Health services administration

In reply: We would like to thank Hassed and colleagues for their comments on the “therapeutic footprint” and their questions about locating specific therapies within the model. While it was outside the scope of our article to critically analyse different treatments using the model (as benefits and risks will vary from patient to patient), we would like to direct Hassed et al to a more detailed consideration of the risks and benefits of chemotherapy.1 We do not see our model as a tool to categorise or economically appraise specific treatments, but rather as one to help conceptualise the key issues to be considered when proposing treatment — the evidence for benefits and risks, contextualised according to treatment goals. The model provides a basis for comparison, taking us beyond arbitrary and unhelpful arguments about the distinctions between complementary and alternative therapies and their boundaries. We hope that the model will encourage evaluation of evidence for all therapies and support critical evaluation not only of drugs, but also lifestyle interventions that may benefit patients. The primary or essential purpose of the model is to encourage the posing of questions like those articulated by Hassed and colleagues to any therapist — whether they identify as medical, complementary or alternative.

Christine R Sanderson · Bogda Koczwara · David C Currow

Objective: To determine the prevalence and content of policies, standardised order forms (SOFs) and patient information leaflets (PILs) pertaining to “not-for-resuscitation” (NFR) orders in Australian public hospitals.Design and setting: Cross-sectional postal survey conducted across Australia from August to December 2005, using a one-page questionnaire.Participants: Directors of Medical, Nursing or Clinical Services of all public hospitals in Australia with 60 or more beds, excluding psychiatric, military and private hospitals.Main outcome measures: Prevalence of documented NFR policies, by hospital characteristics, and content of these policies, SOFs and PILs.Results: 222 hospitals were surveyed, and 157 responded (71%). Of these, 85 (54%) had NFR policies, 62 (39%) had SOFs, and four (3%) had PILs. Hospitals with more than 200 beds were more likely to have NFR policies than those with 60–200 beds (P = 0.04). More metropolitan than rural hospitals had NFR policies (P = 0.01). More hospitals with 60–100 beds had SOFs than hospitals with 101–200 beds (P = 0.03). “NFR” was defined in 53% of policies, while 97% of policies explicitly stated where NFR orders were to be documented, 89% stated who was allowed to make them, 37% stated that advanced care directives (“living wills”) were to be respected, and 89% stated that competent patients should be involved in discussions regarding their NFR status. The most common items noted in SOFs were the name and signature of the issuing medical practitioner (92%) and documentation of the discussion with the patient (81%).Conclusions: There was wide variation in the content of hospital policies, SOFs and PILs pertaining to NFR orders. Aspects of current polices show room for improvement.

Navdeep S Sidhu MB ChB, PGCertHealSc(Resus) · Margaret E Dunkley MB BS · Melinda J Egan

Mishandled concerns about clinical standards resulted in whistleblowing in four Australian hospitals. Official inquiries followed with recommendations to improve patient safety. 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. Without first rebuilding trust, staff will not report mistakes or other concerns about safety. Successful implementation of patient safety procedures requires policies to stress the professional duty of staff to report concerns about colleagues when they believe there is a risk to patients.

James A Dunbar MD, FRCPEdin, FRACGP · Prasuna Reddy PhD · Bill Beresford FRACMA, FAFPHM, FRACGP · Wayne P Ramsey AM, MHA, FRACMA · Reginald S A Lord AM, MD, FRCS, FRACS

Chronic disease self-management education programs aim to empower patients through providing information and teaching skills and techniques to improve self-care and doctor–patient interaction, with the ultimate goal of improving quality of life. The recent 2006–07 federal budget allocated an unprecedented $515 million over 5 years for activation of patient self-management activities, commencing this financial year. Previous attempts in other countries to incorporate self-management education activities into the health care sector have faced setbacks because of inadequate integration into primary care. Engagement of health care professionals and their endorsement of self-management activities is critical to success.

Joanne E Jordan BSc, BA, MPH · Richard H Osborne DipApplBio, BSc, PhD

A program of this size is bound to experience challenges The National Health Service (NHS) in the United Kingdom is undertaking the world’s largest civil information technology (IT) project,1 committing £12.4 billion over 10 years to improve services and quality of patient care through the strategic use of IT.1 The size of this commitment makes the NHS National Programme for IT (NPfIT), delivered by the NHS Connecting for Health (CfH) agency, of major international importance. NPfIT covers 330 acute hospitals and mental health trusts, and primary and community care organisations across England (Scotland, Wales and Northern Ireland have opted not to participate). At the core of the program is the “Spine”, a central link to a patient register, electronic prescription service, messaging service, and a summary care record. A web-based booking system, Choose and Book, which allows patients to select or change appointment times, is currently used for 12% of bookings. Radiology picture archiving, electronic prescription transfer, email, and an NHS-wide directory have been implemented, but electronic patient records, a common user interface and secondary use of data are significantly delayed. The NHS chose to procure systems centrally and implement them locally. Procurements included NHS-wide systems (email and Choose and Book), enterprise-wide agreements (eg, with Microsoft), and five local service providers to implement the regional solutions. Local service providers are free to choose and change subcontractors. Local systems must conform to national standards, as in Australia where all jurisdictions have agreed to use standards promulgated by the National E-Health Transition Authority. Clear differences are our federal structure that allows each state its own procurement process, financial and regulatory framework, and controls, thus hindering the unified “big bang” approach possible for England. Once all costs of implementation and training are accounted for, the final budget for NPfIT could blow out to as much as £30 billion.2 In June 2006, the UK’s National Audit Office reported on CfH.3 Despite the cost overruns, delays,4 and growing clinical unrest, the report was less damning than expected. The muted response may reflect that some things have gone well, that a program of this size is bound to experience challenges, and the political cost should the program be perceived as a failure. Other nations grappling with health service reform can already learn many lessons from NPfIT. Get the procurement model right. Procuring contracts centrally resulted in vigorous supplier competition and saved about £4.5 billion. However, the speed of procurement meant that the NHS had not prepared key policy areas (eg, information governance), standards (eg, for messaging and clinical coding), and information system architecture (neither enterprise architecture nor detailed technical architecture was ready). Further, the contracts bound suppliers to a vague specification that has cost the NHS around £30 million in legal fees to sort out. Payment to suppliers is contingent on delivery of “working” systems (although up-front payments have occasionally been made). Consequently, the significant delays in systems roll-out have not as yet resulted in a national scandal because the public purse appears protected. Under-performing companies have not been paid, and some have suffered large, late-delivery penalties. For example, iSOFT is reported to be struggling because of its failure to deliver on time and the resulting penalties. It posted a £344 million annual loss, has taken a hammering in its share price, and is being investigated by regulators.5 It is not clear what risk- management process can handle the worst-case scenario of one or more providers going bankrupt, leaving complex “legacy software” that cannot be maintained by other organisations. Safety comes first. IT can be a powerful enabler, but if poorly implemented or used, it can result in patient harm.6 Yet system safety was not written into the initial procurement specifications.7 Somewhat late in the day, CfH developed a safety accreditation process and appointed a National Clinical Safety Officer. Failure to account for safety also brings commercial risks. A program failure, such as failing to correctly populate patient data into the allergy field of the shared records on the Spine, could easily generate widespread clinical misadventure, triggering massive legal claims and a stock market hammering. The delayed common user interface should have additional safety benefits. Once trained on one system, clinical staff can change their employment and, regardless of the next system used, still have some consistency of user interface and information presentation, hopefully resulting in reduced training time, increased clinician effectiveness and safer practices. Skills shortages will impede progress. CfH has been hampered by a workforce that lacks experience in large-scale IT implementation and familiarity with health services.8 Compounding this, the severe procurement contracts paradoxically may send some health IT companies to the wall, reducing the number of organisations able to implement systems in the UK, or elsewhere. Perhaps a staged approach, with systems roll-out designed to also increase the skills base and capacity of the workforce, might have been more sustainable. For the lifetime of CfH, there will always be questions about the capacity of CfH suppliers to deploy their best and brightest to other parts of the world. This is in part because suppliers may see success with CfH as a “loss leader” into the global market, and failure or delay there will also generate significant penalty. “Fast follower” nations hoping to capitalise on the investment of an “early adopter” nation like England may end up paying a premium on UK prices, rather than the cheaper prices some expect, as companies seek to recoup any losses incurred in the UK. Clinical engagement comes first, not last. A significant criticism in the National Audit Office report was that procurement occurred before clinical engagement, perhaps because extensive consultation was thought to slow the process. This has resulted in significant disquiet among some clinicians and the priorities of the program not fully matching those of the clinical community.9 How significant a failure this decision was will become clearer in time. Picking the wrong patient consent model may be a deal breaker. Patients must give consent for their information to be stored electronically and made available to others.10 CfH has chosen an “opt out” model in which patients by default are included within the system, and make an informed choice to leave it. For this to be fair, patients would need to be reached by an educational campaign before system implementation. Strident critics, such as the British Medical Association, counter that an informed choice to “opt in” would be a fairer model, as there is no room for doubt about a patient’s intentions. Given that the shared record is not yet widely available, there is significant room for increasing disquiet in years to come, not just among clinicians, but also the public. “Opting out”, while technically simpler, may end up being the Achilles heel of the new system should significant examples of breach of confidentiality hit the media. “Opting in” might eventually prove to be the cheaper model when all costs are considered, not just the technical ones. Clinical knowledge services are an early clinical winner. Almost ignored in the CfH program hype has been the NHS National Knowledge Service which provides, among other things, the electronic National Library for Health — a vast array of evidence sources for working clinicians. With no apparent significant delays in its delivery, no dependence on other components of CfH, and a relatively small budget by the program’s standards, it is likely that the IT system most clinicians see first and gain immediate benefit from will be Internet access to clinical evidence. Political leadership is key. CfH exists because of strong political support within the government and Cabinet, and direct leadership from the Prime Minister. Without such political leadership, it seems unlikely that modernisation on this scale would ever be attempted, nor steered over the inevitable road humps encountered on the way. Evaluation is not an afterthought. Too often, token effort is expended on measuring clinical improvements long after major decisions have been made and systems delivered. CfH has therefore established and funded an evaluation board. However, evaluation also has a major formative role — early versions of systems are iteratively trialled to make sure they fit into clinical workflows, are acceptable to clinicians, and don’t have negative side effects. The CfH decision to consult late with clinicians has meant that there were limited opportunities for formative evaluation to shape specifications, and we may now be seeing the opportunity cost of that decision. Perhaps history will record that the NHS was not sufficiently prepared to take on such a fast-paced, radical and extensive modernisation program, that it was compromised by workforce shortages in health informatics, and fell into the trap of leading with technology rather than clinical need. Perhaps countries like Australia will draw another, somewhat heretical, conclusion from the exercise — that IT is not like water, which can be delivered equally to all. With scarce resources, Australia should begin its IT modernisation program with just a few national clinical centres of excellence, where IT skills and efforts can be concentrated. With time, successful technologies, processes and work practices, as well as the personnel trained in them, can then migrate to the rest of the health system.

