Health services administration

In response to persisting quality problems in clinical practice, policymakers in various countries, including Australia, are experimenting with pay-for-performance (P4P) schemes that tie a portion of provider payments to performance on measures of quality. Rigorous studies of P4P efficacy are relatively few, with many focused on preventive care in ambulatory settings and many suggesting only modest gains in performance. Several key issues need to be considered in determining the optimal design and implementation methods for P4P programs, including: the choice of clinical practice area; the size of financial incentives and who should receive them; the selection of quality measures and performance thresholds that determine incentive eligibility; data collection methods; and the best mix of financial and non-financial incentives. A proposed framework to guide Australian initiatives in P4P emphasises early clinician involvement in development, a phased approach from “pay-for-participation” in performance measurement to P4P within several pilot demonstration programs, and investment in clinical information technology.

Ian A Scott FRACP, MHA, MEd

To the Editor: Women of the remote Indian Ocean Territories (Christmas Island and the Cocos Islands [see map]) regularly question why their comprehensive obstetric service, allowing deliveries on the Islands, ceased in 1998. A study in 20051 aimed to provide answers for these women. There is one general practitioner on the Cocos Islands and two on Christmas Island. Previously, procedural GPs attended to most deliveries. Now, pregnant women must leave the Islands 4 weeks before their expected delivery. The financial, physical, emotional, and cultural costs of this are substantial. Reports published in 20022 and 20043 identified community concerns, but resisted recommendations to resume on-Island birthing, because of perceived low birth numbers and difficulty sustaining the skills of clinicians. Both studies relied on external birthing data, as the Indian Ocean Territories Health Service (IOTHS; administered by the Department of Transport and Regional Services) had not documented numbers of deliveries. The Alberton Report,3 extrapolating from Australian Bureau of Statistics (ABS) data, assumed that the population of children aged less than 1 year in a census year equalled the number of deliveries the year before. The ABS has a system to protect the confidentiality of small isolated populations and purposely does not report these numbers. The Bath Report2 relied on data from the Western Australian Midwife Notification System (MNS). The MNS reported 136 births to Island women from 1995 to 2004, while our study (Western Australian Centre for Remote and Rural Medicine)1 recorded 326 births. Thus, the MNS attributed only 41% of known births to Island women during 1995–2004, and only 23% during the period considered by the Bath Report. We believe that the MNS data shortfall occurred for two reasons. Firstly, women frequently provide their temporary mainland address on the MNS form for practical reasons. Secondly, one in seven women leaving the Islands to deliver their babies choose to give birth in a state other than Western Australia to be closer to family, and these births are not attributed to women from the Islands. The methods used by the Alberton Report, the MNS and the Bath Report result in underestimations of the number of confinements for Island women by up to 77%. It is regrettable that this situation has not been previously recognised or acknowledged, and that recommendations for the resumption of obstetric services by the IOTHS have repeatedly been based on incomplete data. If records of the numbers of births for Island women had been collected and considered by the IOTHS, Island families might again enjoy a comprehensive on-Island delivery service for low-risk pregnancies.

Susan Downes · Sally M Roach

Despite advances in treatment, the greatest gains in cancer control are achieved through prevention The translation of basic cancer research on cell growth to the clinic has resulted in a paradigm shift in cancer treatment by providing new therapeutic targets. The initial successes — the monoclonal antibodies trastuzumab and rituximab — have improved the survival of patients with breast cancer and lymphoma, as has the small molecule imatinib mesylate in chronic myeloid leukaemia; all have less toxicity than conventional cytotoxics.1 The challenge is to fund these new high-cost drugs. Although targeted drugs can be limited to the specific patient populations expressing the appropriate target, further funding is then required to screen patients for those targets. New models of cost- and risk-sharing between governments and industry must evolve to pay for these developments. A similar evolution in the diagnosis of cancer will see genomics and proteomics become a more important guide to treatment selection and prognosis than traditional pathology tests.2,3 These research technologies will need to be developed in such a way that they can provide guidance to clinicians as quickly as conventional techniques, and will also require upskilling of current clinicians, pathologists and their trainees. Investment in cancer research pays considerable dividends.4 There is a need for more funding of translational research — it has been an ongoing concern that Australia lacks the infrastructure to take promising new drug discoveries all the way from the laboratory into clinical practice. Newer fields, such as health services research, with its potential to address the pressing issue of inequities in access to treatment and cancer outcomes in rural and remote Australia, and psychosocial research, require new sources of funding. The challenge in Australia is to make research less fragmented and better targeted to questions of international importance, which we have the capability to competitively pursue. Although breakthroughs in cancer treatment generate significant media coverage, the greatest gains in cancer control in Australia are to be made in prevention strategies based on established science. Evidence-based health promotion campaigns have provided strong economic returns, yet governments invest only 1.7% of the overall health care budget in primary prevention.5 More than 21% of cancer deaths in Australia are attributed to tobacco use. Add smoking to excessive sun exposure, inadequate fruit and vegetable intake, alcohol, inactivity and obesity, and more than 34% of cancer deaths in Australia can be attributed to modifiable behaviour.6 Currently, 17.4% of Australians smoke.7 Australia has a smoking prevalence among the world’s lowest, but from a public health perspective it remains unacceptable that almost one in five Australians incurs a significant yet avoidable cancer risk by continuing to smoke. The prohibition of broadcast tobacco advertising in the mid 1970s was the first key policy step in a series of tobacco control reforms that have since been shown to have saved 17 000 Australians from premature death.8 This government initiative required no taxpayer funding, but a cultural shift. Where funds have been invested, the returns have been enormous, with the $176 million spent on antismoking campaigns over the past 30 years delivering $8.6 billion in benefits.9 There remains no more effective cancer control measure than reducing smoking, but there is a risk that the incremental reduction in smoking prevalence achieved over the past 30 years will stall unless the tobacco control effort is sustained. Smoking also contributes significantly to social inequities in health outcomes. For example, a smoking prevalence of 50% among Indigenous Australians10 is believed to be a major cause of the significantly poorer cancer survival rates among Aboriginal and Torres Strait Islander peoples. Targeted approaches are needed to break the cycle of social disadvantage, smoking, and cancer evident in specific population groups. Moreover, studies on tobacco control achievements over recent decades strongly suggest that a more sustained, whole-of-government commitment, built around integrated policy, social marketing, and research, could bring smoking prevalence down in Australia by a further 1% annually. Estimates based on recent trends indicate that reducing smoking prevalence by 5% in 5 years would save more than $1.15 billion in health care costs over the next 30 years.8 Yet some major political parties continue to accept donations from tobacco companies,11 and governments delay legislation to ban smoking in enclosed public spaces, and invest taxpayer funds in tobacco companies on the basis of sound economic management — despite having to spend more taxpayer funds on treating tobacco-related diseases (at least until patients die of them). While public policy has been gradually reducing the tobacco burden, obesity is escalating as a community health crisis. Obesity is linked to colorectal cancer, postmenopausal breast cancer, and kidney, oesophageal, gall bladder and endometrial cancers.12 Obesity control includes encouraging and facilitating physical activity and communicating dietary advice. The tobacco experience suggests that restricting junk-food advertising to children is likely to have an important impact, as supported by early Canadian data.13 This measure is not about restricting choice, as well targeted multimillion-dollar advertising campaigns already create an imbalance in the choices that uninformed and often disadvantaged families see as being available to them. Other lifestyle messages require more subtle public education. Advice from the SunSmart skin cancer prevention program must balance the need to avoid excessive sun exposure with the importance of low-level sunlight for vitamin D production. Similarly, while any alcohol consumption carries some cancer risk, the more you drink, the higher the risk — a factor that should be balanced against the benefits of very low alcohol intake in preventing cardiovascular disease. Cancer screening is another area that is presenting new opportunities and challenges. The benefits of breast cancer screening need to be continually reinforced to ensure high participation rates by eligible women. A new challenge for cervical cancer screening is ensuring continued high participation despite the introduction of the human papillomavirus immunisation program. The new National Bowel Cancer Screening Program requires community and professional education, a patient registry to ensure follow-up, and extra resources and minimum standards to meet increased colonoscopy demand. This will test the shared responsibilities for health care between national and state/territory governments — a potential barrier to efficient health policy implementation. The community must also understand that an ineffective screening test — one that evidence shows lacks the specificity and sensitivity to reduce cancer mortality on a population basis — is worse than no test at all, as the false positives and negatives can lead to poorer health outcomes than would surveillance on a case-by-case basis. The key is ensuring that evidence guides the implementation of government-funded measures aimed at cancer prevention and early detection — at a time when we could prevent well over a third of all cancer deaths in Australia using existing prevention and early detection technology. By investing more taxpayer funds in the high proven returns of cancer prevention and early detection, we could make resources available to better support the significantly increasing numbers of new cancer patients associated with population ageing over the coming years. Savings generated through improved prevention could also fund targeted cancer research to help further reduce the impact of cancer in the future. Increasing the cancer workforce, and improving workforce training and support through a more integrated approach across jurisdictions, is also pivotal to ensuring we can provide optimal multidisciplinary cancer care to meet the challenges of the future.

