Health services administration

To the Editor: After the recent New South Wales parliamentary inquiry into Royal North Shore Hospital, one might ask whether the deliberations will deliver real change to the hospital system. An article in the Lancet draws attention to some adverse outcomes in London hospitals.1 One such case is reported from the evidence and conclusions of the Islington Coroners’ Court into the death of a man as a result of his outpatient management. The report states: The jurors have . . . taken into consideration the large number of patients attending Guy’s Hospital as casual patients, [and] are of the opinion that the skilled supervision is insufficient, and should be increased; but they . . . believe the deceased received all the care and attention which the present arrangement of the hospital affords. The report goes on to discuss the effect of the excessive numbers of patients each house surgeon is expected to manage daily. The writer is of the mind that “the reported cases are now so frequent that something will have to be done”. As for immediate solutions, the report suggests: The officers of hospitals will have to be a little more careful. The committees and governors of hospitals must not impose impracticable quantities of work on one man’s shoulders; they must take steps either to diminish the amount of casual out-patient work, or they must increase the number of competent and qualified persons. The article concludes that “there is another party in these questions who is not entirely free of blame — viz., the public”. The writer supports the public’s right to “express indignation at defective diagnosis and accommodation in hospitals” but implores the public to be more liberal with hospital funding. The conclusions are straight to the point: The committees of hospitals cannot multiply beds and qualified house-surgeons without funds, any more than one can make bricks without straw. And if the maimed and the diseased are not to be denied skilled advice and accommodation at hospitals, or are not to be passed from one hospital to another, the public must be far more liberal in its support of hospitals than it has been. This report was published in the Lancet on 20 August 1881. Has nothing changed?! The public has now relinquished its responsibility for running public hospitals to the state. I hope more permanent solutions to the problem will follow the recent inquiry! As the writer suggested in 1881, “something will have to be done”.

Catherine E Storey

The United Kingdom, Australia and New Zealand use different criteria for public funding of pharmaceuticals, but all include estimates of clinical effectiveness and cost-effectiveness. Drug appraisal is done through the National Institute for Health and Clinical Excellence (NICE) in the UK, the Pharmaceutical Benefits Advisory Committee (PBAC) in Australia, and the Pharmaceutical Management Agency (PHARMAC) in NZ. Of the 10 drugs deemed least cost-effective by NICE between 1996 and 2005, all were approved for funding in the UK, six were approved in Australia and five were approved in NZ. Australia and NZ refused funding for drugs for obesity, influenza and growth deficiency. All three countries made exceptions in order to fund drugs of poor cost-effectiveness for some “dread” diseases, but some drugs for less alarming conditions were either not funded or heavily restricted.

James P Raftery MA, PhD

One aim of Medicare’s Enhanced Primary Care (EPC) initiative is to encourage multidisciplinary care of patients with chronic disease by funding five allied health treatment sessions per patient per year. In many cases, the number of funded treatments is far less than standard clinical practice indicates, particularly when the five visits are shared between service providers. We believe clinical outcomes may be compromised by adhering to the funded hours, and inequity of outcome may arise based on socioeconomic status and the ability of patients to pay. Research that determines how patients and allied health practitioners are responding to this initiative is required. Research is also required to evaluate whether EPC enhances clinical outcomes compared with no allied health intervention and standard allied health practice.

Michele M Foster PhD · Geoffrey Mitchell FRACGP, PhD · Terry Haines BPhysiother(Hons), GCertHealthEcon, PhD · Sean Tweedy BHMS, MHMS, PhD · Petrea Cornwell BSpPath, PhD · Jennifer Fleming BOccThy(Hons), PhD

With new funding for the National Health and Medical Research Council (NHMRC) to provide an evidence base for policy and practice reform, it is timely to revisit Australia’s recent experiences with health services research and policy development. We provide a broad review of the contribution of Australian health services research to the development of health policy over the past 20 years. We conclude that three preconditions are necessary to influence policy: political will; sustained funding to encourage methodological rigour and build decisionmakers’ confidence; and the development of sufficient capacity and skills.

Jane P Hall BA, PhD · Rosalie C Viney BEc(Hons), MEc, PhD

Sick to death. Hedley Thomas. Sydney: Allen & Unwin, 2007 (ix + 427 pp). ISBN 978 1 74114 881 7. Typically, journalists write readable books; even journalism textbooks are easy to follow. So it is with Hedley Thomas’ story of Bundaberg Hospital’s saga with Dr Jayant Patel. The journalist credited with publicly exposing the discredited surgeon (and more importantly, the terrible deficiencies of the Queensland public health system) leads us on a trail of discovery, ineptitude, political chicanery and tragedy. The tragedy lies with the patients who put their trust in both their local hospital and Patel, then Director of Surgery, a trust that was shattered and will take a generation to repair. There is a terrible poignancy in the level of personal harm suffered and documented in the book. The ineptitude is staggering: from the local hospital administration up to the highest levels of Queensland Health. In retrospect, how easy it would have been to avoid much of the scandal by conducting a proper investigation into Patel rather than trying to cover up the truth. Instead, here is a tale which harmed almost everyone who came in contact with it. Thomas chronicles rather than analyses as he exposes how a thriving department of surgery was destroyed by an appalling administrative culture and turned into Patel’s fiefdom. Thomas is mostly, but not always, accurate. He relies a little too much on National Party gossip instead of checking facts. Gastroenterologists would no doubt be astonished to learn that they are the most qualified practitioners to perform oesophagectomies, Patel’s signature procedure. At the end of 427 pages, one has to reflect on whether there are any winners. Many Bundaberg patients are still waiting for compensation, surgical waiting lists are no better, and institutional reform of Queensland Health is still required. Burdensome legislation makes medical registration and quality assurance in Queensland inefficient and insidious. There were no political winners, except, perhaps, the incumbent state government. Plus ça change, plus c’est la même chose...

David Molloy

The Journal’s priorities for health care under the new government are clear Curiously, during the recent federal election campaign, the health policy pronouncements of both the Labor and Liberal parties1,2 failed to address one of the major issues with the potential to affect the quality of Australia’s health systems, namely: progressive job dissatisfaction among health professionals. These health care workers must surely be utterly demoralised, for every day they are confronted by the deterioration, indeed, decay, of the systems in which they work and struggle to deliver high-quality care. Of prime concern to the public and health professionals is the systemic deterioration of our public hospitals, burdened as they are with ever-expanding waiting lists, reduced bed capacity, poorly coordinated clinical services, access block and overcrowded emergency departments.3 Add to this the stress of staff shortages, chronic underfunding and dysfunctional management, and it is easy to understand why our public hospitals scored so low in the recent Public hospital report card of the Australian Medical Association.3 This report provides an independent analysis of performance indicators such as bed capacity, access and equity, productivity and funding. Tellingly, all states and territories attracted criticism — not one escaped a pressing need for reform.3 So disturbing is this sorry state of affairs that one fears a repeat of the infamous Bundaberg Hospital scandal.4 Indeed, there has already been a flurry of distressing reports cataloguing near misses and clinical mishaps in emergency departments across the nation.5 General practice also has its share of problems. These include: increasing workforce shortages, especially in rural areas; the burden of red tape; inefficiencies in the interface between general practice and hospitals or community aged care; and numerous other issues related to continuity of care and access.6 And these difficulties will definitely be further stressed by the ageing of our population. With a newly elected Labor government, all Australians look forward to the inherent energy of a new government with a mandate for reform, expecting them to produce the best health system for all Australians. And for this to happen, both the new Health Minister and Prime Minister must be held accountable. The community has wearied of the cynical and perpetual denial of political responsibility and desperately longs for an enactment of Harry Truman’s dictum: “The buck stops here”. But this expectation has to be tempered by the need for plain speaking and honesty. It is deceitful for any government to promise the delivery of a Rolls-Royce health care system, but fund it as though it were an FJ Holden. As to the precise nature of the health reforms the government should pursue, there is a plethora of advice and recommendations.7-10 The Journal has only a few priorities: The present debate about federal–state government responsibility for health services should cease. We need a decision now about whether one level of government or two should be responsible for all Australian health care delivery, and the debilitating and destructive blame game should then cease. Preventive medicine should be given first priority. The inertia in tackling the obesity epidemic is an indictment of the profession and, in particular, the impotence of its public health sector. We desperately need enactment of a national policy with an array of incentives and penalties. In Indigenous health, the momentum engendered by the Northern Territory intervention needs to be sustained, in real partnership with Indigenous Australians. Patients and the public should have a stronger voice in decisions related to health care. To quote Peter Baume, a public health commentator and former Liberal senator and minister: [T]he agenda of the public is more important than the agendas of professionals and the groups that represent them. It would be great to have a system where difficult questions of resource priority were decided before citizen juries, instead of being decided secretly and off stage.11 Finally, changes in health need to involve doctors and return the practice of medicine to its appropriate focus: health care that is enabling and effective.12 Three principles should guide this reform: first, the goal at all times should be ensuring value for patients; second, changes in medical practice should be organised around medical conditions and care cycles; and, third, outcomes and cost should be measured.12 This tripartite approach is necessary to ensure that value for patients is achieved by a move from the current practice paradigm, focused on discrete, uncoordinated and episodic service delivery, to one characterised by integrated and coordinated care, wherein patients actively participate in their own management and are responsible for compliance with care plans.12 The role of organised medicine in Australia is to ensure that health reform is not only realistic, but is realised. It must be said, however, that any cynic, observing the system’s downward spiral, might reasonably question the strength of the profession’s advocacy role and political power. After all, the decline and decay in health care delivery has occurred despite professional protestations. Doctors’ advocacy must become more aggressive, and doctors need to become a politicised profession.13 We have had enough of commissions and inquiries! The time for talking is over. We need action. We need reform. Is the time not ripe for a united and independent task force — one with appropriate professional and consumer representation, which will ensure that the government remains on-task, pursues a reform agenda and reports widely on progress? Is it not time for doctors and other health professionals, who are arguably the only thing our health system has going for it, to question whether they should continue propping up a second-rate system that is jeopardising the quality of care and is increasingly of risk to patients? Doctors and their patients are resolved that the time for change is now. All expect the newly elected government to deliver. And soon.

