.5 (2.1–6.9) Estimates for mainland states* 2.9 (1.7–4.2) 5.0 (3.3–6.6) 4.0 (3.0–5.0) 4.3 (2.7–5.9) 7.2 (5.2–9.1) 5.7 (4.5–7.0) * Formed by weighting the sample data from each state according to the distribution of all Year-4 schoolchildren by mainland states.

Mu Li · Creswell J Eastman · Kay V Waite · Gary Ma · Margaret R Zacharin · Duncan J Topliss · Philip E Harding · John P Walsh · Lynley C Ward · Robin H Mortimer · Emily J Mackenzie · Karen Byth · Zelda Doyle

Objective: To quantify time doctors in hospital wards spend on specific work tasks, and with health professionals and patients.Design: Observational time and motion study.Setting: 400-bed teaching hospital in Sydney.Participants: 19 doctors (seven registrars, five residents, seven interns) in four wards were observed between 08:30 and 19:00 for a total of 151 hours between July and December 2006.Main outcome measures: Proportions of time in categories of work; proportions of tasks performed with health professionals and patients; proportions of tasks using specific information tools; rates of multitasking and interruptions.Results: The greatest proportions of doctors’ time were in professional communication (33%; 95% CI, 29%–38%); social activities, such as non-work communication and meal breaks (17%; 95% CI, 13%–21%), and indirect care, such as planning care (17%; 95% CI, 15%–19%). Multitasking involved 20% of time, and on average, doctors were interrupted every 21 minutes. Most tasks were completed with another doctor (56%; 95% CI, 55%–57%), while 24% (95% CI, 23%–25%) were undertaken alone and 15% (95% CI, 15%–16%) with a patient. Interns spent more time completing documentation and administrative tasks, and less time in direct care than residents and registrars. The time interns spent documenting (22%) was almost double the time they were engaged in direct patient care.Conclusions: Two-thirds of doctors’ time was consumed by three work categories: professional communication, social activities and indirect care. Doctors on wards are interrupted at considerably lower rates than those in emergency and intensive care units. The results confirm interns’ previously reported dissatisfaction with their level of administrative work and documentation.

Johanna I Westbrook BAppSc, MHA, PhD · Amanda Ampt RN, MHIM · Leanne Kearney RN · Marilyn I Rob MA, CStat, PhD

Objectives: To describe how intern time is spent, and the frequency of activities performed by interns during emergency department (ED) rotations.Design and setting: Prospective observational study of 42 ED interns from three Melbourne city teaching hospitals during 5 months in 2006. Direct observations were made by a single researcher for 390.8 hours, sampling all days of the week and all hours of the day.Main outcome measures: Proportion of time spent on tasks and number of procedures performed or observed by interns.Results: Direct patient-related tasks accounted for 86.6% of total intern time, including 43.9% spent on liaising and documentation, 17.5% obtaining patient histories, 9.3% on physical examinations, 5.6% on procedures, 4.8% ordering or interpreting investigations, 3.0% on handover and 4.9% on other clinical activities. Intern time spent on non-clinical activities included 4.2% on breaks, 3.7% on downtime, 1.7% on education, and 1.3% on teaching others. Adjusted for an 8-week term, the ED intern would take 253 patient histories, consult more senior ED staff on 683 occasions, perform 237 intravenous cannulations/phlebotomies, 39 arterial punctures, 12 wound repairs and apply 16 plasters. They would perform chest compressions under supervision on seven occasions, observe defibrillation twice and intubation once, but may not see a thoracostomy.Conclusions: The ED exposes interns to a broad range of activities. With the anticipated increase in intern numbers, dilution of the emergency medicine experience may occur, and requirements for supervision may increase. Substitution of ED rotations may deprive interns of a valuable learning experience.

Jia Ni Zhu · Tracey J Weiland BBSc(Hons), PhD · David M Taylor MD, MPH, FACEM · Andrew W Dent MPH, FRCS, FACEM

