Health services administration

Susan F Hurley Associate Professor, School of Population Health, University of Melbourne; and Health Economics Consultant, Bainbridge Consultants, 532 Brunswick St, North Fitzroy, VIC 3068. susanhurleyATbainbridgeconsultants.com To the Editor: Previous analyses of costs to the Pharmaceutical Benefits Scheme and costs for stroke and acute myocardial infarction hospitalisations suggest that tobacco control programs are a good investment.1,2 To further highlight the economic benefits of reducing smoking rates, I estimated the hospitalisation costs attributable to cigarette smoking in Australia for 2001–2002 by applying aetiological fractions to hospitalisation data.3 Aetiological fractions were calculated using 2001 National Health Survey smoking prevalence data and relative risks of hospitalisation for current and former smokers, as previously calculated by English and colleagues through linkage of data from the Busselton health survey and the Western Australian Hospital Morbidity Data system.4 Counts of separations (hospitalisations), bed-days, and average costs for hospitalisations in Australia in 2001–2002, by sex and 5-year age category, were obtained from the Australian Institute of Health and Welfare. They had been sourced from the National Hospital Morbidity Database (http://www.aihw.gov.au/hospitals/nhm_database.cfm) and the National Hospital Cost Data Collection (http://www.health.gov.au/casemix), linked by the common variable “DRG4.2”. The results (Box) show that, in 2001–2002, almost 300 000 hospitalisations, costing $682 million, were attributable to cigarette smoking. English and colleagues estimated previously that, in 1992, 129 000 hospital separations and over 1.1 million bed-days were attributable to cigarette smoking.4 Although the proportion of the Australian population who are smokers has decreased since then, from 26% to 23% in 2001,5 cigarette smoking is still associated with substantial health care utilisation and costs. The actual costs are even greater than the $682 million per annum estimated by my analysis, as the following were not considered: hospitalisation costs for those aged 80 years and over; pharmaceutical costs (estimated at $126 million for cardiovascular drugs on the Pharmaceutical Benefits Scheme1); community care costs (such as general practitioner visits); and patient contributions to hospitalisation costs. In stark contrast to the $682 million spent on hospitalisations attributable to smoking, the Australian Government has committed an average of only $2 million per year over the last 10 years to tobacco harm minimisation programs.6 Hospitalisations, bed-days and costs attributable to cigarette smoking in Australia in 2001–2002* Hospitalisations Bed-days Costs† Proportion Number Proportion Number Proportion $ (millions) Men 7.6% 138 000 14.6% 891 000 7.6% $339 Women 8.6% 153 000 9.8% 581 000 8.6% $342 Total 8.1% 291 000 12.2% 1 472 000 8.1% $682 * For people aged 40–79 years. † Estimated costs are conservative, as they are based on average cost per hospitalisation for the total population. However, the higher proportion of bed-days than hospitalisations attributable to smoking suggests smokers tend to have longer stays and thus higher than average costs.

Susan F Hurley

Objectives: To investigate the perceptions of Australian health and medical researchers 4 years after the Wills Report recommended and led to a substantial increase in health and medical research funding in Australia.Design, setting and participants: A telephone poll of 501 active health and medical researchers, conducted between 28 April and 5 May, 2003.Main outcome measures: Researchers’ views on the adequacy of funding, infrastructure and support, salary, community recognition, the excitement of discovery and research outcomes such as publication and patenting in research.Results: Research funding was the most important concern: 91% of researchers (455/498) viewed funding as “very” or “extremely” important to their role, but only 10% (52/500) were “very” or “extremely” satisfied with the level of funding. Research infrastructure and support were seen as “very” or “extremely” important by 90% of researchers (449/501), while only 21% (104/501) were “very” or “extremely” satisfied. Researchers in medical research institutes were significantly more likely to be satisfied (27% [56/205] “very” or “extremely” satisfied) with the level of infrastructure and support than those working in universities (15% [41/268] “very” or “extremely” satisfied; P = 0.001). Among the factors that motivate researchers, the excitement of discovery stood out in terms of both high importance and satisfaction. Publications were viewed as more important research outcomes than patenting or commercial ventures.Conclusions: Funding and infrastructure support remain overwhelmingly researchers’ greatest concerns. University-based researchers were less satisfied with infrastructure and support than those in independent medical research institutes.

