Health services administration

With united, sustained action, general practice organisations and practitioners can help stop our men dying or “diseasing” too early What is it with men’s health? Ten years ago, men’s health nights in pubs were all the go. Now we don’t even have those. There’s the occasional event or TV item, but always a one-off. Women’s health researchers, practitioners and advocates get lots of resources and publicity, and good on ’em. But men are still dying too early from stuff that can be prevented. (Anonymous man, Daylesford, Victoria, 2006) As National Convenor of GPs4Men, the Australian General Practitioners’ Network for Men’s Health, I hear occasional comments like this from patients I see in my full-time rural general practice. Recently, I have run into colleagues who, noting the absence of men’s “health bites” in the media, ask if I’m still involved. My answer is “yes, but differently”. “Spare” time previously spent on activities with GPs4Men, particularly liaison with members, has been leached away by work on the Royal Australian College of General Practitioners’ (RACGP) position statement on men’s health (to match the 1997 position statement on women’s health), now endorsed and available on online,1 and the ongoing RACGP men’s health curriculum review. GPs4Men was founded in 2003 in response to the lack of policy and funding for men’s health on a national level. Australia still has no national men’s health policy, despite the existence of a women’s health policy since 1989. It would be naïve to suggest that simply developing a policy would be sufficient to deal with all the challenges of men’s health — policy without adequately funded programs = “piffle”. Yet, for those of us involved in men’s health, there remains an overwhelming desire to see a formal acknowledgement by the federal government (whether a policy, position statement or other document) of the broad and unique issues of men’s health, and a preparedness to fund a national program to address these issues. I wonder whether the government’s problem might be that the problem seems “too big”. A multiplicity of interest groups — including sociologists, “masculinists”, “men’s shed” workers, community nurses, endocrinologists, GPs, urologists, social workers and educators — all hold valid points of view. But has this very diversity led to an apparent government standstill due to “overload”? Whatever the reason, GPs simply must do something about Australian men’s health. The recent RACGP health inequalities study clearly demonstrated the appallingly high mortality rates for men compared with women across the socioeconomic spectrum.2 Notably, it showed that: the mortality rate for 25–64-year-old men in the most socially advantaged group of the population was higher than that for 25–64-year-old women in the most socially disadvantaged group; and men in the most socially disadvantaged group had a mortality rate nearly double that of the most socially disadvantaged women. Further, there can be no argument that groups of men — Indigenous men, war and service veterans,3 and men affected by poverty — are at high risk of health problems and have specific medical needs. At present, the federal government’s response seems to be to restrict funding largely to men’s sexual health programs — based, presumably, on the unassailable assertion that testes and prostates are unequivocally male. The problem with this approach is that it ignores key issues; not only the stark statistics, but also the differences between how men and women view their bodies (especially in dysfunction), and in how they use the health care system. The major recipient of federal funding in men’s health ($4 million over 4 years) — the male reproductive health centre, Andrology Australia — runs excellent community and medical education programs. However, it is beyond this organisation’s terms of reference to tackle the crucial issue of men’s underuse of the health care system. It would again be simplistic to suggest that simply finding ways of bringing men into more effective contact with GPs would solve the problems of men dying or “diseasing” too early. Many other issues also demand attention, from men’s involvement in pregnancy and postnatal depression, to masculinity issues in schools and the workforce, to addictions, to social isolation and relationship problems. Nevertheless, bridging the chasm between GPs and their potential male patients is crucial, as GPs are the key providers of primary health care. Marketing health to men needs to be viewed as a crucial and do-able component of any worthwhile campaign to improve men’s health. Such marketing is too important to just be left in the hands of a group of enthusiastic health professionals. Men’s health needs the sort of marketing expertise used by those who are intent on persuading teenagers to smoke. It should be sustained, professional, well funded and be driven by clear goals. Men’s health is also desperate for high-profile sustained support. The Prime Minister’s newly appointed obesity ambassadors, Harry Kewell and Kieren Perkins, should have their portfolios enlarged to encompass the broader issues of men and their health. We need the support of influential figures like the Prime Minister and the Minister for Health to achieve this. Their early morning walks and bike riding, respectively, serve as excellent examples for Australia’s men. The membership of GPs4Men (of about 70 individual GPs and almost a third of the 118 Australian Divisions of General Practice [ADGP]) believes that it is the responsibility of the GP Reference Group organisations — the RACGP, the ADGP, the Australian Medical Association (AMA) and the Rural Doctors Association of Australia (RDAA) — to make a joint submission to our federal government for a federally funded men’s health program that puts into action a men’s health policy. It is up to those who fund health care to find ways of taking Australia’s overworked GPs to where men are more comfortable using their services, especially the workplace. It is up to those who deliver health care to identify the best way forward. Not only united but also sustained effort will be required from general practice organisations. The AMA produced a position statement on men’s health in 2004,4 but has since seemed to move on to other priorities. The RACGP has had a Women’s Health Taskforce since 1997; surely it is time for the college to have an active Men’s Health Taskforce. The ADGP is moving slowly towards greater activity in men’s health, with a session dedicated to men’s health at its upcoming national forum on the Gold Coast in November this year. Many GPs and Divisions would respond to local needs for men’s health programs, but cannot because of lack of funding. The RDAA has also expressed its broad support for men’s health; understandably so in the light of the dire state of rural men’s health. In the absence of any structural or funded initiatives, there is still much being done and that can be done in general practice. All GPs (and possibly all medical practitioners) should consider how they can increase the uptake of their services by the “unreachable” group — 30–60-year-old men. I believe that general practice has some way to go before we can feel satisfied with how we market health to our male population. “Man-friendly” appointment systems and consulting times with after-work times and more on-the-day appointments, waiting rooms, and reception staff are key parts of a “whole-of-practice” approach, as are outreach services to workplaces and other venues. Similarly, a “whole-of-consultation” approach involves offering options to the men we do see which take into account the fact that many men prefer a more physically-based approach to lifestyle prescription, and may require specific direction about follow-up. Community resources which meet men’s exercise needs are often lacking. For many men, a trusting relationship with a personal physician or practice is built over a series of consultations. Australia’s men, our women’s and men’s groups and our GPs believe that men’s health is much more than sexual health — this is not the case in much of the developed world. We therefore have a great opportunity to lead the world, or at least to share the lead in the important area of men’s health.