Ian N Olver MD, PhD, FRACP

Objective: To investigate whether hospital utilisation and health outcomes in Victoria differ between people born in refugee-source countries and those born in Australia.Design and setting: Analysis of a statewide hospital discharge dataset for the 6 financial years from 1 July 1998 to 30 June 2004. Hospital admissions of people born in eight countries for which the majority of entrants to Australia arrived as refugees were included in the analysis.Main outcome measures: Age-standardised rates and rate ratios for: total hospital admissions; emergency admissions; surgical admissions; total days in hospital; discharge at own risk; hospital deaths; admissions due to infectious and parasitic diseases; and admissions due to mental and behavioural disorders.Results: In 2003–04, compared with the Australia-born Victorian population, people born in refugee-source countries had lower rates of surgical admission (rate ratio [RR], 0.85; 95% CI, 0.81–0.88), total days in hospital (RR, 0.74; 95% CI, 0.73–0.75), and admission due to mental and behavioural disorders (RR, 0.70; 95% CI, 0.65–0.76). Over the 6-year period, rates of total days in hospital and rates of admission due to mental and behavioural disorders for people born in refugee-source countries increased towards Australian-born averages, while rates of total admissions, emergency admissions, and admissions due to infectious and parasitic diseases increased above the Australian-born averages.Conclusions: Use of hospital services among people born in refugee-source countries is not higher than that of the Australian-born population and shows a trend towards Australian-born averages. Our findings indicate that the Refugee and Humanitarian Program does not currently place a burden on the Australian hospital system.

Ignacio Correa-Velez MD, PhD · Vijaya Sundararajan MD, MPH · Kaye Brown PhD · Sandra M Gifford MPH, PhD