Louise G Shewan BA(Hons), PhD · Andrew J S Coats DM, DSc, FRACP · Jane A Glatz BSc(Hons), PhD, MBA · Christine C Bennett FRACP, MPaed

Public debate is required if families are required to fill the gap left by hospitals which now only “care” for the illness and not the patient I told myself I would write this article as I was dragging my 8-year-old’s drip behind her at 3:30 am when she decided it was time to go for a walk in the semi-lit hallway of a paediatric teaching hospital. My daughter has severe autism, intellectual disability and suffers from epilepsy. Although I am probably a little better informed than most, given my experience in the field of bioethics and health law, I am a lay person. Thus, my description of events will be in terms that are perhaps not medically accurate, and from my own perspective. Having discussed my experience in a non-statistically-rigorous fashion, as a lay person does, with several others who have recently been hospital inpatients or whose relatives have been inpatients, I find that my impressions are uniformly shared. My discourse should not be interpreted as a criticism of the staff of the hospital, whom I found to be as accommodating as conditions allowed. I would also like to make it clear that my concerns should not be dismissed as a commentary on the nursing aspects of my daughter’s hospital admission. They are intended as a critique of the direction of the way hospital services are generally delivered, and this — as is well understood — is the result of many contributing factors. Before her hospital admission my daughter had had a urinary tract infection that had been treated with various antibiotics. Nonetheless, she kept vomiting up anything that passed her lips as well as having occasional bouts of diarrhoea. Her temperature remained very high. Her eyes were sunken, and she was pale and weak. It was fortunate that one of my daughter’s therapists decided to accompany me to the emergency department. She stayed with me from 11 am until 3 pm. Had she not done so, I don’t know how I could have gone to the toilet or obtained anything to eat. My daughter cannot communicate readily, does not understand the concept of hospital, and would have been distraught at being left in an unfamiliar environment with unfamiliar faces, and at dealing with the shock of having an intravenous line inserted. It is not possible to explain these things to her. Fortunately, humane staff in the emergency department permitted me to use a hospital phone to call my husband, otherwise this would have been an impossibility. (Even if I had one, mobile phones cannot be used, and a public phone was some distance away.) I was provided with a plastic bag in case my daughter vomited. When she did, I did not know where to dispose of the bag. I imagined that I should not put it in an ordinary rubbish bin. I wandered out of my daughter’s cubicle and asked a nurse, who directed me to a bin for infectious waste. Later in the day, a Red Cross volunteer provided me with a cup of tea and a sandwich. Having spent most of the day in the emergency department, and being intermittently assisted by helpful and polite medical, nursing and administrative staff, my daughter was admitted to the general medical ward. My daughter could not move herself from the trolley to the bed so nurses did this and then departed. The job of straightening the bed was left to me. I was then given most useful advice from the mother of an infant in the next bed who had been in the hospital for some time. She told me that there was a toilet for parents, but if the queue was too long, the nurses sometimes let you use the toilet for the children. As I shortly discovered, the parents’ toilet was nauseating. The bin in the toilet seemed not to have been emptied for some time and was overflowing. No one told me there was a shower. It became clear, although no one mentioned this, that the tasks of toileting and cleaning my child, as well as making her bed and eventually feeding her, were reserved for me. I was asked to collect all of my daughter’s urine and a specimen of her faeces. Again, for a host of reasons, I had thought that this was a nursing task. I did not feel confident about doing this and this was not because it was distasteful, although I must admit I wasn’t thrilled about it. It was more because I was not familiar with where things were kept, and how to get my daughter to urinate into the container that was placed in the toilet. It also took me some time to realise that collecting the urine was not now for the purposes of testing but just to see how much she was passing. I was therefore also unsure of what to do if the faeces contaminated the urine. It is well known that hospitals are not places that are conducive to sleep unless you are so unwell that staying conscious is the challenge. Consequently my daughter was able to sleep for most of the night, but I was not. An older nurse helped me set up a single “sofa bed” for myself. By morning I had a headache, was coughing and sneezing (not related to the hospital stay) and was exhausted. A lovely nurse popped in to provide advice about parking fees, the family resources centre, use of the internet and the room on the floor available to parents. While my daughter was asleep, I chanced using the accidentally discovered shower, hoping she would not wake in the meantime, and found it to be in a similar state to the toilet. During the morning, the paediatric consultant ordered an ultrasound of my daughter’s renal system and appendix. This eventuated by about 4 pm. While waiting in the x-ray department, my daughter was sitting on my lap when she had an episode of diarrhoea. Luckily her 20-year-old sister was present so I was able to find someone to give me a towel to try to clean my daughter and myself. My daughter was provided with a surgical gown. My jeans were not the best. Fortunately, the ultrasound was normal. At around 5 pm, a charming doctor payed us a visit and said we could either stay another night or leave. I asked her what she would do in our position. She advised that the intravenous fluids had probably provided my daughter with some stability and she was more likely to begin eating at home than in hospital. That being the case, my response was that the hospital would have to put me in chains to keep us there. My daughter is now fine. I am left wondering why it has come to be, amid the continual structural reforms, that health professionals have time to attend to equipment and defined clinical tasks, and not to people. Indeed the most “care” I received was from the Pink Lady who volunteers her services one day a week. The time devoted by health professionals to personally tending to my daughter would have amounted to a matter of minutes. Parents come into a hospital already worn down by worry. They are tired. They do not expect that the responsibility for care will be left to them. I have discovered that my experience is not confined to paediatric hospitals, nor indeed to the public hospital system. One woman told me that she paid professional carers to look after her mother day and night while in a private hospital. Another said she had been so shocked at the lack of personal care that she and her sister stayed on to look after their mother. In another instance, a woman in her 80s described having to make her own bed with an intravenous line in tow, and being regularly left sitting in the shower unable to move after major surgery. Is this a failing of our health care institutions, or just what we should come to expect? While I have no wish to be inflammatory, some of the problems I have mentioned are clearly matters that should return to the province of hospital staff. Basic issues of cleanliness on the ward cannot be a responsibility of patients or their relatives. Failing to attend to an elderly patient left sitting in a shower is frankly disrespectful. Insofar as my daughter has special needs, I felt some additional care was taken in the mechanics of her treatment. By this, I mean three nurses were on hand when she was injected with gentamycin, and a specialist was called when a young doctor failed to insert the intravenous line after several attempts. The woman taking meal orders did try to be flexible in getting the kitchen to produce food to meet my daughter’s idiosyncratic tastes. Otherwise, there seemed to be no cognisance of the fact that some effort needed to be made to engage her and gain her confidence. Nor was there any recognition of the difficulty I faced in leaving her side for short periods. In regard to some of the other issues, such as the extent to which families are expected to look after their loved ones in hospital and to which inpatients are required to fend for themselves, there is clearly need for public debate. Changes of this magnitude should not be introduced by stealth or attrition. If we are moving towards a system in which care from families is routinely required, then this ought to be made clear. At least then we may be better prepared.