Gregory O Malcher DObstRCOG, DCH, FRACGP

Australians look forward to dividends from increased funding Despite our relatively small population, Australia has made an impressive global impact in health and medical research (HMR). Our research output is twice the Organisation for Economic Co-operation and Development (OECD) average on a per capita basis,1 with high international visibility by citation,2-4 and Australia boasts five Nobel Prizes in Physiology or Medicine. HMR is a “golden egg”. Its consequences — disease prevention, improved longevity and quality of life — reduce hospital admissions and stays, and contribute to both workforce productivity and wealth creation. Examples of outstanding success in Australian translational HMR include Frazer’s cervical cancer vaccine, Cade’s use of lithium for treating bipolar disorder, Clark’s bionic ear technology, and Marshall and Warren’s unravelling of the role of Helicobacter pylori in peptic ulcer. The Access Economics report commissioned by the Australian Society for Medical Research in 2003 put figures on the value of the golden egg: every dollar invested in health research and development (R&D) yields an average annual return of $5.5 Despite these successes, and the Australian Government’s visionary legislation for a 6-year phased-in doubling of the National Health and Medical Research Council (NHMRC) budget enacted in 1999, Australia has slipped down the OECD ladder in terms of government spending on health R&D (this was 0.12% of gross domestic product [GDP] just a few years ago, compared with the OECD average of 0.2%).1 Many of Australia’s best and brightest health and medical researchers, judged by their peers to be in the top 10% internationally, have been missing out on NHMRC Fellowship support (almost 35% of applicants scoring in the “excellent” category were not funded in 2005). Moreover, without further increased HMR spending, projections indicate that success rates for Fellowships would fall by a further 50% by 2011, with project grant success rates dropping from 21% in 2006 to 8%–9% in 2011. This 5-year scenario, however, was averted in the May federal budget when the government allocated an additional $905 million for HMR. This injection was universally applauded and includes $670 million to be administered by the NHMRC, made up of $500 million over 4 years for research grants, and $170 million for Australian HMR Fellowships which will run over the next 9 years supporting 50–65 outstanding researchers over 5-year terms. The $500 million for grants will be incorporated into NHMRC’s base allocation for research, increasing this from $420 million in 2006 to over $700 million by 2010. The NHMRC will continue to serve as the main administrator of these funds, as it should, for transparency and equitable distribution based on peer review. The remaining $235 million earmarked in the federal budget for HMR will support adult stem-cell research ($22 million) and infrastructure and capital works programs shared among 17 research facilities nationally ($213 million). This is on top of the $200 million in infrastructure provided to institutes last year, builds on Wills’ Strategic review,2 and is the government’s response to the 2004 Grant Investment review.1 The NHMRC has now become a statutory agency. This development strengthens its independence and facilitates clear lines of responsibility for governance and financial accountability. Increased funding coupled with this restructure provides a key opportunity for the NHMRC to improve HMR outcomes through new strategic initiatives, wide-ranging stakeholder consultation, organisational resource-building, and articulating its vision and plan early in its triennium. A recent editorial in the Journal suggested that much of the NHMRC’s success under the new governance structure would be dependent on effective leadership by the new Chief Executive Officer (CEO), who now reports directly to the Health Minister.6 The NHMRC’s new CEO is Warwick Anderson, past Head of the School of Biomedical Sciences at Monash University, and its Chair is Michael Good, Director of the Queensland Institute of Medical Research. In April last year, Anderson described 10 challenges for Australian HMR, which included the capacity to respond rapidly to national and international health needs, improving collaborative links, enhancing our strong record of discovery-based research, and developing a more “wide and deep” workforce.7 Effective change will require a fresh look at policy by the NHMRC and all levels of government, for example, by (i) encouraging increased private sector investment from sources “outside the square” (eg, health and superannuation funds, life insurance companies), possibly through tax incentives; (ii) expanding established schemes (ie, development grants) for increased leverage of non-government monies; (iii) greater recognition of high-performing “David” (rather than “Goliath”) research organisations, that may be embedded in universities and hospitals, with adequate infrastructure support; (iv) restoring faith in career structure for the nation’s best health and medical researchers (eg, narrowing the growing gulf between Career Development Awards and Fellowships; providing local allowances for Fellows just as allowances are provided to C J Martin overseas postdoctoral Fellows depending on location; and encouraging more clinician–scientist researchers into the sector); (v) increased state government support of HMR, building on local strengths in technology and innovation (eg, “Smart State” and “Health Futures” initiatives); (vi) ensuring Australia’s record of groundbreaking fundamental research is not compromised by the “translational (applied research) wave”; and (vii) ensuring health services and population health research continue to develop in capacity and quality, as these will be increasingly relied on as the population ages and socioeconomic differentials widen. The longer term needs to be in our sights, and we should be mindful of sustainability in the post-2010 era, particularly if issues arising from the now complete doubling of the United States National Institutes of Health budget are any guide.8 This is true of the Australian HMR Fellowship scheme, which will attract top scientists (including the most senior NHMRC Fellows, presumably drawing more junior Fellows into the existing scheme), yet the program’s fate is unclear after individual terms. Moreover, even with increased HMR investment, which starts with a modest (around 5%) increase in 2007, the NHMRC has received close to 30% more applications for project grants this year compared with 2005, which may negatively impact on success rates, and mean missed opportunities for knowledge, health and wealth creation unless additional funds can be sourced for 2007. This becomes more of a concern in the current evaluation round, despite commendable intentions of improving efficiency and reducing “reviewer fatigue”, given the absence of external peer review or the opportunity for applicant rebuttal. Mechanisms of perpetually increasing funding for HMR should therefore be explored and debated. This could include indexing the HMR budget to the health budget or the OECD average for government HMR funding. Investment in HMR is vital and should be an ongoing priority for any government in the developed world. Greater funding will help Australian researchers build on previous gains, and turn both curiosity-driven and priority-driven knowledge into new medicines and treatments, with flow-on health, social and economic returns nationally and abroad. We are opening an exciting new chapter in Australian HMR and I can’t wait to turn the pages.

Levon M Khachigian PhD, DSc

Objective: We aimed to assess the pattern of use of drug-eluting stents (DESs) in patients undergoing percutaneous coronary interventions (PCIs) in Victorian public hospitals.Design, setting and patients: Prospective study comparing the use of one or more DESs versus bare-metal stents (BMSs) only, in consecutive patients undergoing 2428 PCIs with stent implantation from 1 April 2004 to 31 December 2005 at seven Victorian public hospitals.Main outcome measures: Adherence to current Victorian Department of Human Services guidelines which recommend DES use in patients with high-risk features for restenosis (diabetes, small vessels, long lesions, in-stent restenotic lesions, chronic total occlusions and bifurcation lesions).Results: Of the 2428 PCIs performed, at least one DES was implanted in 1101 (45.3%) and BMSs only were implanted in 1327 (54.7%). In 87.7% (966/1101) of PCI with DESs, there was at least one criterion for high risk of restenosis. DESs were more likely to be used in patients with diabetes (risk ratio [RR], 2.45; 95% CI, 2.02–2.97), small vessels (RR, 3.35; 95%CI, 2.35–4.76), long lesions (RR, 3.87; 95% CI, 3.23–4.65), in-stent restenotic lesions (RR, 3.98; 95%CI, 2.67–6.06), chronic total occlusions (RR, 1.30; 95% CI, 0.51–2.88) and bifurcation lesions (RR, 2.23; 95%CI, 1.57–3.17). However, 66.2% (1608/2428) of all PCIs were in patients eligible for DESs according to Victorian guidelines, and in 39.9% (642/1608) of these PCIs, a BMS was used.Conclusion: In Victorian public hospitals, DESs have been largely reserved for patients at high risk of restenosis in accordance with Department of Human Services guidelines. However, many patients with high-risk criteria for restenosis did not receive DESs. Greater use of DESs in these patients may improve outcomes by reducing the need for repeat revascularisation.

on behalf of the Melbourne Interventional Group (MIG) investigators

Complex societal factors unrelated to evidence of efficacy influence the increasing use of complementary and alternative therapies, which can be viewed as one form of health consumerism. The “therapeutic footprint” is a conceptual model that “plots” medical therapies and complementary and alternative therapies in relationship to one another and to their levels of risk and supporting evidence, acknowledging that medical therapies also entail risks. Philosophies about management of risk and adverse effects differ between complementary and alternative therapies and standard medical care, due to fundamental differences between professionalism within medicine and the demands of health consumerism. In standard medical care, patients’ risks are mediated prior to treatment via the doctor–patient relationship and informed consent. With complementary and alternative therapies, protection mechanisms for consumers come into effect mainly after a problem has occurred. Understanding this difference helps doctors whose patients are using complementary or alternative therapies to define the boundaries between these therapies and professional medicine and provide appropriate disclosure of risks. Discussing complementary and alternative therapies and how they differ from standard medical care can provide opportunities to explore patients’ concerns and improve the therapeutic relationship.

Christine R Sanderson BM BS, MPH, FRACP · Bogda Koczwara BM BS, FRACP, MBioethics · David C Currow BMed, MPH, FRACP