Studies demonstrating health benefits of religion are many and growing in number, and some claim the results are ripe for application in clinical settings.1,2 However, others argue that the research is not nearly as good or consistent as portrayed, and caution against acting rashly on inconclusive evidence.3,4 The goal of this supplement is to determine what this growing body of research means for Australian practitioners and patients. Religion involves beliefs and practices related to the sacred, where the sacred is defined as God, the numinous (mystical or supernatural) or ultimate truth. Religion is a unique construct, different from other psychological and social phenomena. Spirituality, on the other hand, is more difficult to define, as its definition today has changed — from one based in religion to a more diffuse concept, self-defined by each individual. The result is that there is no widespread agreement on what spirituality means, producing a real challenge when trying to measure it. Attempts to measure spirituality have taken two approaches: Asking questions about religious involvement; Asking questions about positive psychological characteristics, such as meaning and purpose in life, connectedness to others, peacefulness and high personal values. There are two problems with the latter way of defining and measuring spirituality. The first is that atheists might claim that they are neither religious nor spiritual — yet argue, rightly, that their lives have purpose and meaning, that they experience connection with others, and that they maintain high personal values. The second problem with defining spirituality in terms of positive psychological characteristics is that doing so produces a construct that is really a quasi-indicator of mental health. This makes it difficult or impossible to interpret research on the relationship between spirituality and health, especially mental health. Correlating a construct defined by indicators of mental health (spirituality) with another mental health construct (eg, wellbeing, life satisfaction, depression or anxiety) will always lead to an association between the two. Such an approach could also lead to false relationships between spirituality and physical health, given the strong links between mental and physical health. The word spirituality, when used in research, should be restricted to those things that have something to do with the sacred (as defined above). If there is no connection with the sacred, then it should not be referred to as spiritual or spirituality. We already have psychological and social terms to deal with concepts that all humans have in common, regardless of belief, and I think we should keep these concepts distinct from religious terms. I realise that many others in both the United States and Australia will not share this opinion, including a number of authors who have contributed to this supplement. From a purely scientific standpoint, if we are to study the relationships between religion, spirituality and health, it is essential to have constructs that are clear and non-overlapping. For these reasons, I refer mainly to religion when discussing relationships with mental and physical health. My definition of religion, however, is quite broad and means a lot more than just institutional religion or religious affiliation. Another reason for using religious language when discussing the research is that most published research has really been examining religion, even if it is presented and discussed in terms of spirituality. However, when talking with patients in clinical practice, there are good reasons for using the word spirituality, rather than religion. Research shows that, while many patients do not distinguish between being religious or spiritual,5 others feel alienated from institutional religion and see themselves more as spiritual than as religious. This may be particularly true for patients in Australia. The term spirituality is vague enough to allow patients themselves to define the playing field. Why should religion and health be connected? The argument is a rational one. If religious people have a world view that gives hope and meaning in the face of stress and loss, if they have social support from other members of the religious community, and if they live healthier lifestyles by smoking less, drinking less, and making more conservative, less risky decisions in marriage, the workplace, and recreational activities, there is good reason to expect that they will have better physical health as well. All of these factors influence health in ways that are increasingly being understood through the field of psychosomatic medicine.6 It should not be surprising, then, that in 2006 more than 70 published research studies examined the relationships between religion, spirituality and health, many finding positive relationships.7 The articles in this supplement review research on religion, spirituality and health relevant to Australian patients and practitioners and discuss the application of that research to clinical practice. Although not all of the research comes from Australia, the articles provide an important summary and background that will assist Australian researchers in designing and implementing future research. While most of the articles do not contain original research, they begin to address some of the research gaps identified by Peach in 2003.8 Williams and Sternthal9 assess the importance of religion and spirituality to Australians and discuss the evidence for both positive and negative effects of religion on health (→ Spirituality, religion and health: evidence and research directions). Eckersley10 looks at the relationship between spirituality, religion and health in a broad cultural context (→ Culture, spirituality, religion and health: looking at the big picture), while Wilding11 presents a case study to illustrate the meaning of spirituality at a personal level (→ Spirituality as a sustenance for mental health and meaningful doing: a case illustration). The different approaches to spiritual assessment in health care practice are summarised by Rumbold12 (→ A review of spiritual assessment in health care practice), and Winslow and Wehtje-Winslow13 raise a number of ethical issues relating to the provision of spiritual care (→ Ethical boundaries of spiritual care). Jantos and Kiat14 present evidence on the health benefits of prayer (→ Prayer as medicine: how much have we learned?), and D’Souza15 suggests ways in which clinicians can approach the subject of spirituality with their patients (→ The importance of spirituality in medicine and its application to clinical practice). Hopkins and colleagues16 focus on evidence-based strategies that could be implemented by church-associated organisations to reduce high-risk behaviours in young people (→ Developing healthy kids in healthy communities: eight evidence-based strategies for preventing high-risk behaviour), and, at the other end of the age spectrum, MacKinlay and Trevitt17 provide a model of spiritual tasks in later life (→ Spiritual care and ageing in a secular society). The contributions presented here suggest that spirituality and religion are important to many Australian patients, and that the spiritual needs arising from religious beliefs should be identified and addressed as part of whole person health care. They also suggest that much more research in this area is needed in Australia. While some of the findings of US research may be applicable to Australian patients, there are important cultural differences between the two countries that may influence the relationship of religion to health and the needs of patients in this regard.

Harold G Koenig MD

Levels of spirituality and religious beliefs and behaviour are relatively high in Australia, although lower than those in the United States. There is mounting scientific evidence of a positive association between religious involvement and multiple indicators of health. The strongest evidence exists for the association between religious attendance and mortality, with higher levels of attendance predictive of a strong, consistent and often graded reduction in mortality risk. Negative effects of religion on health have also been documented for some aspects of religious beliefs and behaviour and under certain conditions. Health practices and social ties are important pathways by which religion can affect health. Other potential pathways include the provision of systems of meaning and feelings of strength to cope with stress and adversity.

David R Williams PhD, MPH · Michelle J Sternthal MA

Religion provides things that are good for health and wellbeing, including social support, existential meaning, a sense of purpose, a coherent belief system and a clear moral code. But these benefits can also come from other sources. Conversely, religion is shaped by its social context in ways that affect its social role. Religion is no panacea when it comes to improving health. Religion’s role in health needs to be examined in a broad context, especially the ways in which culture influences religion’s expression of the spiritual.

Richard M Eckersley BSc(Hons), MScSoc

Objectives: To (i) assess changes in clinical indicators of adults diagnosed with diabetes and (ii) estimate changes in risk factors and incidence of diabetes among adults without diabetes living in the Torres Strait and Northern Peninsula Area Health Service District in Queensland from 1999 to 2005.Design and participants: (i) Annual audit of clinical records of Torres Strait Islander adults on diabetes registers in 21 primary care clinics, and (ii) a 5-year follow up of a community cohort of 207 Torres Strait Islander adults without diabetes who participated in the Well Person’s Health Check in 2000–01 and 2005–06.Main outcome measures: Weight, height, waist circumference, fasting blood sugar (those without diabetes) and glycated haemoglobin (HbA1c; those with diabetes) levels, blood pressure (BP), fasting triglyceride and high-density lipoprotein cholesterol levels, urinary albumin-to-creatinine ratio and smoking status.Results: The number of adults included on the diabetes register increased from 555 in 1999 to 1024 in 2005. The mean age of patients diagnosed with diabetes decreased from 53.3 to 51.5 years, and their mean weight increased from 86.8 kg to 95.6 kg. Mean HbA1c level remained unchanged at about 9%, but the proportion with HbA1c level < 7% increased from 18.4% to 26.1%, and the proportion prescribed insulin increased from 14% in 2002 to 22% in 2005. The proportion with BP < 140/90 mmHg increased from 40.3% in 1999 to 66.8% in 2005. In the sample of 207 adults without diabetes, from 2000 to 2006, there was a weight gain of about 1 kg per person per year, and an annual increase in waist circumference of 0.8 cm in men and 1.2 cm in women. Crude incidence of diabetes was 29 (95% CI, 19–41) per 1000 person-years. There was a significant increase in diastolic blood pressure and fasting blood sugar levels, and no change in smoking habits.Conclusions: Clinical care of adults with diabetes has improved and more people with diabetes are being diagnosed. However, weight gain and high rates of glycaemia remain a challenge and will result in a large burden of complications, including renal failure. Incidence data from this sample extrapolate to 120 (95% CI, 103–147) new cases of diabetes in the District each year. Urgent action to improve nutrition, decrease smoking and increase physical activity is required to improve metabolic fitness in younger people.