Enrico W Coiera MB BS, PhD

Objective: To assess changes in the cost and availability of a standard basket of healthy food items (the Healthy Food Access Basket [HFAB]) in Queensland over time.Design and participants: A series of four cross-sectional surveys (in 1998, 2000, 2001 and 2004) describing the cost and availability of foods in the HFAB over time. In the latest survey, 97 Queensland food stores across the five Australian Bureau of Statistics remoteness categories were compared.Main outcome measures: Cost comparisons for HFAB items by remoteness category for the 97 stores surveyed in 2004; changes in cost and availability of foods in the 81 stores surveyed since 2000; comparisons of food prices in the 56 stores surveyed in 1998, 2000, 2001 and 2004.Results: In 2004, the Queensland mean cost of the HFAB was $395.28 a fortnight. The cost of the HFAB was 29.6% ($113.89) higher in “very remote” areas than in “major cities” (P < 0.001). Between 2001 and 2004, the Queensland mean cost of the HFAB increased by 14.0% ($48.45), while in very remote areas the cost increased by 18.0% ($76.93) (P < 0.001). Since 2000, the annualised per cent increase in cost of the HFAB has been higher than the increase in Consumer Price Index for food in Brisbane. The cost of healthy foods has risen more than the cost of some less nutritious foods, so that the latter are now relatively more affordable.Conclusions: Consumers, particularly those in very remote locations, need to pay substantially more for basic healthy foods than they did a few years ago. Higher prices are likely to be a barrier to good health among people of low socioeconomic status and other vulnerable groups. Interventions to make basic healthy food affordable and accessible to all would help reduce the high burden of chronic disease.

Michelle S Harrison BSc, GradDipDiet, MPH · Terry Coyne BSc, MSc, PhD · Amanda J Lee BSc(Nutr), PostGradDipDiet, PhD · Dympna Leonard BSc(Diet), MPH · Simone Lowson BAppSc(Nutr), PostGradDipDiet, MPH · Anita Groos BSc(Hons), MSc, DrOecTroph · Bronwyn A Ashton BHMS(Ed), GradDipNutrDiet, MMedSc

Objective: To document the risk-factor profile and risk-factor knowledge of patients with an acute coronary syndrome (ACS) not attending standard cardiac rehabilitation.Design and setting: Cross-sectional comparison in a tertiary hospital.Participants: Patients admitted to hospital with an ACS, residing within 20 km of the hospital, and without severe comorbidity who did not access cardiac rehabilitation (NCR) were compared with a group about to commence standard cardiac rehabilitation (SCR).Main outcome measures: Risk-factor profile, knowledge of risk factors via face-to-face assessment, quality of life.Results: Of the 446 patients eligible for cardiac rehabilitation, 208 attended for assessment (NCR: n = 144; SCR: n = 64). The NCR group had higher mean (± SEM) low-density lipoprotein (LDL) cholesterol levels (2.6 ± 0.1 v 2.3 ± 0.1; P = 0.02), and were more likely than the SCR group to have a total cholesterol level of > 4.0 mmol/L (78% v 53%; P < 0.001) and an LDL cholesterol level > 2.5 mmol/L (47% v 25%; P = 0.01). They were more likely than the SCR group to be physically inactive (77% v 22%; P < 0.001); obese (46% v 33%; P = 0.04); depressed (21% v 5%; P < 0.001); or current smokers (21% v 1%; P < 0.001). Compared with the SCR group, the NCR group also had higher risk scores (LIPID risk score) (4.5 v 2.1; P < 0.001); lower quality of life (Medical Outcome Short Form [SF-36] Health Survey); and significantly poorer knowledge of risk factors. Among patients with at least two modifiable cardiac risk factors, the NCR group were less likely than the SCR group to be able to state at least one risk factor (24% v 38%; P < 0.001).Conclusions: Patients not participating in cardiac rehabilitation after an ACS have more adverse risk profiles and poorer knowledge of risk factors compared with those about to commence cardiac rehabilitation. Alternate models for secondary prevention are required to improve health outcomes in patients not attending cardiac rehabilitation.

Julie Redfern BAppSc, BSc · Elizabeth R Ellis MHealthLaw, MSc, PhD · Tom Briffa BPhysEd, MPhysEd, PhD · S Ben Freedman MB BS,PhD, FRACP

Objective: To determine barriers that affect access to health care for refugees from sub-Saharan Africa resettled in Sydney.Design: Descriptive epidemiological study and survey.Participants and setting: Parents of newly resettled refugee children seen at a tertiary hospital paediatric clinic between 10 June 2005 and 19 May 2006.Main outcome measures: Socioeconomic indicators, health seeking behaviour, social barriers, and beliefs about health.Results: Parents of 34 of a possible 35 families (97%) agreed to participate. Barriers to accessing health care include language barriers, financial handicap, lack of health information, not knowing where to seek help, and poor understanding of how to access health services. Most refugee families established connections with community and religious groups soon after arrival in Australia.Conclusions: Our findings suggest that most refugee families are not totally isolated in Australia, but form early connections with cultural, social and religious groups of their own ethnic background. These groups provide an opportunity to deliver health education and health information that would improve their access to health services.

Mohamud Sheikh-Mohammed MIPH, MHSc, DipMedLabSci · C Raina MacIntyre FRACP, FAFPHM, PhD · Nicholas J Wood MB BS, FRACP · Julie Leask PhD, MPH, DipAppSci · David Isaacs MD, FRACP, FRCPCH

Objective: To describe the clinical features and management of African migrants recently arrived in Western Australia and subsequently diagnosed with malaria.Design, participants and setting: Retrospective case record analysis of African migrants aged ≥ 16 years with malaria referred to Royal Perth Hospital (RPH) from the WA Migrant Health Unit (MHU) between 1 March 2003 and 30 September 2005.Main outcome measures: Demographic variables; clinical and laboratory variables; Plasmodium species; antimalarial medications used and their efficacy.Results: 57 (3.5%) of 1609 adult African migrants screened at the MHU were diagnosed with malaria and referred for treatment. 52 were infected with P. falciparum, two with P. ovale, one with P. malariae, and one with both P. falciparum and P. malariae; the malaria parasite could not be identified in one individual. No patients had severe malaria by World Health Organization criteria. Most patients (53/57) were treated as outpatients with oral antimalarial therapy; four patients without severe malaria were admitted to hospital for treatment and observation. Atovaquone–proguanil was the antimalarial medication most commonly used (in 52/57), and treatment was well tolerated in most patients. Post-treatment follow-up was possible in 50 patients; all 27 of those who were followed for 4 weeks or longer were cured. Cure could not be concluded in patients with shorter follow-up periods. All follow-up blood films were negative for malarial parasites.Conclusions: Outpatient treatment of malaria in recently arrived adult African migrants appeared to be safe and efficacious in our cohort.

Desmond T Chih MB BS · Christopher H Heath FRACP, FRCPA · Ronan J Murray FRACP, FRCPA

The National Health and Medical Research Council Act 1992 (Cwlth) was amended in 2006 to streamline governance arrangements and help the National Health and Medical Research Council (NHMRC) to become a more responsive organisation and more effective at both acquisition and implementation of new knowledge. As part of the NHMRC’s plans for the future, we will implement the recommendations of the Investment Review of Health and Medical Research on policy- and practice-focused research, commercialisation, and recruitment of health and research professionals to the NHMRC. The NHMRC is also improving its process for selecting and supporting the best research across biomedical, clinical, public health and health services disciplines; and will develop, trial and introduce new forms of communicating evidence-based information.

Warwick P Anderson BSc, PhD

Research and publication misconduct is commoner than many believe, hard to detect and difficult to investigate, with institutions often being reluctant to take action. The first countries to set up formal systems for policing research misconduct were the United States and some Scandinavian countries. The US Office of Research Integrity (ORI) is a useful model for other countries; rather than conduct investigations, the ORI supervises the investigation by the respondent’s institution. The United Kingdom has taken more than 10 years to set up a national supervisory body — the UK Panel for Research Integrity in Health and Biomedical Sciences. Unlike the ORI, it has no statutory basis. It is too early to tell whether the procedures set up in the UK will work. The present trend for governments to encourage universities to link up with industry may lead to a culture of secrecy and confused accountability. In any country, including Australia, intent on policing research, it is only possible for editors, reviewers or readers to initiate investigations, not undertake them, as power lies in the hands of employers, research funders and regulatory bodies.

Harvey Marcovitch FRCPCH

Institutions investigating allegations of research misconduct are vulnerable to claims that their processes are inadequate or that they have an institutional conflict of interest. The Office of Research Integrity in the United States sets down standards for and reviews the adequacy of investigations of research misconduct by institutions; recognises that internal politics and the involvement of non-experts can lead to honest mistakes being regarded as serious misconduct; requires complainants and investigators to act “in good faith”; and reduces damaging publicity when complaints are misconceived or false. Australia needs an office of academic integrity to ensure that all complaints are thoroughly investigated; the investigative procedures meet international standards; fair processes are provided for complainants and respondents; and institutions are protected from claims of “cover-up” and institutional conflict of interest.

Bruce M Hall MB BS, FRACP, PhD

Research conduct in Australia and worldwide is mostly unaudited. The purpose of good research governance is to ensure integrity in research through accountability, transparency and responsibility. Institutional responsibility for research governance has been adopted by Monash University’s Department of Epidemiology and Preventive Medicine, providing clear lines of accountability for researchers as well as support and guidance. A research audit tool has been developed, identifying areas where practice could be improved especially among less experienced researchers; the most common adverse findings concerned research protocols and procedure manuals. The need for participant confidentiality, privacy and data security was found to be understood, and adhered to widely by all researchers. An evaluation of the effect of audit on researchers found that the process was well accepted.