Martin B Van Der Weyden MD, FRACP, FRCPA

The first 100 days after an election are full of enthusiasm, energy and chaos, and they are crucial to establishing the shape, style and content of the new government’s tenure. The electorate is eager for plans, changes and new ideas, and for election promises to become reality. Early action that is visible and accepted will secure the credibility of longer-term plans. Here, in an open letter to the new Health Minister, we state our hopes for Australian health and health care in that 100-day period Dear Minister, You have come to this task with a raft of policies and initiatives that you and your party have promised to implement, and you probably have a long list of ideas and issues that you want to address, or that others have lobbied for. In a previous issue of this Journal, we put forward eight challenges that we think you will face,1 and you have outlined your own list. Your first 100 days will be crucial, but please don’t rush into action. Take time to consider three fundamental things. First, what health system will be best for Australia in the 21st century, taking into account the health needs of all Australians and how the electorate wants its tax dollars spent? Second, what distinctive role can you, as the federal health minister, play to achieve that system and leave the nation healthier as a consequence of your term as minister? After all, you are accountable to all Australians for precisely such an achievement. Third, you need a strategy, so that your reforms and policies are not just isolated initiatives, but form a coherent plan that will ensure that current problems are addressed and health benefits are maximised. A carefully formulated plan is the difference between just replacing the cracked tiles on an old leaking roof and rebuilding the roof with a better design, updated technology and new tiles. The challenges you face are of two orders: issues that are now causing a huge increase in costs as their incidence grows (examples are chronic disease, childhood obesity, the uptake of new technologies and the workforce crisis), and others that are polity issues (such as the current dual — or should we say duel? — Commonwealth and state–territory funding streams, the public–private mix, and the focus on treatment at the expense of prevention, affordability and equity). It is the polity issues that demand that the “roof”, the protection that our nation’s health care system offers, is redesigned and brought up to date. Without such attention, there will be no sustainable solutions to the other issues that threaten to inundate us; a few new or recycled tiles just won’t do. We urge you to spend your first 100 days, first, planning several high-priority, national concerted actions in the three broad health service policy areas — prevention, community-based care and hospital services — and, second, developing national consensual mechanisms that will address the polity issues robustly and drive the concerted actions. Both these approaches, tackled simultaneously, are essential. United States Government Accountability Office The US Government Accountability Office (GAO) is known as “the investigative arm of Congress” and “the congressional watchdog”. GAO supports Congress in meeting its constitutional responsibilities, and helps improve the performance and ensure the accountability of the federal government for the benefit of the American people. GAO’s work includes oversight of federal programs; insight into ways to make government more efficient, effective, ethical and equitable; and foresight of long-term trends and challenges. GAO’s reports, testimonies, legal decisions and opinions make a difference, for Congress and the nation.2 You have promised a national health and hospitals reform commission, which will meet in the first 100 days of government. While requiring a broader focus than so far described, this commission could give you the expert support and consultative mechanisms needed for comprehensive and robust planning. Your initial success will be measured by the key performance indicators — cooperation and buy-in from the states and territories, non-government organisations, the private sector, health professionals and the public. At the end of 100 days, there must be evidence of a strong developing consensus and growing public confidence that you will stop the blame and cost-shifting of the past and create a new health system to meet national needs. But the gloss of these early glory days will last only if there are long-term commitments of resources to planning, infrastructure (including more effective e-health systems), the workforce, and research and development; to making patients’ experiences and outcomes central to health care decision making; and to monitoring and evaluating the effects of health-policy changes on health, so we know what is working and what is not. This last point is crucial to your long-term success. So we also propose that you establish an office of accountability for health to ensure that you and your partners in health planning and reform can know that agreed outcomes are being achieved, and the public can know that their tax dollars are wisely invested. The United States Government Accountability Office is a good model (Box).2 We offer here two of many reasons why we need the equivalent of the US Government Accountability Office. The cost of medical errors in Australia is over $1 billion annually and could be as high as $2 billion.3 About half of all medical mistakes are preventable.4 The current failure to collect comprehensive national data means that our progress towards better quality and safety remains anecdotal. The Editor of this Journal has spoken out on the failure to clearly enunciate and implement a comprehensive range of relevant safety indicators, mandatory incident reporting and learning systems for mishaps, and an outcome measurement system, stating that “Australians deserve better than this”.5 We agree. The cost of obesity in Australia last year was $21 billion in ill health and disability, premature death and productivity losses.6 Over 3 million Australians are obese, and this could rise to over 7 million people within 20 years if current trends persist unabated and unaddressed.6 The last Australian Schools Health and Fitness Survey was conducted in 1985, and the last National Nutrition Survey in 1995. This means that policymakers are hindered by the lack of current data to inform the development of new policies. Without ongoing measurements and feedback there is no way to evaluate the effect of implemented policies. It is only through repeated surveys, done by the same people using the same survey instrument, that we are able to assess progress and evaluate the success of individual initiatives. The overwhelming impression left from the election campaign is of 6 weeks of piecemeal policies, and local funding commitments that add to the multitude of health programs but do not strengthen or reform the health system. Your task now is to build a better health system that can deliver better health programs more effectively and efficiently. The multiple challenges must be tackled, with a focus on better health outcomes and better value for money. They can only be resolved by a shared national vision, national leadership and national action across a period that may encompass decades, but your actions in the first 100 days and investments in the first 3 years will be critical. This surely is where the Australian Government must play its main role and where a committed Health Minister can make a real difference and leave a lasting legacy. Since 1933, when Franklin Delano Roosevelt tackled the worst effects of the Great Depression in a rush of breathless reform,7 the first 100 days of a new government have provided the test of its leadership and reformist credentials. Australian state government leaders, from Jeff Kennett in Victoria to Geoff Gallop in Western Australia, have adopted this benchmark for achievement. We strongly advise you to embrace this benchmark, and we wish you well in the 100 days ahead.

Lesley Russell BSc(Hons), BA, PhD · Stephen R Leeder AO, MD, PhD · Bruce K Armstrong AM, DPhil, FRACP · James A Gillespie BA, PhD · George L Rubin FRACP, FAFPHM

Initiatives to prevent access block should be aimed at long-term structural changes to bed availability to meet the needs of a complex and ageing population; current management practices are creating a growing mismatch between supply and demand The Australasian College for Emergency Medicine and the Australian Council on Healthcare Standards have defined access block for emergency patients as the percentage of all patients admitted, transferred or dying in the emergency department (ED) where their total ED time exceeds 8 hours.1 Simply put, access block is the absence of flow at a system level, not just the ED. In United States literature, access block is referred to as “overcrowding”. How does flow stop?In Australia, the total number of acute hospital beds has decreased over the past two decades, with a 14% decrease in the number of public hospital beds between 1992 and 2002.2,3 In the US, the number of medical and surgical beds declined by 18% from 1994 to 1999, while ED attendances increased by 15%.4 During this time, there have been concomitant decreases in inpatient length of stay and more day procedures and day admissions.5 However, in the United Kingdom, after a period of decline, the number of multiday admissions per 1000 residents increased in 2002 and 2003. This was thought to be the result of postponed demand related to illnesses for which there were waiting lists, and to the increasing burden of chronic disease. In 2003, 30% of the multiday admissions could be attributed to just 20 International classification of diseases, ninth revision (ICD-9) diagnoses, and a third of these were attributable to chronic heart disease.6 CapacityCapacity decisions in hospitals are generally made without the help of quantitative model-based analyses.7 Hospital managers have been stimulated to reduce the number of beds and increase the occupancy rates to improve operational efficiency. Modelling is usually based on average bed occupancy. However, this model is not capable of describing the complexity and dynamics of the patient flow. This is known as the flaw of averages. A formula has been described that can be applied to almost every queuing system.8 It shows the relation between the expected number of patients in the system, EB(t), the average length of stay (μ), and the unscheduled need, described by the Poisson process, λ: EB(t) = λμ For example, at an intensive care unit (ICU), five patients arrive per day on average. The average length of stay is 6 days. The parameters of this queuing system are: λ = 5 and μ = 6. Using the above formula, the expected number of patients at the ICU is 30. If management decides to size the unit on this average bed number, operational problems will occur on a regular basis. The probability (Pi) that more than 30 beds are occupied at any time is easily calculated according to the formula: Pi = e-λμ(λμ)i/i! where e = expotential and i = the number of beds occupied. In this example, Pi = 0.45 (ie, need will exceed capacity 45% of the time).9 It has been shown that a high degree of reserve capacity (up to 30%) is required to avoid high rates of surgery cancellations because of unavailable beds downstream.10 However, most health policy experts believe that a 15% capacity buffer is adequate, and an acute hospital can expect regular bed shortages and periodic bed crises if average bed occupancy rises to 90% or more.11 Ageing populationIt is projected that between 1996 and 2016, the general population in Australia will increase by 21% or 3.1 million, the number of people over the age of 65 years will increase by 59% or 1.3 million, and those over the age of 80 years will increase by 76% or 368 000.12 The effect of the ageing population on access block is twofold. As noted earlier, there is already a relative decrease in access to residential care beds in the community, especially beds designated for high-dependency patients, in the face of a significant growth in the number of people seeking placement.13,14 It has been shown that incidence rates of institutional aged care double for each 5-year interval from the age of 60 years.15 The general effect of illness and ageing must also be considered. In one study, undertaken between 1990 and 2004, while there was a 54% increase in the total number of ED patients, there was a disproportionate increase of 198% in the number of patients aged over 70 years, including a 671% increase in the number of those aged over 90 years. The time taken to manage patients increased with age, with older patients (aged over 70 years) being 4.9 times more likely to require admission to hospital than younger patients (aged 30 years or less), and older patients’ average length of stay was 6.9 times longer. There were 3.3 times more younger patients than older patients, but older patients occupied 9.8 times more ED bed-days.16 Preventing avoidable hospitalisationsIn response to unprecedented and sustained increases in demand for health care services that were placing significant pressures on hospitals, the Victorian Government committed $582 million as an initial investment over 4 years from 2001–02 to 2004–05 to implement the Hospital Demand Management Strategy. Of this allocation, $150 million was invested to develop new approaches to caring for patients known to have a high risk of deterioration in their health, and thus preventing avoidable hospital use in the future. These new approaches to patient care were developed, implemented and evaluated through a program called the Hospital Admission Risk Program (HARP). Many patients with complex and chronic illnesses were treated as hospital outpatients or in the community. These programs have shown good initial outcomes with HARP patients experiencing 35% fewer ED attendances and 52% fewer ED admissions, and 41% fewer days in hospital.17 There are, however, some emerging data that question the sustainability of the early gains of these programs, in the face of age and worsening disease.18 The federal–state divideIn Australia, health care is funded by both federal and state governments. Public hospital funding is largely provided by the state, and primary and subacute care is funded by the federal government. Aged care provides a good example. The federal government has responsibility for residential aged care. In the absence of adequate residential capacity for the aged, patients are inappropriately accommodated in public hospitals. Solving this problem will require a combined approach to stop the “buck passing” between the federal and state governments.19 OutcomesAccess block is not an inconvenience. It is not a problem of EDs. Access block is an illness, and not a benign illness. It has a morbidity and mortality rate and a growing literature about it. A search in MEDLINE (1950 to Week 2 of October 2007) using the keywords access block, crowding and overcrowding identified 163 articles. This Journal alone has published 26 articles in recent years. We know that access block causes ambulance diversion,20 independently predicts increased inpatient length of stay21,22 and increases patient mortality.23,24 One study reported 43% more deaths in an overcrowded cohort compared with a non-overcrowded cohort of ED patients, with the effect more profound in the older population. Another showed a linear relationship (R2 = 0.95) between the degree of overcrowding and 7-day mortality.24 There is a high correlation between overcrowding and patients who leave an ED without treatment. Another report showed a 0.665 correlation between increasing overcrowding and the rate of patients who left before being treated.25 While most of these patients are not in the high-acuity triage categories, tragic consequences can nevertheless arise. In the case of one patient who died of infective endocarditis after being discharged from an ED, the coroner concluded that “it has to be recognised that as a matter of common sense, in an environment of severe overcrowding the potential for error on the part of medical practitioners, especially in a setting where a decision has to be made as to whether a patient should be discharged or not, will inevitably exist”.26 A previous editorial in this Journal proposes two solutions — reduce hospital demand and optimise bed capacity.27 I would propose that we acknowledge the limitations of the first strategy as our population ages and requires increasing community support. As shown earlier, bed capacity needs to be able to meet surge requirements and not the average need. While ED and inpatient reforms have and will deliver some gains, the problem we now face is bed stock. ED overcrowding is not caused by patients in low-acuity triage categories who present to the ED and are able to be quickly discharged. These patients are dealt with through a variety of “streaming” processes (eg “fast track” or “likely discharge” models of care). It is patients who need hospital admission who drive the system into ED cubicle block and overcrowding.