Robyn A McDermott MB BS, MPH, FAFPHM · Bradley G McCulloch BSc, MPH · Sandra K Campbell RN, MAE · Dallas M Young BAppSc, MHP

The recent surge of interest in links between spirituality and health has generated many assessment approaches that seek to identify spiritual need and suggest strategic responses for health care practitioners. The interpretations of spirituality made within health frameworks do not do justice to the way spirituality is understood in society in general. Spiritual assessment should not impose a view or definition of spirituality, but should seek to elicit the thoughts, memories and experiences that give coherence to a person’s life. Spiritual assessment tools should not be used without adequate exploration of the assumptions made. Assessment processes need to be adequately conceptualised and practically relevant.

Bruce D Rumbold PhD

The Australian government’s Healthy for Life program is supporting capacity development in Indigenous primary care using continuous quality improvement (CQI) techniques. An important influence on the Healthy for Life program has been the ABCD research project. The key features contributing to the success of the project are described. The ABCD research project: uses a CQI approach, with an ongoing cycle of gathering data on how well organisational systems are functioning, and developing and then implementing improvements; is guided by widely accepted principles of community-based research, which emphasise participation; and adheres to the principles and values of Indigenous health research and service delivery. The potential for improving health outcomes in Aboriginal and Torres Strait Islander communities using a CQI approach should be strengthened by clear clinical and managerial leadership, supporting service organisations at the community level, and applying participatory-action principles.

Ross S Bailie MD, FAFPHM · Damin Si PhD · Lyn O'Donoghue BSc · Michelle Dowden RN

A wholly state-funded or federally funded system of health care, concentrating on providing integrated services, might circumvent the political blame game During 2005 and 2006, the bipartisan House of Representatives Standing Committee on Health and Ageing conducted a nationwide inquiry into how the Australian Government could take a leading role in improving delivery of highest quality health care to all Australians.1 This inquiry received 159 submissions and conducted hearings and interviews in each Australian state and territory. The fractured relations among the state, territory and federal governments that surface when the bills for health care roll in motivated the Committee’s choice of title for its report — “The Blame Game”. The Blame Game describes conflict in the division of roles and responsibilities between federal and state governments, and the disconnection between public and private health systems, defining these factors as causes of impaired economic efficiency (which they are), but without linking them to the changing nature and extent of disease in Australia. Like atheromatous plaques tolerated for years, blame-game policies are now stenosing, blocking effective financial channels for health services to flow to those with chronic health problems. The growing pressure for care of patients with chronic illness makes resolving the blame-gaming of health service financing more urgent than if it were a matter of financial inefficiency alone. Of course, all health services — acute and chronic — would benefit from abolition of the blame game, but financing care for people with chronic illness should be rearranged as a working example of care across all providers funded from one source. This could reduce the transaction costs that proved problematic with the Australian coordinated care trials.2 Three actions now might prevent an infarct in our ability to provide health care in the future. National agendaFirst, we need a national agenda for the future of health care in Australia. This could start from the principal recommendation of The Blame Game: a national health agenda focused on financing health care. However, the agenda should reverse the usual priorities and begin from a concern for health, and only then consider financing arrangements. This would be a splendid prelude to negotiating the next Australian Health Care Agreements (AHCAs) in 2008. An agenda headed by the prevention and management of chronic illness could draw on the National Chronic Disease Strategy (NCDS).3 The NCDS identified the scope of the problem — chronic illness accounts for 80% of the burden of disease (including mental illness and injury) and for some 70% of health expenditure in Australia. Other evidence is also at hand to support action. Information flow among care providers is critical to managing chronically ill people across institutions and over time — these problems are being addressed by the National E-Health Transition Authority. Programs of extended primary care are testing ways of serving the complex needs of patients in the community. There are some (although not many) programs of prevention supported in all jurisdictions or collaboratively through the Better Health Initiative.4 Despite this, no long-term programs engage all sectors of the health and social care system. Pilot projects, most often in general practice and limited in their ability to include specialist, allied health and social care, have flourished briefly, but there has been no serious long-term commitment. Reform in Australian Health Care AgreementsSecond, we need reform in the next round of AHCAs between the Australian Government and the states and territories. These 5-yearly bilateral agreements pledge the parties to public hospital financing. The AHCAs must now build on the developing collaborative spirit of the Council of Australian Governments (COAG), as evidenced in the agreements for the Better Health Initiative. This will not be easy, and to move from the anodyne rhetoric of collaboration to adequately funded action is a big leap. Thus far, there is no indication of sufficient spirit of cooperation within COAG. For example, of the $3.5 billion worth of initiatives in the National Action Plan on Mental Health, many rely on rearrangements of current funding, which might look distressingly like cost shifting. The impact of COAG’s national reform agenda on increased workforce participation by reducing morbidity associated with chronic illness will be minor, at around 0.6%.5 The AHCAs need a new format, outlining how services are to be provided for people, rather than how hospitals are to be funded. It needs to be recognised that funds for chronic disease management are probably five times too low, given that fewer than 20% of patients leaving hospital and requiring continuing care receive best practice care. Medicare rebates for specialist outpatient services may make the funding process more transparent, but they have negligible impact on the necessary integration of care. New funding modelsThird, we need the other instruments of health care payment, including the Medicare Benefits Schedule (MBS), to be aligned with the way sick people require care. Public hospital funding models are based on episodic care for largely independent health problems, and these models continue to be used despite the knowledge that this is not the case for many people admitted to hospital. Patients with chronic illness require continuing care, often increasing stepwise with the addition of increasing social care over years, and involving multiple health service elements from primary care to hospital and back. Health care for people with chronic disorders should be available from a common fund that is spent in line with agreed principles of best practice. The Better Health Initiative pays specialists to integrate services for people with cancer, but continues to rely on incentives for general practitioners to integrate services for people with other chronic illnesses.4 Only medical practitioners can make an MBS claim for case management and care planning, and there are no mechanisms for federal funding for continued and team-based allied health and other interventions to prevent avoidable hospital admissions. Incentives for high quality care for managing chronic disease would be a welcome feature of a reformed MBS. ConclusionThese three steps — a national agenda, a reformed set of health care agreements, and new approaches to funding community-based care — offer one way forward in confronting the rising tide of demand for care of people with serious and continuing illness in Australia. Blame, as we know, is a poor game to play if the object is to seek improved clinical safety and quality. It serves us no better in developing our health policies for tomorrow.