Bebe Loff PhD

From the 1930s to the 1960s, Royal Newcastle Hospital was the centre for innovation in Australian health care. Many of the innovations were driven by a visionary medical superintendent, Chris McCaffrey, and the staff he appointed. Among the reforms he introduced were: an overarching emphasis on efficiency; the appointment of salaried specialist staff, now widespread; the unit record system for medical records, now universal; a domiciliary care service, now established in most of Australia; and an emphasis on audit and quality studies, now largely abandoned in the form pioneered in Newcastle. These innovations were vigorously opposed by organised medicine and barely tolerated by the health bureaucracy. They are unlikely to be replicated in the current environment where hospitals are run by managers in a culture dominated by budgetary considerations.

John M Duggan AM, MD, FRACP · Peter I A Hendry AO, MB BS, MD(Hon), FRCPA

The Presidents of the colleges told us that what does not kill them makes them stronger Australian and New Zealand College of Anaesthetists (ANZCA) To serve the community by fostering safety and quality patient care in anaesthesia, intensive care and pain medicine President: Michael Cousins Professor and Head of Department of Anaesthesia and Pain Management, Royal North Shore Hospital, Sydney, NSW Medical degree: University of Sydney (1963) Wants to be remembered for: Founding the Faculty of Pain Medicine; creating taskforces on key issues (eg, perioperative medicine); fostering research (eg, ANZCA Foundation). Year of inauguration of college: 1992 (previously, Faculty in College of Surgeons) Current number of fellows in Australia: 2900 Australasian College of Dermatologists (ACD) Refulgent in tenebris (They shine resplendent in the dark; ie, They succeed in difficulties) President: Anne Howard Head of Dermatology Unit, Western Hospital, and Dermatologist in private practice, Melbourne, VIC Medical degree: University of Melbourne (1975) Wants to be remembered for: Making the college attractive for women and younger doctors, and improving its transparency. Year of inauguration of college: 1966 Current number of fellows in Australia: 300 Australasian College for Emergency Medicine (ACEM) President: Andrew Singer Clinical Director of Emergency Medicine, Canberra Hospital, ACT Medical degree: University of Sydney (1984) Wants to be remembered for: Strengthening the training program; improving the perception and status of emergency medicine. Year of inauguration of college: 1983 Current number of fellows in Australia: 700 Royal Australian College of General Practitioners (RACGP) Cum scientia caritas (With scientific knowledge and tender loving care) President: Michael Kidd General Practitioner; Professor and Head of Department of General Practice, University of Sydney, NSW Medical degree: University of Melbourne (1983) Wants to be remembered for: Acting with integrity; supporting education and mentoring; and creating leadership and training opportunities. Year of inauguration of college: 1957 Current number of fellows in Australia: Over 11 000 have FRACGP (over 7500 financial members) Royal Australasian College of Medical Administrators (RACMA) Let us progress in unity by working together in harmony President: Philip Montgomery Area Executive Director - Royal Perth Group, North Metropolitan Area Health Service, Perth, WA Medical degree: University of Western Australia (1977) Wants to be remembered for: Leading a team that provided contemporary educational programs; conducting the hospital “orchestra” to deliver a good product; and having a sense of humour. Year of inauguration of college: 1968 Current number of fellows in Australia: 400 Royal Australian and New Zealand College of Obstetricians and Gynaecologists (RANZCOG) Ab umbris ad lumina vitae (From shadows to the light of life); and Excellence in women’s health President: Kenneth Clark Obstetrician and Gynaecologist, Palmerston, New Zealand Medical degree: University of Otago (1981) Wants to be remembered for: Having vision and honesty; trying to ensure the College has a future and is not emasculated because of complacency and lack of forward thinking. Year of inauguration of college: 1978 Current number of fellows in Australia: 1300 Royal Australian and New Zealand College of Ophthalmologists (RANZCO) Ut videant (That they may see) President: Allan Rosenberg Ophthalmologist, Sydney NSW Medical degree: University of Sydney (1974) Wants to be remembered for: Being a pair of safe hands, who looked after ophthalmology and also medicine. Year of inauguration of college: 1965 Current number of fellows in Australia: 700 Royal College of Pathologists of Australasia (RCPA) Medicine is pathology President: Vincent Caruso Director of Pathology, Western Diagnostic Pathology, Perth, WA Medical degree: University of Western Australia (1973) Wants to be remembered for: Dealing with the professional issues fairly; bringing a commonsense approach to the management of the College; and listening to the Fellows and trainees. Year of inauguration of college: 1956 Current number of fellows in Australia: 1800 Royal Australasian College of Physicians (RACP) Hominum servire saluti (To serve the health of our people) President: Jill Sewell Deputy Director, Centre for Community Child Health, Royal Children’s Hospital, Melbourne, VIC Medical degree: University of Melbourne (1971) Wants to be remembered for: Passing on wisdom; thinking broadly and including a wide variety of people; looking after patients and colleagues well; sticking at things (“enough ripples can make a wave”). Year of inauguration of college: 1938 Current number of fellows in Australia: 7600 Royal Australian and New Zealand College of Psychiatrists (RANZCP) Ex veritate salus (Out of truth [or understanding] comes health [or wellbeing]) President: Julian Freidin Psychiatrist, Alfred Hospital Homeless Outreach Psychiatric Service, Melbourne, VIC Medical degree: University of Melbourne (1981) Wants to be remembered for: Turning the College into something much more functional, useful and externally focused. Year of inauguration