George Braitberg FACEM, FACMT, DipEpiBiostats

Objectives: To assess changes in emergency department (ED) activity and visits to EDs that could have been managed by general practitioners (GP-type visits) in the Christmas and New Year holiday period compared with the rest of the year.Design and setting: Retrospective descriptive and analytical comparison of New South Wales ED visits in the holiday period and the rest of the year; data were obtained from the NSW Emergency Department Data Collection database for the period 2001 to early 2006. More detailed information in 2005–2006 allowed GP-type visits to be assessed in this period only.Main outcome measures: The change in the number and percentage of weekly ED visits during the holiday period.Results: Between 2001 and 2006, average weekly counts of ED visits increased by 9% (95% CI, 7%–11%) during the holiday period. The holiday increase was largely accounted for by visits that were less urgent, and for patients who were not admitted, did not arrive by ambulance, had a shorter treatment time and arrived between 08:00 and midnight. In 2005–2006, average weekly counts of GP-type visits increased by 21% (95% CI, 15%–28%) compared with 8% (95% CI, 4%–12%) for ED visits overall. However, GP-type visits accounted for only 39% of the additional holiday visits. GP-type visits increased mainly for adults and more in urban than rural areas.Conclusions: The Christmas and New Year period is the busiest time of year for NSW EDs. However, only some of the additional holiday visits can be attributed to GP-type visits. Improving access to GPs, but also to broader hospital and community-based health care services over the holiday period, should be considered for managing the excess demand.

Wei Zheng MPH · David J Muscatello MPH · Adam C Chan MB BS(Hons), FACEM

To the Editor: Sydney’s St Vincent’s Hospital, like many other hospitals, experiences a high occupancy rate which sometimes exceeds 100%, because of continual presentations to the emergency department (ED). NSW Health has recently encouraged new models of community acute/post-acute care (CAPAC) which allow patients to be managed in their homes, thus easing ED overcrowding and avoiding unnecessary presentations.1 However, those presenting most frequently to the ED at St Vincent’s Hospital are homeless. In response, this hospital has sent an outreach team consisting of a medical registrar and a community nurse to the streets of Sydney to deliver a “Backpack” CAPAC service (Figure). The outreach team provides diagnostic support to homeless people in shelters and crisis centres in the inner City of Sydney area. The team has successfully directed appropriate subacute cases to other health services, without the necessity for attendance at the ED. Extended episodes of treatment have also been given, including courses of intravenous antibiotics for a range of infections — even subacute bacterial endocarditis has been treated using portable infusion devices. Inclement weather causes some homeless people to seek refuge in stormwater drains around Sydney. One such patient, with a community-acquired methicillin-resistant Staphylococcus aureus cellulitis, was visited daily in a stormwater drain — his place of residence. Linkages have also been created with mental health services and non-government organisations. The Backpack CAPAC service continues St Vincent’s Hospital’s 150-year tradition of providing acute health care to the vulnerable and needy in our community. As this service was initiated with community donations, it has also reduced the drain on health resources. St Vincent’s Hospital’s outreach team on the streets of Sydney delivering the “Backpack” community acute/post-acute care service to the homeless.

Andrew A Mahony · Stephen F Wilson

Government actions to protect the public’s health are not always consistent What, if anything, will move a government to intervene to improve the health of its population? Government action seems to depend not on how many people will die if it fails to act but rather who they are and how they will die. When almost 3000 people died after aircraft were flown deliberately into buildings in Washington and New York in 2001, the United States government moved rapidly, with no regard for cost. In an unprecedented move, it immediately grounded all aircraft flying over the US, allowing them to fly again only subject to sweeping restrictions on what could be taken on board. Had the government failed to act rapidly, it would undoubtedly have faced widespread condemnation, not least from the representatives of corporate America, which had, in the attack on New York, been the target of mass murder. Yet, of all the Americans who died in 2001 as a result of violence, only a fraction were killed in the attacks on 11 September. More than 10 times as many fell victim to firearms, either at their own hands or the hands of others.1 Successive US governments have steadfastly refused to enact effective gun control, seemingly unmoved even by tragedies such as the mass shootings at Columbine High School in Colorado in 1999 and Virginia Tech (Virginia Polytechnic Institute and State University) in Blacksburg, Virginia, in 2007. In 2004, President George W Bush allowed a law banning sales of semiautomatic assault weapons to lapse at a time when his government was enacting unprecedented security measures in what is termed the “war on terror”. Utilitarian principlesIf it is not the body count that drives politicians to act, what is it? Perhaps, in the rational world that we often aspire to inhabit, it is pragmatism. Knowing what works is purported to be a key principle by some politicians who ask us to vote for them on the basis of their technical ability and experience. Unfortunately, this does not seem to be the answer either. In 1967, the US Federal Government held back funding for highways from states that did not mandate the use of motorcycle helmets. Deaths among riders fell markedly. In 1976, under pressure from bikers’ groups, the US Congress reversed this policy, leading to a marked increase in deaths in those states repealing the laws.2 When should governments act?When, if ever, is a government justified in taking action to improve the health of its population? It is easy to see why this seemingly simple question leaves so many people confused. Maybe we can look to philosophers for guidance. The most frequently quoted, in this respect, is the 19th century British philosopher, John Stuart Mill. In his classic text, On liberty, he argues that “the only purpose for which power can be rightfully exercised over any member of a civilised community, against his will, is to prevent harm to others”.3 Yet, he also recognised that individuals are not always able to make free choices, a view shared by Karl Marx, who argued that “men make their own history, but not of their own free will; not under circumstances they themselves have chosen but under the given and inherited circumstances with which they are directly confronted”.4 The question of how these arguments apply in any given circumstances is at the heart of the dilemmas that confront public health advocates. In applying philosophy to public health, the first question is whether an action threatening an individual’s health causes harm to others. In some cases, such as drunk driving, the answer is obvious. In others, such as the harm caused by passive smoking, epidemiological research has been required to provide the answer.5 These examples deal only with situations in which there is direct physical risk to others. It has also been argued that, by consuming collectively funded health services, an individual engaging in self-destructive behaviour is harming others by using resources that would otherwise be available to those falling ill through no fault of their own.6 This argument can be taken further. There is now compelling evidence that ill health in a population weakens economic growth, because, with illness, people reduce their labour supply and productivity.7 Is this a justification for governments to act? Certainly, governments intervene in many other ways to promote growth, through fiscal policy and direct investment in research, skills and physical infrastructure. So far, few have accepted explicitly the importance of investing in the health of their population as a strategy to promote growth, even though, in some analyses, this provides a greater return than investment in education.7 The second question is whether individuals really are making free choices. In some cases, it is apparent that they are not. Therefore, almost all governments act decisively against narcotics, although many have yet to recognise the equally addictive nature of nicotine. As a result, some have failed to support effective “quit smoking” programs using nicotine replacement therapy. This may be only a matter of time. Government action against opiates is now widely accepted, but it was only 150 years ago that the United Kingdom went to war with China to protect its right to trade in opium.8 Addiction is only one way in which the choices of individuals are constrained. It is self-evident that behaviour is shaped by the environment. At the extremes, a person living in Mongolia has little option but to eat an unhealthy diet, dominated by animal fat and bereft of fresh vegetables. In contrast, an inhabitant of Crete may find it difficult to eat anything but a healthy diet. Similarly, an inhabitant of rural Nepal has little choice but to walk, while someone in Los Angeles may search in vain for a sidewalk. Governments can do little to change things such as climate and the topography of a country, but they can change many others, by ensuring that health is included in policies for (among others) transport, agriculture, fiscal management, and regional development, so as to remove the constraints that individuals face when making healthy choices.9 Governments have few reservations about using these policies for other goals, including promotion of economic growth, so why not health? Current inconsistencies in policyGovernments are often extremely inconsistent. They are willing to intervene actively in the lives of individuals to protect the health of their populations in some circumstances, but not in others. The war on terror has yet to be matched, in intensity and resources, by a war against tobacco. Governments that promote individual choice see no incongruity in their support for a small number of companies that, through their domination of the retail sector in some countries, constrain our choices about what to eat.10 It seems that no universal theory can explain when a state will act to safeguard the health of its population. Maybe this should not come as a surprise. Policy making is messy. Otto von Bismarck, unifier and first Chancellor of Germany, is reputed to have remarked that two things should never be made in public — laws and sausages. Policies are often a product of events (frequently following tragedies rather than pre-empting them) and interest groups, many of whom see promotion of health as a threat.11 The pursuit of health is as legitimate a goal for governments as national defence or economic growth. All involve balance between individual and collective interests. The challenge for public health is to advocate a greater degree of consistency than currently exists.

Martin McKee CBE, MD, FRCP · Ruth Colagiuri BEd, GradCertHlthPolMgnt

To the Editor: Influenza experts have warned of the possibility of an influenza pandemic, and planning for such an event is underway.1,2 The provision of health care during a pandemic will pose particular challenges. Health care workers will be at risk of exposure, and will become ill at rates similar to those for the general population. Compounding inevitable staff shortages will be health care workers absent from work because of a need to care for dependents or fear of catching influenza. Prompted by discussions on an appropriate response to pandemic influenza, we solicited opinions from employees within our network (including medical, nursing, clinical support, catering and administrative staff) about their attitudes to working during a pandemic. Between 1 February and 30 April 2007, a survey that could be self-administered and completed anonymously was placed on our hospital intranet. Our staff were advised of its presence by email and through advertising on the intranet. The survey could also be completed when attending for influenza vaccination. Participants could complete surveys directly onto an electronic database, or return them to the investigator. We received 1440 completed surveys, including those from 137 medical staff (10%), 628 nursing staff (43%), and 352 clinical support staff (25%). The overall response rate was approximately 14% (1440/10 000). The mean age of respondents was 42 years (range, 18–73 years); 83% were female and 36% had dependent children. Overall, 74% agreed they needed more education on pandemic influenza (medical staff, 66%; nursing staff, 78%; P = 0.025) and 48% believed a pandemic would occur in the next decade (medical staff, 39%; nursing staff, 52%; P = 0.025). Sixty-seven per cent stated they would be available to work during a pandemic; 26% (medical staff, 18%; nursing staff, 27%; P = 0.05) stated they would stay home to care for dependents, while 10% admitted they would stay away because of fear of catching influenza. Most employees expected to be provided with personal protective equipment (92%), antiviral medications (90%) and vaccine (89%). Sixty-four per cent believed the hospital should supply their families with antiviral medications, and 63% thought their families should receive vaccine. Twenty per cent believed they would require a place of residence while working during a pandemic (medical staff, 32%; nursing staff, 24%; P = 0.05), 45% were prepared to be relocated to another site (medical staff, 58%; nursing staff, 40%; P < 0.001) and 36% were prepared to change to another duty (medical staff, 30%; nursing staff, 39%; P, not significant). Our survey has highlighted areas that may need attention in preparing for a pandemic. As a minimum, we believe targeted education is required now for all health care workers who will be expected to work during a pandemic. Our ability to cope will depend on the depth of our preparation.