Laurann E Yen BSc, MPsych · Robert W Wells BA · James A Gillespie BA(Hons), PhD · Stephen R Leeder BSc(Med)(Hons), PhD

To the Editor: We welcome your recent focus on rural and remote health. Kamien and Cameron’s editorial addressed medical workforce supply issues,1 and the accompanying article ranged across not only workforce supply issues, but also broader systemic issues, including the roles of different levels of government.2 Coincidentally, the Australian Institute of Health and Welfare released its latest medical workforce report, which reported a rise in the number of doctors per head of population overall, particularly specialists, and particularly in urban areas, but decreased numbers of doctors in the bush, particularly in remote areas.3 Most of the media response ignored the contemporaneous nursing workforce report,4 which described a much more even geographical distribution of the nursing workforce — the largest health professional group. We agree that access to health care is more than a workforce supply issue.2 While we acknowledge the critical importance of general practice, perhaps part of the problem in improving access has been an almost exclusive policy focus on medical workforce supply issues, and not the broader consideration of a range of factors that will improve access to effective primary health care services for the 30% of Australians living in rural and remote areas. Our recent systematic review of models of rural and remote primary health care service delivery in Australia identified a number of essential requirements of successful primary health care models.5 These inter-related requirements are adequate workforce supply; appropriate workforce organisation; adequate funding and appropriate financing; leadership, good management and governance; adequate infrastructure; and strong linkages — both internal and external. Successful models also exhibited an appropriate level of community participation. There are a number of demonstrably successful rural and remote models, such as the Katherine West Health Board, an exemplary remote comprehensive primary health care service.5 To generalise these successful models and improve access, we need a rural and remote primary health care policy framework for Australia that coordinates national, state and territory resources to ensure that all of these essential requirements are systematically addressed. We agree with Kamien and Cameron1 that a solution will not be forthcoming until governments take a courageous stance in overcoming the implementation gap associated with translating research evidence into policies and programs. The time has never been riper for Commonwealth, state and territory governments to assume leadership and agree on an evidence-informed implementation strategy to assure rural and remote communities of accessible, high quality health care. Our systematic review5 provides a solid base to underpin such a response.

John Wakerman · John S Humphreys · Robert W Wells · Pim Kuipers · Philip Entwistle · Judith Jones

Variation between laboratories and reference sources in the units used for reporting pathology results raises the possibility of medical error. Data submitted to the RCPA Quality Assurance Programs demonstrate wide variation in the units used for reporting therapeutic drug concentrations. This potential source of medical error needs to be addressed by all parties involved in communicating drug concentrations and providing support information.

Graham R D Jones MB BS, DPhil

To minimise the health impact of pandemic influenza, general practice will need to provide influenza-related and non-influenza primary health care, as well as contribute to the public health goal of disease control. Through interviews and workshops with general practitioners, nurses and policy leaders between March and July 2006, and literature analysis, we identified potential models of general practice in an established pandemic, and assessed their strengths and weaknesses. Three possible clinical models were identified: a default model of no change to service delivery; a streamed services model, where general practices reorganise themselves to take on either influenza-specific care or other clinical services; and a staff-determined mixed model, where staff move between different types of services. No single model or set of strategies meets the needs of all general practices to deliver and sustain the essential functions of primary health care during an established pandemic. Governments, general practice and the relevant peak professional bodies should decide before a pandemic on the suite of measures needed to support the models most suitable in their regions. Effective participation by general practice in a pandemic requires supplementary infrastructure support, changes to financial and staffing patterns, a review of legislation on medicolegal implications during an emergency, and intensive collaboration between general practices.

Christine B Phillips MPH, MA, FRACGP · Mahomed S Patel MB BCh, FRACP, FAFPHM · Nicholas Glasgow FRNZGP, FRACGP, FAChPM · Christopher Pearce MFM, FRACGP, FACRRM · Paul Dugdale MPH, PhD, FAFPHM · Alison Davies MPubPol, BPhty · Sally Hall RN, GradCertClinMan · Marjan Kljakovic FRNZCGP, FRACGP, PhD

To the Editor: In his message From the Editor’s Desk,1 Van Der Weyden laments what he perceives to be “the absence of many voices in protest” against the current Council of Australian Governments’ (COAG) proposals2 for national systems of registration and accreditation of the Australian health workforce. The absence of an “overwhelming public response” to the proposals can surely be attributed to the general public’s lack of awareness of the proposals. It cannot be said, however, that the medical profession has been idle. By the time this letter is published, the situation in regard to the proposals is likely to be much clearer. To date, all elements of the medical profession have been very active in seeking to achieve the best possible outcomes from the COAG proposals for our patients and for the profession. These efforts were impeded initially by the lack of specificity available from the COAG Health Working Group. Clear evidence of the effectiveness of the efforts of the Australian Medical Council, the Australian Medical Association, and the Committee of Presidents of Medical Colleges (CPMC) and its individual member Colleges was the abandonment of the second consultation paper after the profession’s analysis and evaluation of the proposals presented. As I write, government officials are meeting to develop a new model which recognises the profession’s criticisms and views. The profession’s message clearly has reached the federal Minister for Health, who asserted recently that it appeared that “the best way forward is to have separate national registration boards for medicine and for each of the other health professions”.3 This is a significant departure from the original COAG proposal. The CPMC and its member Colleges are well aware of the undesirable developments in other countries where governments are attempting to take control of regulation of the medical profession, as mentioned by Van Der Weyden.1 At their meeting on 15 February, the College presidents endorsed a two-page statement of key issues in regard to the COAG proposals. This statement has been sent to the premiers, chief ministers and health ministers in each state and territory, as well as to the relevant federal government agencies. At the same time, it is appropriate for the Colleges to cooperate responsibly with government initiatives, provided those initiatives do not diminish in any way the safety and quality of health services provided in Australia or threaten the sovereignty of the Colleges in the determination and maintenance of standards for their respective disciplines.