Stephanie J Poustie MPH, CertCritCare, BN · David McD Taylor MD, FACEM · Andrew B Forbes BSc(Hons), MSc, PhD · Marina A Skiba BEd · Mark R Nelson MFM, FRACGP, PhD · John J McNeil MB BS, PhD, FRACP

Many voices proposing innovative strategies — which way forward? Australia is considered by much of the world as the “great outdoors”, with tourists travelling from afar to see our landmark deserts, rainforests and other natural wonders. Yet we are, in fact, an urbanised nation, with fewer and fewer Australians living outside capital cities. And with the shrinking of our rural population, a growing problem has emerged: increasingly noticeable disparities in health outcomes, with people in the bush generally doing less well than those in the cities. Over the past decade or so, a range of initiatives have been implemented to try to address the dwindling rural health workforce. To gain some insight into how these initiatives are progressing, we interviewed leaders from key medical organisations with a specific interest in rural health care (Boxes). They shared with us not only their medicopolitical views, but also their personal experiences in rural and remote practice. Despite much effort, the workforce and health care picture painted is still one of a parched landscape which, in places, is becoming progressively drier. Without much “rain” forecast for the next 10 years, the leaders we interviewed advocated a raft of further innovative strategies which, if introduced sooner rather than later, may help to avert the deepening rural health care drought. Solving the workforce shortageRecruitment: the role of exposureAll experts agreed that recruitment into rural and remote practice is a key problem, exacerbated by a national medical workforce shortage. In response, there has been a recent proliferation of new medical schools, and development of rural clinical schools and university departments of rural health. However, there will be a time-lag of 10 years or more before any real effect is seen in the workforce. Until then (and afterwards), exposure to rural and remote practice early on in medical careers, from student years onwards, is seen as the key to long-term recruitment into rural and remote practice. Not just exposure per se, but supported, positive and continuous exposure. Royal Australasian College of Surgeons (RACS) Representative: John Graham Roles: Elected Councillor, RACS; previously, rural representative to Council, RACS (2000–2006) and Chair, Divisional Group of Rural Surgery, RACS (2004–2006) (also, Co-chair, Rural Specialists’ Group, Rural Doctors Association of Australia) Alma mater: University of Sydney, 1972 Discipline: Vascular and renal access surgeon Location: Lismore, New South Wales, since 1992 Childhood: Born in Sydney, primary school in Singapore and high school in Sydney “I was the second resident ever to come to Lismore and I knew that if ever an opportunity came to go to the country that it was something that I could really encompass and that I would enjoy doing.” John Graham, Elected Councillor, Royal Australasian College of Surgeons (RACS) and, previously, rural representative to the RACS Council, said, “We know, for instance, from the figures that have come from James Cook University in Cairns, that if you can get your medical students into a rural training program early on, then you’re likely to retain more of them in rural practice”. And the opportunity for rural exposure can only increase, with the need to accommodate the training and early career needs of increasing student numbers. David Campbell, President of the Australian College of Rural and Remote Medicine (ACRRM), is also a director of a regional clinical school in Victoria, which has already been “oversubscribed” by students. Students see a rural placement as an opportunity to “suck it and see”, and to experience the breadth of skills that rural doctors have. Furthermore, Campbell said “the smart ones” also understand that the rural setting is a better training environment. “They’re not going to be standing at the back of a group of 20 people at a major teaching hospital in the city; instead, they’ll be dealing one to one with clinicians.” Graham, and Ross Maxwell, President of the Rural Doctors Association of Australia (RDAA), warned that the “exposure” plan can fall down when graduates who have had rural exposure as medical students enter the workforce. Graham extolled the value of rural rotation in the prevocational years of training. David Rivett, Chair of the federal Rural Reference Group of the Australian Medical Association (AMA) and New South Wales AMA Board representative for rural NSW, agreed, saying that the “hub-and-spoke” model, in which a rural hospital has an urban linkage and affiliation, helps “expose” doctors in the early years of their medical careers. However, rural rotations should be given due recognition. “There’s an intrinsic, inbuilt feeling in a lot of tertiary hospitals that rural practice is not second rate, but even third rate”, he said. Maxwell pointed out two other common, important problems with some rural rotations — being too short to allow the doctors to feel as though they belong and, even worse, traumatising relatively inexperienced doctors by sending them out to single-doctor towns without support. Exposure to rural practice has long been a part of general practice training in Australia. Chris Mitchell, Chair of the National Rural Faculty of the Royal Australian College of General Practitioners (RACGP), says that a lot of people, including him, ended up in rural general practice because they found they liked it during a mandatory rural term in their early postgraduate years. The two specialty college representatives we interviewed would also like to see some sort of mandatory training in the rural setting as part of specialty training programs. However, Paul Bauert, Chair of the Rural Taskforce of the Royal Australasian College of Physicians (RACP), flagged some obstacles. “There’s been a great deal of resistance to it [the mandatory rural term] from the Division of Paediatrics and Child Health trainee committee, and there’s been an absolute resistance to it from the RACP adult divisions from both the Fellows and the trainees.” Graham said that, although there is no mandatory training term for surgery, registrars who take up a rural-based training position go home with both the benefit of exposure to rural and remote practice and an RACS logbook that is better than they can achieve elsewhere. Marketing: the big picture versus the bottom lineOpinions varied as to how rural and remote medical practice should be marketed to students and new graduates. Mitchell said the lifestyle and clinical satisfaction of rural general practice should be promoted across the whole journey of general practice. “We’re doing it in a piecemeal kind of way, but we’ve got to be targeting schools, medical students, prevocational registrars and also, of course, vocational registrars.” However, Maxwell saw a problem in pushing a career in rural practice purely on flexibility, mobility, a great lifestyle and wonderful practice, when the time commitment is often very full-time. “We really need to make sure that rural medicine has a very good professional profile, so that we can then attract people who may otherwise consider being specialists”, he said. Further, Maxwell saw a need to compete with other opportunities for doctors. Since reviewing salary packages and making them more attractive, Queensland has been successful in recruiting enough doctors to exceed the set target. “The fact is that, before, they weren’t competing; so, of course, they weren’t going to attract doctors — if you won’t compete, you’ll never win”, he said. Training conundrumsTraining for rural and remote practice carries the dual challenges of training the right people and training them in the right way. Mitchell believes that the current general and rural training streams for vocational training for general practice in Australia require urgent review. In his opinion, the rural training stream, with its rules, regulations and restrictions, is far less appealing to Australian graduates than the more flexible general pathway. Although about 40% of registrars in the general stream have an interest in rural training, no incentives or rewards are directed towards the general pathway. Mitchell adds, “We’ve got to provide incentives for those people who train in rural areas, and those incentives should increase with increasing remoteness, not only financial but also in terms of increased educational resources and increased support”. The extra year of skills training in the rural stream will soon be recognised by a rural health Fellowship rather than the existing Diploma. But there is competition. From as early as 2007, there may be an alternative path to a rural general practice via a Fellowship offered through the ACRRM. Campbell said the ACRRM’s position is that the best training environment for rural practice is “in rural areas by rural doctors” and that the RACGP model, in which rural practice is an “add-on”, is the wrong model. Instead, the ACRRM’s 4-year program involves “immersion” in rural medicine. Doctors will be able to train in a variety of environments relevant to rural practice, including a hospital environment, and will be able to complete requirements in any order they choose. Although most training will be based in the rural environment, it is anticipated that ACRRM Fellows will also be able to work as generalists in urban practices. Rivett said the specialist colleges also need to train more generalists. “There’s a dearth of general physicians and general surgeons, who are core people to provide high-quality services aside from your rural GP. It can’t all go on the heads of rural GPs.” Bauert concurred that physicians practising in rural and remote areas will need to be trained as generalists, rather than as subspecialists. Rivett added that these generalists will need to be buttressed and given career support. “If you’re a generalist for 10 years, maybe you can go back and get a step up to become a gastroenterologist or cardiologist, or whatever. That rural time will be given some recognition and give you some precedence in the system.” According to Graham, from the beginning of 2008, the new RACS training program will select trainees directly into the specialties. We may have to work towards having rural surgery as its own specialty “and, if you like, buy slots in each of the other training programs”. “Difficult, untried, but necessary, if we are to train people with the broad exposure necessary for work in rural surgery”, he said. With the specialist colleges becoming more and more sub-specialised, Bauert believes the ACRRM’s original proposal to look after all doctors who were going bush, not just GPs, could work well. The ACRRM could be an overarching body, taking on the mantle of responsibility for trainees and supporting Fellows from all colleges. “You could have an ACRRM member, who may be a Fellow from a different college, providing support and most of the supervision, and then you would have regular video links with your formal supervisor — a Fellow of your own college, in a nearby centre or hospital”, he said. Campbell has an even broader vision. He believes that if we can support and start to champion the rural environment as an ideal medical training environment, it has the potential to change the way health services are delivered across the nation by restoring the role of the generalist, “if we get a large enough cohort of doctors being trained in rural practice, with the range of skills that rural doctors have got”. Maxwell came to a similar conclusion; he said that while we are yet to see if rural clinical schools can help address the workforce problem, if nothing else, they will hopefully give a generation of graduates an experience which leads to a more generalist practice. Australian College of Rural and Remote Medicine (ACRRM) Representative: David Campbell Roles: President, ACRRM (also, Director, East Gippsland Regional Clinical School, Monash University, Bairnsdale, Victoria) Alma mater: University of Adelaide, 1978 Discipline: Rural general practice Location: Lakes Entrance, Victoria, since 1983 Childhood: Adelaide (“a big country town”) “For as long as I can remember, I wanted to go into rural practice because I saw that as probably the only opportunity within the profession to develop and retain a whole range of skills.” Overseas-trained doctorsThe Australian rural workforce now relies heavily on international medical graduates. No longer considered as temporary solutions, in some towns, overseas-trained doctors (OTDs) have become part of the community. Much progress has been made in terms of their initial assessment; however, orientation, support and supervision are further challenges that have yet to be adequately met. Rivett pointed out that if a supervisor is the OTD’s employer, he or she may have a vested interest in not reporting problems, for fear of losing a valued employee. “The supervisor needs to be a more independent person, actually supposed to sit in with them for some hours on a regular basis. And for that to happen, it would need to be properly funded”, he said. Further, in terms of support, OTDs do not have the same “network of mates” to ring for advice; Rivett said they need to be given an artificial network to support them. Graham suggested that overseas-trained surgeons ought to first spend time in a larger hospital close to their designated practice location, so that they understand the Australian hospital system and network with the surgeons with