Rhonda L Stuart · Elizabeth E Gillespie

Australian health systems must rise to the challenge of providing thrombolysis to more stroke patients The substantial benefits and relative safety of tissue plasminogen activator (tPA) for acute ischaemic stroke within 3 hours of symptom onset have been accepted by stroke clinicians around the world.1 It is one of the most effective treatments in acute medicine, with a 30% increase in excellent outcomes and a “number needed to treat” for clinical improvement as low as three patients.2 A European register of 6483 patients (SITS-MOST, Safe Implementation of Thrombolysis in Stroke Monitoring Study) indicated that tPA is safe and effective, even when used in relatively inexperienced centres.3 The clinical benefits overwhelm a small rate of bleeding complications, chiefly symptomatic haemorrhagic transformation of the infarct. The rate of symptomatic intracerebral haemorrhage was actually lower in this large register than in the earlier randomised clinical trials.3 Small Australian tPA audits have confirmed these conclusions.4,5 Based on level 1 evidence, the therapy was licensed in Australia in 2003, and is recommended in Australian, North American and European stroke guidelines.6 However, despite this overwhelming information, probably some thousands of Australian patients are effectively denied tPA each year.7 This is a major challenge for our health system. Batmanian and her colleagues have made an important contribution,8 demonstrating that a 24-hour comprehensive protocol delivered by a team involving emergency physicians and stroke neurologists can deliver thrombolysis to 14% of their acute stroke patients (→ A protocol-driven model for the rapid initiation of stroke thrombolysis in the emergency department). This figure is in line with the best international stroke centres. The involvement of emergency physicians is essential to optimise the delivery of tPA, particularly given the worldwide shortage of stroke specialists. With a protocol aimed at rapid triage, assessment and investigation of stroke patients, Batmanian et al have shown that nearly all eligible patients can receive thrombolytic therapy. Their centre at St Vincent’s Hospital (Sydney) and other Australian centres are participating in the ongoing SITS international registry, aimed at auditing the efficacy and safety of tPA for acute stroke. Nearly 400 Australian patients have now been entered on this registry, with safety of tPA consistent with the benchmark European figures (Dr M Parsons, neurologist, John Hunter Hospital, Newcastle, personal communication). A key barrier to the use of tPA is delayed arrival to hospital after stroke onset. In the St Vincent’s study, 40% of patients arrived within 3 hours, a higher rate than in many centres. Improved access to tPA and other acute stroke therapies can be enhanced by public education about stroke symptoms (such as the FAST: Face, Arm, Speech, Time campaign of the National Stroke Foundation in Australia), followed by rapid ambulance transport to a hospital with an organised acute stroke team. The public must be educated to call an ambulance, not a general practitioner, when stroke symptoms occur. Australian studies have confirmed that ambulance officers can accurately diagnose most strokes.9 Ideally, paramedics inform the emergency department of their impending arrival, facilitating the 60-minute “door to needle” target time for tPA therapy. Implicit in achieving good outcomes after therapy is rapid access to a stroke care unit (SCU), the benchmark for optimising outcomes in a condition with a high mortality rate and the commonest cause of disability in our society.10 Stroke strategies in most Australian states have been developed to increase the access of acute stroke patients to SCUs, which are expert multidisciplinary and geographically localised units, using evidence-based protocols for acute stroke therapy. In Australia, these are generally not intensive care units (ICUs), although cardiac monitoring is desirable during the acute period. In the St Vincent’s study, patients were monitored in the ICU for up to 24 hours, because the protocol mandated a 1 : 2 nursing care ratio. We generally admit tPA patients to our SCU during or after the initial 1-hour infusion in the emergency department. Our SCUs use a 1 : 4 nursing ratio. We do not consider that ICU management is needed for most patients, but acknowledge that differing models will suit different institutions. Acute reperfusion therapy is the most promising approach for acute stroke. The evidence for efficacy of tPA within 3 hours is overwhelming, although there is still some debate about treatment in the very elderly, patients with very severe neurological impairment, or those with extensive early ischaemic changes on computed tomography (CT) scan. Meta-analysis of the tPA trials shows that there are treatment responders beyond 3 hours. A number of trials, such as the ECASS 3 and the IST 3 trials, are aimed at extending the current time window for intravenous tPA. Intra-arterial thrombolysis or mechanical clot retrieval may be alternative approaches for selected patients who do not respond to tPA within 3 hours, or within later time windows.11 Thrombolysis is based on the recanalisation of occluded arteries and reperfusion of the ischaemic penumbra, a region of injured brain that is potentially salvageable with rapid restoration of blood flow. Identification of the penumbra using magnetic resonance imaging or perfusion CT may also allow individualised therapy at longer windows.12 In 2007, we do not recommend routine use of intravenous tPA beyond 3 hours, but strongly encourage Australian clinicians to enrol patients into trials addressing these hypotheses. Intravenous tPA is relatively simple to use, particularly with an effective partnership between emergency physicians and stroke clinicians, using appropriate protocols and stroke unit care. It is highly effective and relatively safe. In the 12 years since it was proven, the major systems failure in most countries has been delivering it to more patients. In Australia, we should not shirk from this challenge.

Stephen M Davis MD, FRACP · Peter J Hand MD, FRACP · Geoffrey A Donnan MD, FRACP

The Queensland approach may deliver empirical evidence on whether performance monitoring leads to improved quality of care Several high profile medical disasters have occurred recently in Australia and England and have raised concern about quality of care and patient safety. In Australia, the major disasters have included those at the Bundaberg Hospital in Queensland,1 and the Campbelltown and Camden Hospitals in New South Wales; and in England, the Bristol Royal Infirmary scandal2 and the Shipman Affair.3 Although the specifics in each instance are unique, a common outcome from the subsequent inquiries has been a recommendation for some form of centralised performance monitoring using routinely collected data. Why? Because retrospective desktop analysis of routinely collected data signalled the medical disaster before the “whistle blew”. What is interesting about Queensland Health’s response to the Bundaberg scandal, as described by Duckett et al in this issue of the Journal,4 is that these workers have combined their preferred casemix-adjusted statistical analysis (variable life-adjusted display [VLAD] plots) with an explicit protocol for action (→ Identifying variations in quality of care in Queensland hospitals). In so doing, Duckett et al have recognised that the ultimate purpose of data (and analysis) is to guide action5 (for improvement) while avoiding the commonly held casemix adjustment fallacy.6 The casemix adjustment fallacy begins with a deceptively simple equation that informally relates the variance in outcomes (eg, mortality) to a combination of three variables — chance, patient casemix factors, and quality of care. Statistical techniques are used to account for chance and patient casemix factors. The residual unexplained variance in outcome is then prematurely assigned to quality of care.6 This is naïve, because it assumes too much and is an oversimplification. For example, it assumes that the outcome variance equation is of a closed form (three variables only, when we have no basis to conclude this); it assumes perfect data (no errors in data, no measurement error) and perfect casemix adjustment (when we know that important casemix variables are not as yet measured or measurable); and, finally, it fails to recognise that all statistical models are but simplified approximations subject to error. This casemix fallacy — where the residual unexplained variance in outcome is automatically attributed to quality of care — is to be diligently avoided7 if the process of monitoring is to remain credible and useful in improving quality of care. The protocol for action developed by Duckett et al has two key characteristics: use of a pyramid model of investigation,6,7 which recognises that, in searching for assignable causes of variation, a useful strategy (which mitigates the casemix adjustment fallacy) is to systematically check five variables (data, patient casemix, structure, process of care, and carers), underpinned by an explicit clinical governance framework. A key feature of the pyramid model of investigation is the prior degree of belief, for which there is empirical evidence,8 that the vast majority of explanations for unusual variation will be located at the base (data, patient casemix) and the least likely explanations will be located at the apex (quality of care and carers). Indeed, as part of the Shipman Inquiry, two general practitioners were flagged as having “unacceptably” (the casemix adjustment fallacy) high casemix-adjusted death rates. Application of the pyramid model of investigation aided the discovery that this excess mortality was credibly explained by the numbers of patients in nursing homes — place of death was not included in the casemix adjustment method. Furthermore, the inclusion of data (at the base of the pyramid) ensures that data improvement is an integral part of any monitoring process, as this is usually a highly cost-effective way of reducing variation, to the benefit of all concerned. So it is a matter of concern that Duckett et al found that data improvement was frequent and “frustrating to hospitals and clinicians”. One reason for this frustration is because concepts such as “true positives” and “false positives” from diagnostic testing are applied to performance monitoring — but this is unhelpful and misleading. Consider, for example, a signal of high mortality which is due to a data error. If we predicate the definition of signals of special cause variation on malpractice or quality of care,9 then we are required to concede that a false-positive signal has occurred. But the notion of a false positive in the evaluation of a diagnostic test is based on a comparison with a reference “gold standard” test, by which the “true” disease state of each patient is known (albeit using the gold standard). In contrast, in performance monitoring, there is no gold standard and the true state of each data point is unknown, so the notion of false-positive signals makes little sense. Furthermore, in diagnostic testing, a false-positive result can mislead us into taking the wrong action, whereas finding and fixing a data error actually moves us in the right direction — towards understanding and eliminating special causes of variation.10 The possible confusion with diagnostic testing should be remedied through clarifying the purpose of monitoring and providing training on the method and its limitations. Duckett et al have adopted VLAD plots, which are simple visual tools for displaying variation. They show the indicator of interest one patient at a time, while accounting for the prior risk (casemix adjustment) and the play of chance as indicated by upper and lower limits. It is important to appreciate that, wherever the limits are set (except for 0 or infinity), we will occasionally commit an error of commission (when we wrongly identify a signal from the noise) or an error of omission (when we fail to detect a true signal from the noise). The choice of limits is, as Duckett et al state, a matter of judgement that is informed by statistical theory, economic consideration, and empirical evidence. What is exciting about the Queensland approach is that it is well poised to deliver the oft-lacking empirical evidence (because most monitoring systems do not include a specific action protocol) on the use of a performance monitoring system. This empirical evidence is the ultimate criterion by which to judge the usefulness of the performance monitoring system itself. As Duckett et al recognise, performance monitoring is the search for signals of variation from background noise in the presence of imperfect data, imperfect casemix adjustment, and imperfect methods of action. Although the performance monitoring system must be alert to “bad apples” (and this is noted in the pyramid model for investigation), care needs to be taken to ensure that the search for “bad apples” does not become the primary aim, as this will (most likely) increase fear and thereby hinder genuine continual improvement.9 Ultimately, performance monitoring needs to embrace the wider aspects of the science of improvement,9 in which statistical methods for analysing variation are but one component. The other major components involve “appreciation of a system”, “theory of knowledge” and “psychology of humans”, in which all stakeholders in the performance monitoring system cooperate towards the aim of continual improvement. The challenge for performance monitoring in general6,10 has been that it has itself been at variance with key principles of the science of improvement, and so the extent to which the Queensland model delivers continual improvement remains to be seen.