Michael J Cousins

To the Editor: Your statement that the present “grab for control [of Australian medicine] by governments” is unprecedented is not correct.1 Between 1946 and 1949, the federal government came close to nationalising the medical profession.2 The lines were drawn earlier. In 1941, the Federal Council of the British Medical Association (BMA) in Australia (now the Australian Medical Association) made recommendations about the provision of medical services. Two years later, in response to a report by the National Health and Medical Research Council, Outline of a possible scheme for a salaried medical service, the BMA laid down a more detailed policy, with retention of the existing (largely private) general practitioner and specialist services. The government responded by proposing a scheme under which patients would pay nothing directly for medical care, with costs to be met from general revenue.3 Asking the doctors to cooperate, the government indicated that it would if necessary seek other means to achieve its object.4 The referendum of 1946, one of the few to be passed, gave the federal government power to provide a range of social services, including pharmaceutical and hospital benefits and medical and dental services. There were, however, a few words of critical importance in the question put to the people — “but not so as to authorise any form of civil conscription”. It was the Leader of the Opposition, Mr (later Sir) Robert Menzies (acting on a request from Sir Henry Newland, President of the BMA Federal Council and a surgeon of great distinction), who moved the amendment, which the government accepted. The referendum enabled the government in 1948 to pass the National Health Service Act 1948–49 (Cwlth). Resistance by the BMA to what it regarded as objectionable features led to an attempt to coerce the profession by enforcing the Pharmaceutical Benefits Act 1947 (Cwlth), which required compulsory use of a Formulary issued to all doctors. (In the event, only 2% of doctors ever used it.) The BMA took the issue to the High Court of Australia, which decided in August 1949 that a section of the Act amounted to civil conscription and was invalid. Later in the year, the heavy defeat of the government, the result of its attempt to nationalise the banks, sealed the doctors’ victory.5 Over the next few years, the coalition led by Menzies introduced a health service based on the principle of voluntary insurance for hospital and medical benefits, which is still in force. There are clear lessons to be learned from this history.

Derek H Meyers

Objective: To investigate predictors of evidence-based surgical care in a population-based sample of patients with newly diagnosed colorectal cancer.Design, patients and setting: Prospective audit of all new patients with colorectal cancer reported to the New South Wales Central Cancer Registry between 1 February 2000 and 31 January 2001.Main outcome measures: Concordance with seven guidelines from the 1999 Australian evidence-based guidelines for colorectal cancer; predictors of guideline concordance; the mean proportion of relevant guidelines followed for individual patients.Results: Questionnaires were received for 3095 patients (91.6%). Between 0 and 100% of relevant guidelines were followed for individual patients (median, 67%). Concordance with individual guidelines varied considerably. Patient age independently predicted non-concordance with guidelines for adjuvant therapy and preoperative radiotherapy. Adjuvant chemotherapy was more likely if a patient with node-positive colon cancer was treated in a metropolitan hospital or by a general surgeon. Surgeons with a high caseload or specialty in colorectal cancer were more likely to perform colonic pouch reconstruction, prescribe thromboembolism or antibiotic prophylaxis, and were less likely to refer patients with high-risk rectal cancer for adjuvant radiotherapy. Bowel preparation was less likely among older patients and in high-caseload hospitals.Conclusion: Effective strategies to fully implement national colorectal cancer guidelines are needed. In particular, increasing the use of appropriate adjuvant therapy should be a priority, especially among older people.

Jane M Young MPH, PhD, FAFPHM · David C Leong MB BS, FRACP · Katie Armstrong BAppSc(HIM) · Dianne O’Connell BMaths(Hons), PhD · Bruce K Armstrong DPhil, FRACP, FAFPHM · Allan D Spigelman FRACS, FRCS, MD · Stephen Ackland MB BS, FRACP · Pierre Chapuis MB BS, DS, FRACS · Andrew B Kneebone MB BS, FRANZCR · Michael J Solomon MB BCh(Hons), MSc(ClinEpid), FRACS

To the Editor: Aspects of the article by Dunbar and his colleagues on the impact of hospital inquiries are disturbing.1 The abstract states, “In the aftermath of the inquiries, common themes included loss of trust in management and among clinical colleagues, and loss of trust from patients and the community”. Rather, the loss of trust in these instances arose from fundamental problems with the culture in the organisations involved. It was this that led to the inquiries. In the case of King Edward Memorial Hospital (KEMH), the Douglas Inquiry was set up to investigate obstetric and gynaecological services at the hospital between 1990 and 2000, and sought “to identify and assess the deficiencies in the provision of those services, over that period”.2 But when the final report of the Douglas Inquiry was originally published in 2001,2 there was a chapter missing, which was only released under Freedom of Information legislation in December last year. I have seen a copy of this “missing chapter”, courtesy of The West Australian newspaper, which gained its release. It revealed various problems with clinical practices at KEMH, many of which were described as “very unsafe” and which had been going on throughout the 1990s. Nearly 100 cases were covered in this missing chapter, but these were only a small selection of the total adverse outcome events, including several deaths, that occurred over the decade. And the reason for not releasing this chapter? It was kept secret for 5 years because of intense lobbying of the state government by members of the medical profession — to quote The West Australian, “The current State Government [caved] in to the medical lobby and kept secret the most crucial chapter”.3 Just before it was released, the President of the Australian Medical Association (WA) was still arguing against its release and was quoted as saying, “I can imagine that it would be very painful to these families who were involved and I very much doubt there is anything in it that would serve the public interest by releasing it now”.4 What about accountability? Transparency? Trust? Dunbar et al state that, “At ... KEMH, there were longstanding problems that had not caused harm”.1 This is an extraordinary comment given that an inquiry was thought necessary, and the clinical problems revealed by this inquiry stretched back over 10 years — during which time no action was taken — until a newly appointed chief executive officer at KEMH, Michael Moodie, blew the whistle. What concerns me most about Dunbar and colleagues’ article is that in the wake of these inquiries, the authors, who “include the Directors of Medical Services who went into the hospitals following these events” (ie, the inquiries), now seek to argue that such matters are best left to be dealt with internally by “health service providers”.1 We need transparency in such matters. The health service “belongs” to the Australian people — or at least it ought to. It is not the doctors’ health service. These inquiries and the details outlined by Dunbar and colleagues show that, in addressing these sorts of problems, we cannot have trust in most internal reporting systems in hospitals. We cannot trust some of our doctors. When will they ever learn?