To the Editor: The timely article by Healy and colleagues1 should provoke debate within the profession. The authors’ decision to not consider “the relative merits of national versus regional registration boards” should not stifle discussion in the Journal. In particular, Australian doctors and the public should be aware that the medical board system to which we are accustomed is not operational in most countries. In much of the English-speaking world, boards comprise mainly doctors and have considerable independence from government; medical boards in non-English-speaking countries are generally part of the health bureaucracy.2 The fundamental danger of having a Council of Australian Governments-inspired national registration “body” lies in the potential for a switch from the “English” system of self-regulation under common law to the “European” model of bureaucratic rule under administrative law. Public and professional suspicion of self-regulation lay behind the 1987 amendments to the Medical Practitioners Act 1938 (NSW), which removed the power of deregistration from the New South Wales Medical Board, handing it instead to the Medical Tribunal chaired by a District Court Judge. This move avoided both the “Scylla” of public distrust of the profession and the “Charybdis” of criticism, such as have afflicted the boards in Victoria and elsewhere, where boards retained that power. No less important problems with a national board lie in the assessment of local problems and surveillance of doctors whose registration is conditional. This is already difficult in the larger states, such as Queensland, NSW and Western Australia. The continued failure of the centralised Health Insurance Commission to prevent and prosecute the abuse of Medicare by doctors, despite repeated ineffectual changes to the legislation,3 does not encourage optimism that a national medical board could effectively manage impaired doctors or those performing below standard. Having served on Commonwealth working parties on both mutual recognition of medical qualifications and Medicare “overservicing” and “inappropriate practice”, I would opt for an independent, publicly accessible national database containing a “uniform set of items that are allowable under existing privacy legislation”.1 The elements of such a database are already operational in the safe hands of the Australian Medical Council (AMC). It should not be too difficult, and certainly less cumbersome, for state and territory governments and medical boards to agree on that uniform set, on the foundations already laid by the AMC, and to continue the AMC’s ownership of the database.

Peter C Arnold

In reply: Arnold makes some interesting points about the balance of state and professional involvement in medical registration arrangements. Wherever the balance is struck, politicians, bureaucrats and medical professionals all derive their power in some measure from the public whom they serve. Our point is that variations in registration information and public access to multiple registers make it difficult for members of the public to access and use the information, especially given the mobility of the medical workforce between jurisdictions. A public national medical register should be seen as a practical measure to improve public accountability, rather than as a battleground between the profession and the bureaucrats. We did not express a view in our article1 on how national access to medical registration details should be arranged. As Arnold suggests, the Australian Medical Council is one candidate for maintaining a national database. It is well placed to publicly call on the existing state medical registration boards to cooperate speedily to make national access a reality, pending the negotiations underway regarding a national medical board.

Judith M Healy · Paul Dugdale

Social marketing. Why should the devil have all the best tunes? Gerard Hastings. Oxford: Butterworth-Heinemann, 2007 (xvii + 367 pp). ISBN 978 0 7506 83500. Not so long ago, it seemed businesses couldn’t swap their products for our money fast enough before disappearing. Now we can’t even have a haircut without surrendering our name, address, phone number and date of birth. Welcome to relationship marketing. Today’s companies really do care about our satisfaction because customer satisfaction underpins repeat business, explains Gerard Hastings in Social marketing. Why should the devil have all the best tunes? Hastings, the United Kingdom’s first professor of social marketing, argues that public health needs to expand the use of these successful marketing strategies to make health promotion more powerful. By examining commercial practices and dissecting case studies of public health interventions, he demonstrates how health promotion is moving beyond fear campaigns and short-term interventions to building relationships with people and providing practical, ongoing assistance to encourage risk reduction and healthier living. Hastings clearly and succinctly explains the theories underlying social marketing: stages of change, social cognitive theory and exchange theory. He argues that social marketing requires strategic analysis of the problem, of the competing forces and of the target population to underpin solutions that work. Hastings and his colleagues at the University of Stirling, Scotland, recently demonstrated the power of analysing a problem by systematically reviewing the impact of junk food advertising and finding there are adverse effects on children’s food preferences, purchases and consumption. Understanding competing forces is crucial, he argues, because one of the reasons we have binge-drinkers, smokers and people who eat and drink unhealthily is that companies have been better at marketing than have health professionals. Hastings’ well structured and clearly written book equips readers with a valuable tool of public health that can be used to counteract the “hazard merchants”, who market death and disease through products (such as tobacco), and to promote healthier living.