whom they are going to be relating. Retention: essentialMaxwell said the health care system in most rural communities is relatively fragile — very much dependent on a small team of people with the right skills mix. Sustaining this requires constant regeneration of the workforce, which is proving to be a challenge. Apart from not bringing young Australians into rural medicine in anything like adequate numbers, older doctors who have broad experiences and procedural skills are being replaced by a cohort of doctors who may not have those skills. Graham’s greatest fear is that, if 35% of our rural surgical workforce retire in 5 years, as has been suggested, the surgical workforce will be depleted before the problem starts to be addressed. Thus, there is a current urgency to retain as many rural and remote doctors as possible over the next 10 years. Rivett advised increasing grants for the retention of ageing rural doctors: “. . . generous retention grants or tax breaks to try and keep those people in the workforce till we get new people there”. More generally, most of the leaders we interviewed identified similar elements that can help lead to longevity of a doctor’s career in rural medical practice, including a reasonable workload, access to a local hospital and having a variety of work, including procedural work. Adequate cover and improved locum support were stand-outs, for both professional and lifestyle reasons, as was recognition, both professional and financial, of their efforts. Rivett suggested that GPs and specialists be provided with locum support to go to a tertiary centre for some months to up-skill in any area they choose. Also, they should have a “leg up” if they want to go back to that tertiary centre at some time to further their career. He thought state governments could, fairly easily, overcome the “indemnity barrier”, where hospital administrators have vetoed planned up-skilling because of concerns about the adequacy of medical indemnity provisions. Although the rural lifestyle is often touted as one of the desirable things about rural practice, it can be a drawback when workforce shortages lead to long hours and difficulty in taking leave. Rivett said there should be an agreed core number of doctors for each rural location, a number that allows people to have a lifestyle. “Generation X and Y certainly don’t want to work the crazy hours that us dinosaurs have worked in the past”, he said. If a town needs four doctors for them to have a reasonable lifestyle, and if patient numbers are not sufficient for a fee-for-service Medicare Benefits Schedule income to support them, then subsidies are needed so that the town becomes an attractive place to work. Mitchell works in a well staffed general practice of “part-timers” in a town of 7000–8000 people. There are usually between four and five doctors working at any one time; they are all involved in the after-hours roster, and they cover their own leave. “Family friendliness” was seen as crucial, as was access to educational services. Maxwell said that although only about 30% of GPs in rural and remote areas are women, compared with more than 50% nationally, most young doctors moving to rural Australia are women, and Mitchell pointed out that nearly 60% of new medical graduates are women. Hospital obligations are very difficult to fulfil when there are no facilities to assist doctors with families — what do you do if you get called in to deliver a baby while you are out shopping with the kids? Mitchell said we need both adequate on-call allowances and adequate leave provisions for visiting medical officers (VMOs); these issues apply to specialists as well as to VMO-GPs. Workforce efficienciesInformation technology (IT) was generally seen as a potential tool that is yet to be fully utilised, particularly in the clinical setting. Rural-based physician trainees can link in with their training program in Melbourne, and Bauert has used IT to link with doctors in a smaller hospital, providing supervision and finding out what may turn up at his hospital over the next few days. Mitchell’s practice routinely keeps copies of high-quality evidence-based guidelines on its server to assist in quick searches for relevant information. Maxwell thinks that remote doctors would have stronger drivers to use IT. However, it seems that IT use in clinical practice is still struggling with some fundamental teething issues. Despite its huge potential as a workforce solution, there has not been a commitment to providing the required IT infrastructure, or an appropriate fee structure for the time and expertise involved. For example, there is no system to pay for specialists or rural doctors to give or receive opinions over the phone or electronically. Campbell pointed out that there are international models which we should consider adopting. “There’s a really good model in Alaska being run now, whereby small, isolated rural health teams are provided with what they call an IT cart — where the health worker can do an ECG, do spirometry, take a photograph of a tympanic membrane of the ear, load that onto the system, and then send an email to the clinicians back at the base hospital, who will then give them a report about that patient. Now, it’s not real-time, but they get a report within a few hours and they are able to deliver care in that way. It works extremely well.” Developing the role of practice nurses has helped to take some of the pressure off doctors. However, while there was strong support for health care teams headed by doctors, this did not extend to health care workers replacing doctors. Rivett recalled an instance where a nurse practitioner was sent by the state government into a country town to help the solo GP. The GP’s practice was decimated to the point where he left town; the nurse practitioner left some months later, and the town was left with no primary health care worker. Bauert is aware that remote area nurses supported by visits from district medical officers have sustained remote communities in the Top End of the Northern Territory, but his personal feeling is that the level of care cannot be the same as if there were a full-time GP or viable general practice service there. Nevertheless, all agreed that task substitution or, at least, collaboration rather than competition, remains a way of keeping the doctor’s workload tolerable. For example, Graham said surgeons in rural towns could be supported in their on-call commitments by appropriately trained GPs. Rural Doctors Association of Australia (RDAA) Representative: Ross Maxwell Roles: President, RDAA (also, South West Area representative, Queensland AMA Council; and Board member, Health Workforce, Queensland) Alma mater: University of Queensland, 1982 Discipline: Rural general practice Location: Dalby, Queensland (on the Darling Downs), since 1989 Childhood: Rural Queensland “I grew up on a sheep and cattle property 50 km west of Winton. Fantastic childhood, spent a lot of time working the property with my mum and dad.” Economic incentives matterRemuneration was perceived to be a huge barrier to the recruitment and retention of rural and remote doctors. Although all representatives were aware of oft-proposed geographic provider numbers, in the main they preferred rural incentive and retention packages. Bauert pointed out that Darwin has recently been experiencing the “Vortex to Queensland”, achieved not via geographic provider numbers, but through location allowances and incentives — the further from a major centre, the higher the incentive. Maxwell reminded us how industry copes with a workforce problem; for example, the mining industry — if they want a workforce in a certain area, they provide the economic and professional conditions that will attract the workforce. They make the incentives clear and specific and they present them up-front. Maxwell reasoned that the argument for geographically determined enhanced Medicare rebates had foundered around the question of whether the intrinsic intellectual content of consultations in rural and remote practice is different. However, GPs who work out bush do feel there is a context around what they do that is different — because they manage not just the primary kind of care, but also hospital-level care and serious emergencies. Another key difference between metropolitan and rural practice is the additional on-call commitment without any extra financial incentive, and with accompanying family and general lifestyle issues. Mitchell did not consider rural and urban practice to be very different. “When you look at BEACH [Bettering the Evaluation and Care of Health] data, the vast majority of work done by rural GPs and city GPs is very similar. I’m not suggesting that there isn’t a need for procedural competence in certain contexts of rural general practice, but those contexts are basically confined to working in RRMA [Rural, Remote and Metropolitan Area classification] 4 and 5 towns, where there is a hospital appointment. There are about 1000 proceduralists out there, but about 5000 rural general practitioners.” He saw the remuneration problem as applying to both rural and urban general practice. “It’s certainly just as difficult a specialty as any other”, he said. The key problem, as he saw it, is that the reward for general practice is “pathetic” compared with the financial reward for some other medical specialties. “This is affecting the choice that medical graduates make when they’re coming through with a huge HECS [Higher Education Contribution Scheme] debt”, he said. Keeping rural communities aliveAlthough some rural communities, particularly those on the coast, are growing, many others are crumbling, experiencing the progressive loss of infrastructure. Bauert believes that the rural GP is really the “glue” that can hold a lot of remote communities together. Rivett thought a GP in a town would be vitally important in maintaining an aged care facility and in allowing people with chronic diseases to be cared for in the community, without having to shift to a city location. Although Mitchell did not want to suggest that rural GPs are not a linchpin in their community, he did consider that communities need more than GPs; they need an entire infrastructure. “It’s very challenging for rural communities when they lose their GP, but it’s also very challenging for the GP to remain in a rural community that’s losing its school, that’s lost its accountant and its bank and all of the infrastructure that allows it to function.” Mitchell saw the plight of dying communities as irreversible without investment. “What is required is a proper resourcing of these communities and a push to get people in other careers going to the bush, like bankers and accountants.” There also needs to be better and more equitable resourcing of education, as well as health. “We balance a lot of issues in terms of schooling — like balancing physics to English. Well, I think we need to really look at some sort of balance for rural origin versus city students, as well.” Going further, he asked: “Is there any real reason why government departments have to be in completely overcrowded cities? There are lots of regional centres crying out for that sort of capital investment.” Australian Medical Association (AMA) Representative: David Rivett Roles: Chair, AMA Rural Reference Group (federal); New South Wales AMA Board representative for rural NSW Alma mater: University of Melbourne, 1972 Discipline: Rural general practice Location: Batemans Bay, NSW, since 1975 Childhood: Mostly spent in Melbourne and Adelaide, with 2 years in Switzerland “Holidays in Deniliquin, NSW, as a 10–12-year-old, playing in irrigation ditches and being chased by sheep and cattle was enough to give me a love of the country.” Exploring models of health care deliveryHub-and-spokeBauert thought the “perfect world” of rural health care delivery — a good hub-and-spoke model, involving programs like the Medical Specialist Outreach Assistance Program, in which specialists go out to remote communities several times a year, providing support to the district medical officers, GPs, nurse practitioners and Aboriginal health workers — was shattered by the poor funding arrangements for such outreach programs. Although largely from a single source (the federal government), money for various programs seems to be inefficiently doled out from separate “buckets”, instead of being centrally administered, with considerable “wastage” as various federal and territory bureaucrats decide how best to distribute it. Also, conditions under which practitioners can access the money are not determined by practising doctors, but seem to be engineered by bureaucrats to show accountability. Rivett concurred: “If you look at the Specialist Outreach Assistance Program, it’s a great concept, poorly funded and poorly administered.” He said specialists are providing a great service, but not getting proper support; for example, they may not be being funded for travelling expenses. Maintaining small rural hospitalsThe steady decline and loss of rural hospitals and access to procedural services were of major concern to all leaders we interviewed. Campbell said that the decline is not necessarily linked to the viability of a rural town. “It seems to be an independent process really, related to lack of funding support and lack of adequate training for people with the skills to be involved with those services.” Hospital services are being repeatedly downgraded, or not upgraded to match the growth of towns. Doctors leave centres when frustrated about not being able to get rostered time off or time to attend training courses, having