Gavin H Mooney

In reply: Mooney makes assertions in his letter and elsewhere1 that cannot go unchallenged. He is wrong in stating that the “missing chapter” from the Douglas Inquiry report2 “was kept secret for 5 years because of intense lobbying of the state government by members of the medical profession”. To quote the then Minister for Health, “... sections of the [inquiry’s] report were withheld on advice from the Crown Solicitor, mainly for the protection of patients”.3 Detailed reasons for information provided to the inquiry being kept private were published in 2001.4 I stand by my statement that “I very much doubt there is anything in [the missing chapter] that would serve the public interest by releasing it now”. The report on the Douglas Inquiry made 237 recommendations. The reality is that Dr Bill Beresford, who stepped in as Acting Chief Executive Officer (CEO) of King Edward Memorial Hospital (KEMH), did an outstanding job in implementing the report’s recommendations and making a good but under-resourced hospital much better. Mooney is also wrong to describe Michael Moodie as a whistleblower. He was the CEO of the hospital and accountable for the services it provided. The only person he would be blowing a whistle to was himself, if he failed to act. True, the problems stretched back over 10 years; many of the issues were highlighted in a report released in 1990.5 Among these were the findings that “King Edward is understaffed by 5.2 FTE [full-time equivalent] generalist obstetricians and gynaecologists” and “... the after hours cover is inadequate and potentially unsafe” (Vol. II, p152). I believe it was the failure to act by successive state governments and health ministers, who had the ultimate responsibility for provision of health services, that led to the problems at KEMH. For at least a decade now, the need to collocate Western Australia’s tertiary obstetric services with adult tertiary services has been advocated, so the increasing proportion of mothers with significant comorbidities, including diabetes, heart disease and substance misuse, can have optimum access to services, including adult intensive care. While this principle appears to have been accepted,6 there has been no indication as yet of its implementation. Mooney and the community can trust doctors; the lessons from the Douglas Inquiry have been learnt, and its recommendations implemented.

Geoffrey J Dobb

In reply: We are grateful to Mooney for drawing our attention to the “missing chapter” of the Douglas Inquiry report, which came to light after we had submitted our article for publication. Open and fully public inquiries are necessary for all parties involved.1 To the best of our knowledge, the Douglas Inquiry is the most thorough review ever undertaken of clinical standards in an Australian hospital.2 It is difficult to know how other hospitals would have compared over the same period.3 Our article concentrated on how these hospitals recovered, as organisations, to improve patient safety. We called for “open, honest, and timely investigation undertaken within the organisation”, which avoids prolonging the recovery that, paradoxically, can make hospitals less safe.4 In the United Kingdom, the General Medical Council enforces a national system that puts patient safety first and makes covering up for a poorly performing colleague an offence.5,6 It also requires Directors of Medical Services to act in patients’ best interests. Concerns about a colleague’s performance are handled locally, because experience has demonstrated that this works best for patients and doctors. We would like to see the proposed national registration body for health professionals in Australia make reporting such concerns obligatory.

James A Dunbar · Prasuna Reddy · Bill Beresford · Wayne P Ramsey · Reginald S A Lord

Is it unethical to avoid using all available information to monitor drug safety? Adverse effects of health care have recently been in the news, from the worrying unexpected cardiovascular risks associated with use of the cyclooxygenase-2 inhibitor rofecoxib (Vioxx) to reports of high percentages of complications following routine surgery.1,2 As medical care becomes more complex, sophisticated and expensive in Australia, it is paramount that we have the best systems in place to monitor its impact and evaluate its safety and efficacy. In this issue of the Journal, Kelman and colleagues acknowledge the limitations of randomised controlled trials (RCTs) in detecting all harmful effects of medicines and make a plea for modernising Australia’s system of pharmacovigilance by building upon the latest technological and data capabilities that we have. They recommend shifting from the existing archaic system of postmarketing surveillance, which relies on piecemeal reporting of adverse events, to a more systematic approach that would include using existing centrally collected, administrative health care databases. Kelman et al claim that by merging information from prescriptions and the Pharmaceutical Benefits Scheme with readily available data on major health outcomes (eg, deaths, hospital admissions, registers of cancer and other diseases), Australia would have a powerful capacity to evaluate the effects of drugs in real-world situations. What are the advantages and disadvantages of such a proposal, and what is happening internationally? The system proposed by Kelman et al has several advantages: The data already exist, and it may even be irresponsible to not use them for important evaluations of health care outcomes; Such data linkage would provide more comprehensive information on both drug use and outcomes and hence would be less likely to be biased than RCTs, which use selected samples with variable participation; The data would cover a large patient population, increasing the likelihood that any adverse effects would be rapidly identified; and It is an inexpensive system compared with very large RCTs or other epidemiological studies, and it would allow greater capacity for pharmacoepidemiology to evaluate the appropriate use of drugs across the whole population. However, there are also potential disadvantages associated with such a data linkage system: There are privacy concerns surrounding the use of individual patients’ data; The analysis and interpretation of linked datasets pose considerable challenges; for example, with common adverse events such as heart attacks or stroke, any associations found must be analysed in relation to other known risk factors, details of which may not be available or may not be accurately reported in the linked data; and There will be costs involved in establishing a national capacity for data linkage. In some jurisdictions, such as Western Australia (through the WA Data Linkage Unit), such data linkages have been carried out for many years, both to evaluate medical care and to conduct epidemiological studies on heart disease, cancer, birth defects, and other health problems.3-5 As a result, the WA Data Linkage Unit and the researchers it serves have considerable experience in linking, analysing and interpreting the complexities of such data, and have developed best practice in relation to privacy concerns. These analyses have had a major impact on improving health services in the state (see Brook et al5 for examples). If all Australian health care data were linked to drug exposure data (from the Pharmaceutical Benefits Scheme), this linkage could provide very precise estimates of the risks and benefits of drugs for the whole population, as well as for subgroups that are often excluded from RCTs, such as children, pregnant women, and people with multiple diseases or other risk behaviours, such as smokers. If linked data are routinely evaluated for outcomes associated with new drugs, adverse events could be detected before considerable harm is done to patients. We must be able to demonstrate to the community that linking data for the sake of the public good does not invade their privacy. Both the National Health and Medical Research Council and the Australian Law Reform Commission are preparing reviews that will help to clarify and, we hope, support these activities. The WA Data Linkage Unit has developed a protocol for linkage that aims to protect privacy.6 This “win–win” approach means that researchers who require linked data on drug exposures and patient outcomes never see any patient-identifiable information. Since the WA Data Linkage Unit’s protocol has been in place, requests for access to identifiable data have reduced markedly.7 When people in the general community were asked if they approved of their information being used in this way, they were found to be not only supportive of it, but they questioned why it was not already being done (C Kelman, Associate Professor in Population Health, Australian National University, personal communication, 2005). Most international developments in pharmacoepidemiology are taking place in the United States, Canada and the United Kingdom, with relevant authorities in these jurisdictions concerned about the safety and cost of drugs, and ensuring efficacy and appropriate prescribing.8 Their recommendations generally support those of Kelman and colleagues. While health care data linkage systems similar to that in WA exist in England, Scotland, the US and Canada, none of these systems are nationwide or have the routine ability to link health care records with drug prescription data; Australia could perhaps lead the world in this regard. We strongly believe that Australia has an opportunity to establish a cutting-edge capacity to monitor its health care system. We also believe that if society has the capability to better monitor the safety of new drugs, it may be unethical not to do so — avoiding the use of information that would help reduce risk to individuals suggests a willingness to allow people to be harmed. At the very least, this conflicts with the physician’s duty to patients to “first, do no harm”. We think the time has come to expect more — not simply to avoid harm and reduce risk to individual patients, but to actively seek to maximise the wellbeing of all citizens. Improved pharmacovigilance is one important step towards this goal.