Catriona M F Bonfiglioli

The Australian Primary Health Care Research Institute (APHCRI) is part of the Primary Health Care Research Evaluation and Development (PHCRED) strategy.1 The Institute was the most recent element of the PHCRED strategy to be established, beginning research activities following the appointment of the Research Advisory Board (RAB) in November 2003. APHCRI’s mission is to “provide national leadership in improving the quality and effectiveness of primary health care through the conduct of high quality priority-driven research and the support and promotion of best practice”.2 APHCRI has a specific focus on the links between primary health care evidence and policy. Its activities not only fund research programs, but also seek to build capacity within the research community and policy community to facilitate the adoption of evidence into policy. There are two important interdependent features in the APHCRI model adopted to fulfil this mission. Firstly, it is a “virtual” institute operating a “hub and spoke” model. The Institute comprises staff based at the Australian National University (the “hub”) and, within different streams of research activities, multiple “spokes” undertaking commissioned programs of research. Secondly, the Institute has a specific pool of funds to commission research — it both funds research and undertakes research. The Institute’s RAB sets the research priorities, oversees the independent assessment of applications for funding and determines the successful spokes. Groups compete to be commissioned within a particular stream of research, but, once successful, collaborate as part of the virtual institute. In this article, we provide an overview of the approach APHCRI has taken to bring research evidence to bear on policy formation. We also reflect on lessons learned through the process of conducting our fourth research stream. Linkage and exchange, APHCRI styleInfluencing policy with research evidence is not a simple “linear” proposition. Health policy draws on many information inputs apart from research evidence, including political realities.3 APHCRI has adapted the Canadian Health Services Research Foundation “linkage and exchange” approach4 in order to make its research products more useful to policymakers. APHCRI links together four groups of participants to exchange knowledge from their different perspectives. These are: Policymakers and decisionmakers in both the federal and state/territory spheres; Providers of primary health care services and the various organisations with which they are associated; Researchers; and Users of primary health care services, and the various organisations with which they are associated. Members of these four groups serve on the RAB. APHCRI’s research priorities are iterated with policy advisers and the RAB to ensure they are relevant to policy. Expert review committees, convened to assess applications within the different streams, include members with expertise across these groups. The assessment criteria for applications within streams reflect the emphasis on policy and provider expertise in addition to more usual academic criteria. Stream 4APHCRI organises its research programs in “streams”. Each stream has a particular focus and may have several spokes or individuals working within it (the numbers of the streams denote the chronological order in which they were announced). The Institute’s Stream 4 program (with $1.8 million funding in total) further sharpened the linkage and exchange focus. It aimed to increase both the capacity of researchers to respond to policy priorities and the capacity of policy advisers to utilise research evidence. A list of policy-relevant topics, approved by the RAB, was identified in consultation with the Australian Government Department of Health and Ageing. A total of 12 spokes were commissioned to address these topics, using a common methodology to address two broad questions: What do we know about the topic?; and What are the possible options for the Australian context? The first question focuses the systematic review that is synthesised by the research team. The second question requires the researchers to use the results of the review to develop evidence-based recommendations for ways forward for Australia’s primary health care system. The policy options include consideration of funding arrangements (existing and alternative), delivery arrangements and governance arrangements reflecting system-level perspectives. An overview of the steps, timelines and major activities that comprised Stream 4 is presented in the Box. Within this supplement, we summarise key findings from each spoke on the topics as follows: Chronic disease management (Cranston et al,6 Dennis et al7); Integration, coordination and multidisciplinary care (Jackson et al,8 Mitchell et al,9 Powell Davies et al10); Innovative models for comprehensive primary health care delivery (McDonald et al,11 Naccarella et al,12 Humphreys et al13); Innovative models for the management of mental health in primary health care settings (Griffiths and Christensen14); Children and young Australians, health promotion and prevention (McDonald et al,15 Hearn et al16); and Workforce (focus on competency-based training) (Glasgow et al17). Systematic review and interactions between policy advisers and researchersThe