too many commitments, or lack of access to theatres — whenever there is a financial crisis, theatre lists are cut back. The problem may lie in the different goals held by health bureaucrats compared with health practitioners. Rivett put it bluntly: “If you want to be a successful bureaucrat, you’ve got to have an underspend in your department’s budget for the year. That’s how success is measured. Not what [health-related] results you achieve, but how well you do at saving dollars.” Campbell has found trying to provide a medical service in an environment where the nearest hospital is 40 minutes away extremely difficult and costly. His practice has self-funded a very large three-bay emergency area to deal with the “things that turn up at the door”. A state-run community health facility in the same district shuts its doors at 8 pm. Campbell has waged a long, unsuccessful campaign trying to convince the Victorian state government to direct more resources to his town. “I’ve famously been told by one health minister, when I said that Lakes Entrance was the largest town in the state without a hospital, ‘Well, not for long, we’re going to close some’.” Whatever the cause of the hospital closures, Rivett said that he would like the next Council of Australian Governments agreement with the states to lock in rural hospitals where they are, prevent further downgrading, and look at federal funding to maintain rural health care. “We need some sort of buttress and a guarantee that these facilities will be available into the future”, he said. “There’s got to be some vision from health bureaucrats as to what’s going to happen in rural health care in years to come. You can’t just have patients getting flown 100 km for treatment all the time. It affects their families enormously.” Primary care infrastructureCampbell does not think that the model of the doctor-owned practice is necessarily suitable for rural practice in the future, particularly small town practice. Why would anyone want to put some capital input into something that is going to lose value as time goes by, rather than gain value? “Local government or state government or maybe universities could own the infrastructure and actually take responsibility for managing the practices, and just provide an opportunity for doctors to come in and do their job without having to worry about capital input or the management side of things”, he said. Mitchell also thought it was important to have “easy entrance, gracious exit” sorts of models, whereby the practice infrastructure is owned by a third party. Mitchell’s view was that what the community needs is health services and, while throwing dollars at doctors will help, it will not necessarily address the lack of services for rural communities. “We actually need to look at some other models. I really think that we need some primary care infrastructure to be built, so that rural GPs can be working at the centre of teams”, he said. Extended practice teams should be made up of nurses, advanced nurses, medical assistants and allied health workers, all working under the delegation of GPs. “The reality is, whether you’re talking about city general practice or rural general practice, it has been starved of funds for infrastructure investment. It is far more efficient in my view to deliver community health services through general practices than it is through a side-wing on a public hospital.” Mitchell added that we also need a primary health care strategy, to allow for strategic rather than ad-hoc investment of resources, with all organisations involved. “I think we need to stop the fixation that we’ve got on secondary and tertiary care in Australia and seriously start investing in primary health care facilities. And, in particular, we need to do that in rural areas”, he said. “There are flexible ways to set up your services, but it does take a lot of effort to find your way through all of these things. At the moment, our practice has to find the program that we can slot into, like cardiac rehab and pulmonary rehab. What we need is a system-wide approach that doesn’t rely on [individuals’] enthusiasm.” Royal Australian College of General Practitioners (RACGP) Representative: Chris Mitchell Roles: Chair, National Rural Faculty, RACGP; Vice-President, RACGP; (also Chair, North Coast GP Training, New South Wales) Alma mater: University of Newcastle, 1986 Discipline: Rural general practice Location: Lennox Head, NSW, since 1991 Childhood: Born in Brisbane, grew up in Hobart “I got sent up here as my first basic GP term . . . came up and basically just fell in love with rural general practice.” Matching services to needs, and supply to growthSeveral of the doctors expressed frustration at the difficulty of getting government to invest adequately in growing communities. Mitchell said one of the issues particularly facing coastal areas is population growth that outstrips the supply of doctors and health services. Much of the population growth is in the over-65-years age group — people who require a lot of care. Graham said that regional hospitals identify strongly with one another. “Although we seem similar to a small metropolitan hospital, there is a quantum leap between the resources we have and the resources they have.” He said the major problem that regional hospitals face is funding the work they are able to do and expected to do, leading to bed shortages and theatre closures, with more than 50% of rural surgeons reporting that they consider their working environment to be fragile. An associated, important issue is that the medical community that practises in the country is generally not involved in the governance of its own resources. Graham also said that being part of a larger health area can cause its own problems. Despite differing needs, hospitals can find themselves competing with other hospitals in their area for funding. “There was a time when we felt that the needs, for instance, of Lismore would be considered in terms of the Lismore surrounds, but now we’re all tied in the one big area. We do keep spending money at a higher rate than Coffs Harbour or Tweed or Port Macquarie, and so there’s sort of a move to try and downgrade us and build them.” He acknowledged that a greater political imperative may be at work — “swinging seats” may be influencing funding distribution. Campbell said that the issue of economic viability of rural health services is based on a false premise. “If you’re talking about equitable delivery of services then you shouldn’t really be inserting comments of viability as well. I mean, you’ve got to understand that perhaps sometimes these services, per capita, are going to cost a bit more in rural areas.” The critical role of governmentThere was much frustration with fragmentation of health funding and with bureaucracy. Campbell said, “underpinning all of our issues is the problem with the Commonwealth–state funding structure”. He said that when teasing out all problems, the brick wall “we run up against” is the Commonwealth playing off against the states or vice versa. Mitchell said, “I think I understand the frustrations of the Commonwealth when they throw money in and the state government pulls it out. I also understand the frustration of the state government providing services under their signature that could be done much more cost-effectively in a community setting”. Fighting aside, Campbell said the problem is the fairly piecemeal approach to issues at both federal and state level, which represents a “band-aid” approach without any major affirmative policy initiatives to address the issues at either level of government. A very stark exposition of the state–federal divide in health care delivery in a small rural community is having a hospital sitting at one end of town, which is funded by the state, and a general practice (funded fee-for-service by Medicare) sitting at the other end. How can towns, instead of having two competing and not always complementary systems, actually have one health system which works really well? Mitchell personally thinks it would be really sensible if the “federals” took it over and stopped funding the state for some rural health services. As an example of inefficiency, he considered that, rather than having four or five different on-call services run by various practices in a small town, it would be far more appropriate for the doctors to be delivering their services in the safety of the hospital facility, using the infrastructure that is already there, while continuing to bill Medicare for their services. Maxwell believes that, rather than there being any political conspiracy to not support rural health care delivery to the fullest degree, what looks like inactivity may actually be inertia and the fact that people “see the world in the context of their own street”. He regards it the work of organisations like the RDAA to try to remind politicians and bureaucrats that they have to have policy constructs that are workable and will deliver services in rural Australia. We wondered if this problem could be overcome by specific representation, and asked several of the leaders whether they thought a Federal Cabinet Minister for Rural Health could assist in implementing specific rural health policies. Most had not considered the idea, but Campbell was open to the suggestion. “To do something meaningful for rural health, there may need to be someone with a focus solely and wholly on improving rural health and education for rural health, unaffected by the needs and the power of the metropolitan or centralist driven policy”, he said. Royal Australasian College of Physicians (RACP) Representative: Paul Bauert Roles: Chair of Rural Taskforce, RACP; Council of Division of Paediatrics and Child Health, RACP (also, President, Northern Territory AMA; Federal Councillor, AMA; NT representative, Australian Doctors’ Fund) Alma mater: University of Queensland, 1977 Discipline: Paediatrics Location: Darwin, NT, since 1977, with periods away for training and family reasons Childhood: My father was in the army; I got used to moving between different locations and changing schools “I was attracted to rural practice by a sense of adventure, something different.” Prime Minister, I think you should . . . When we asked the leaders which two problems they would advise the Australian Prime Minister to address to improve the rural health situation, there were some consistent priorities. Almost all raised Indigenous health. For example, Bauert said, “Until we decrease the disparity between access to health by Indigenous people compared with non-Indigenous people, Australia as a nation isn’t going to grow. If we can do that, we as a country would become a little more supportive of rural communities and more, if you like, compassionate”. Campbell said, “The major issue with regard to rural health in Australia is Aboriginal health. The first thing I would do is set up state-based systems of community control for delivery of Aboriginal health services, appropriately supported on an equitable basis”. Mitchell said, “The preoccupation with Indigenous health is essential. The problems, in many ways, are similar; they’re just far worse for Aboriginal communities”. Among other key recommendations were: an affirmative action policy to ensure equitable provision of infrastructure for rural communities, including access to local hospitals that provide a comprehensive range of services and integrated primary care facilities; and making general practice a career-of-choice again, via recognition and reward for general practitioners. There was also a call to be more attuned to the voice of the people in rural Australia, and in particular, the voice of the rural medical community. Graham said, “Really, at the end of the day, the medical community reflects the needs of the community at large”. Breaking the droughtIn speaking with these leaders in rural health, we were struck by their different but equally innovative responses to the rural health care crisis, many of which they have implemented in their own practices: responses that often rely on the goodwill of those directly involved and which are not necessarily sustainable. Thus, not surprisingly, nearly all the leaders we spoke to called for the systematic application of strategies not only to increase the rural workforce but also, just as importantly, to ensure ongoing health care delivery in rural and remote Australia. Now that we have heard these many voices, it may be time to seek unity on a strategic direction forward. Underpinning Australia’s rural health care crisis is the concept of access. As Campbell put it, “I think we can directly equate health status to access. We know that where we improve access, we improve health. There’s no doubt about that”. The key strategies proposed by these leaders for improving access include: a hub-and-spoke model for secondary and tertiary care; the sustenance of small rural hospitals; the recognition of general practice (including rural practice) as a specialty in its own right; and the development of an innovative, collaborative primary health care infrastructure. Our Prime Minister, John Howard, has said of the current drought affecting Australian farmers, “When the bush suffers, all Australians feel their pain”. While our government can only wait with other Australians for rain to fall on the land, they can and should act now to promote the flow of health services to our rural heart, otherwise it will go into terminal failure. In the land of the “fair go”, it is time to decide upon and implement the best strategies on offer, in the interests of equality and better health for us all.