of college: 1963 Current number of fellows in Australia: 2100 Royal Australian and New Zealand College of Radiologists (RANZCR) Lumen afferimus morbis (We cast light on disease) President: Liz Kenny Senior Radiation Oncologist, Royal Brisbane and Women’s Hospital; and Medical Director of Cancer Services, Central Zone Queensland, QLD Medical degree: University of Queensland (1980) Wants to be remembered for: Making a difference, both to individuals with cancer and to cancer care at the state and national level. Year of inauguration of college: 1949 Current number of fellows in Australia: 950 Royal Australasian College of Surgeons (RACS) Fax mentis incendium gloriae (The torch of the mind is the flame of glory) President: Russell Stitz Colorectal Surgeon, Brisbane, QLD Medical degree: University of Queensland (1966) Wants to be remembered for: Improving the influence of surgeons in surgical care in the public hospital system; increasing the role of newer surgical subspecialties in the College. Year of inauguration of college: 1927 Current number of fellows in Australia: 3600 The Presidents of the medical colleges in Australia and New Zealand could be excused for feeling besieged. The colleges, as the bodies responsible for training and accrediting medical specialists (and setting and maintaining standards for general practitioners), are being challenged by many factors, including medical advances, the medical workforce shortage and societal changes. The latter include the growing “culture of suspicion”, whereby professionals are no longer trusted to regulate themselves, and increasing government oversight. In the past 10 years, the colleges have been scrutinised by the Australian Competition and Consumer Commission, the Australian Health Workforce Officials’ Committee, the Australian Medical Council and the Productivity Commission. At the same time, they have to counter longstanding negative perceptions held by some of the public, and even the profession, that they are conservative “closed shops” run by GOBSAT (“good old blokes sitting around tables”), and that they have enormous power and are interested only in maintaining income. We interviewed the Presidents of the 12 medical colleges to find out about their recent challenges and how they are responding to them. Although the colleges (with the exception of the College of General Practitioners) also have jurisdiction in New Zealand, we focused on Australia. Solving the workforce shortagesAlmost all the Presidents believe there is a shortage of specialists in their field or, at the very least, a maldistribution (eg, urban versus rural–regional). The problem will only worsen with the ageing of both patients and practitioners, increasing workforce feminisation and cultural change, with younger doctors unwilling to work the traditional long hours. For the Presidents of the College of Physicians (Jill Sewell) and the College of Radiologists (Liz Kenny), providing sufficient workforce is their college’s greatest recent challenge. It is “a moral and ethical obligation”, said Michael Kidd (President of the College of GPs). However, opinions vary as to how this can best be achieved and who carries the ultimate responsibility — the colleges or government. For the Presidents, there is a natural tension between providing more specialists and maintaining the professional standards that are fundamental to their organisations. The most obvious approach is to train more specialists, and several years ago the Australian Medical Workforce Advisory Committee (AMWAC) set targets for increasing the number of trainees in many specialties and subspecialties. Providing more training positionsFor colleges that cannot place all suitable applicants, creating more training positions is a vexed issue, as other stakeholders are involved: these positions are traditionally in public hospitals and financed by the state governments, with the colleges responsible for their accreditation. Not only is adequate funding required, but the colleges demand adequate educational value. The situation is not helped by the move of many doctors from the public to the private sector, particularly in specialties such as pathology and radiology. Several Presidents talked of working hard and “knocking on every door” to meet or exceed AMWAC targets for positions. President Vincent Caruso says the College of Pathologists has lobbied state and federal governments with limited success. The College has tapped into the private sector to fund a number of training positions either fully or with support from the federal government. The College of Surgeons, in particular, blames government for a shortage of advanced surgical training positions. “We think it is morally reprehensible that, earlier this year, 130 people were in this transitional position [awaiting advanced training posts]”, said the President, Russell Stitz. “We are keen to look at integrating basic and advanced stages. Politically that is difficult because health departments want people at the basic training level to fill their service requirements.” Attracting more traineesOn the other hand, colleges that cannot fill all their training places see the need for their specialty to be made more attractive to junior doctors. “Recruitment is a key issue for colleges of obstetricians and gynaecologists around the world”, said President Kenneth Clark. Indemnity must be kept under control and negative lifestyle portrayals avoided to encourage recruitment. The College of Psychiatrists has developed a recruitment package to encourage medical students to consider psychiatry as a career. However, President Julian Freidin does not feel that solving the psychiatric workforce shortage is the College’s responsibility alone, as it does not control all the workforce and financial levers. “The College is talking with the government about significant issues that deter students — all training positions are hospital-based, in acute settings that can be highly pressured, and psychiatry is less well paid than other branches of medicine.” The youngest specialty, emergency medicine, has also not reached AMWAC targets