disparate nature of much of the published literature required careful consideration of the appropriate methods for systematically reviewing and synthesising such evidence. Stream 4 drew heavily on the Journal of Health Services Research and Policy supplement, “Synthesizing evidence for management and policy-making”,18 to underpin its approaches, particularly the narrative synthesis approach of Mays and colleagues.19 Additional funding was provided to Stream 4 participants to allow their engagement in structured meetings in Canberra on four separate occasions during the 12 months of the program. These served five main purposes: Facilitating agreement on methodological issues (eg, common approaches to searching for primary health care literature or economic literature, assignment of quality criteria to diverse literature, “stopping” rules to allow a decision to be made that enough material has been obtained); Minimising duplication of effort through sharing of material and, where more than one spoke was working on a topic, agreeing on how the work of one spoke would complement the work of others on that topic; Facilitating interactions with policy advisers to provide provisional results to them and to test emerging options for their policy relevance; Allowing access to international experts to ensure a high standard of review (eg, Nicholas Mays, Professor of Health Policy at the London School of Hygiene and Tropical Medicine, delivered a workshop on systematic review methods); and Ensuring that progress against stated milestones was achieved so that the results were delivered in a timely fashion. Presentation of resultsThe research teams were asked to present their results (preliminary and final) in different ways through the program. The intent was twofold — addressing the concern of policymakers that research results are often not delivered in a timely fashion, and presenting the final reports in a manner that was easily accessible. The structured research components in Canberra allowed presentation of early results, as did the meetings between the individual spokes and their reference groups and interactions with key stakeholders. Throughout this interaction, the independent nature of the process was maintained by careful attention to the scientific method involved in synthesis and critical internal and external review. The final reports were prepared for web-based presentation using the “1:3:25” approach,5 with one page summarising the key take-home messages, three pages providing an overview, and the longer report containing all the information, including full references and appendices where appropriate. What have we learned?Most spokes found the systematic review process very demanding. A number of participants had experience with the Cochrane approach to systematic reviews, but did not find this suitable for the kind of literature being surveyed. The volume of potential literature identified in the searches was very large, and making decisions about when to stop searching and how to adjudicate the relevance and weight that should be given to retrieved material was a challenge throughout the process. The result for most spokes was a greater proportion of the 12 months being spent on the review process than had been anticipated at the outset, with a relatively lesser proportion of time iterating potential options with key stakeholders. Researchers are accustomed to writing for research audiences. Most spokes found the production of the one- and three-page summaries of the options for non-research audiences challenging. Researchers tended to default into research writing mode — for example, qualifying statements in the summary documents to convey the sense of uncertainty around them rather than stating the implications for policy less ambiguously. While policy advisers played a significant role in priority setting for the research program, participation by policy advisers in the structured sessions in Canberra was more variable. Senior policy advisers usually had unanticipated demands being made on their time and thus were unable to attend. More junior policy advisers were hesitant to offer critical comments from a policy perspective on the material being discussed, and had to balance the commitment of being present for the full day against the other requirements of their roles. Engagement with senior policy advisers was more successful when the separate spokes arranged to meet with individuals outside the structured sessions. Locating the material on the Internet has made it easily accessible to Australian audiences and, to some extent, international audiences. The number of hits suggested the resources have been useful, and, interestingly, it seems the full reports are most often visited rather than the one- or three-page summaries. Anecdotal accounts suggest that the recent Australian Government intervention in the Northern Territory has resulted in much use being made of the reports by McDonald et al15 and Humphreys et al,13 although this can not be corroborated through analysis of APHCRI website activity. Anticipating future policy challenges in an explicit and timely fashion allows for a repository of relevant research information to be developed.20 What has followed Stream 4?Because of the largely positive experiences associated with the conduct of Stream 