Ann T Gregory MB BS, GradDipPopHealth · Ruth M Armstrong BMed · Martin B Van Der Weyden MD, FRACP, FRCPA

In reply: Grattan-Smith is obviously concerned about “Doctors behaving badly?” as an appropriate title for the editorial by Tattersall and Kerridge.1 He is also agitated by my column From the Editor’s Desk “Tilting at titles”.2 The editorial’s title was not the result of Machiavellian machinations — its creation belongs entirely with the editorialists. Grattan-Smith may not feel that accepting pharmaceutical company largesse is bad behaviour, but the public sees it otherwise, as evidenced by the unprecedented coverage of the “Roche affair” in The Australian,3,4 the Sydney Morning Herald,5 and the BMJ.6 The public comments were not flattering: “the gluttony of the whole thing was mind blowing”3 and its defence by doctors was “in poor taste and displays the supreme arrogance of the privileged”.7 The public and most doctors expect the relationships between the pharmaceutical industry and doctors to be open and transparent. We believe this to be the case with the pharmaceutical advertisements in the Journal, and the MJA/Wyeth Prize. Our advertising policy prevents pharmaceutical companies from placing advertisements within or adjacent to articles that might have relevance to the drug being advertised. Wyeth generously donates $10 000 each year to the authors of the best original research published by the Journal on the understanding that Wyeth has no input to the selection process. Research has already been independently peer reviewed for publication before being considered for the prize, and the winner is decided by the Journal staff and the members of our independent Content Review Committee. Grattan-Smith’s concern with my column was its questioning of the title “doctor”, which apparently is now a source of confusion for patients in busy hospitals. He cites Samuel Johnson’s concept of a doctor and quite rightly so. Physicians of his time had every right to call themselves Doctors. They were graduates from Oxford and Cambridge who pursued a long, formal and inflexible course. It began with a Masters in the liberal arts, proceeding through the Licentiate and then a Doctorate in Medicine by dissertation.8 These doctors were the epitome not only of scholarship but also of elitism. Those with moderate means were barred from pursuing medicine at Oxford and Cambridge, as were non-conforming Protestants and Roman Catholics. It took the Scottish medical schools in Edinburgh and Glasgow to break down the English citadel. In our times, the use of the title “doctor” by medical practitioners is a privilege granted by the community and the state, and has to be earned and sustained by open professional conduct. A closeted freebie of “a few glasses of Kooyong Pinot Noir and a good feed” is what most of the public perceives as doctors behaving badly, and it is perception that counts.

Martin B Van Der Weyden

Five months in Cambodia restored my perspective I knew very little about Cambodia before I landed at the airport in Phnom Penh. I imagined luminous green rice paddy fields, smiling brown faces, and the perfect antidote to my disillusionment with medicine after only 2 years working in the Australian public health system. My medical resident jobs had seemed to require more secretarial ability than clinical skills, and hours were lost begging for an urgent investigation or trying to secure an outpatient appointment within the next 6 months. I wanted to witness the power of basic medical treatment — to save lives with a course of penicillin, to save sight with a few doses of vitamin A. I had teamed up with a small Australian non-government organisation called Awareness Cambodia and agreed to take on the task of establishing an outpatient medical clinic in the rural province of Kampong Speu. I had 5 months in which to do it. The van ride into Phnom Penh from the airport was enough to trigger a surge of panic as I tried to digest a series of confronting images. A mother clutching her very young baby with one hand and, with the other, manoeuvring her motorbike through a sea of traffic; a barefoot boy with a swollen belly, his naked younger brother in tow, begging at a busy intersection; pre-pubescent girls in make-up and pyjamas loitering outside ramshackle wooden brothels. The brutal realities of living in a developing country hit me hard in the face. The next few weeks were spent doing the necessary groundwork around Phnom Penh and Kampong Speu, visiting the local hospitals and established clinics. From what I could see, a bed in a public hospital was no more than a bed in a cheap guesthouse. Only the intensive care unit had any equipment — a few oxygen tanks and perhaps one functioning cardiac monitor. To my horror, I discovered that it was not uncommon to use blocks of ice for postoperative analgesia (applied, for example, directly over a patient’s midline abdominal wound), and that, because of sheer lack of staff, the patient’s families performed almost all of the nursing duties. Hospitals run by foreign non-government organisations were so overloaded that patients would literally have to win a lottery to receive care in these hospitals. In the clinics I attended it was rare to see a doctor listen to a patient’s chest before prescribing three antibiotics for a chest infection, and intravenous (IV) drips were consistently the favourite therapy among Cambodians, who believed that they could cure anything from a headache to a sore toe. It was not unusual to see an IV pole protruding through the window of a passing car, or held up by a devoted parent as the family rode home on their trusty motorbike. In a corner of Phnom Penh, I discovered a network of pharmacies stocked wall-to-wall with the latest broad-spectrum antibiotics and a never-ending stream of patients buying them, without prescription. In the countryside, Western doctors had to compete with village doctors, some of whose remedies were like something out of a bad fairytale. A colleague told me that she asked why a child in one village had a glass eye and was told that the eye had been used in a concoction to cure the child’s mother of a serious illness. I personally remember a woman with scabies who was non-compliant with the standard topical permethrin treatment, opting instead to pour hydrochloric acid on her wounds to take away the itch. I faced different problems in my interactions with the government health centre that we planned to work with. The centre appeared to have all the fittings required for a clinic, including a wealth of power outlets, light fittings and taps, but there was no electricity or running water. Instead of being glad that we were providing doctors and free medicine, our initial proposal for a fortnightly outpatient medical clinic for the villagers in Kampong Speu province was met with hesitation because of fears that it would increase the workload of the health centre staff. As they only earned US$18 per month, out of necessity, they ran their own private clinics in the afternoon. We ended up having to supplement the government workers’ salaries before we were allowed to provide our free service to the villagers. To save myself from jumping on the next plane back to Australia I had to focus on small goals and achievements. I began to take pride in our clinic and the fact that when we examined patients we spent a good 10 minutes with them, instead of the usual 2 minutes. We checked people for anaemia with simple laboratory tests, and we gave them vitamin supplements and treated them empirically for worms — but it was a far cry from what I had imagined. The sickest patients, who needed our help the most, were the hardest to treat. A 21-year-old man with pancytopenia readily comes to mind. We referred him to the local hospital because he could not stand up and was bleeding from his gums. But his family could not afford the blood transfusions he needed, let alone the hospital costs and the further investigations required. He ended up relying on herbal remedies and died six weeks later. It was not uncommon to find families falling deep into debt trying to save their loved-ones, often to no avail. Other families would put their sick relatives in a hut on the outskirts of the village and leave them there to fend for themselves — out of sight, out of mind. Nothing was easy. If we decided to refer a patient to the local hospital or to Phnom Penh, we needed to spend the next few hours working out the logistics of finance for transport, meals, compensation for lost income, and a carer for the six or seven children left behind. Ethical dilemmas emerged on a daily basis. An elderly woman presented with fatigue and occasional per rectal bleeding and, on examination, was slightly pale. In Australia she would have been on the next colonoscopy list. In Cambodia this would mean a long trip to Phnom Penh to the only public hospital that performed colon-oscopies. But who was going to pay for the colonoscopy? And, more pertinently, what would we do if we found something? Was it ethical to submit an otherwise well 70-year-old woman to an abdominoperineal resection or partial colectomy when she might not survive the operation? Was it worth sending her family deep into debt? Or was it more ethical to treat her anaemia with iron tablets and improve her quality of life? Working in Australia was beginning to seem like a dream. But having said all this, I will never forget one woman’s smile as we helped to secure an operation for her granddaughter’s cleft palate, and I still treasure the bowed thanks from the villagers for making them feel better, if only by turning up every week, listening to their problems and giving them our time. My 5 months in Cambodia may not have unfolded as I expected, but I do not regret it. I learnt that I am lucky to live in a country where I, and my patients, have access to free health care and where I can practise medicine with the knowledge that there are good referral systems in place. I thought I would go to Cambodia and change people’s lives, but instead when I went there it changed mine. The experience gave me perspective, not only in my medical practice but in all aspects of my life. My time in Cambodia has helped me see an abundance of resources and opportunities that I couldn’t see before.

Melanie Cheng MB BS

Objective: To establish the extent to which sperm, oocyte and gonadal tissue collection and storage is offered to children newly diagnosed with cancer.Design, participants and setting: A cross-sectional survey of all paediatric oncology services in Australia and New Zealand (ANZ) in December 2005.Main outcome measures: Sperm, oocyte and gonadal tissue collection and storage practices at paediatric oncology services; comparisons with recently published North American practices and with current recommendations for best practice.Results: 12 of the 13 centres (92%) completed the survey. All centres offered sperm preservation, but only 10 (83%) offered oocyte/ovarian tissue preservation. Two centres were using gonadotrophin-releasing hormone analogues for fertility protection in postpubertal females. Five (42%) had offered fertility preservation to patients before the completion of their sexual development. All centres were more likely to offer sperm preservation than oocyte preservation for any given disease. The most common diseases for which conservation was offered were lymphomas and sarcomas. The anticipated cumulative dose at which centres elected to offer fertility preservation varied widely, both for the alkylator cyclophosphamide (any to 10 g/m2) and for abdominal/pelvic irradiation (any to 12 Gy) and spinal irradiation (any to 18 Gy). Fertility counselling was offered in a variety of settings by nine (75%) of the centres. Despite 11 centres (92%) agreeing that fertility preservation guidelines would be helpful, only two (17%) had guidelines in place.Conclusions: There are inconsistencies in the indications for and methods of gamete conservation in paediatric oncology centres throughout ANZ. Variations in practice on a background of unresolved medical, legal and ethical issues suggest the development of guidelines would be helpful.

John A Heath PhD, FRACP · Catherine J Stern MB BS, FRACOG

Hospitals will be particularly challenged when pandemic influenza spreads. Within the health sector in general, existing pandemic plans focus on health interventions to control outbreaks. The critical relationship between the health sector and other sectors is not well understood and addressed. Hospitals depend on critical infrastructure external to the organisation itself. Existing plans do not adequately consider the complexity and interdependency of systems upon which hospitals rely. The failure of one such system can trigger a failure of another, causing cascading breakdowns. Health is only one of the many systems that struggle at maximum capacity during “normal” times, as current business models operate with no or minimal “excess” staff and have become irreducible operations. This makes interconnected systems highly vulnerable to acute disruptions, such as a pandemic. Companies use continuity plans and highly regulated business continuity management to overcome process interruptions. This methodology can be applied to hospitals to minimise the impact of a pandemic.