Strategies to close the gap between development and implementation of guidelines In the past decade, evidence-based clinical guidelines have become a major feature of health care. Researchers and clinicians in many countries have established programs to summarise the evidence for managing specific health problems and to disseminate practice guidelines. However, clinical use of guideline recommendations does not necessarily follow. Numerous studies show that recommendations are frequently not applied in practice and that many patients do not profit from evidence-based insights.1 Large variations in performance between clinicians, practices and institutions are commonly observed. Two reports in this issue of the Journal (Bryant et al and Irving et al) illustrate this well.2,3 In the first, an audit in a hospital outpatient clinic showed that large numbers of patients with diabetes do not achieve recommended treatment targets for control of glycaemia, blood pressure and lipid levels, despite evidence that control of these risk factors produces better outcomes.2 The second, a study of six Australian dialysis units, showed that, despite high levels of awareness of iron guideline recommendations in participating units, there is considerable variation in achievement of targets and widely differing practices in unit processes for iron management.3 Guidelines are expensive — the cost of producing a single guideline may range from US$50 to US$500 000, not to mention the substantial donated time from many contributors.4 Given the lack of practical impact of many clinical guidelines, a critical observer might well ask, “Why spend so much money and effort on something that is so poorly adhered to in practice?” However, the question should really be, “What can we do to increase the use of best evidence guideline recommendations?” Guideline developers, research funders, health care managers and policymakers may need to consider a few key strategies: the need for greater focus on producing guidelines in formats that promote their use; the requirement for planned (and funded) implementation programs that take into account the complexity of change in health care; and the need to improve our knowledge about cost-effective methods of achieving sustained practice changes. Worldwide, many guideline developers give little consideration to the use of their products in the real world. The reality is that guidelines are too often “lost in translation”.5 Many current programs for guideline development seem to be “science-driven”, rather than scientifically based but “customer-driven”. Guideline developers would do a far better job if they focused on the needs of the end user and provided clear statements, decision aids, patient education materials and practical tools to manage difficult problems in practice. More guidelines need to identify specific evidence-based indicators and criteria for clinical performance (as the guidelines discussed in this issue of the Journal do). These provide the capacity to monitor performance and give feedback to clinicians. Public reporting of significant aspects of care quality would help meet the urgent need in society for more transparency about important aspects of health care provision, and would provide a clear imperative to improve implementation and ensure guideline recommendations are feasible and do not become outdated. There is also a need to seek a better balance between the resources devoted to summarising evidence and developing guidelines and those spent on finding the most effective ways to improve patient care. Evidence-based guideline development reflects just one specific approach to improving care — it assumes that professionals are rational decisionmakers who will act on convincing information about the pros and cons of specific routines. Most of the time, effective change in health care demands other models, ranging from those that emphasise patient involvement in decision making to those that focus on organisational development.6 Sadly, good evidence for the cost-effectiveness of many of these strategies aiming to change practice is lacking.6-8 Greater investment by research funders in studies that would improve this knowledge base would help direct implementation resources and effort to where they could be of most use. Policymakers who seek to change health care practices need to understand that some current expectations about the impact of clinical guidelines are unrealistic. A belief that developing and disseminating systematic reviews and guidelines will improve patient care ignores the complexity of change in health care. Guidelines do not implement themselves — most need well developed, well executed and sustained implementation programs,7 and even such programs usually have only a moderate effect on performance in terms of care improvement (around 8%–10%).8 Many factors play crucial roles in blocking or stimulating relevant changes in performance. These are not only related to professional decision making, but also to patient behaviour, interaction with colleagues, team functioning, organisational conditions for change, resources, and economic or legal conditions.7,9,10 This aspect was clearly demonstrated in the renal impairment study.3 For most complex changes in health care, we need to build bridges between the different approaches to better care — guidelines, performance indicators and feedback; patient empowerment; quality management; organisational change; improving culture, teamwork and leadership in the workplace; and creating the necessary financial incentives.6 So, with a change of focus in current guideline development and more realistic expectations of the role of guidelines in improving patient care, with better knowledge about costs and effects of change strategies, and with clinical guidelines embedded in comprehensive programs for change, evidence-based guidelines for clinical practice may become more relevant in the future.

Richard Grol PhD · Heather Buchan MB ChB, MSc, FAFPHM

There is a desperate need for effective mental health services for prisoners and ex-prisoners Deinstitutionalisation in Australia has seen the number of public and private psychiatric hospital beds fall from 30 000 in the early 1960s to 8000 today. The population of Australia doubled during this time. There is no doubt that many people with serious mental illness are not being managed well in the community.1 Some mental health researchers,2-4 as well as the popular press, argue that there has been a recent related transmigration of people from psychiatric beds to remand centres (which house prisoners who have been charged with an offence but not yet convicted) and prisons. Australian remand centres often contain more seriously mentally ill people than general hospital mental health inpatient units. However, it is unclear whether the apparent rise in prevalence of mental illness among prisoners reflects a genuine increase or an improvement in detection rates. Statistical modelling of the effect of deinstitutionalisation on the number of prisoners with mental health problems is fraught with methodological challenges and the absence of longitudinal data.5 This debate has tended to overshadow other major areas of concern about mental illness among prisoners.6 As Herrman et al pointed out 15 years ago, whatever the cause, services for people with mental illness in Australian prisons are inadequate and in need of urgent reform.6 On 30 June 2005, there were 25 353 people in prisons in Australia. This represents an overall imprisonment rate of 163 per 100 000 adults, although there was considerable variation between states. The average age was 34.5 years (with 20.2% aged under 25 years); 6.8% were women; 22.2% were Indigenous people (the Indigenous imprisonment rate was 2021 per 100 000); and 60.4% had been in prison previously. In Queensland, the Department of Corrective Services estimates that the custodial population will increase by 90% over the next 10 years. Australian and New Zealand studies have shown that many people involved in the criminal justice system have had psychiatric contact before entering the system. Prevalence rates for all psychiatric morbidities in the prison population are markedly higher than rates in community samples.6-14 This is particularly evident for substance misuse, with up to 80% of remandees and prisoners dependent on alcohol, cannabis or amphetamines before entering prison.6,7,12,14 However, few published studies allow direct comparison with rates of psychiatric morbidity in community populations. Butler et al9 compared the 12-month prevalence rate for prisoners in their survey to the results of the National Survey of Mental Health and Well-Being, a community-based survey. Prevalences of psychiatric disorders in prisoners were more than double those among people living in the community (Box). Studies in remandees have found prevalences of psychotic illness, such as schizophrenia, ranging from 5.1% to 9.6%.10,13 By comparison, in the general community, the 1-month prevalence is 0.5% for psychosis and 0.3% for schizophrenia.15 Other Australian and New Zealand studies of prisoners have found prevalence rates of between 25% and 50% for non-psychotic disorders such as major depression, anxiety disorders and post-traumatic stress disorder.6,8-10,12 Ex-prisoners also have an increased relative risk of mortality. Death from all causes in some groups was found to be 17 times higher than in the general population in the 2 weeks following release.16 The main causes of excess death are associated with drug and alcohol misuse. These deaths have been cited as an indicator of the poor mental health of prisoners. The experience of release may present an additional challenge to prisoners’ mental health and wellbeing, particularly in the absence of ongoing support. Despite these high morbidity and mortality rates, treatment services for prisoners and ex-prisoners are very limited and often ineffectual. This makes little sense, even from a criminal justice perspective, as comprehensive services can delay or prevent recidivism in mentally ill offenders.17 In February 2006, the Council of Australian Governments (COAG) announced a major reform of mental health services in Australia.18 In April 2006, the Prime Minister announced the Australian Government would commit $1.8 billion over 5 years to this reform. In July 2006, COAG released a National Action Plan on Mental Health, to be supported by a total federal, state and territory government commitment of almost $4 billion over 5 years.19 While only some of the funding announced at COAG by the states and territories is new funding, there is a clear commitment by governments to improve the state of mental health services in Australia. As COAG reforms bind all government agencies, they bring with them the opportunity to improve services in all the relevant government departments in order to provide the range of health, housing and community services needed by people with mental illness. This must include improved and expanded prison mental health services, court diversion programs, and well resourced inpatient and community forensic services that link mental health, judicial and correctional services and provide specialist pre-release assessment, consultation and liaison for clinical managers. Diversion from the criminal justice system of mentally ill people who have committed minor offences is one of the few opportunities for community-based prevention. Access to stable housing and to appropriate vocational rehabilitation services is essential for functional recovery. All of these programs will need specially trained and supported mental health and custodial personnel, including psychologists, psychiatrists and specialist case managers. Adequate training of other personnel involved, such as court and police staff, is also necessary. Thus, crucial to the success of the COAG package will be necessary workforce reforms. Forensic and prison mental health services are target areas for the COAG National Action Plan. However, drafting and funding an action plan is one thing; turning good intentions and money into better services is another, much harder task. To know whether services are improving, we will need public reporting of specific performance indicators, which are currently being developed. In time, the data may be able to tell us whether the historical deficiencies in care for people disadvantaged by both mental illness and involvement in the criminal justice system are at last being addressed. Comparative prevalence of psychiatric disorders in prisoners and in people living in the community9 Prevalence Disorder In prisoners In community Any psychiatric disorder 80% 31% Psychosis 7% 0.7% Affective disorder 23% 9% Anxiety disorder 38% 11% Substance abuse disorder 66% 18% Personality disorder 43% 9%

Paul White MB BS, FRANZCP · Harvey Whiteford MB BS, MPH, FRANZCP

Australia is largely self-sufficient in its supply of safe, fresh blood products because of the goodwill of non-remunerated, volunteer donors, plus rigorous testing and processing standards. CSL Limited is the sole provider of plasma fractionation services in Australia, enjoying exclusive rights under the Plasma Fractionation Agreement with the Australian Government. In the Australia–United States Free Trade Agreement (AUSFTA), Australia agreed to review its current contract with CSL Limited, and to recommend to the states and territories that the process be opened up to overseas tender. Overseas tenders for off-shore fractionation services are likely to be highly competitive due to their low manufacturing costs and accumulated expertise. Off-shore fractionation could compromise the safety of Australia’s blood supply through delays in processing and transportation, issues related to quality control, and even the siphoning of stock to overseas markets. This could compromise the long-term care of Australian patients and create a serious national security risk in the event of a terrorist attack or natural disaster. Australia’s AUSFTA obligation to recommend changes does not equate to an obligation to actually proceed. The states and territories should carefully consider whether such changes would be in our national interest. The long-term security of the Australian people in the current security environment is dependent on continuance of an on-shore fractionation plant and appropriate back-up facilities.