as quickly as expected, said its President, Andrew Singer, for similar reasons: “the pay structure, with most employed as staff specialists at lower pay than, say, procedural specialists; and perceptions that the work is difficult and high pressure”. However, some Presidents see the problem arising further upstream, from past government decisions limiting “the pipeline” of medical students. With the recent proliferation of medical schools, numbers will increase, but there will be a long lag before any effect is seen on workforce numbers. Reducing training timeMost Presidents dismiss the suggestion to reduce training time as being neither practicable nor a solution to workforce shortages. “If you just rush some people through faster, you will help for a couple of years, but you are still on the same conveyor belt”, said Sewell. Training has traditionally been time-based, with a certain number of years required in a registrar position before a barrier examination. Although some colleges are planning to move from a time-based to a competency-based program (see Training programs), they do not feel this will allow any substantial reduction in training time because of the amount of material that needs to be covered and the nature of rotations. Many colleges defend the length of their program because of a desire for their fellows to be generalists. For example, according to Michael Cousins (College of Anaesthetists), an anaesthetist in a country hospital must be able to cope with a wide range of patients and situations. Freidin also pointed out that there is a large service component during training. “Over the 5 years that psychiatrists work as registrars, they spend only a short time training. They are working to keep the state system from falling apart.” Recruiting overseas-trained doctorsThe medical workforce pressures mean that Australia relies heavily on overseas-trained doctors. All the colleges have procedures, in conjunction with the Australian Medical Council (AMC), to assess the suitability of these doctors to practise in Australia. Kidd summed up his college’s position, which is typical: “Any doctor recruited to work in independent practice anywhere in Australia should be at the level of a Fellow of the College and should either have attained that Fellowship, be judged by the College to have had equivalent training and assessment, or be working under supervision towards meeting the Fellowship standard”. However, the colleges find assessing overseas-trained doctors a challenge. There is “such a difference between qualifications on paper and actual competencies of practice”, said Kenny. And the procedures of some colleges have been criticised as overly slow, onerous and even anticompetitive. A range of other schemes allow overseas-trained doctors to practise in Australia without ever coming into contact with a college, and required standards vary between schemes and also between different states and territories. Cousins elaborated: “In states such as Queensland, it has been possible to employ overseas-trained doctors in career medical officer positions and to allow them to practise de facto as specialists, without going through the college process”. The colleges want to see standardisation of procedures and requirements across colleges and jurisdictions. The federal government has asked the colleges to define rapid assessment pathways, particularly for areas of need, and to identify appropriate overseas qualifications. A continuing concern in this process, according to Cousins, is indemnification against claims of discrimination against particular overseas programs. Task substitutionAnother suggestion that might help relieve medical workforce pressures is to transfer some tasks of doctors to other health professionals. Indeed, the Productivity Commission proposed a multiskilled “generic” health worker in its recent position paper on issues affecting the health workforce.1 While Presidents such as Sewell felt there was merit in “skills transfer and better use of the health workforce in a broader way”, all stressed the need to maintain quality of care. For example, Allan Rosenberg of the College of Ophthalmologists contended that, “with adequate training, substitution of certain tasks is possible, but only a doctor has a holistic approach to treating the patient as a whole person”. For the College of Obstetricians and Gynaecologists, task substitution is probably their greatest recent challenge. Their President, Clark, said the College is not anti-midwife. “It is perfectly reasonable for women to have other care options. What they must have is immediate access to specialist care.” Some colleges strongly support the development of health care teams headed by doctors. The College for Emergency Medicine sees itself as a leader, having “embraced advanced nursing roles and brought allied health staff into non-traditional areas in the emergency department”, said Singer. Similarly, public sector psychiatry is very open to the idea of clinical teams with a psychiatrist as “the leader who has the best ability to integrate the biological, psychological and social”, said Freidin. Kidd would like to see dedicated GP nurses in every general practice. Kenny believes in “role evolution”, and is evaluating its potential together with the radiographer and medical physicist professional bodies. In addition, many specialist colleges are willing to share workload with appropriately trained GPs. For example, the College of Dermatologists sees that GPs, including those working in specific skin cancer clinics, fill a need in the detection and management of skin cancers. Yet, a concern for many is the potential for task substitution to create a two-tier system, whereby some Australians receive a lower level of care than others. For example, the College of Anaesthetists wishes to maintain Australia’s pre-eminence for low anaesthetic mortality. “The general public expects not to die undergoing anaesthesia for a routine procedure”, said Cousins. Moreover, many Presidents pointed to a shortage of other workforce in their respective fields (eg, nurses and biomedical scientists), limiting