Ralf L Itzwerth DipSoz · C Raina MacIntyre FRACP, FAFPHM, MAppEpi · Smita Shah MB ChB, MCH · Aileen J Plant PhD, MPH, FAFPHM

To the Editor: We recently read with concern the article by Scott and Ward on public reporting of hospital outcomes.1 While we do not want to enter into the debate about whether the public release of hospital performance reports is beneficial or harmful, we would like to address some issues relating to the accuracy of administrative data. The authors stated that “data are often [our italics] inaccurate, incomplete, or provide insufficient clinical detail” and that the “accuracy of diagnosis coding is vari-able”. They also mention the potential for “gaming” or “up-coding” by hospitals to make their institutions look better in public reports. We believe the authors’ argument regarding coding inaccuracies is flawed. One of the articles they cited was not about coding accuracy but about mortality differentials between metropolitan and non-metropolitan regions.2 Another cited article quoted an example of a 100% miss rate for coding of dementia as a comorbidity that was based on only three cases.3 As the authors later stress in their article, it is important that sample size be considered when interpreting data, to ensure that the effects of random error are minimised. We agree with the authors’ final point that distinguishing complications from presenting diagnoses (or comorbidities) is currently difficult using hospital coded data. However, the Victorian and Queensland hospital data collections now include an “alpha flag”, which is a letter attached to each coded diagnosis to indicate whether the diagnosis was present on admission to hospital or whether it arose during the episode of care. Moves are underway to introduce a minimum national requirement to use the alpha flag as one method of identifying complications arising from medical or surgical care. There are a number of national and state initiatives that aim to ensure the national morbidity data collection is as accurate as possible and that it provides data directly related to its purpose (and therefore not necessarily useful for other purposes). There is currently a national debate about the purpose of this collection. It is clear that there are issues surrounding the capture and coding of hospital data that are not well understood by data users. Because of that misunderstanding, reports such as the one by Scott and Ward paint an unjustifiably bleak picture of the quality of the data.

Kerry Innes · Kirsten McKenzie · Sue Walker

In reply: Innes and colleagues accuse us of overstating the potential inaccuracy of coded administrative data. They refer to state and national initiatives underway to ensure such accuracy, but offer no hard statistics that would reassure us that such data, in their current form, are as accurate as they need to be for purposes of quality monitoring and public disclosure. Until they do, we feel we have good reason to recommend caution in light of the few published Australian reports that are available (which we cited1,2), together with other research3 and feedback from clinical directors, about significant error rates when coded diagnoses are audited by clinicians or compared with independent datasets maintained by clinicians (Professor David Johnson, Director of Nephrology, and Dr Paul Garrahy, Director of Cardiology, Princess Alexandra Hospital, personal communication). In Queensland, formal regular audits on coding accuracy were initiated only in October 2005. They involve small numbers of randomly selected charts from each hospital and focus on specific coding issues identified for each hospital (Professor Stephen Duckett, Executive Director of Reform and Development, Queensland Health, personal communication). While we welcome (and were aware of) the introduction of “alpha flags” to distinguish in-hospital complications from pre-existing conditions, these remain a recent development (especially in Queensland), and others with considerable experience in their use express caution in interpreting results in the absence of rigorous validation.4,5

Ian A Scott · Michael Ward

Inequity in rural cancer survival in Australia is not an insurmountable problem: it is a test of our health systems Australia has lower cancer mortality rates than comparable nations like the United States, United Kingdom, Canada and New Zealand. However, there is increasing evidence that this success may be bypassing the 2.8 million Australians who live in rural and remote Australia.1-3 Indeed, the further from a metropolitan centre patients with cancer live, and adjusting for stage of presentation, the more likely they are to die within 5 years of diagnosis.2-4 Geographical isolation, a relative shortage of health care providers, and a higher proportion of disadvantaged groups such as Indigenous people are acknowledged to be contributing factors.3 How access to specific treatment and support services may explain the differences in cancer survival was a central question of the first national mapping of rural and regional oncology services, commissioned by the Clinical Oncological Society of Australia. The study showed that the availability of oncology services diminished as geographical isolation increased, and that quality and availability of services by location directly influenced survival rates. For all survey criteria assessed, service provision was measurably and significantly poorer in rural and remote centres than in benchmark metropolitan and large regional centres (see Box). Established rural and visiting oncologists, nurses and other cancer care professionals provide a vital service, but they are evidently stretched well beyond capacity. While much of the study’s findings are alarming, the data support our rationale for what we believe are achievable reforms to reduce the geographical inequity in cancer services. Access may not be the only explanation — some remote patients may, for example, choose not to have treatment — but there are ways in which access to quality care can be improved. The centrepiece of our recommendations is the establishment of Regional Cancer Centres of Excellence (RCCEs) in regions with a suitable population. These centres would provide multidisciplinary care, improve support and educational services and, by being mentored by major metropolitan centres, could provide a link to smaller, more remote services. They would also boost access to clinical trials and may provide a critical mass for technological platforms like positron emission tomography scanning. We have pragmatic evidence that RCCEs do work, through the success of a centre in Albury–Wodonga, a former outreach facility that now has five resident oncologists, a clinical trials unit and a two-machine radiotherapy service. Reported benefits include an increase in the number of new patients treated locally from 150 to 750 a year, an eightfold increase in chemotherapy day treatments, establishment of multidisciplinary clinics and more than 10% of new patients participating in a clinical trial.4 The Border Cancer Care Coordination Project, a pilot study funded by the Australian Government, with contributions from the Victorian and New South Wales governments, showed that a modest investment in expanding the Albury–Wodonga service has significantly improved the coordination of care and quality of experience for patients, carers and health professionals. The pilot study employed cancer care coordinators, an oncology social worker, clinical psychologists, a multidisciplinary meeting co-ordinator and a researcher. Information gathered through this project and reported to key stakeholders showed that patients across the wider catchment area were better able to access multidisciplinary care, regardless of their postcode, insurance status or whether they were treated in an acute or community setting. The best way to gradually roll out a network of similar centres is to build them where a radiotherapy unit is in place. Radiation oncology is essential to multidisciplinary cancer care. And, while it is costly in capital outlays and maintenance, and generally immobile, it is the most cost-effective in terms of operational cost versus efficacy.6 A number of non-metropolitan centres have radiotherapy units (Wagga Wagga, Wollongong, Albury–Wodonga, and units are soon to be operational in Coffs Harbour and Port Macquarie in NSW; Ballarat, Bendigo, Geelong and Latrobe Valley in Victoria; and Townsville, Tugun and Nambour in Queensland). There are plans for new units in Darwin, Toowoomba and the NSW far north coast. The combined population of these centres is more than 1.5 million, and an additional 700 000 people are estimated to live within a 150 km radius. Attracting two medical oncologists and a range of allied health service providers to each of these centres would provide a platform for a multidisciplinary team approach to patient care, and enhanced remote supervision by engaged clinicians. It would also be consistent with the Australian Medical Workforce Advisory Committee’s recommendations on practitioner-to-patient numbers. Moreover, a recent unpublished survey by the Medical Oncology Group of Australia showed a high proportion of medical oncology trainees would consider regional practice provided there was adequate support. While awaiting this longer-term solution, we also advocate structural reforms such as a national quality assurance framework (eg, service accreditation, and the use of clinical practice guidelines). Investment and improved innovation in delivering psychosocial support services and the coordination of government-funded travel and accommodation schemes are also required in the interim. Telemedicine is another flexible model that should be supported, as it has proven beneficial in reducing the impact of extreme distance.7,8 Distance education and mentoring are also proving effective.9 RCCEs would provide many of these improvements within their region. Inequity in rural cancer survival is not an insurmountable problem, but it is a real test of our health systems. Investment needs to be made now to deliver long-term benefits. The first step is recognising the extent of the problem and identifying practicable solutions. The second step will require a whole-of-government response. Mapping rural and regional oncology services5 — key findings Nationally, 21% of all 157 rural hospitals administering chemotherapy (RHACs) had a resident medical oncology service; 41% had access to a visiting service, with times of availability ranging from weekly to once in 6 months; 38% had neither a resident nor visiting medical oncology service, and this was more likely to occur as remoteness increased. Chemotherapy-trained nurses administered chemotherapy in 61% of RHACs Australia-wide. Chemotherapy was increasingly administered by people other than a chemotherapy-trained nurse, such as other nurses and general practitioners, as the remoteness of RHACs increased. Medical oncologists write most chemotherapy orders in 100% of benchmark metropolitan centres, but only 58% of RHACs reported that most orders are written by a medical oncologist. The degree of supervision and involvement by medical oncologists or haematologists is not always clear. 22% of RHACs had a dedicated palliative care doctor and 59% had dedicated palliative care nurses. 7% of non-metropolitan hospitals that reported administering chemotherapy had access to a radiation unit — a total of 11 radiation units for all 157 RHACs. Of the 26 available radiotherapy machines in regional centres, fewer than half (46%) were reported as fully staffed. Most RHACs provided access to allied health care services, but many reported long waiting times, out-of-pocket expenses or services restricted to inpatients. Multidisciplinary clinics were held in 43% of RHACs. Dedicated oncology counselling services were available at 39% of RHACs. 61% of all RHACs requested urgent access to psychological services and support; 65% indicated travel support was a problem for rural patients. Patient transport refunds were criticised in many returned surveys. Results from the two metropolitan centres and one large regional centre surveyed were used as a benchmark for comparison of service provision in RHACs.

Craig R Underhill MB BS, FRACP · David Goldstein MB BS, MRCP, FRACP · Paul B Grogan

Objective: To investigate the effectiveness of the Northern Territory Women’s Cancer Prevention Program in improving cervical screening participation for Indigenous women.Design: Descriptive longitudinal period prevalence study.Participants: All NT resident women aged 20–69 years who had at least one Pap smear recorded on the NT Pap Smear Register between 1997 and 2004.Main outcome measures: Indirectly estimated percentage of NT Indigenous women in rural and remote areas with a predominantly Indigenous population (accounting for 55% of the NT Indigenous population) who participated in screening, in biennial periods between 1997 and 2004. Participation by all eligible NT women (both Indigenous and non-Indigenous) is also reported by region for the same period.Results: In 1997–1998, estimated participation for Indigenous women was about half the national rate (33.9% [95% CI, 32.6%–35.2%] v 63.9% [95% CI, 63.8%–63.9%]). Participation increased to 44.0% (95% CI, 42.7%–45.4%) in 1999–2000, and changed little thereafter; participation was higher in the Top End compared with Central Australia, and varied from 16.6% to 75.0% between remote areas. Participation rates for all women living in rural/remote regions were lower than those in urban regions.Conclusions: Recruitment of Indigenous women for cervical screening has improved since 1999. This may have partly contributed to the fall in their cervical cancer incidence and mortality in recent years. Although in most areas Indigenous participation is lower than national levels, in one area it was considerably higher. Improvements can be achieved by learning from these communities, to further close the gap in morbidity and mortality between Indigenous and non-Indigenous women.