Hilary J Bambrick BSc, BA(Hons), PhD · Thomas A Faunce LLB(Hons), BMed, PhD · Kellie Johnston BSc(Hons), LLB(Hons)

We can learn from the US Breakthrough Collaborative, which increased organ donation rates by 20% in 3 years Organ donation saves lives. This trite but true slogan applies to all the solid organs that are currently transplanted. Even in patients with kidney failure, where dialysis provides long-term treatment, the mortality rate is reduced significantly in those who receive transplants compared with those remaining on the waiting list.1 Improved survival, improved quality of life and reduced economic costs of care provide an unusual coincidence of benefits from this therapy. For example, with respect to cost, the recently published Economic impact of end-stage kidney disease in Australia2 contains a careful and conservative assessment of the direct costs of kidney transplantation (excluding costs from comorbidities, transport, loss of income and other incidentals). It reports that the cost of the first year after both live and deceased donor transplants is $62 375, with additional costs related to the donor of $8178 and $3000, respectively. The subsequent annual cost is $10 749 for both types of recipients. These costs compare with an annual dialysis cost of $48 631 for satellite-based patients, $56 828 for peritoneal dialysis, and $82 764 for hospital-based patients (excluding costs from comorbidities, transport, loss of income and other incidentals). Consequently, the cost advantage of transplantation is clear within 1–2 years. However, organ donation and transplantation continue to provoke ethical, legal and clinical debate with respect to procurement of organs from both living and deceased donors. The shortage of organs for transplantation in Australia is a key problem that has been well documented in recent times; it was the subject of an editorial in this Journal just over a year ago,3 responding to a report in the same issue of the adverse impact on Australians arranging kidney transplantation overseas.4 The variability of donor procurement rates between major hospitals was highlighted as demonstrating the potential for improvement. Since that time, the national Australian organ donation rate has sadly remained static at 10 donors per million population. Now, in this issue of the Journal, Opdam and Silvester address the process of organ procurement in hospitals in Victoria and underline the potential for increasing organ donation through change in hospital practice (page 250).5 They describe a carefully performed audit of Victorian hospitals, which assessed the potential for increasing the number of organ donors and confirmed the interhospital variation in donor performance in the Melbourne area. The main issues identified by Opdam and Silvester as opportunities for improving the donation rate were an increase in the consent rate and an increase in the identification of potential donors. Their study found that “there is limited but real potential to increase the number of organ donors in Victoria”. They state that “a maximum practically achievable organ donation rate for Victoria was estimated to be 15 to 17 donors per million population”. This “practically achievable rate” compares to a mean actual donation rate for Victoria of 9.2 donors per million population over the past 5 years. The economic impact alone of an increase of 50% in the donor procurement rate applied nationwide, as conservatively modelled in the report Economic impact of end-stage kidney disease in Australia,2 would be to save $26 million over the next 10 years (apart from an arguably even more important significant improvement in quality of life). There is no reason to doubt that the findings of Opdam and Silvester would apply in all states of Australia — they have been replicated (albeit in unpublished studies) in other states. How then does Australia break the present pattern and lift its donation rate to an internationally accepted benchmark of 15–20 donors per million population? Over the past few years, we have looked to the Spanish experience, but we should perhaps also pay attention to recent activities in the United States, where the organ donation rate has increased significantly. Over about the past 30 months, there has been a sustained rise in numbers, from a national mean of 508 donors per month (before October 2003) to a current mean of 614 donors per month — an outstanding increase of 20% on top of an already respectable rate of 24 donors per million population. Even allowing for the difference in rates of traumatic death between Australia and the US that might affect the number of potential donors, this performance is impressive. The explanation for the improved performance in US donor procurement appears to lie in a sustained strategy, starting in 1997 and culminating in the Organ Donation Breakthrough Collaborative, announced as a national program in April 2003 and commenced in October 2003.6,7 The details of the Collaborative approach have been recently described and can be summarised as an intensive effort to facilitate “breakthrough transformations” in the performance of organisations working together to achieve common goals, based on strategies shown to work in highly successful organisations. A key element is to identify best practices associated with higher donation rates in lead organisations, with a particular focus on early identification of potential donors and the consenting process — factors already identified by Opdam and Silvester as pertinent locally. The methodology of the Collaborative begins with selecting a planning committee of expert teams from hospitals interested in participating, and developing strategies to achieve the target (a “change package”). These strategies are then tested, modified if necessary and implemented. The strategies adopted are guided by what has been shown to work elsewhere and are always multiple in their focus (see Box). The announcement by the federal Minister for Health and Ageing, Tony Abbott, in February this year, that up to 20 of Australia’s major hospitals would be invited to participate in a similar Collaborative, with the aim of increasing organ and tissue donation rates, is welcomed.8 This project, facilitated by Australians Donate (the peak national body for organ and tissue donation for transplantation in Australia), commenced in May 2006 with the aim of building on the US experience. The potential for increase in Australia’s organ donation rate is substantial, as evidenced in the article by Opdam and Silvester. The expected outcome of the Collaborative project is a sustainable increase in the donation rate emanating from more effective early detection of potential donors and a higher conversion rate of potential to actual donors, thus realising the wishes of most Australians to be donors after death.9 There seems every reason to believe that many of the critical “success” factors in the US experience — engagement and commitment of the whole institution, a strong emphasis on support and teamwork of those in the frontline of the process, and a particular focus on an effective consenting process — will also be successful in Australia. The US Organ Donation Breakthrough Collaborative6 Overarching principles Unrelenting focus on change, improvement and results Rapid, early referral and linkage Management of an integrated donation process Aggressive pursuit of every donation opportunity First things/first changes Create a hospital presence or in-house coordinator for the organ procurement organisation Analyse and apply current hospital-specific data Identify a physician or clinician “champion” Conduct monthly reviews of death records Establish clinical triggers for referrals Hold “huddles” for the donation team Identify effective donation “requesters” Conduct after-action reviews Strategies established as successful (“high-leverage” changes) Advocate organ donation as the mission Involve senior leadership to get results Deploy a self-organising team of staff from the organ donor agency and hospital Practice early referral and rapid response Master effective requesting Implement donation after cardiac death

Timothy H Mathew MRACP, FRACP · Jeremy R Chapman MD, FRACP, FRCP

Despite astounding advances in scientific knowledge and technological capabilities, modern medicine is not free of significant problems. A persistent high rate of diagnostic errors, the prevalence of medical (iatrogenic) harm and the growing demand for complementary and alternative medicine indicate an urgent need for improvement. An important step is a return to three quintessential clinical paradigms that have become neglected with the advent of high-technology medicine: the need to emphasise prevention and early, presymptomatic diagnosis; the crucial role in decision making of skilful history taking and examination, backed by evidence; and enhanced attention to patient autonomy and emotional factors. Possible reasons for the current neglect of these Altneuparadigms (“old–new” paradigms) are considered, and techniques for restoring their primacy in medicine are discussed.

Ami Schattner MD

Use of locum medical officers is increasing in the NSW hospital system. Locums are expensive, and have highly variable expertise and experience. Locum employment arrangements are ambiguous. Locum work may divert junior doctors from participation in specialist training. Attempts to regulate the locum workforce must be accompanied by measures that increase the appeal of public hospital work and vocational training positions.

Clare A Skinner MB BS, MPH, BA(Hons) · Rebecca L Riordan BNursing, MSc(Public Health) · Kylie L Fraser BAppSc(OT) · John D Buchanan LLB, GradDipEcon, PhD · Kerry J Goulston AO, MD, FRACP

Objectives: (i) To determine the proportion of patients in New Zealand who claim compensation from the national no-fault compensation program after experiencing a compensable injury; and (ii) to identify characteristics of injured patients who are least likely to claim despite having sustained a compensable injury.Design: We estimated the percentage of eligible patients who claim no-fault compensation by linking a national claims database (Accident Compensation Corporation) to records reviewed in the New Zealand Quality of Healthcare Study (NZQHS). Bivariate and multivariate analyses were used to investigate socioeconomic and sociodemographic differences between claimants and injured non-claimants.Participants and setting: Patients who experienced an adverse event associated with care in NZ public hospitals in 1998 and claimed compensation with the ACC, the national no-fault insurer (n = 741). Patients identified by the NZQHS as having sustained an adverse event associated with hospital care in the same year who did not file a compensation claim (n = 839).Main outcome measures: Adverse events, compensable adverse events, and compensation claims.Results: Among patients judged by NZQHS reviewers to be eligible for compensation, 2.9% (6/210) claimed. Odds of claiming after an adverse event were significantly lower for patients who were elderly (odds ratio [OR], 0.20; 95% CI, 0.14–0.28), from the most deprived areas (OR, 0.36; 95% CI, 0.23–0.57), or of Māori; or Pacific ethnicity (OR, 0.47; 95% CI, 0.32–0.69 and OR, 0.26, 95% CI, 0.11–0.58).Conclusions: Despite few apparent institutional or economic barriers, the proportion of injured patients in NZ who seek compensation after sustaining a compensable injury is very low. Hence, substantial underclaiming occurs in both negligence and no-fault systems. The disproportionately low propensity of elderly, poor and minority patients to seek compensation also appears to be pervasive.