the potential for task substitution. Responding to government oversightThe Presidents are generally philosophical about currently increasing government regulation, seeing it as “a fact of life that will not go away” (Stitz). Some also described benefits, such as increased interest in funding training posts and in ensuring supervisors have time for training. But there is no doubt that this regulation is a challenge that demands considerable time and resources. The ACCC reviewThe review of the colleges by the Australian Competition and Consumer Commission (ACCC) originated in the widening of the Trade Practices Act 1974 in the mid-1990s to include the medical profession. The ACCC began investigating allegations that the College of Surgeons was in breach of the Act by restricting entry to advanced training. The implication was that the college was a “closed shop”, inflating specialist incomes by limiting competition. To avoid legal action, the College applied for authorisation of its conduct, which can be granted if the ACCC is satisfied that the public benefit outweighs any detriment caused by the lessening of competition. In 2003, this authorisation was granted for 4–6 years, subject to the College making reforms to increase transparency, accountability, stakeholder participation and procedural fairness of its processes. Stitz believes the situation is now largely resolved. “The end result is we have robust processes, and jurisdictional representatives on all our major educational committees. But we are having a bit of trouble with the resources needed to service the ACCC requirements for timely accreditation of hospitals and assessment of overseas-trained surgeons.” The ACCC then turned its attention to the other colleges and began a joint review, with the Australian Health Workforce Officials’ Committee (AHWOC), of the extent to which college processes for selection, accreditation and assessment incorporated the general principles of the College of Surgeons’ authorisation. Several other Presidents mentioned going out of their way to make contact with the ACCC and trying to work “within the rules”, believing the recommended changes were desirable. Sewell (Physicians) said: “They are wanting us to do certain things slightly differently. Many we have been trying to achieve anyhow, such as working more closely with the [government] jurisdictions about the distribution of the training workforce and our educational processes”. Others, such as Freidin (Psychiatrists), feel there is no suggestion their colleges are restraining trade — they have been “caught up in the general review”. The ACCC–AHWOC report on the colleges earlier this year observed that many had implemented, or were intending to establish, approaches similar to ACCC recommendations, but that implementation was in its very early stages and varied between colleges.2 The colleges were invited to assess their progress individually. AMC accreditationIn the past 5 years, the colleges have also been scrutinised by the Australian Medical Council (AMC), which has long accredited medical schools and their curricula. In 1998, the AMC was invited by the federal government to develop processes to accredit the college programs for specialist medical training, continuing professional development and assessment of overseas-trained doctors. The AMC has been reviewing the colleges at the rate of one or two a year since 2001. The Presidents described the AMC reviews as exhaustive: “It was a major evaluation, with face-to-face meetings and site visits relating to our entire educational and examination program”, said Cousins. The College of Physicians underwent the process in 2004; Sewell considered it “a really important opportunity to look at everything we do educationally”. Those still to be reviewed are anticipating the challenge. Anne Howard (College of Dermatologists) commented that the review (scheduled for 2007) is “a good opportunity to work out our curriculum and make sure we have the correct selection, training and assessment processes. But it will be fairly time consuming and expensive, especially for small colleges like ours, because they want a lot of material”. Similarly, Philip Montgomery of the College of Medical Administrators (scheduled for 2008) said “the most important challenge for us is making sure that all our processes and the quality of our education program are such that we get full accreditation”. Reinventing themselvesThe soul-searching prompted by this intense scrutiny is no doubt a factor in many of the recent changes made by the colleges to their processes, educational programs and governance. Training programsA major role of the colleges is to oversee vocational training in what has been traditionally a time-based, master–apprentice system. Several Presidents highlighted changes to the underlying philosophy of their programs. For example, the College of Anaesthetists has “modularised” training and is adapting these modules for distance education. Both the College of Physicians and the College of Radiologists are moving to competency-based rather than time-based programs. Kenny said the College of Radiologists is putting enormous effort into curriculum development. “With the help of professional educators from the University of NSW, we are looking at a project that articulates the skills and competencies we expect of our trainees and graduates. These will be part of the actual training program and will be assessed.” She believes that defining required competencies could also have benefits in assessing overseas-trained doctors and task substitution. The College of Physicians intends its planned competency-based program to increase flexibility, as “trainees will be able to demonstrate their competencies at their own rate”, said Sewell. (The College has allowed part-time training for many years.) Not all colleges have complete responsibility for training in their specialty. For the College of GPs, a major crisis was the loss of the contract for vocational training in 2002. GP training is now overseen by a government-owned company and contracted out to regional consortia, which