Mohammed A Mohammed PhD · Andrew J Stevens

In April 2004, Melbourne’s Peter MacCallum Cancer Centre, Australia’s only stand-alone dedicated cancer hospital, became the first Australian site to offer digital mammography (DM). In the first year of DM operation, 1208 mammograms were performed on 1157 women; 17 new cases of invasive carcinoma and six new cases of ductal carcinoma-in-situ (DCIS) were detected; and 30 hook-wire needle localisations were conducted in 29 patients. We developed a unit policy to manage indeterminate microcalcifications newly demonstrated on DM that were not previously detected by conventional screen-film mammography (CM): those believed to have malignant morphology were recommended for biopsy, and those without were recommended for 6-month DM follow-up to confirm microcalcification stability. DM detected 56 new stand-alone microcalcifications (18 suspicious and 38 indeterminate). Tissue diagnosis of 12 suspicious microcalcifications yielded four cases of DCIS and one of atypical ductal hyperplasia. Of the indeterminate microcalcifications, 35 have demonstrated stability at DM follow-up to date, over a mean period of 23.6 months. From our experience, we believe DM’s superior demonstration ability uncovered microcalcifications previously undetected by CM, rather than microcalcification progression. We suggest that routine review with DM, rather than biopsy, is appropriate management when new indeterminate microcalcifications without malignant characteristics are identified by DM.

Emma Pun MMed, FRANZCR · W F Eddie Lau BPharm, FRANZCR · Robin Cassumbhoy FRANZCR · Anthony J Taranto FRANZCR · Alexander G Pitman BMedSci, FRANZCR

To the Editor: I was not surprised by the results published by Fassett et al1 regarding clinical handover. Despite being a crucial part of health care, clinical handover has only recently become a topical issue in the clinical governance arena. In May 2007, the World Health Organization launched the “Nine patient safety solutions” to “help reduce the toll of health care-related harm affecting millions of patients worldwide”.2 Solution number three relates to “communication during patient hand-overs”. Australia is in fact leading the international collaboration on clinical handover through the National Clinical Handover Initiative. This was recently launched by the Australian Commission on Safety and Quality in Health Care to develop and implement standardised solutions to patient safety problems associated with clinical handover.3 At a state level, the Victorian Quality Council conducted a clinical handover survey of Victorian health services in May 2006 to provide an overview of areas of concern relating to clinical handover.4 The Council launched a pilot project in 2007 to look at morning handover processes between junior doctors. Despite these efforts, hospitals are still struggling with the issue of clinical handover at the local level. All health professionals know that clinical handover is good clinical practice, but they need to be provided with the tools to carry it out properly. Clinical handover, depending on your definition, includes referral letters from general practitioners, discharge summaries from hospitals, as well as handover of clinical information between different shifts, treating teams, wards, health professionals and health services. It makes sense that the process of handover of clinical information be carried out in a standardised format, as the minimum dataset required is consistent for most circumstances. While there is a need for standardisation, health organisations must also be able to devise local innovative solutions that work for them. Information technology can assist in developing a solution to this issue. For example, different local health services have already developed in-house systems for electronic discharge summaries that are integrated with an electronic health record. While national quality bodies endeavour to develop national standards and tools for clinical handover, local health services must not sit idly and wait for these, but must continue to innovate and provide workable local solutions for their own health professionals. Otherwise, future surveys of clinical handover will continue to show that a problem still exists in relation to this issue.

Erwin Loh

In reply: Our national survey was specifically confined to medical morning handover report, one of many forms of clinical handover.1 The clinical governance area may have only recently recognised the importance of clinical handover, but it has been a topical issue for many years in the clinical arena, particularly in the United States.2 While Australia may be leading the way in international collaborations, our survey suggests that this is not translating into clinical practice. Rather than commissions and councils providing tools and guidelines to carry out clinical handover, clinical leaders need to participate and conduct clinical handover themselves at the local level. From our previous experience with morning report, we provided simple tips on how to implement clinical handover at the local level,3 and these have been incorporated into Australian Medical Association guidelines.4 Information technology can be employed to help with the clinical handover process. However, when using the all-inclusive definition of clinical handover suggested by Loh, this task is complex, as research has shown that information management needs vary significantly between different clinical environments and would require multiple end-user-defined outputs from a standardised data repository.5,6 Clinical handover needs to be implemented from the bottom up (by clinicians) rather than from the top down (by commissions).

Matthew J Fassett · Terry J Hannan · Iain K Robertson · Steven J Bollipo · Robert G Fassett

Can politicians rise to the challenge, or do doctors need to become politicised? As the federal election campaign unfolds, two key questions emerge: how will alternative health care policies of the two major political parties influence voter choice, and how will health care change once the political victors take charge of the Treasury? There is actually no paucity of political and professional opinion as to how health care in Australia should change. The looming election merely triggers a crescendo in the chants of the Greek chorus of health care experts — “we need to change this” or “we must do that” — all part of an incessant stream of advice, mostly devoid of any evidence base, calling for reform of our health care system. Presently, our system is characterised by “fragmented roles, responsibilities and regulatory arrangements . . . inadequate co-ordination between governments, planners, educators and service providers . . . inflexible regulatory practices . . . perverse funding and payments incentives . . . and entrenched custom and practice”.1 There is actually no paucity of political and professional opinion as to how health care in Australia should change Furthermore, the system is beset with such problems as: reduced opportunities for Australians to access health care when and where they need it; downstream effects of a chronic shortage of doctors, nurses and other health professionals and the system’s chronic reliance on overseas imports; a diminished focus on prevention and primary care; insufficient financial support and a wastage of resources inherent in the current federal–state funding structure; lack of political resolve to undertake reform; and the abysmally poor health status of Indigenous Australians. In short, the system is diminishing in its capacity to deliver universal access to equitable and quality care. It is ripe for reform. Some experts advise that there should be structural change rather than continual incremental changes to tackle the major problems,2,3 and observe: Our health leaders lack the will for health reform because they are strongly influenced by the vested interests that abound in health — doctors (particularly specialists), state health bureaucracies, parochial political interests, private health insurance funds, pharmacies and the pharmaceutical companies.2 Missing from all this rhetoric is a clear, prioritised account of the precise challenges facing our health system. Also missing are detailed enunciations of the health policies and plans of the major political parties contesting the election. To demystify the confusion and rhetoric, in this issue of the Journal we have canvassed the views of a group of seasoned and respected health experts who outline their perspectives on the current challenges facing Australia’s health care system (→ Challenges in health and health care for Australia), along with the electioneering health policies of the Liberal Party (→ Good health systems, getting better), the Labor Party (→ Taking leadership — tackling Australia's health challenges), and the Australian Medical Association (→ A mandate to strengthen the health system). Some of our readers may well ask why the MJA is straying into politics. In embarking on this initiative, the Journal is simply returning to a longstanding tradition of the MJA and following the lead of the Journal of the American Medical Association which, during the 2004 United States presidential election, boldly published responses to the question “How would you ensure access to health care for the citizens of the United States?” by presidential hopefuls George W Bush and John Kerry.4,5 But there is a more fundamental reason. In contemplating our apparent foray into politics, we turned to Julian Tudor Hart (the Welsh general practitioner who described “inverse care law” — that the availability of health care varies inversely with the need for it), who recently decried New Labour’s introduction of private providers to serve the United Kingdom’s National Health Service in his book The political economy of health care.6,7 Among other claims, he contends that if political parties are incapable of confronting the challenges of modern health care, then doctors need to become a politicised profession.8 Have we reached that point in Australia? We might know better when the outcome of this federal election is known, whether the newly elected government will have the political will to pursue reform and will step out from the comforting shadow of the blame game.

Martin B Van Der Weyden MD, FRACP, FRCPA

The next Australian Government will confront major challenges in the funding and delivery of health care. These challenges derive from: Changes in demography and disease patterns as the population ages, and the burden of chronic illness grows; Increasing costs of medical advances and the need to ensure that there are comprehensive, efficient and transparent processes for assessing health technologies; Problems with health workforce supply and distribution; Persistent concerns about the quality and safety of health services; Uncertainty about how best to balance public and private sectors in the provision and funding of health services; Recognition that we must invest more in the health of our children; The role of urban planning in creating healthy and sustainable communities; and Understanding that achieving equity in health, especially for Indigenous Australians, requires more than just providing health care services. The search for effective and lasting solutions will require a consultative approach to deciding the nation’s priority health problems and to designing the health system that will best address them; issues of bureaucratic and fiscal responsibility can then follow.

Bruce K Armstrong AM, DPhil, FRACP · James A Gillespie BA, PhD · Stephen R Leeder MD, PhD, FRACP · George L Rubin FRACP, FAFPHM · Lesley M Russell BSc(Hons), BA, PhD