Marie M Bismark MB ChB, LLB, MBHL · Troyen A Brennan MD, JD, MPH · Peter B Davis PhD · David M Studdert LLB, ScD, MPH

Objective: To evaluate the outcomes of the research investment of the National Heart Foundation of Australia (NHF).Design and setting: The NHF Research Evaluation Working Group was established in 2002 to oversee evaluation of research funding and outcomes data collected over a 5-year period. The evaluation included a bibliometric analysis conducted by the Research Evaluation and Policy Project at the Australian National University.Outcome measures: Level and leverage of research funding; funding levels across the disciplines of biomedical, clinical, and public health research; and visibility and knowledge impact of NHF-supported research in international cardiovascular journals.Results: The NHF’s investment in research increased by 27% from 2001 to 2005. This increase resulted from leveraged support for fellowships and scholarships of $1.5 million over this period, and $2.2 million from the pharmaceutical industry. There was an increase in fellowship and scholarship funding from 26% in 2001 to 46% in 2005. There was a 75% increase in the funding allocated to public health research from 2002 to 2004. NHF-funded research publications were found in high impact journals at levels above Australian and world averages, but received fewer citations than expected based on citation rates for all similar articles.Conclusions: The NHF has been successful in implementing a policy to allocate 50% of its research funding to people and 50% to projects. This strategy has led to an increase in funding support for public health research. NHF-funded research has performed very well in terms of knowledge impact. The NHF is now well placed to strategically fund relevant research in the future.

Moira A Clay PhD · Claire Donovan PhD · Linda Butler BEcon · Brian F Oldenburg PhD

Contemporary medicine has much to its credit, but has created an insatiable demand for new technologies and more health services, fed by commercial promotion, professional advocacy and sociopolitical pressure. Total health expenditure at the national level is now almost 10% of gross domestic product and is expected to top 16% by 2020. After recent inquiries into the failings of its public health system, the Queensland Government has committed itself to a 25% increase in expenditure on health over the next 5 years. But will it lead to better population health, and is it sustainable? The return-on-investment curve for modern health care may be flattening out, in an environment of growing numbers of older patients with chronic illnesses, maldistribution of services and hospital overcrowding. A change in thinking is required if current medical practice is to avoid imploding when confronted with the next major economic downturn. Health policy, service funding and clinical training must focus on critical appraisal of the effectiveness of health care technologies and the structure and financing of health care systems. Practising clinicians will be obliged to provide leadership in determining value for money in the choice of health care for specific patient populations and how that care is delivered.

Ian A Scott FRACP, MHA, MEd

Why try a doctor when you need a dentist? Oral conditions have some of the highest prevalence and incidence rates of all health problems in Australia.1 They are frequently associated with pain, functional limitations and interference with usual activities. Most people experiencing oral symptoms will visit, or at least contemplate visiting, a dentist. But why are some patients with oral conditions presenting to general practitioners? While signs and symptoms associated with dental caries and periodontal diseases are usually understood to be problems for dentists, sequelae of these conditions, such as abscesses, facial swelling, altered taste and halitosis, may sometimes be considered more of a medical than an oral problem. Furthermore, differences in the way dental and medical services are organised and delivered may provide a greater incentive for patients to present to GPs rather than dentists. This applies not only to conditions for which an ill-defined boundary exists, but also for management of acute symptoms of common oral conditions. Mansour and Cox outline some of these common oral conditions in this issue of the Journal (page 64).2 One result of the evolution of the medical and dental professions over the past century is a “separateness” that has diminished both professions’ understanding of the other’s discipline. While it is highly desirable to reduce this knowledge gap, it seems unlikely to be readily closed, given the existing curriculum pressures created by scientific and technological advances. A logical response to the inappropriate presentation of patients with oral conditions to GPs would be to both remove the incentives for this type of presentation and to provide more certain pathways for dental referral when they do occur. Indeed, Mansour and Cox recommended dental referral for most of the cases described and for all possible outcomes of their decision-making algorithm. But while the need for referral to dentists is generally well recognised, the ability to refer may be limited. Both the initial presentation to a GP and the difficulties in referral to a dentist are shaped by problems in accessing dental care in Australia. There are only about 9000 practising dentists in Australia (approximately 50 per 100 000 population),3 the vast majority of whom work in either the central business districts or middle-class residential suburbs of the major population centres, leading to significant maldistribution. Equally important is the fact that 86% of dentists work in the private sector, where they alone determine location, hours worked and fees charged. Outside normal business hours, the number of available dentists is very limited, and access is frequently restricted to existing patients of a practice. In some instances, major public hospitals and the limited number of dental hospitals do provide after-hours access to on-call dentists, but this is the exception rather than the rule. Publicly-funded dental care is usually restricted to holders of concession cards, which reduces those eligible to about 34% of the adult population. Further rationing of dental treatment occurs because of the limited facilities and shortage of dentists in the public sector. Only 19% of eligible dentate adults (ie, those with natural teeth) receive any dental care from public dental services in any year.4 An overall shortage of dentists makes access to dental treatment even more difficult. Within 4 years, Australia is predicted to be short of some 1500 dental care providers, mostly dentists.5 This shortage creates a bottleneck in the supply of dental treatment. It is most harshly felt by people already having difficulty obtaining dental treatment — low income Australians and those living in rural areas. However, the bottleneck also extends to dentistry in the “main street”; that is, private general dentists in middle-class residential areas. Increasing the number of positions in our universities for dental students may eventually overcome this problem — assuming there are academics to teach them and funding to competitively employ some of them in the public sector at the completion of their education. However, the current national output of less than 250 graduates a year does not begin to address the shortfall. Increased education of auxiliary dental personnel (hygienists and therapists) should lead to increased prevention programs, but is unlikely to address the problem of adults presenting with acute conditions. Cost is another significant barrier to accessing dental care. An estimated 25% of dental patients delay seeking treatment because of the expense.6 Public funding for dental treatment is dramatically less than for medical treatment. At present, public funding from the federal government is directed at the 30% private health insurance rebate, while state and territory government public funding is directed at low income adults and schoolchildren. The outcome is an inequitable pattern of public assistance in accessing dental treatment. Ironically, the average taxpayer may well pay the most and receive the least in terms of support in accessing dental treatment. The majority of patients will face the full cost of any dental treatment. The current average hourly rate for dental practices is $350 (of which overheads represent 73%).7 Thus it is likely that any substantial care (be it diagnostic or therapeutic) will represent a significant financial burden to the patient. The incentive for patients with oral conditions to present to a GP is obvious. GPs are more available, obtainable out of hours, and can be seen without the need to pay substantial out-of-pocket costs. The corollaries of these same issues are often the substantial barriers to dental referral for patients presenting to GPs. Recently, the federal government recognised the need for dental care among patients with a GP Management Plan and Team Care Arrangements or an Enhanced Primary Care multidisciplinary care plan. Essentially, approved patients may be referred to a dentist for an assessment and two other services within a 12-month period. In 2005, there were only 2055 referrals for dental assessment (Item 10975),8 and these resulted in 2500 items of treatment or referral to a dental specialist (Items 10976, 10977). The total cost of dental diagnostic and treatment procedures was just over $500 000 (or $250 per 100 000 population). These data indicate a negligible level of referral under these plans. Specific issues within these plans act as further barriers to referral for dental care. For GPs, the cost and time involved with administrative requirements far exceed the value of the remuneration. Referral cannot proceed until the original care plan has been completed and paid for, which largely negates treatment of acute conditions. The relatively small number of appointments permitted, dentists’ unfamiliarity with the Medicare remuneration system, and the level of remuneration make dentist participation professionally and financially unrewarding. The result is that current referral plans available under Medicare are unlikely to provide a simple or effective pathway for dental referral and treatment. Currently, patients with acute oral conditions should hope that the problem occurs during normal hours in a major population centre, that the condition is not part of a larger problem, and that they are wealthy enough to have a regular dentist who has the time to see them. For patients who are not so fortunate, presentation to a GP is likely to remain an option. As outlined by Mansour and Cox, on most occasions, little, if any, effective help can be offered beyond referral to a dentist. The short-term results are frequently only palliative, at best, and without appropriate follow-up care — resulting in increased costs to the public purse and ongoing suffering to the patient.