include the College, to be performed to College standards. Another exception is the College of Medical Administrators, which includes, as its basic qualification, a university masters degree in public health or administration. Montgomery explained: “We used to run the program itself and set the curriculum and examinations, but it was a little antiquated. The universities are very good at running these masters programs, and the courses are available”. In fact, the Committee of Deans of Australian Medical Schools has suggested to the Productivity Commission that universities should have a “major role” in vocational training.3 Overwhelmingly, the Presidents thought this was not practic-able. Many questioned where the universities would get the required teachers, as all their fellows are already involved in college programs. Sewell saw benefit in “working together with universities around specific skills and specific courses”, but “would not want to see a wholly parallel system of university vocational training which competed with the colleges. We are not that big a pond”. She also pointed out that “as clinicians provide an enormous amount of teaching to medical students (often unpaid) as well as to vocational trainees, there is considerable expertise in medical education outside the universities”. Continuing professional developmentTraditionally, continuing professional development (CPD) for college fellows is a voluntary program comprising lectures, seminars and conferences. However, a number of colleges feel more is required, such as making CPD compulsory and introducing audit components. The College of Surgeons is keen for its Fellows to participate in external audits, such as the national breast cancer audit, and is supporting the roll-out of a binational audit of surgical mortality. The College of Obstetricians and Gynaecologists is the most demanding: “For the last decade we have required adequate compliance with our continuing education program, which includes compulsory practice review. We can — and do from time to time — remove the Fellowship”, said Clark. His college has also led a national project on CPD — the LEAP (Learning, Education and Professionalism) framework. This includes practice review and is being trialled by other colleges under the auspices of the Committee of Presidents of Medical Colleges (CPMC) (see below). “We have now reached a joint belief at CPMC level that this is the way we should be going. We are trying to counter the position that it is an optional extra”, Clark continued. Nevertheless, while other Presidents support CPD, most are dubious about the value, or even the possibility under their by-laws, of making Fellowship contingent on revalidation. GovernanceTraditionally, colleges have been run by councils of their members, plus a smaller executive. There are moves to create smaller, more business-oriented governing bodies. In addition, the ACCC is pushing for governing bodies to include representatives of other stakeholders — trainees, the government jurisdictions and the community. The College of Ophthalmologists moved 2 years ago from an executive council to a board run along the lines of corporate law. Rosenberg believes they are “ahead of the pack”. “We were looking at ourselves long before the ACCC review. The aim was to make changes to work within the law and look after our fiduciary interests, while retaining the collegial feel. We have pretty well followed the AHWAC and ACCC recommendations. We try to prevent crises by being proactive.” Many colleges now have trainee repres-entatives on their federal or state councils or other committees. The move to include community representatives has been slower, and those appointed tend to have other desirable expertise. The GPs have just appointed the first layperson to council. “She is bringing a strong background in financial management, strategic planning and corporate governance, as well as the layperson’s perspective”, said Kidd. The College of Physicians has longstanding relationships with several consumer organisations but has not involved them in council. Sewell believes “they do not want to sit on a lot of committees, as there are not enough of them. They want to be involved when significant policy decisions are being made”. The colleges are also beginning to involve the government jurisdictions, particularly in educational planning (eg, the College of Physicians has an AHWOC representative on its educational strategy implementation board). However, the ACCC–AHWAC report in July 2005 called for more progress in involving the jurisdictions in decisions affecting the workforce.2 Committee of Presidents of Medical CollegesIn the face of the pressures, some Presidents see a particularly important role for their professional association, the Committee of Presidents of Medical Colleges (CPMC). “The Colleges have tended to be their own little worlds and to act in isolation”, explained Clark. “We need to be supporting each other more, and looking after the smaller and weaker colleges. We have been slow to share teaching and staff resources.” Some Presidents also believe the CPMC needs to move from being just about information-sharing to being a body in its own right. The smaller colleges particularly appreciate the CPMC. According to Howard, “The meetings are terrific, with a real feeling of cooperation. We are looking at what sort of training modules we can help each other with”. Montgomery said, “The CPMC is a collaborative body, and very good for networking with other colleges, learning from each other and keeping up to date. It is particularly useful in being able to communicate directly with the Department of Health and Ageing and the peak bodies around Australia”. On the other hand, some groups have criticised the CPMC as too timid and too agreeable with government, and some colleges may continue to put their own case. What of the future? On being President . . . . We asked the Presidents whether, with all the demands, they have time for a private life. “Of course”, they all replied. Yet most acknowledge that the college workload is immense, especially in