In view of the impending election, we asked representatives from the two major political parties for their policies on health. The Minister for Health and Ageing replies. On any fair judgement, Australia has excellent health systems. Our healthy life expectancy ranks just behind that of Japan, Iceland and Sweden. There has been a 10-year increase in Australians’ life expectancy since 1960, and a 3-year increase since 1996. These results testify to the effectiveness of the individuals and organisations involved in providing health care. Australia does not need radical experiments in health care delivery. We need refinements and improvements that build on our existing strengths. Our greatest strength, of course, is the dedication and professionalism of Australia’s health staff, who can invariably be trusted to act in their patients’ best interests. Australia’s health systems face four key challenges: the affordability of increasingly sophisticated health services; the expansion of the health workforce to meet the needs of an older population; the treatment of chronic disease in the community rather than in hospitals; and the integration of complex services to deliver seamless care to patients. All these challenges have been substantially addressed since 1996, but there is still a great deal to do. In particular, the next round of Health Care Agreements should not be about government but about health services. The real test of health policymakers (and would-be policymakers) is not the intensity of their critique, but the practicality of their specific proposals for change. It is easy to say, for instance, that we must take the pressure off emergency departments, or we must put more stress on prevention rather than cure. It is much harder to specify how these worthy objectives might be achieved. It is important to pledge more money for health programs but also to maintain the strong economy needed to sustain them. Since 1996, the Howard Government has boosted spending on health and ageing from 15% to 22% of the federal budget. In the current financial year, the federal Government alone will spend $52 billion on health and ageing, including $13 billion through the Medicare Benefits Schedule, $9 billion under the Australian Health Care Agreements, $8 billion on aged care, $7 billion through the Pharmaceutical Benefits Scheme and $3 billion on private health insurance rebates. The Government has improved the private sector as an essential complement to a strong Medicare system. Most importantly, the Government has respected the fee-for-service principle because this is the best way to ensure that money is spent on patients rather than bureaucracy. Eleven-year-old governments do not change their spots. People can expect the same values and better services if the Government is returned. AffordabilityThe Howard Government has made health care more affordable through record bulk-billing rates, the new Medicare Safety Net and the Private Health Insurance Rebate. Since 2003, largely thanks to the bulk-billing incentive payments that were part of the Strengthening Medicare program, general practitioner bulk-billing rates have recovered to over 78%. For children under 16 years, people over 65 and people living in rural areas, bulk-billing rates are now at an all-time high. At 73%, the overall bulk-billing rate for GPs and specialists is also at an all-time high, 2 percentage points above the rate in March 1996. Bulk-billing is important and should be widely available, especially for people who see their doctors frequently, but not everyone can expect to be bulk-billed for everything all the time. In 2004, the Government introduced a new Medicare Safety Net for people with high out-of-hospital, out-of-pocket medical costs to rebate 80% of the gap between the Schedule fee and the doctor’s charge. Last year, more than 1.5 million Australians stood to benefit from this safety net, which paid an additional $260 million in Medicare rebates. By contrast, the Labor Party promised to abolish this safety net at the last election and is still making up its mind at this one. The Government has made private health insurance more affordable and more widely available, after private coverage fell from 70% to 35% under the former Labor Government. More than 9 million people (including a million people earning less than $25 000 a year) now have the choice and security that private cover brings. This is a 30% increase since the late 1990s. Although more than 80% of privately covered services have no gap, about 15% of private hospital episodes still involve gaps (averaging nearly $700), for which no informed financial consent was previously obtained. The Government is working with the Australian Medical Association and other professional bodies to ensure that patients are warned in advance about all reasonably foreseeable medical costs, because these “nasty surprises” cause people to drop their private cover. This Government is a reluctant regulator and hopes that it will not be necessary to make obtaining informed financial consent mandatory, but will have to act if rates do not continue to improve. WorkforceThanks to the Howard Government, record numbers of doctors and nurses are in training. Even before the Australian Medical Workforce Advisory Council formally told the Government in November 2002 that there was an across-the-board deficiency in future doctor numbers, the Government had been moving to expand doctor training places. In 2004, there were nearly 1300 medical graduates from Australian universities. In 2012, there will be about 2800 domestic graduates. There have also been large expansions in places for other health professionals (including, most recently, 500 extra places a year for enrolled nurses trained wholly within hospitals). The Government has already committed $60 million for registrar positions outside public hospitals, and will continue to expand private-sector procedural training, as almost 60% of all operations are now done in that sector. The Government has funded nine new medical schools and established 14 rural clinical schools and 11 university departments of rural health. The Government is paying country doctors up to $25 000 a year in special rural retention payments and has boosted the pay and training support offered to rural proceduralists. This has already boosted country doctor numbers by 30% since 1996 (in full-time workload equivalent terms based on Medicare data), but more needs to be done as small country centres are always only a retirement away from a workforce crisis. The Government is working with the states to establish a national system for the registration and accreditation of health professionals. Once registered, doctors (and other health professionals) should be able to work anywhere, and there should be a high, uniform professional standard for everyone practising in Australia. Under the Government’s model, each profession will have its own national registration and accreditation board to set standards and procedures. Each national professional board will be assisted by a national registration and accreditation secretariat. Existing state registration boards will become committees of the national board and will administer the registration process in their state. Each board will be sovereign over its own profession, subject only to the national Health Ministers Council, which will operate by consensus. There will be a national health registration advisory council, but it will have no authority over the individual professions’ boards. The Government will continue to oppose any state’s move to use national registration to push “task substitution”. For instance, the Government supports the use of nurses in general practice as part of a team rather than as independent nurse practitioners. Chronic diseaseWithin a generation, chronic disease (such as heart disease, the complications of diabetes, and cancer) will account for 80% of Australia’s total disease burden. The Government has anticipated this by expanding Medicare to prevent the onset of chronic disease and to treat it in the community before it triggers life-threatening crises requiring admission to hospital. Since 1999, under the Enhanced Primary Care Program, the Government has encouraged GPs to focus on promoting wellness as much as on treating sickness. After a series of refinements, this Program is now working well for patients with chronic disease. In the past financial year, there were nearly 700 000 Medicare-funded GP care plans, nearly 400 000 team care plans, and nearly a million Medicare-funded allied health professional consultations on GP referral. In the first 8 months of operation, there were nearly 300 000 GP mental health care plans and nearly 600 000 Medicare-funded psychologist consultations. As well, in the past financial year, there were more than 250 000 Medicare-funded comprehensive health checks for people aged over 75. The Budget changes to the Medicare dental scheme are likely to be one of the most important recent innovations in health. From 1 November 2007, GPs can refer patients who have team care plans to private dentists for up to $4250 worth of Medicare-funded dental work. This is directed to people with chronic disease and contributing poor oral health, rather than to the 650 000 people estimated to be on state public dental waiting lists. Still, many of the latter are pensioners who are likely to be covered by the new measure, which, like all Medicare programs, will be demand-driven rather than budget-limited. From 1 November, Medicare will fund longer consultant physician items for patients with multiple morbidities. From mid 2008, there will be subsidised lifestyle modification classes available on GP referral for patients at serious risk of developing type 2 diabetes. It is too early to be definitive about the reductions in hospital admissions arising from the use of care plans. Still, general practices involved in the collaborative quality improvement program report significant improvements in patients’ management of blood sugar and other chronic-disease variables. Certainly, more practices are starting to focus on their patients’ long-term health outcomes. As well, GPs are becoming health managers for their patients, coordinating the delivery of a network of Medicare-funded services, rather than simply treating as much as they can themselves. There are still many GPs in solo or small practices delivering excellent care. There are also increasing numbers of primary health care centres involving collocated GPs, practice nurses, visiting specialists, part-time allied health professionals, on-site diagnostic services and a pharmacy. These are largely funded through Medicare on a fee-for-service basis. They represent private health professionals’ intelligent responses to the changing imperatives of health care under the Medicare system. This sensible evolution of services is potentially threatened by government-funded “super clinics” in competition with the private profession. Seamless health care deliveryWhich level of government delivers care is not important as long as it is the right care at the right time. The fact that public hospitals are the responsibility of the state governments, while most other health programs are the responsibility of the federal government, does not matter as long as people receive the appropriate level of care. The existing divisions of governmental responsibility are a function of history rather than logical design. This does not mean that health institutions cannot be made to work well as things stand, or that the theoretical benefits of major structural change justify the costs of upheaval. For its part, the Howard Government is determined to run federal health programs well, effectively manage the interface between federal and state programs, and fund state health services in ways which maximise service delivery. This Government believes in solving problems, not creating more bureaucracies or inquiries to tell people what they already know. The states habitually claim that public hospital problems are really the federal government’s fault. In fact, the triage system means that emergency patients are seen promptly, and general practice-type patients are seen only when there are no more pressing cases. In any event, the Government has restored bulk-billing rates and funded over 140 after-hours GP services since 2004 through higher Medicare rebates and cash grants. Some of these have been collocated with public hospital emergency departments. As well, the Government has boosted the number of operational aged care places, from 145 000 in 1996 to 210 000 now; funded 2000 “step-down” places under the current Health Care Agreement, and introduced a transition care program for 13 000 patients a year who are too sick to go home but no longer need acute hospital services. Public hospital problems are caused more by bad management than by poor funding. Doctors and nurses are the “meat in the sandwich” between penny-pinching managers and the patients affected by their decisions. The states’ “top-down” management structures typically give local managers little real autonomy. Any local revenue is invariably “clawed back” by head office. Critical new spending decisions are invariably referred to committees, and then passed up the line to a director-general or the minister’s office for further procrastination. It is no wonder that many of the best staff seek refuge in the private sector, while their colleagues soldier on out of a sense of duty to patients rather than faith in their superiors. Putting a different bunch of bureaucrats in charge will not be change for the better. The proposal for a Commonwealth-funded, community-controlled public hospital at the Mersey site in Tasmania is about running hospitals better, not swapping a state bureaucracy with a federal one. It is not a precursor to the federal takeover of all public hospitals, but a test case for a better management system that the states should consider adopting. The Mersey will be run by a chief executive officer accountable to a local hospital board, including representation from local hospital staff. Staff will have an incentive to be creative because the hospital will keep any extra revenue. The government’s immediate postelection task will be the renegotiation of the Health Care Agreements. At present, these are block grants to the states. How the states spend the $42 billion the Agreements provide is entirely up to them. All that is required in return is to at least match the growth in Commonwealth funding, report on waiting lists, and guarantee to treat public patients at no charge. A re-elected Government will provide at least as much public hospital funding under future Agreements as it does under the current ones. The Government is considering how the next Agreements might drive better hospital performance and, in the long term, fund services rather than bureaucracies. Certainly, the next Agreements should be about better services to patients rather than turf wars between governments. There are two further matters vital to modern service delivery and fair health systems in Australia. The Government will make Pharmaceutical Benefits Scheme and Medicare data on patients available to these patients online, securely and accessibly, before the end of 2008 as its practical contribution to establishing an integrated electronic health record. The Government will also ensure that there is sustained follow-up treatment for problems identified by Indigenous child health checks in the Northern Territory. Spending on Indigenous health and aged care programs has more than doubled in real terms since 1996, but more needs to be done to give Indigenous patients access to health services comparable to that of the general Australian community. Australians are entitled to have high expectations of their health care systems and to demand much of the governments responsible for them. The latest opinion poll reveals that people are twice as inclined to blame the state governments as the federal government for problems in health care. This might be a good guide as to which side of politics can really be trusted to keep Medicare safe.