Roderick I Marshall BDSc, MDSc, FRACDS(Perio) · A John Spencer MDSc, PhD, MPH

Dentofacial pain is a common presentation in general practice, and more than 50% of cases arise from dentally related pathology. In a carious tooth, pain that is site-specific, severe and spontaneous usually denotes extension of caries into the tooth pulp. Caries does not always appear as a cavity in the tooth, but may lie beneath intact enamel or on surfaces between teeth. Examination of tooth pain should include firm percussion (eg, with a tongue depressor). Tenderness on percussion denotes progression of infection into the subdental tissue. Pain occurring 24–48 hours after a tooth extraction is commonly caused by superficial osteitis in the exposed alveolar bone. Examination will reveal the absence of a blood clot in the extraction socket and severe tenderness on local palpation. Severe pain related to impacted wisdom teeth is frequently caused by pericoronitis, an infection in the gingival tissues surrounding the tooth. The surrounding gingiva is erythematous and tender to palpation. Localised facial swellings of dental origin require immediate referral to a dentist. Progressive facial swelling requires aggressive antibiotic therapy and referral to hospital for definitive management.

Mohammed H Mansour MSc, MD · Stephen C Cox OAM, MSc, FRACDS

Objective: To investigate the feasibility, achievement and acceptance of indicators of quality general practice in the RACGP Standards for general practices (third edition), using complaints registers as a case study.Design, setting and participants: A purposive sample of convenience of 200 general practices (stratified according to location and size) participated in a field test of quality and safety proposals during an accreditation survey visit between October 2004 and February 2005. Included was a test of the proposal for a complaints register (a document where complaints made to the practice are recorded).Main outcome measures: Achievement of the complaints register proposal, assessed by accreditation surveyors; questionnaire rating of the feasibility and acceptance of the proposal.Results: Few practices used a formal complaints register (79/200; 39.5%), with large practices more likely (12/20; 60.0%) and very remote practices less likely (1/11; 9.1%) to use one. The proposal for complaints registers was rated feasible by 123 general practices (61.5%) and rated acceptable by 121 general practices (60.5%).Conclusions: The proposal for complaints registers in general practice, while popular with policymakers, gained limited support when tested in Australian general practice. This shows the need for a balance between the expectations of policymakers, the need to increase performance by setting standards, and the practicalities of every-day general practice.

Ronelle L Hutchinson BA(Hons), PhD · Ian T Watts BSW, DipSocPlan, MBA(Exec)

Objective: To compare general practice career choices of four cohorts of medical graduates.Design and setting: Retrospective longitudinal study of medical graduates. Data on employment since graduation, nature of current employment, and postgraduate qualifications were collected by postal survey in 2003.Participants: Four cohorts of Monash University Medical School graduates who completed their degrees in 1980, 1985, 1990 and 1995 (n = 386).Main outcome measure: Proportion of each cohort pursuing a general practice career.Results: At 8 years after graduation, half of the graduates in the 1980 and 1985 cohorts were working in general practice, compared with 38% of 1990 graduates and 33% of 1995 graduates. Differences were mainly attributable to fewer female graduates working as GPs: female GPs comprised 62% of the 1980 cohort compared with 31% of the 1995 cohort. Graduates in more recent cohorts also entered the general practice workforce at a later stage than those in earlier cohorts.Conclusion: A rapidly declining proportion of new graduates from Monash University Medical School, particularly female graduates, are choosing general practice as a career. This will exacerbate future shortages in the general practice workforce.

Catherine M Joyce BA(Hons), MPsych, PhD · John J McNeil PhD, FRACP, FAFPHM

Thirty years’ experience in the US with non-physician clinicians shows they can deliver quality care Like Australia, the United States is experiencing physician shortages,1 and non-physician clinicians have become ever more important as providers of patient services. Most prominent among these are nurse practitioners (NPs) and physician assistants (PAs), as reviewed by Hooker in this issue of the Journal,2 but others also contribute to providing “physician services” in the US. They include alternative and complementary medicine providers (chiropractors, naturopaths and acupuncturists), mental health providers (psychologists, clinical social workers, counsellors and therapists) and members of several specialty disciplines (optometrists, podiatrists, nurse anaesthetists and nurse-midwives). Over the past 30 years, all have struggled to obtain licensure in the various states, to expand their practice prerogatives, and to achieve broader reimbursement from third-party payers. The progress that NPs and PAs have made is evident in Hooker’s review. The question is, do they contribute to quality? This editorial will comment on NPs, PAs and psychologists. A broader review, which forms the basis for this essay, assesses the full range of disciplines.3 Characteristics of NPs and PAs: Although commonly evaluated together, NPs and PAs are trained quite differently. Most NPs work in primary care settings, and, while having the authority to practise independently in more than a dozen states, most work within the context of physician practices. However, the goal of NPs is independence and collegiality rather than dependence and supervision. Nursing educators recognise that achieving this goal requires more advanced training. To that end, a pathway (described below) has been developed for doctoral-level nurse practitioners (DrNPs) who could become the primary care providers of choice for patients with most chronic illnesses.4 In contrast to NPs, PAs retain their dependent relationship with physicians, working in a delegated or supervised manner, and while some PAs prefer greater independence, the American Academy of Physician Assistants is committed to retaining an “interdependent relationship” with physicians. Nonetheless, the autonomy of PAs is often substantial. For example, most states allow them to practise within a radius of 50 miles or a 1-hour drive from their supervising physician, as long as the opportunity for telephone contact is maintained. While direct contact is required, its frequency varies from daily in most states to weekly in some and only monthly in a few, and several states require supervising physicians to review only 10%–15% of the PA’s patient charts. Only half of PAs work in primary care. Others span a range of specialties, including cardiology, dermatology, gastroenterology, neurology, general surgery, the surgical subspecialties and obstetrics and gynaecology. PAs assist in surgery, oversee specialty clinics and perform minor procedures, such as endoscopies and biopsies. Like NPs, they participate in patient education, counselling and chronic disease management. Their prerogatives are commonly stylised to the particular relationship that they have developed with their supervising physician. NP and PA outcomes: A rich body of literature has assessed the quality of care provided by NPs and PAs. In a landmark study published in 1974, shortly after the inception of these two professions, NPs were shown to perform within their scope of office-based practice as effectively as physicians,5 and, by the end of the 1970s, 40 studies evaluating both NPs and PAs reached similar conclusions.6 These were reconfirmed not only for NPs and PAs, but also for nurse-midwives, in an even larger body of work, which was summarised by the Office of Technology Assessment in 19867 and by Brown and Grimes in 1993.8 These assessments indicated that NPs and PAs could provide care for 60%–90% of the patients who present to primary care practices. The period after Brown and Grimes’ 1993 analysis8 has been marked by a progressive expansion of the licensed prerogatives of both NPs and PAs. While most research on quality and effectiveness continues to focus on primary care, some has assessed the performance of NPs as case managers for patients with chronic conditions, as well as their effectiveness in areas of even greater complexity, such as oncology home care, care of at-risk pregnancies and care provided in hospital emergency departments and neonatal intensive care units. Throughout these studies, health outcomes of NPs were similar to those of physicians, with equal or lower costs, shorter waiting times and higher patient satisfaction. Conclusions were similar, whether the research was performed by physicians, nurses, health services researchers or combinations of these. The same general conclusions were reached in a broad series of reports on PAs’ outcomes in both primary care and specialty practices. Collectively, they demonstrate that PAs perform competently within the framework of their delegated responsibilities, and that the levels of complexity and autonomy at which they function are greater when they have worked for sustained periods with the same physician. Doctoral-level NPs: The newly created DrNP degree is intended to further expand the capability of NPs.4 These practitioners will be trained to practise at the level of family physicians, with hospital-admitting privileges and full parity of reimbursement. Unlike NP training, which is oriented to office-based primary care, DrNPs are expected to care for their patients at a range of sites — emergency department, hospital, office, home, rehabilitation centre or nursing home. A model of such a practice has been established by faculty members at the Columbia University School of Nursing, New York.9 In a randomised study of follow-up care for patients who presented to an emergency department and had no personal physician, care by either physicians or Columbia nursing faculty showed similar outcomes at 1 year in terms of both clinical status and patient satisfaction.10 While the patients in this study had unusual demographic characteristics (most were Hispanic, female, young and poor), and follow-up was relatively brief (1 year), the remarkable success of this experience is inescapable. Psychologists: Like NP and PA training, the training of doctoral-level psychologists expanded in the 1970s in response to a desire for low-cost community services. Both counselling psychologists and primary care physicians now provide these services for patients with anxiety, mood disorders and other common psychiatric conditions. However, the care delivered has been judged appropriate in 90% of patients treated by psychologists, compared with fewer than 20% of those treated by primary care physicians.11 Indeed, primary care physicians fail to detect mental disorders 50% of the time, prescribe pharmacological agents for only 60% of those who are diagnosed correctly, and use adequate levels of treatment less than half the time.12 The value that psychologists bring to this patient population is without question. The second aspect of care by psychologists is more controversial — the use of psychopharmacological agents. Although leaders in psychology in the early 1990s looked with disdain on prescriptive authority, efforts to obtain such authority had already begun in Hawaii in 1984, and proceeded without success in 14 other states.13 In 1991, the US Congress authorised a pilot program for prescribing psychologists in the military, and 10 subsequently completed the required 2-year training program. Their prescribing was limited to a formulary, and they initially practised under the supervision of a psychiatrist, but within several years almost all were permitted to practise independently. Indeed, each became the chief of a clinic or department.14 While this program was discontinued because of the training costs and redundancies, the psychologists who participated were judged to have prescribed safely and effectively, and the quality of their care was rated as good to excellent. However, even when practising “independently”, these psychologists were working within institutional settings rather than in community practices. In 2002, New Mexico became the first state to license prescribing psychologists, patterning its program after the military.13 Similar legislation is pending elsewhere. However, even without such state action, a small group of psychologists who also trained as NPs have been prescribing under their nursing licences, and many psychologists prescribe de facto through their relationships with family physicians. Nonetheless, psychiatrists protest that psychologists are not adequately prepared for this role, and many psychologists agree. And while most psychology graduate students have no interest in pharmacotherapeutics, the profession is attempting to integrate the use of psychotropics into its training programs and to build for a future in which such practices are common. Conclusion: A large body of evidence supports the principle that NPs, PAs, psychologists and others provide quality care. Based on this experience, the expectation is that their contributions will progressively broaden over time as the US adjusts to its growing physician shortage.1 The strongest body of evidence in support of their effectiveness and safety is derived from care that is at the least complex end of the clinical spectrum or that is provided under the umbrella of physician involvement. Fewer studies have critically examined outcomes at the leading edge of their practice prerogatives and under conditions that are free of physician oversight. Therefore, as the scope of practice of non-physician clinicians continues to expand, more research will be needed to examine outcomes under conditions of greater clinical complexity and autonomy.