Fiona J Stanley FAFPHM, MFCCH, FRACP · Eric M Meslin PhD

Objective: To assess whether the rates of Down syndrome births in Queensland vary according to rurality (ie, whether the mother lives in a rural or urban area) and type of antenatal care provider, and to consider any implications for antenatal care.Design and setting: Population-based study of Down syndrome births in Queensland between 1990 and 2004, stratified by rurality and type of antenatal care provider (private obstetrician, public hospital or shared care).Results: Since 2000, there has been a large fall in maternal-age-adjusted rates of Down syndrome births among mothers living in urban areas (−14.3% per year; 95% CI, −22.7%, −5.0%) and among mothers receiving their antenatal care from private obstetricians (−27.5% per year; 95% CI, −37.6%, −15.8%). Similar decreases have not occurred among mothers living in rural areas (0.0%; 95% CI, −11.7%, 13.1%) or among mothers receiving antenatal care from public hospitals (+2.9%, 95% CI, −10.3%, 17.9%).Conclusion: Possible reasons for the observed trends include unequal access to antenatal screening; confusion about screening guidelines and protocols; late presentation for antenatal care; and differences in attitudes to screening and termination of pregnancy among expectant parents, such that they may choose not to have screening or not to act on a positive screening test result.

Michael D Coory FAFPHM, PhD, AStat · Timothy Roselli BAppSc, BSc(Hons) · Heidi J Carroll MB BS, MPH

Objective: To compare the location and accessibility of current Australian chronic heart failure (CHF) management programs and general practice services with the probable distribution of the population with CHF.Design and setting: Data on the prevalence and distribution of the CHF population throughout Australia, and the locations of CHF management programs and general practice services from 1 January 2004 to 31 December 2005 were analysed using geographic information systems (GIS) technology.Outcome measures: Distance of populations with CHF to CHF management programs and general practice services.Results: The highest prevalence of CHF (20.3–79.8 per 1000 population) occurred in areas with high concentrations of people over 65 years of age and in areas with higher proportions of Indigenous people. Five thousand CHF patients (8%) discharged from hospital in 2004–2005 were managed in one of the 62 identified CHF management programs. There were no CHF management programs in the Northern Territory or Tasmania. Only four CHF management programs were located outside major cities, with a total case load of 80 patients (0.7%). The mean distance from any Australian population centre to the nearest CHF management program was 332 km (median, 163 km; range, 0.15–3246 km). In rural areas, where the burden of CHF management falls upon general practitioners, the mean distance to general practice services was 37 km (median, 20 km; range, 0–656 km).Conclusion: There is an inequity in the provision of CHF management programs to rural Australians.

Robyn A Clark BN, MEd, FRCNA · Andrea Driscoll BN, MN, MEd · Justin Nottage BEnv, GradDipSpISc · Skye McLennan MPsych · David M Coombe BApplSci(BioEnv · Errol J Bamford BEcon · David Wilkinson PhD, DSc · Simon Stewart PhD, FCSANZ

Objective: To identify the views of health professionals, patients and their carers on strategies to improve the use and management of warfarin in older patients with atrial fibrillation.Design: Qualitative study based on analysis of group interviews.Setting: A major metropolitan teaching hospital, from 1 March to 30 April 2003.Participants: 14 patients (≥ 65 years) with established atrial fibrillation and taking warfarin, three carers, 12 specialists, eight general practitioners, six community pharmacists, nine hospital pharmacists, and 11 nurses volunteered in response to flyers promoting the study.Results: Suggested strategies to improve warfarin management targeted support services for GPs and patients. Hospital-based clinicians felt that dissemination of trial evidence to GPs to support treatment recommendations is required, and that GPs need to enlist allied health professionals in the management of patients taking warfarin. GPs preferred access to practical advice from expert colleagues on the day-to-day management. Patients requested more information about warfarin therapy, as access to information is inadequate, particularly from primary sources (GPs, community pharmacists). Verbal and written information are equally important, but a single counselling session or supply of a booklet was viewed as inadequate. Participants identified various interventions for all levels of warfarin management; from the collective input, a framework for management strategies was developed.Conclusions: Health professionals and patients require more customised information to support warfarin use and management.

Beata V Bajorek PhD, BPharm · Susan J Ogle MB BS, FRACP · Margaret J Duguid BPharm · Gillian M Shenfield DM, FRCP, FRACP · Ines Krass PhD, BPharm

To the Editor: Sanderson et al provide an interesting viewpoint about how the community, including medical practitioners, have embraced complementary and alternative medicine (CAM).1 However, if we were reviewing this article for publication, we would ask the authors to: make a valid distinction between those complementary and alternative therapies promoted as curative versus those considered palliative; define how they decided which therapies belong to one or other side of the arbitrary CAM boundary; review and justify the boundaries for the “therapeutic footprint” in a more evidence-based and rigorous way; locate specific therapies inside the footprint; locate where chemotherapy lies within the footprint, in light of the recent review showing, for the vast majority of adult malignancies, its marginal survival benefits considering its high costs, both monetary and healthwise;2 emphasise that there are relatively few recorded adverse events for CAM compared with conventional cancer care (Therapeutic Goods Administration Medicine Summary reports 2003, 2004, 2005 — Dr K Mackay, Acting Director, Adverse Drug Reactions Unit, TGA, personal communication); and vigorously question the marketing of conventional medicines, such as trastuzumab (Herceptin, Roche), to vulnerable patients and an uncritical public when the evidence suggests huge expense and little, if any, survival benefit.3 Perhaps a distinction also needs to be made between CAM therapies, many of which provide proven symptomatic relief, and those lifestyle interventions, such as exercise,4 dietary change,5 and social support, which provide symptomatic relief and may also confer a survival benefit. It does not serve the profession well when many cancer patients and their carers have to go outside the medical system to access information, advice and therapies which they should have easy access to within the system. In fact, we might even question how helpful these arbitrary boundaries are when all that patients and doctors want is to use what works and what is safe.

Craig S Hassed · Vicki Kotsirilos · Marie Pirotta · Avni Sali