Tony Abbott MP

In view of the impending election, we asked representatives from the two major political parties for their policies on health. The Shadow Minister for Health replies. Labor recognises that national leadership is needed to drive better health outcomes for the community. Hospitals and health services are struggling to meet demand; our health workforce is overworked and under stress; and many Australians have problems accessing the care they need. Federal Labor has a $2 billion health and hospital reform plan which will kick-start the reform process needed to end the “blame game” between the states and the Commonwealth, to better equip our health system for the needs of the future, and to put preventive health care at the centre of our approach, rather than at the margins. Poor health affects the quality of life of Australians and their families, and can have significant economic effects by reducing their ability to participate in the workforce and through lost productivity and higher costs for business. A constellation of challenges face our health system: Long term trends, such as population ageing, the increasing prevalence of chronic disease, labour costs and shortages, and the escalating cost of new health technologies; Costs and inefficiencies generated by blame and cost shifting between levels of government over funding agreements that concentrate on inputs rather than health outcomes; Health care services that reflect these flawed funding arrangements rather than the needs of patients; and Health care services that fail to intervene early or comprehensively to maximise people’s productivity and workforce participation. Under the Howard Government, our health system is plagued by rising costs and is increasingly unable to cope with the changing health needs of Australian families. Labor believes change is needed to ensure these challenges are tackled, guaranteeing the long-term sustainability of the Australian health system. Australians are sick and tired of politicians passing the buck when it comes to health care and hospitals. To end the blame game, Federal Labor has announced that it will take responsibility for improving Australia’s health and hospital system — easing pressures on families and delivering long-term productivity benefits to the community. To deliver that change, Labor has proposed the single biggest health reform since Federation. Big picture reform: Labor’s National Health and Hospitals Reform PlanA Rudd Labor Government will invest $2 billion in a National Health and Hospitals Reform Plan to kick-start investment in immediate reforms to reduce blame and cost shifting and improve health services for Australians. Labor’s reform funding program will: Invest in hospital and primary care infrastructure that will help drive needed reforms; Provide incentive payments to state and territory governments if they achieve agreed reform milestones based on improved health outcomes, not simply inputs; and Provide more appropriate care options for older Australians. Our aim is to improve health outcomes and reduce the pressure on our hospitals. We will fund projects that: Reduce avoidable hospitalisations and readmissions to hospital; Reduce non-urgent accident and emergency presentations; Decrease waiting times for people who require essential hospital services, such as elective surgery; Provide more appropriate non-acute care for older Australians; and Increase access to medical and specialist services in the community. Within the first 100 days of its election, a Federal Labor Government, through the Council of Australian Governments (COAG), will establish a National Health and Hospitals Reform Commission to develop a long-term health reform plan for the nation. This Commission, headed by an eminent Australian, will, in cooperation with the states and territories, and in consultation with health experts, professionals and consumers, develop stringent performance benchmarks that the states and territories will be required to meet. Pressing issues, ranging from rural health to workforce, will be key parts of the Commission’s work. The Commission’s early work will form the framework for developing the next Australian Health Care Agreements. Our aim is to deliver better health outcomes through negotiation with the states. However, if the states and territories have not begun implementing a national reform plan by the middle of 2009, a Rudd Labor Government will seek a mandate from the Australian people for the Commonwealth to assume full funding responsibility for the nation’s public hospitals. If a Commonwealth takeover of hospital funding was supported by the Australian people, a model would be devised that ensures the future of state, private and community-managed hospitals. There would be provision for regional and local authorities to participate in the management of public hospitals and to ensure responsiveness of local hospitals to community needs. Under Labor’s proposal, no public hospitals would be managed directly from Canberra. The assumption of Commonwealth funding for all public hospitals would require a parallel reduction in Commonwealth outlays to the states and territories at the point of transfer, to ensure there would be no windfall gain of any description to the states and territories. Despite some mischievous suggestions, this will under no circumstances involve an increase to the GST. At the time of writing, three important components of this national strategy have been detailed. GP Super ClinicsAs part of the $2 billion Health and Hospitals Reform Plan, a Rudd Labor Government will invest $220 million in the health system to establish GP Super Clinics in local communities — bolstering frontline health care for Australian families. Labor’s GP Super Clinics plan will help get doctors and other health professionals into areas that need them most, working together to meet the new service delivery challenges of modern medicine. The plan will provide infrastructure funding for general practitioners and other health professionals, including allied health workers, nurses and some specialists, to work together in the one place, providing a greater range of quality services in local communities — and much greater convenience for patients. The clinics will be tailored to the needs of local communities and particularly targeted to rural, regional and outer urban areas where Medicare has not been utilised to its fullest extent because of workforce shortages. Along with incentives to pay for administrative and nursing support, funds can be used to provide teaching rooms and facilities to make the GP Super Clinics attractive to new graduates, trainees and GP registrars — encouraging health workers into regions where there are currently workforce shortages. With 65% of Australia affected by a GP workforce shortage, initiatives that encourage doctors to train and work in underserviced areas are crucial to the long-term sustainability of our health system. By having renovated or purpose-built facilities that allow space for group sessions and a range of staff, the GP Super Clinics will have a particular focus on assisting people to stay well or to better manage existing chronic conditions. Labor’s GP Super Clinics will: Help take the pressure off hospitals; Provide a greater focus for tackling the challenge of chronic disease in local communities; Attract medical graduates and health professionals to areas of need; and Mean much greater convenience for patients. Aged careCurrently, about 2300 older Australians who have been assessed as needing residential aged care are waiting in hospital wards. Some have waited months for a bed in a nursing home. This is tough on families, and also means that much needed hospital beds are not available to Australians of all ages waiting for surgery or medical treatment. A Rudd Labor Government will help older Australians waiting in hospital wards to get an aged care bed or to return home sooner. This will ensure that older Australians get more appropriate care, and that significant pressure is taken off our hospital system. Under Federal Labor’s initiative, $158 million will be invested over the next 5 years to create up to 2000 transition care beds for older Australians who are currently waiting in hospital for an aged care bed and to allow others to return to their home. Federal Labor will also provide $300 million of loans at zero real interest rates to aged care providers to make up to 2500 permanent residential aged care beds available sooner to older Australians. Preventive healthFor the past year, Federal Labor has been arguing to move prevention to the centre, not the margins, of our health system. A Rudd Labor Government will treat preventive health care as a first-order economic challenge, as well as a health issue — because failure to do so will have a long-term negative impact on workforce participation, growth in productivity and the overall health budget. A Rudd Labor Government has committed to: Develop a National Preventative Health Strategy to provide a blueprint for tackling the burden of chronic disease, with an initial focus on obesity, tobacco and excessive consumption of alcohol. The Strategy will be supported by an expert taskforce. Shift the focus from so-called “6-minute medicine” in general practice by beginning a reform process to provide incentives for GPs to practise quality preventive health care, including longer consultations; Broaden the focus of the major health care agreement between the Commonwealth and the states and territories beyond hospital funding by developing a National Preventative Health Care Partnership; and In its first term, commission the Treasury to produce a series of definitive reports on the impact of chronic disease on the Australian economy, and the economic benefits of a greater focus on prevention in health care. A focus on prevention would mean nothing without attention to the health of Australian children. There can be no better investment in Australia’s future. By ensuring that children are able to develop healthy habits early in life, we take a significant step forward in our battle against chronic diseases. We have committed Labor to some major initiatives for children: All children starting school will receive a health and early skills assessment. The Healthy Kids Check will include an assessment of a child’s basic health, such as teeth, hearing, balance and sight. The Australian Early Development Index will be rolled out from 2008. This rigorous checklist, covering five key aspects of children’s development, will assess how Australian children are faring when they reach school age. A Healthy Habits for Life guide will provide practical information to help parents assist their children to develop healthy habits for life. $12.8 million will be provided to establish the Stephanie Alexander Kitchen Garden Program in 190 primary schools across Australia. The program will tackle the rising trend of childhood obesity by giving children hands-on experience in healthy eating: teaching them how to grow, harvest and cook produce, as part of the school curriculum. $1.7 million will fund research that brings together the lessons learned from community obesity prevention projects, analyses the data to determine which projects work, and shares this knowledge with other communities who want to be involved in similar initiatives. $3.5 million will be provided to develop and distribute guidelines on healthy eating and physical activity in early childhood settings. This package forms the start of the comprehensive approach needed to tackle children’s health and the particular issues with childhood obesity. Severe problems in our health systemFor years, Australia has struggled to provide decent health services to our Indigenous and rural communities. Delivery is often hampered by workforce shortages, which have not been planned for, or dealt with consistently, by the Howard Government. These issues, and Labor’s commitments, will be part of Labor’s overall health strategy, but some concerns and commitments are flagged here as an indicator of our concern. Rural healthInvestment under Labor’s $2 billion National Health and Hospitals Reform Plan will prioritise areas where need is greatest, based on indicators that include workforce shortages and poor infrastructure. Those areas will include many rural and remote areas of Australia, as we have noted with our GP Super Clinics plan. The Reform Commission will have the task of developing a long-term rural health strategy. Federal Labor believes it is worth considering in this process whether the next Australian Health Care Agreements should include a rural health service commitment. It is time to consolidate and invest in existing successes, not to continue with more and more pilot programs. Consistent with this approach, Federal Labor will reform the Rural Medical Infrastructure Fund, expanding its eligibility and raising its funding cap to ensure more communities can access this important source of funding. Indigenous healthA Rudd Labor Government has committed to closing the 17-year gap in life expectancy at birth between Indigenous and non-Indigenous people within a generation. Labor will make a $260 million down-payment on this commitment with our investment in Indigenous early childhood health. This initiative will ensure that Indigenous women have access to: Proper antenatal care (including a visit to a midwife or doctor, an ultrasound examination and a general health check); Practical advice on parenting, breastfeeding and nutrition for their babies; Home visit services for new Indigenous mothers and children aged 0–8 years (in conjunction with the states and territories). Dental healthLabor has announced the first instalment of its plan to establish a Commonwealth Dental Health Program and will fund up to one million additional dental consultations and treatments for Australians needing dental care. Federal Labor will invest up to $290 million in a Commonwealth Dental Health Program — one of the first programs scrapped by the Howard Government in 1996. The Howard Government’s Medicare Chronic Disease Management scheme has failed to help the hundreds of thousands languishing on dental waiting lists. Over the past 3 years, it has helped only 7000 people, owing to its complex eligibility and referral criteria. The complexity of the referral process has also overloaded GPs with even more red tape, creating more work for doctors who are already under pressure. As part of Federal Labor’s determination to take national leadership and end the blame game in health, our funding will be available for the states and territories to help clear the backlog at public dental clinics. They will either supplement their existing services or purchase private-sector appointments for the hundreds of thousands stuck on their waiting lists. Our dental plan is a significant investment in making health care more affordable for Australians. We know that rising health costs under the Howard Government are a challenge for many families, and we will work to tackle this situation. Because we realise that many family budgets now rely on them, we support the private health insurance rebates and the Medicare Safety Net. ConclusionFederal Labor has outlined a clear, comprehensive national strategy for health care. A national, coordinated strategy has been lacking from Australia’s health system for far too long. Federal Labor believes that the long-term challenges facing Australia in health must begin to be tackled immediately. That is why Labor has announced policies in key areas of health, including primary care, hospitals, prevention and chronic disease, children’s health, dental health, aged care and Indigenous health. Australia deserves a government willing to re-examine the health system, and to drive the changes that we all know are needed. A Rudd Labor Government will do precisely that, delivering clear solutions, responding to the needs of people across Australia, and establishing a long-term direction for the future of health in Australia.