Richard A Cooper MD

Approximately 11 200 new PAs and NPs graduate each year. PAs and NPs are well distributed throughout primary care and specialty care and are more likely than physicians to practise in rural areas and where vulnerable populations exist. The productivity of NPs and PAs, based on traditional doctor services, is comparable, and the range of services approaches 90% of what primary care physicians provide. The education time is approximately half that of a medical doctor and entry into the workforce is less restrictive. The interprofessional skill mix provided by PAs and NPs may enhance medical care in comparison with that provided by a doctor alone.

Roderick S Hooker PhD

We must preserve the elements of our health care system that work well All the signals in health care in the Western world point towards increasing demand and limitations on supply — a development driven by ageing populations, ever-increasing and sophisticated technologies and treatments, and a workforce that is less inclined to work the long hours of years gone by. There have been calls from governments for more flexibility in health care delivery. In the case of primary care, the arguments for substituting “traditional” general practitioner roles seem compelling — primary care in the United Kingdom and Australia is struggling to provide adequate access to care for a population with increasing needs. Surely we must expand our workforce to meet this need — especially if this can be achieved by employing less expensive health care providers? In this issue of the Journal, Sibbald and colleagues review the current status of workforce substitution between nurses and GPs.1 They point to the variety of roles that nurses have adopted in primary care settings: there seems compelling evidence that nurses can, with a great deal of autonomy, effectively deliver routine management of chronic conditions, such as asthma, diabetes and coronary heart disease. Indeed, further roles for nurses, such as cognitive behavioural therapy for psychological problems, are continually being explored.2 The new contract between GPs and the UK National Health Service (NHS), while rewarding GPs for meeting quality targets, underpins nurse-led management with specific chronic disease targets and a strong focus on clinical audit.3 There seems no doubt that nurses can take the lead on these processes effectively and produce favourable clinical outcomes — acknowledging that successful GP–nurse work substitution is, indeed, context dependent, and accepting that issues such as continuity of care, legal liability and practicalities of prescribing are paramount.1 Also in this issue, Parle et al discuss the development of a “medical care practitioner” curriculum in the West Midlands4 — there is considerable interest in bringing this North American model to the UK. On the whole, the pilot study by investigators at the University of Birmingham of the impact of US-trained “physician assistants” on the NHS indicated that introducing this new kind of health care provider into primary care can ease demand.4,5 Further, they have generally been met with positive responses from both their practice colleagues and patients. However, can we assume that because primary care capacity is insufficient there is an “overwhelming need for a mid level clinician working under the supervision of a qualified doctor”?3 The need for extra capacity is being met in part by new doctors. In common with Australia, the UK has chosen to increase student numbers to meet projected future requirements,6 and to reduce to a large extent the dependence on international medical graduates to fill both training scheme places and service posts. The number of places at UK medical schools increased by almost 60% between 1998 (when there were about 3750 places) and 2005, as a result of introducing new 4-year graduate entry programs, establishing four new medical schools, and adding places to existing schools. These new doctors are yet to have an impact on the workforce, but this greater capacity must inevitably influence access. A legitimate role for medical care practitioners seems apparent in secondary care settings, where the arguments of fluctuating skills of junior doctors and trends towards increased specialisation have more salience. In primary care it’s more complex: in Australia and the UK, primary care has been much more central to health service provision than in North America, and we know that a strong primary care focus within health systems can produce favourable health outcomes.7 The US physician assistants (the equivalent of medical care practitioners) have had a significant effect on primary care services,8 but it’s a different environment to ours. While there is something to be said for a mixed economy of approaches to workforce in primary care, there are inherent dangers in drifting towards a system in which primary care is seen as a “second tier” in the health service. A great deal of effort has been invested in trying to promote integration between primary and secondary care, and there are many efficiencies and health gains that can be achieved in doing so. A growing gap between primary and secondary care, in which the two workforces develop fundamental structural differences, can only inhibit this process.9 UK government White Paper, Our health, our care, our say: a new direction for community services13 — key features There is a strong focus on patient involvement in planning and decision making There is an emphasis on partnerships; for example, between health services and local authorities Care is to be moved out of hospitals and “nearer to patients’ homes” Encouragement is given to new entrants, including the private sector, as primary care providers Hence, we need to approach with caution any new innovation that potentially marginalises primary care. While investigating the potential of new layers of health professionals, primary care needs to diversify to meet changing needs. A great deal of diversification is already underway, much of it aimed at improving access, albeit with its own “health warnings”. For example, the development of “GPs with special interests” can improve access to much-needed specialist services. However, it needs to happen in a way that preserves continuity, and the universal, comprehensive nature of primary care.10 Similarly, in Australia, the development of primary care clinics for skin cancer, women’s health and travel medicine has both benefits for access and threats — some argue it undermines the fundamental principles of general practice.11 Developments in informatics and e-health hold further potential for improving access. Increasingly, we are looking at different models of consultation — email and telephone consulting, and greater, quality-assured use of the web hold great promise.12 The UK government’s recent White Paper, Our health, our care, our say: a new direction for community services, while provoking some controversy, has highlighted the importance government places on access to primary care, and points the way towards redesign of referral and treatment pathways, and better use of information technology — diversification of providers is highlighted as one of several options (Box).13 There is a need to keep an open mind about diversification and workforce substitution. While examining the potential of new kinds of health care providers, we should exercise caution before committing significant resources, and ensure we preserve the elements of our health care systems that work well. In the case of primary care, many innovations, which may have equal potential to improve access, are already underway (so we shouldn’t “throw out the baby with the bath water”!). So far, the detailed studies comparing these different approaches to improving access are still to be done.

David P Weller PhD, FRACGP, FAFPHM

A range of demographic, social and other factors are creating a crisis in the provision of clinical care in the United Kingdom for which the physician assistant (PA) model developed in the United States appears to offer a partial solution. Local and national moves are underway to develop a similar cadre of registered health care professionals in England, with the current title of medical care practitioners (MCPs). A competence and curriculum framework document produced by a national steering group has formed the basis for a recent consultation process. A limited evaluation of US-trained PAs working in the West Midlands region of England in both primary care and acute secondary care suggests that PA activity is similar to that of doctors working in primary care and to primary care doctors working in the accident and emergency setting. The planned introduction of MCPs in England appears to offer, first, an effective strategy for increasing medical capacity, without jeopardising quality in frontline clinical services; and, second, the prospect of increased flexibility and stability in the medical workforce. The deployment of MCPs may offer advantages over increasing the number of doctors or taking nurses out of nursing roles. The introduction of MCPs may also enhance service effectiveness and efficiency.