4, the RAB has continued to support the development of the linkage and exchange approach. Stream 6 is repeating the Stream 4 process, with a single focus on addressing the primary health care workforce shortage. Stream 7 provided opportunities for researchers involved in Stream 4 to compete for new linkage and exchange travelling fellowships, allowing Australian primary health care researchers to visit world-renowned international academic primary health care institutions in relevant comparator countries and consider their Stream 4 work in the context of these international settings. On their return, they will provide written reports of their findings and participate in a briefing to policy advisers in Canberra. What has been the impact of Stream 4?Improving the quality and effectiveness of primary health care requires the adoption of evidence into policy and practice. Has APHCRI’s research been taken up in policy? As Nutley et al report,21 direct or instrumental use of research findings to shape policy is unusual. Research evidence is only one source of information that policymakers draw upon. APHCRI does not expect to demonstrate direct links between its research programs and subsequent policy. However, it does expect to contribute to the policy processes through use of its research to assist with conceptualisation of issues and to mobilise support for key reforms. Conceptual use is illustrated by the provision of succinct summaries of relevant information or provision of new ways of framing issues or gaining further insights into the strengths and weaknesses of different options — all illustrated in the articles of this supplement. APHCRI’s Stream 4 program has contributed to debate and raised public discussion of crucial issues confronting Australia’s health system. An example of this is the contribution APHCRI’s Stream 4 program and related activities have made to mobilising support for discussion of the health system reforms necessary to meet the challenges posed by chronic disease. ConclusionAPHCRI’s development of the linkage and exchange approach through its Streams 4, 6 and 7 has been positively received by the primary health care research community. The RAB will continue to develop and implement refinements to this approach, with a view to enhancing the uptake of evidence in policy. Steps, timelines and major activities within Stream 4, Australian Primary Health Care Research Institute (APHCRI) Steps and timeline Major activity focus Setting priority research topics through iteration with Department of Health and Ageing then decision by RAB (Mar–Apr 2005) Clarifying national policy relevance and prioritising issues Call for responses addressing selection criteria (May 2005) Publication of opportunity in national press, through established email networks and on APHCRI website Optional information workshop for potential applicants (Jul 2005) Overview of APHCRI and Stream 4, with workshop presentation freely accessible on the Internet Assessment of responses by the ERC against selection criteria, with recommendations to the RAB (Aug 2005) Independent assessment of all applications initially, then meeting of the ERC to arrive at consensus scores and recommendations to the RAB Decision making by the RAB and commissioning of spokes (Aug 2005) Further discussion of applications, and identification of any issues needing clarification before announcement of decisions First research program component meeting in Canberra (Sep 2005) Discussion of overall program Identification and management of potential commonalities/synergies between spokes Development of shared approach to: systematically identifying relevant black literature; classifying studies; assessing strength of evidence; and synthesising results Research activities Scoping literature Refining questions Establishment of reference groups and stakeholder lists Second research program component meeting in Canberra (Oct 2005) Further specifying research questions Discussing initial mapping exercise Selecting studies Re-running the searches Research activities In-depth searches Discussions with reference groups and stakeholders Additional research program component meeting in Canberra (Jan 2006) Master class in systematic review methods with Nicholas Mays, Professor of Health Policy at the London School of Hygiene and Tropical Medicine Third research program component meeting in Canberra (May 2006) Key findings against key questions Report on key stakeholders engaged thus far and to be engaged Key learnings from the review process to date 1:3:25* report approach Research activities Formatting draft reports into a 1:3:25* template and development of options Fourth research program component meeting in Canberra (Sep 2006) Technical problems with template discussed Provisional options presented and commented on by participants 1:3:25* reports finalised and submitted to APHCRI (Oct–Nov 2006) Editing Standardising presentations Iterating with authors to ensure sense not changed 1:3:25* reports published on APHCRI website (Nov 2006) ERC = Expert Review Committee. RAB = Research Advisory Board. * The 1:3:25 approach uses one page to summarise the key take-home messages, three pages to provide an overview, and a longer report to give all the information, including full references and appendices where appropriate.5