Nicola Roxon MP

The President of the AMA describes the key issues for health This is an exceptional election. Many Australians have memories only of a federal Liberal Government in power, and a health system based on Medicare and public hospitals, with a greater balance and contribution from the private sector in the past few years. The issue for the Australian Medical Association (AMA) is: what will this federal election outcome deliver for the health of Australians? We believe that our health system provides for the community to a degree, but at the same time needs rejuvenation. The AMA wants to ensure that the health system is capable of serving the Australian community properly into the next decade and beyond. The system needs to incorporate clinician-driven ideas, fresh thinking, and more strategically targeted and audited funding and resources. The AMA has put forward its blueprint for reform in the Key health issues for the 2007 federal election document.1 This is not an all-encompassing plan, but highlights the pillars of health that must be reinforced if we are to continue to provide high quality and affordable health services in an equitable way to all Australians — and to ensure that we cover any gaps and improve areas of concern. A few months ago, health was missing from the political table. Neither of the major parties was raising the bids in the great pre-election health policy debate. However, as Election Day draws nearer, health policy continues to rise on the ladder of vote-changing election priorities. Health policy may well decide this election. The signs are there. And some of these indicate a change in thinking. The Government played a trump card with its Indigenous health and child abuse intervention in the Northern Territory, but it is still too early to judge the success of this action. The Mersey Hospital takeover in Tasmania has delivered mixed results for the Government. Is it a one-off to win a marginal seat, or is it a test case for things to come? Perhaps the Coalition is betting that all health politics are local, affecting individuals at the coalface. Meanwhile, the Opposition is running hard with preventive care, its $2 billion National Health and Hospitals Reform Plan, and GP Super Clinics. Questions remain in regard to all these initiatives. Both sides are determined to win the hearts, minds and health votes of the Australian people. The AMA is interested in what will be delivered in terms of real service for Australians. While Labor still promotes itself as the party that brought you Medicare, which is popular with voters, the party has been out of power for 11 years. In that time, the Coalition has established impressive credentials in health policy, especially since 2004. The Medicare Safety Net, the private health insurance rebate and lifetime health cover, additional rebates for bulk-billing children and health care card holders, and “for and on behalf of” items for practice nurses and allied health providers have all added value to the health system and enhanced the ability of medical practitioners to deliver quality health care. Labor has now embraced these changes. While Australia has a good health system by world standards, there is more to do. The AMA does not support “big bang” reform to set the health system up for the next decade. We need to identify and build on the positives. Each year, the system delivers a large number of high-quality health services for a relatively modest overall cost (about 10% of gross domestic product, middle-ranking among OECD countries2). Australians enjoy good health outcomes. For example, the World Health Organization, in its World health report 2000, ranked Australia second in the world for disability-adjusted life expectancy.3 There is value for money in the system: each year, Australians access some 260 million medical services through Medicare (more again in public hospitals), while one in three Australians accesses in-hospital care. The medical workforce works hard to render 100 million general practitioner consultations each year, performing a gatekeeper role that seeks to achieve appropriate early intervention while avoiding wasteful overuse of investigative, specialist consulting and hospital services. There is always room for improvement, particularly in meeting the health challenges of an ageing population. The strengths of the Australian health system include: A well trained, highly professional health workforce; Good quality health infrastructure; Complementary public and private health providers; and A productive health research sector. The weaknesses of the Australian health system largely arise because the nation has not invested enough in the health of the nation. Australia has failed to: Adequately meet the overall current demand for health care; Train enough health professionals to meet the rising expectations and increasing needs of an ageing population; Significantly improve the very poor health status of Aboriginal and Torres Strait Islander peoples; Find ways to deliver adequate health care to people living in rural and remote areas; and Properly educate and inform the community on health promotion and health prevention. Now is the time to invest — and invest substantially and strategically — in the future health of our nation and our people. The AMA’s Key health issues document articulates where the investment needs to be made.1 Indigenous healthAboriginal and Torres Strait Islander peoples have the poorest health of any group living in Australia. Indigenous standardised mortality ratios are more than three times the expected rate, and death rates in the 25–54-years age group are five to eight times those seen in non-Indigenous Australians. Indigenous infant mortality rates are three times higher than for non-Indigenous infants. The 17-year gap in life expectancy between Aboriginal and Torres Strait Islander Australians and the rest of the Australian population must be closed. It is not acceptable in 2007 for any Australian to have a 1920s’ life expectancy. The AMA calls for an additional $460 million per year in targeted resources, particularly for primary care, to be delivered in consultation with Indigenous communities and Indigenous health professionals. Public hospitalsOur public hospitals are dangerously underfunded and under-resourced. Waiting times are long. Emergency departments are overwhelmed and under unsustainable pressure. Doctors are working long hours. Morale is low and at crisis level. Patients want access to good-quality public hospital services in a timely manner. Generally, emergency services fall short of reasonable expectations. Public hospitals should not operate for extended periods at more than 85% bed occupancy. Some public hospitals in Australia are operating at 120% occupancy. Patients are treated in corridors. Patients want to be treated in appropriate settings and to be assured of the safety of the system. All contenders for the election need to take the public into their confidence and, before the election, explain their solutions to the current woes of the public hospital system. The federal government must increase its current funding effort by 8%–9% per annum over the life of the next Australian Health Care Agreement, and commit to a joint federal–state “fix” and regular public audit of the system. Medical workforceIn response to increasingly serious workforce shortages, the Australian Government has embarked on the most significant expansion of medical student places that Australia has ever seen, and announced further measures to increase nursing intakes. Between 2006 and 2012, the number of graduates from medical schools will double. This presents Australia with a unique opportunity to reduce its heavy reliance on overseas-trained doctors. By 2013, around 3400 intern places per year will be required (current numbers are less than half that, at 1622). Similar increases in vocational training places will also be needed. This is a huge challenge for governments, hospitals and medical colleges. A critical issue will be the expansion of training places without compromising the high standards that have underpinned the high quality of the Australian medical workforce. In particular, if doctors are not given enough experience in dealing with a wide range of medical conditions, then the quality of their training will suffer, and the high quality of patient care will be compromised. Workforce substitution (using lesser trained professionals) is not the solution. When Australians are sick or injured, they want to see a doctor. The federal government must provide additional funding and work with the AMA to establish a system for GP training, prevocational training in general practice, specialist training, and training in expanded clinical and rural settings. The states and territories should be locked into cooperating with these arrangements through the Australian Health Care Agreements. Aged careDemand for aged care services is growing rapidly. We are seeing accelerated growth in numbers in the older age group (those aged 65 years and over) and even faster growth in the very old (those aged 85 and over). The AMA expects there will be an increasing preference by users for care in the community, where possible (and for as long as possible), and an increasing need to provide quality dementia care in all settings. A shortage of adequately skilled staff, disincentives for GPs to provide services in both residential and community aged care settings, and difficulty accessing medical specialists continue to affect the quality of care provided to older people. The federal government must lift funding across the board for aged care, and provide additional incentives for GPs to provide services in residential aged care facilities. This will involve better consulting rooms and equipment in these facilities, with access to computers for patient records and prescribing. Health promotion and preventionThe Australian health system has had an emphasis on curative services. To meet patient hopes and expectations, Australia must become more effective in health promotion and prevention. The responsibility for this falls widely on governments to invest in public health education and reinforcement of lifestyle improvements. Then individuals, GPs and allied health professionals can support and sustain healthy lifestyles and preventive medical interventions to have an impact into the future. Individual choices are very important in this area. But so too are the social and environmental factors that affect how people live and work, such as education, income, housing and employment. The key health promotion and prevention challenges include smoking; alcohol and drug misuse; immunisation; obesity; nutrition and exercise; and lifestyle diseases such as diabetes. Government has a leadership role in each of these areas. The AMA calls on the federal government to give GPs greater incentives to spend more time with their patients on health promotion and prevention. Rural healthRural and remote Australia is undergoing great change. Some rural communities are growing rapidly through “sea change” population movements, putting considerable pressure on health and community services. Other communities are struggling to survive a prolonged, drought-accentuated decline. Rural and remote areas deserve, but have not enjoyed, a “fair go” when it comes to access to health care. The lack of access to quality facilities, services and doctors is a key barrier to improving the health and wellbeing of rural communities. Health care in rural areas depends on a strong primary health care workforce and a viable public hospital system. Country patients miss out if they do not have both. Further, without access to quality public hospital facilities, doctors cannot maintain their procedural skill levels, and the opportunity to train new doctors in rural areas is greatly diminished, leaving many communities with no doctors or too few doctors. The AMA wants the government to link rural health to its recent generous drought-relief programs. Whenever funding is allocated to keep people on the land and working in regional communities, to produce food and resources for the nation and for export, a similar priority should be given to providing the medical workforce and equipment needed to keep the rural population healthy and able to work and support their families. The Rural Medical Infrastructure Fund, Patient Assisted Travel Scheme, Medical Specialist Outreach Assistance Program, Rural Retention Program and telemedicine programs need a substantial boost in funding and resources. The federal government must take a leadership role in providing rural and regional Australia with properly resourced doctors in adequate numbers to serve local communities. Preserving the independence of the medical professionOne of the hardest messages to get into the heads of politicians of all persuasions is that the health system cannot succeed without a well trained, independent medical workforce. Patients want to see doctors, and have a right to do so. Too much effort is being put into second-best or third-best options when attempting to solve medical workforce problems. The reality is that doctors cannot be replaced or substituted with lesser trained people. We need better utilisation of the health workforce through a carefully managed team approach, in which the doctor is always the coordinator of care and the clinical leader. Despite patient and community suspicion and concern about doctor substitution, some governments persist with proposals that will ultimately lead to poorer quality patient care. The Council of Australian Governments (COAG) has been pushing one of these perilous barrows for some time, in the form of its plan for a single national system of registration and accreditation for all nine health professions. The federal government has realised the risks in compromising the quality of the health workforce in this plan and is on the brink of rejecting the states-led initiative, but the election has taken the momentum out of this action. The COAG plan must be scrapped postelection, whoever wins. There has been mutual recognition of registration of medical practitioners between the jurisdictions for many years. The AMA supported previous attempts by the jurisdictions to harmonise standards to allow portability of registration across borders with a minimum of red tape. The last attempt to achieve portability for medical registration in 2003–2004 failed because not all the states and territories would agree on harmonising legislation. The new COAG model threatens the safety and quality of medical care in Australia, opening the door to government control — for political expediency — of the accreditation of all medical courses and undergraduate and specialist training. These roles should remain independent of government, and the Australian Medical Council must be retained. The quality of Australian doctors is a pillar of our health system. ConclusionThe AMA wants a government that is prepared to invest in health while times are wealthy, to tide us across the times ahead — with changing population demographics, increasing expectations, increasing ability to investigate and treat deformity and disease, and a sheer increase in population and chronic disease. This requires dollars, clinicians in the driver’s seat, and accountability at the community level. The AMA has some runs on the board, but the quest is eternal. Our responsibility to our patients and the doctors who serve them does not just peak pre-election; it is a constant work that extends beyond election cycles.

Rosanna Capolingua

Objective: To describe tumour characteristics and clinical management of melanomas newly diagnosed in 1996 and in 2000 — before and after publication of the clinical practice Guidelines for the management of cutaneous melanoma by the Australian Cancer Network (1997), and their endorsement by the National Health and Medical Research Council (NHMRC) and republication (1999).Design and setting: Survey of clinicians involved in the management of patients with melanoma sampled from the Victorian Cancer Registry. The Registry is notified of all cases of cancer diagnosed by pathology laboratories and hospitals in both the public and private health sectors in the state of Victoria.Patients: People with a cutaneous melanoma newly diagnosed in 1996 and 2000. All invasive melanomas > 1.50 mm in thickness were included, and for each year random samples were selected of 100 each of invasive melanomas 0.76–1.50 mm in thickness, invasive melanomas ≤ 0.75 mm, and in-situ melanomas, plus 50 melanomas of unknown thickness.Main outcome measures: Biopsy method, adequacy of pathology reporting, adequacy of definitive excision (compared with margins recommended by the Guidelines), and follow-up procedures.Results: The use of partial biopsies increased between 1996 and 2000. Recommended margins of definitive excision were used in only 33.6% of cases. Margins were smaller than recommended for 36% of in-situ melanomas, risking recurrence of primary melanoma. Documented follow-up examinations for subsequent primary skin malignancy were uncommon (6%).Conclusions: Many aspects of the management of primary cutaneous melanoma appear not to meet the recommendations of the published Guidelines. Further studies to explore the reasons for failure to meet the Guideline recommendations are needed.

John W Kelly MD, FACD · Michael A Henderson MD, FRACS · Vicky J Thursfield BSc, GradDip(Applied Stats) · John Slavin FRCPA · Jill Ainslie FRANZCR · Graham G Giles PhD

Globalisation has brought with it many advances in health, but also a new range of challenges. There is a need to move from “nation-focused” (international) public health to global public health — and the terminology we use here matters. Global public health leadership requires that respect be shown to evidence, especially that about the changing nature of disease worldwide. The Australian medical and research communities have a significant opportunity to provide global public health leadership.

Stephen R Leeder FRACP, FFAPHM, FFPHM, AO · Susan U Raymond PhD · Henry M Greenberg MD