Jim V Parle MD, FRCGP · Nick M Ross MA · William F Doe FRCP, FRACP, FMedSci

Meeting future health workforce needs is a challenge for all health professionals There now seems little debate that the medical profession needs to accept task substitution as one solution to the health workforce crisis. The contributions in this issue of the Journal from the Royal Australian College of General Practitioners,1 Royal Australasian College of Physicians (RACP),2 the Royal Australasian College of Surgeons3 and Australian Medical Association (AMA)4 all acknowledge that reality and express a guarded acceptance of moving in this direction. They correctly emphasise that the overriding issue is the detail of how these strategies should be implemented, always bearing in mind the essential principle that patient care must not be compromised. Collectively, these organisations acknowledge that health care is delivered by a team. Who directs that team is perhaps debatable, although it will in most situations be a medical practitioner. We should, however, acknowledge the recent observations of Sir Graeme Catto, President of the UK General Medical Council: The exclusivity of medical knowledge and skill is being broken down. Interprofessional learning is now commonplace in medical education and seems likely to increase. Professional boundaries are being blurred as more and more things that were once the sole domain of doctors are being undertaken by other health care professionals. None of us works alone any longer, but in multidisciplinary teams in which we depend upon the expertise of others. This is not a diminution of medicine, but a strengthening of health care. We must acknowledge that, more than ever before, knowledge is available to patients and the public.” 5 We share the view of the AMA that it is important that health outcomes (slightly different from “health standards”) should not be compromised, but there is little or no evidence that this occurs where task substitution has been introduced. In fact, a Cochrane review of nurse practitioners6 suggested that outcomes for patients in services delivered by nurse practitioners are the same as or better than those delivered by doctors, and that nurse practitioners are well accepted by patients; however, improvements in cost-effectiveness were not as substantial as expected. The Productivity Commission report Australia’s health workforce serves as a blueprint for health workforce reform in Australia and presents task substitution as one plank in tackling what we all acknowledge is a very complex issue.7 But we need to recognise that the Productivity Commission report is about a lot more than task substitution. Certainly it comes from an economic “direction”, but to suggest that we, the providers of health services, have no economic responsibility is not acceptable in the 21st century. The issue is not principally about saving money — it is about using resources more efficiently to meet rising demand. The health workforce currently makes up about 11.3% of the total workforce in Australia, and it has been estimated (with feminisation of the health workforce, changing attitudes towards working, the ageing population, chronic disease and increasing community expectations for health) that we may need over 20% of the total workforce in health-related areas by 2025 if we are to maintain the delivery of services we currently have. Where is this workforce to come from? To date, four options for meeting increased demand in the future have been identified: extending the roles of existing health professionals (eg, nurses and allied health professionals); creating new types of health workers (eg, clinical assistants); improving efficiency by using information technology more effectively in the health industry; placing more emphasis on prevention and health promotion. Task substitution can involve the creation of new autonomous roles (eg, nurse practitioners) or roles in which non-medical practitioners work under the supervision of someone else (usually a medical practitioner) (ie, delegated care). Supervision may be in person (eg, a clinical assistant working in a primary care setting with a general practitioner) or remote (eg, nurses or physiotherapists running minor illness and injury clinics using video links for medical supervision). It appears that two very different types of clinical assistant may emerge in Australia:8 those who work in primary care, and therefore require generalist knowledge, and those who have highly specialised technical skills, such as surgical assistants and endoscopy assistants. As noted by many of the contributors to this issue of the Journal, moving current health professionals to other parts of the sinking ship will provide very limited gains. It is true that we need more health professionals, but we need to retain them and make use of them optimally. Implementing task substitution requires a combination of service redesign, using clinical practice improvement methodology, and progressive competency-based training. Underpinning task substitution is the notion of generic descriptions of health competencies that cross professional boundaries. The UK Skills Escalator9 is an important example and a potential model for adaptation and testing in Australia. The Skills Escalator is a nine-level career framework that starts with supporting roles then moves to assistants and senior assistants, assistant practitioners, qualified practitioners, senior or specialist practitioners, advanced practitioners, consultant practitioners and, finally, more senior posts. It provides a wide variety of entry points into health care careers, encourages and recognises lifelong learning and acquisition of new skills, and is used in an environment that seeks both job satisfaction and service efficiencies by “delegating roles, work and responsibilities down the escalator where appropriate”.9 The physician assistant (delegated care) model, equivalent to assistant practitioner on the Skills Escalator, seems to have been very successful in the United States10 and should be considered and tested in the Australian context. Piloting of delegated care models, including the use of clinical assistants, is already being seriously considered by one Australian state health department and was a major topic of positive debate at a recent annual general meeting of the Australian Society of Urologists. The opportunity is there for the health departments, colleges and universities to work together to identify services that lend themselves to productivity gains through the introduction of delegated care models, define the scope of new practices, develop the curriculum, deliver the learning programs, implement the redesigned services, and evaluate these new models of care delivery. Introducing delegated models of care is something that can be done now, and its focus on interprofessional care and competency-based training is likely to enhance these emerging trends in health education. The universities have the opportunity to establish inter-professional educational models at an undergraduate level so that health professionals of all persuasions learn at a very early stage that they are part of a health care team, that each has an important role, and that, in the future, all disciplines will have the potential to play leadership roles. Meanwhile, we should continue to: research and refine techniques to support health workforce innovation; explore novel techniques for training and assessing skills, including the use of synthetic environments (such as simulation and skills centres) and community-based environments; focus on competency assessment that is truly predictive of performance (as measured by patient safety and outcomes); and develop objective, reliable instruments for monitoring performance, safety and quality, especially when task substitution or role extension is newly introduced. Competencies need to be reassessed as a career progresses. Again, there are major opportunities for the colleges and universities to work together, as is already happening with the development of the Career Medical Officer program by the RACP and the Consortium of Universities for Postgraduate Health Education. As well as the future of health education, task substitution raises questions about registration and funding mechanisms, as highlighted in the Productivity Commission report. It is obvious that innovations are already occurring in the Australian health system, especially in areas under workforce pressure, from which we could learn — for example, the extended role of nurses and physiotherapists in hospitals with medical shortages.11 Further experimentation on various models of task substitution through education, service delivery and consumer partnerships would add to our knowledge. To move the issue of task substitution forward we probably need to move a little further towards accepting loss of “control” of the system. Like many professions (recall Adam Smith, who observed in 1776 in The wealth of nations that all professions tended to form self-interest groups and generally “conspire against the laity”12), we still fail to acknowledge that others may be able to do what we do — perhaps even better in some cases. We will need to reorganise the “ego systems”.13 But what an opportunity! — designing (and testing) a health system that is both patient focused and provider friendly. Surely this is a challenge that all health professions can work together on.

Niki Ellis MB BS, FAFOM, FAFPHM · Lynn Robinson MB BS · Peter M Brooks MD, FRACP, FAFPHM

Technology, community expectations and an ageing population are driving the need for an expanded health care workforce. Doctors embrace task substitution wherever it can be done safely and effectively. Task substitution should occur in the context of: team care that synergises the different skills of doctors, nurses and other health professionals doctors retaining their central role increases in the capacity to extend medical services with efficiency gains no loss of patient safety no fragmentation of care The growth of task substitution could lead to workforce shortages in other health care areas. Public policy on task substitution must take full account of patient preferences and expectations.

Choong-Siew Yong MB BS, FRANZCP

Since the 1960s, Australian society and the medical profession have undergone enormous change. Our society has moved from a relatively homogeneous and conservative community, supported by limited government services, to one that is multicultural, focused on the individual and consumerism, and supported by extensive government programs, with health care a top public and political priority. A defining feature of contemporary society is its mistrust of institutions, professionals, public servants and politicians. The medical profession has changed from a cohesive entity, valuing generalism and with limited specialisation, to one splintered by ultra-specialisation and competing professional agendas. The medical workforce shortage and efforts to maintain the safety and quality of health services are putting acute pressure on the profession. Task transfer or role substitution of medical services is mooted as a potential solution to this pressure. This has the potential to drastically transform the profession. How task transfer will evolve and change medicine depends on the vision and leadership of the profession and a flexible pragmatism that safeguards quality and safety and places patient priorities above those of the profession.

Martin B Van Der Weyden MD, FRACP, FRCPA

The health workforce crisis needs radical treatment; simply educating more health workers will be insufficient, and role substitution among existing health workers is untenable. We propose a new class of health worker who would take on single disease or single procedure responsibilities, working mostly to protocols; and be embedded within current structures. We also propose modular health education which has fewer entry points into the health system, allows transfer between different disciplines, and is based on modules that can be accumulated to allow progress through the system to gain more clinical responsibility.

Christopher B Del Mar DRCOG, FRACGP, FAFPHM · Naomi Dwyer BBus