Nicholas J Glasgow MD, FRACGP · John E Marley MD, FRCP(Edin), FRACGP · Linda J Kristjanson RN, MN, PhD · Janette A Donovan BA, GradDipPubHealth · Sally J Hall RN, GradCertClinMan · Mark F Harris DRACOG, FRACGP, MD · David M Lyle MB BS, PhD, FAFPHM · Elizabeth J Kerr BA(Off Mgt), GradDipAET · Frith Rayner BA, GradDipJournalism

How to safeguard academic integrity when working with Australian governments A recent study revealed that Australian governments regularly suppress embarrassing information by hindering public health research or publication of its findings (Box 1).1 The results resonate with concerns raised in the Report of the independent audit into the state of free speech in Australia.2 Two issues of immediate relevance to Journal readers are the protection of academic independence, and the crucial role of objective evidence in improving outcomes of the Australian health system. Editors of medical journals have rightly opposed contracts with sponsors (such as pharmaceutical companies) that deny researchers the rights to work independently and publish results without the sponsor’s consent.3 While emphasis has been placed on funding support, the same objections apply to conditions imposed by government agencies for data access and representation on research teams. Public health and health services researchers are too often presented with pro-forma contracts for data access or commissioned research funding, on a “take it or leave it” basis, with contractual terms that give the agency a right of veto over publications. Strong institutional guidance is needed to clarify that such contracts can lead to severe publication bias, as evidenced by the Australian suppression study1 and overseas research.4 These contracts are therefore anathema to academic independence. The Australian Code for the Responsible Conduct of Research5 is inconsistent on this point and should be amended in line with the position of the International Committee of Medical Journal Editors (ICMJE).1,3 Incorporating this view is important, because results of public health and health services research are published in a wide range of non-medical and technical media, in addition to medical journals. This is not to say that academic researchers should never undertake research that is strictly for internal use within a government agency. From the outset, research should be either for internal or public consumption; it should not be for public consumption only when the results place the government in a favourable light. The latter creates a conspiracy that will eventually erode the public’s trust in the integrity of researchers and their employing academic institutions. An ethical approach, consistent with the standpoint of the ICMJE, would be to allow government agencies the right to comment on a draft report within a defined period of 30–60 days.3 This will often enhance the quality of the final report by unearthing additional facts that can affect interpretation. It also provides the government agency with a head start on an appropriate response. This would be a constructive process, given that the purpose of public health research is usually for the public to benefit from better informed government decisions. Smith-Merry and colleagues have bemoaned the impediments to a flourishing research culture in Australian health policy circles.6 Moves now afoot through the National Collaborative Research Infrastructure Strategy7 to develop population health and clinical data linkage stand to strengthen the evidence base for a more informed national health policy debate. However, the development of better national health information platforms will fall short of expectations unless careful attention is paid to the rules of engagement between government departments (as the main sources of health data) and researchers (as the major users).1 Key areas where interventions are needed to safeguard academic integrity are shown in Box 2. The challenges ahead will be familiar to leaders of the medical profession who have struggled to introduce adverse incident reporting and other quality assurance programs, with admirable, even if incomplete, degrees of success. The champions of clinical quality and safety have faced up to the suppression of health information at a more local level and have overcome the barriers of cynicism, fear and the cycle of blame.8,9 Analogous tensions exist when researchers work with governments, although a fear of tortious liability is then paralleled by concerns that government agencies and their ministers will be pilloried in the media when a researcher exposes a new health problem. What can we learn from successful clinical quality assurance programs that will reduce the desire of governments to suppress health information and increase their commitment to evidence-based decision making? The answer lies in a complex, gradual, yet not unattainable “culture change”. The existing culture of governmental health decision making needs to change, and there are three steps involved. The first step is to realise that the amount of independent academic research has no net effect on the quantity of bad press that the health system receives. There is an endless supply of anecdotal material for headline stories on the “health care crisis”, which will continue regardless of whether or not public health and health services researchers are suppressed. The second step is to appreciate that there is political mileage (the equivalent of a clinical profession’s credibility) to be gained by supporting ideals and principles that are morally strong — academic independence, a commitment to truth and honesty, and a desire to learn and improve. The third step — the threshold step — is to implement lasting changes to the culture through strong leadership. Unlike the avoidance of publication bias, culture change requires more than adherence to a code of practice. It is also the product of communicating and doggedly enacting a compelling vision. This is most easily achieved when led from the top. Prime Minister Rudd has promised new freedom-of-information laws and a “pro-disclosure” attitude among government and public service staff.10 Senator Carr, Minister for Innovation, Industry, Science and Research, has taken steps to strengthen the independence of the Australian Research Council because “research is not a political plaything to be toyed with at the whim of the Government”.11 These are encouraging signs. The proof of leadership is now to turn the rhetoric into reality, so that an open culture becomes the established norm. 1 Key results of A survey of suppression of public health information by Australian governments1 A national survey of 302 public health academics at 17 Australian universities was conducted in August 2006. They reported 142 witnessed suppression events, including 85 separate instances where 64 respondents (21%) had their own research affected. Suppression took place where a government agency that provided data or commissioned the research put conditions on the release of the results, or where government employees were part of the research team and were restricted in what they could do. Governments most commonly suppressed research by sanitising the results or by delaying or prohibiting the publication of results (66% of events), but no part of the research process was unaffected. In 48% of cases, the affected researchers believed their work was targeted for suppression because it drew attention to failings in health services. Another 26% of cases related to the health status of a vulnerable group (such as Indigenous Australians, refugees or people with mental illness), while in a further 11% the research had pointed to an environmental harm. In 87% of instances, the government agency succeeded, leaving the public uninformed or giving it a false impression. 2 Interventions to safeguard academic integrity when working with governments Public awareness of the issue and its importance Guidelines for managing conflict of interest in the public service Guidelines for avoiding result-dependent publication in academia Mandatory statements by authors that works have not been subject to a right of veto by government Agreements between government and academic bodies that support researcher independence Independent mechanisms to resolve complaints about suppression of health research Best-practice models of synergistic partnerships between government and academic bodies Organisational values that avoid blame and welcome constructive criticism Inclusion of oversight of government–researcher relations in the role of institutional ethics committees Publicly reported surveillance systems to monitor suppression events

C D’Arcy J Holman MB BS, PhD, FAFPHM