Philippa L Binns FRACGP, MAppEpid · John R Condon FAFPHM, PhD

To the Editor: Quality data about patients with injuries requiring hospitalisation is vital to injury policy and prevention strategies.1 The ICD-10-AM is used in Australia to assign codes to diagnoses, procedures, and causes of injury recorded in patient medical records.2 This coded hospital morbidity data provides a key surveillance tool for injury researchers. ICD classifications are designed for statistical reporting and are required for classifying all information encountered in hospital medical records. When insufficient information is available in the medical record to assign specific codes, the use of residual “Unspecified” categories helps to achieve this. Detailed and accurate documentation provided by clinicians in patient medical records is imperative to produce high quality coded data.3 Poor documentation in medical records has been shown to decrease data quality by contributing to an overuse of “Unspecified” codes.4 This is especially so for documenting external cause of injury, which may not be seen as critical to the patient’s care by the treating clinician, with the result that the relevant detail is incomplete or omitted altogether. We aimed to identify the level of precision of coded injury data in Australian hospitals. Using the 2003–2004 national morbidity dataset, 445 098 records containing an injury and an external cause classified by intent were found (Box). At a broad intent level, the majority of injuries were assigned to a specific mechanism code, although in two intent categories, “Accident” and “Assault”, 11% and 13% of injuries, respectively, were assigned to “Unspecified” categories. It is concerning that 45 297 of the injuries requiring hospitalisation lacked adequate documentation in the medical record to permit meaningful code assignment for cause of injury. A significant lack of precision was evident in recording mechanisms of accidental falls and poisonings (across all intents). A quarter of falls and 20% of poisoning cases had no specific information about the causal mechanism or substance. Being the most commonly reported accident mechanism, falls of unspecified cause represented 11% of accidents overall. This lack of detail is particularly concerning given the significant national priority now placed on falls and poisoning injury prevention.5 It is essential that clinicians and coders alike are aware of documentation and coding problems related to capturing data on cause of injury. By working together to improve the quality of injury-related coded data (through improved clinical documentation), accurate and comprehensive information pertaining to the circumstances surrounding injury events requiring hospitalisation will benefit injury policy and prevention initiatives. Precision of recorded cause of injury data across selected ICD-10-AM categories2 for 2003–04 ICD-10-AM categories Specified Unspecified Total Intent Accident 347 781 (89.2%) 42 078 (10.8%) 389 859 Intentional self-harm 29 018 (99.6%) 130 (0.4%) 29 148 Assault 19 385 (87.2%) 2 841 (12.8%) 22 226 Undetermined intent 3 617 (93.6%) 248 (6.4%) 3 865 Total 399 801 (89.8%) 45 297 (10.2%) 445 098 Mechanism Accidental falls 130 089 (74.6%) 44 336 (25.4%) 174 425 Poisoning (all intents) 31 111 (80.0%) 7 798 (20.0%) 38 909

Kirsten McKenzie · Leith F Harding · Susan M Walker · James E Harrison · Emma L Enraght-Moony · Garry S Waller

Making health services more available to and appropriate for Australian men The 6th National Men’s Health Conference, held in Melbourne in October 2005, incorporated the 4th National Aboriginal and Torres Strait Islander Male Health Convention. Since 2003, the Australasian Men’s Health Forum — a not-for-profit peak body for individuals and organisations working with men and boys and their health and social issues, and the organising body of the biennial national conferences — had already been working collaboratively with the organisers of the National Aboriginal and Torres Strait Islander Male Health Convention. As a nation, we need to support Indigenous men, whose health is the poorest of all male population groups in Australia. Over the years of collaboration, it became apparent that the more holistic view of health that Indigenous men hold, as part of their cultural inheritance, could potentially benefit all Australian males. In 2005, a lack of national funding for the Indigenous Male Health Convention prompted a combined event with the National Men’s Health Conference, with some joint sessions and some sessions for Indigenous men on their own. This structured sharing led to an even greater empathy and understanding of the similarities and differences in Indigenous and non-Indigenous men’s health. The combining of the two conferences also enabled the National Men’s Health Conference to further broaden its perspective. Men’s health conferences in Australia have always taken a broad view of health. This is in contrast to international men’s health conferences, which have tended to have an almost exclusive focus on clinical dimensions — the prostate and erectile dysfunction featuring prominently — perhaps reflecting the funding sources of these conferences (World Congress on Men’s Health and Gender; Vienna, Austria <http://www.wcmh.info/>). Although important, a clinical perspective, if focusing too narrowly on disease and malfunction, can miss crucial dimensions, including psychosocial, spiritual and underlying political dimensions. Suicide, for example, is a major issue in men’s health, notably in Australia where, on average, five men a day kill themselves.1 For us to begin to understand and deal with this phenomenon adequately requires social and political perspectives, as well as clinical understanding. The Melbourne conference kept this broad focus on health, as well as the treatment of disease, with sessions on fathering, ageing men and gay men. From keynote addresses by international speakers, insights were gained into male-directed health services in Scotland (Mr Jim Leishman, the Men’s Health Service Coordinator, Northern Health Service, Forth Valley, Scotland — Developing services for men: the Scottish experience) and the building of a national men’s health policy in Ireland (Mr Noel Richardson, Coordinator of National Policy for Men’s Health, Ireland, and Dr Paula Carroll, Health Promotion Department, Irish Health Service Executive — Getting men’s health onto a policy agenda: setting a context to the development of a national policy for men’s health in Ireland.) The lack of a national men’s health policy in Australia was addressed by Micheal Woods in his paper, Dying for a policy: men’s health in Australia. The need for a national men’s health policy was also mentioned in the conference’s opening address, given by Dr Mukesh Haikerwal, President of the Australian Medical Association (AMA), whose presence was an indication of the growing acceptance in the medical profession of the need to consider male-specific issues in health. Of the states and territories, only New South Wales has a men’s health policy, and the AMA committed itself to a “round table” on the need for such a national policy. This has since taken place, and a position paper on men’s health has been issued.2 During the conference, Indigenous men launched the National Framework for Improving the Health and Wellbeing of Aboriginal and Torres Strait Islander Males (available from: Ms Jill Turner, Social Health, Health Strategies Branch, Office for Aboriginal and Torres Strait Islander Health, Jill. TurnerAThealth.gov.au). One of the main underlying themes of the conference was to question the assertion that poor health outcomes of men are a result of assumed “bad” male behaviour — typified by statements such as “Men don’t use doctors enough”, and “Men don’t get in touch with their feelings” — and to shift the focus to asking further questions such as: How can we make health services more available to and appropriate for Australian men? (Box 1). The effort to make services more “male friendly” was evident in many of the presentations (Box 2). Further initiatives in this direction would be welcome at the 7th National Men’s Health Conference, to be held in conjunction with the 5th National Aboriginal and Torres Strait Islander Male Health Convention, in South Australia in 2007, supported by the SA Health Department. In Melbourne, we had 303 delegates, including 75 Indigenous men. We look forward to having you join us next year at an even bigger gathering of all those with an interest in men’s health (Conference contact: Greg Millan, Conference Development Officer, Australasian Men’s Health Forum, gmillanATbigpond.net.au). 1 Where do I fit in? Created by Greg Gaul (reproduced with permission of Men’s Health Information and Resource Centre, University of Western Sydney). 2 Examples of presentations about “male-friendly” health service delivery Wow I’m a Dad. Development of a booklet for first-time fathers Alan Grochulski, Royal North Shore Hospital (booklet co-authored by Salih Ozgul) Indigenous men’s health and wellbeing — “there’s more than just football”. The Royal Flying Doctor Service Mental Health Program Brod Osborne and Johnathan Link, Royal Flying Doctor Service, Far North Queensland Driving to good health — commercial drivers encouraged to “think about it” Fiona Landgren, Clare Burns, Communicating for Health Building capacity for health promotion at Fairfax — a case involving the Men@Work Program Nick Petrunoof, John Fairfax Holdings Ltd HealthBreak: Sleep Safe–Work Smart–Health Program Howard, Lehrke, Wilson, Institute for Breathing and Sleep

John J Macdonald DipCD, Med, PhD · Greg Millan ADip Social Work · Mick Adams PhD Student

Objective: To identify sociodemographic factors associated with help-seeking behaviour for reproductive health disorders in middle-aged and older Australian men.Design: A cross-sectional, population-based, computer-assisted telephone interview exploring sociodemographic factors and general and reproductive health.Participants and setting: Analysis of data from the Men in Australia Telephone Survey (MATeS) of 5990 Australian men aged 40 years and older interviewed between September and December 2003.Main outcome measures: Self-reported diagnosis of prostate disease and erectile dysfunction (ED), help-seeking behaviour (including visiting a doctor, prostate-specific antigen testing, treatment of prostate disease, speaking to a health professional about ED and treatment of ED).Results: Age was a significant predictor of all help-seeking behaviour studied, other than treatment for ED. Controlling for all predictor variables, never-married status predicted a lower likelihood of visiting a doctor (odds ratio [OR], 0.68 [95% CI, 0.48–0.97]) or speaking to a health professional about ED (OR, 0.44 [95% CI, 0.21–0.93]), while divorced/separated status predicted lower likelihood of having a prostate-specific antigen test (OR, 0.63 [95% CI, 0.50–0.79]). Living in a regional or remote area or being from a non-English-speaking background predicted lower likelihood of receiving treatment for ED (ORs, 0.62 [95% CI, 0.42–0.92] and 0.41 [95% CI, 0.24–0.72], respectively), but did not influence screening for prostate disease.Conclusion: Seeking advice or treatment for male reproductive health disorders is predicted by sociodemographic factors specific to different reproductive health problems. As middle-aged and older men do attend doctors, opportunities exist for health professionals to optimise their consultations by routinely discussing reproductive health with all men, to identify under-reported male reproductive health disorders.

Carol A Holden PhD · Damien J Jolley MSc(Epidemiol), AStat · Robert I McLachlan MB BS, PhD · Marian Pitts PhD · Robert Cumming PhD · Gary Wittert MB BCh, PhD · David J Handelsman MB BS, PhD · David M de Kretser MB BS, PhD