the larger colleges, where it could be full-time and may involve at least one day a week travelling. In addition, all still have “a day job”, although many have reduced their hours. Essentials seem to be a supportive partner and the ability to get by on very little sleep (one President gets up at 04:00 to spend 3 hours on college work before their regular job). Kidd described it like an athletic event — he makes a conscious effort to attend to exercise and diet, take time out, and achieve balance. Why have they volunteered for this role? For all, it seems the climax to a long period of service to their college, and a typical response was “wanting to give something back to the profession”. The term as president is mostly 2 years, because, as many said, that is as long as a person can stand. After that, according to one, they ”will be able to kick up their heels”. The Presidents do not expect the pressures on the colleges to abate. However, they do believe that government and public misperceptions need to be corrected. “There is a belief that the colleges have enormous power and are interested only in income”, said Cousins. “We are training, examining, and professional standards organisations. An incredible number of people give vast amounts of time and energy to the colleges. They do it because they believe in the importance of postgraduate education and want to maintain current standards. And they do it for free. It would cost millions to pay for the activities of our college.” Nevertheless, they agree that responsiveness and transparency are needed. “The colleges have to be mindful of what is happening outside themselves and make sure that the community wants and values the specialists they produce”, said Freidin. As Caruso said about CPD, they need to demonstrate their integrity to the public. “It has to be not just done, but seen to be done.” Yet, several Presidents warned that increasing government regulation could alienate the people on whom specialist training, and ultimately health care, depend. Stitz explained: “We are comfortable with government processes that ensure that professional people behave appropriately and that define the broad parameters of educational excellence. But once the parameters are defined, we should be allowed to get on and do the work we are trained to do”. From our interviews, it was clear that the current pressures are challenging not only the colleges, but also the Presidents. Their role has a considerable impact on their lives (Box). Yet, just as responding to the challenges may ultimately strengthen the colleges, so to do the Presidents regard their once-in-a-lifetime role as an enriching experience — they spoke of it variously as an honour, a privilege, and a wonderful opportunity to meet inspiring people and to make a major contribution to their profession and health care in Australia, and “the best job in the world”.

Kerrie A Lawson PhD · Ann T Gregory MB BS, GradDipPopHealth · Martin B Van Der Weyden MD, FRACP, FRCPA

Emergency department (ED) overcrowding is the most serious issue confronting EDs in the Western world.1 As a result, diversion of ambulances to another hospital has become commonplace. This is primarily due to access block — patients in the ED requiring inpatient care are unable to gain access to appropriate hospital beds within a reasonable time frame.2 A reasonable time frame is defined as up to 8 hours spent in the ED by an admitted patient.2 Adverse events associated with ED overcrowding and ambulance diversion have been reported. These include impaired access to emergency care, compromised clinical care, prolonged pain and suffering, and prolonged inpatient length of stay. These adverse events have also been linked to fatalities.3,4 To date, no studies have examined the mortality rate associated with ambulance diversion. I hypothesised that, during periods of ambulance diversion, patients in the ED would have a higher eventual mortality rate, because ED staff, stretched beyond their capacity, may not be able to provide safe care. Methods By placing "No Entry" signs at the point of ambulance entry, we could save thousands of lives each year. All periods of ambulance diversion at Royal Perth Hospital ED for the calendar year 2003 were studied. That year’s ED attendances numbered 51 885, with an admission rate of 43%. Of all attendances, 38.3% arrived by ambulance. The rate of access block during the study period was 30.7%. Each episode of ambulance diversion was recorded as day, date, start time, and end time. From this, the 1-hour period before ambulance diversion (pre-diversion) was determined. (This was considered to represent the period of greatest risk for patients). For comparative purposes, an identical time series was constructed for when the ED was not on ambulance diversion. For example, if the ED was on ambulance diversion on a Wednesday from 11:00–14:00, then the pre-diversion period was 10:00–11:00 and the comparative period becomes the Wednesday 1 week later, assuming that the ED was not on diversion during that period. If it was, then the preceding Wednesday was chosen as the comparative period. If that period was on diversion, then the Wednesday 2 weeks later was used, and so on. This was to allow for valid day-to-day comparisons, and to avoid seasonal variations. The record of each patient episode refers to the period (pre-diversion, diversion or the respective comparison periods) during which the patient arrived at the ED. To avoid duplication of patient episodes, once patients attended the ED, they remained in that defined episode. For example, if a patient arrived at the ED in the pre-diversion period and subsequently died, that death was attributed to the pre-diversion period (even though this patient may have still been in the ED during the diversion period). These data were linked with EDIS (Emergency Department Information System) and TOPAS (The Open Patient Administration System) for each patient attendance. TOPAS is an administrative computer system that, among other things, records patient outcomes, such as discharge or death. The outcome measure used was death. (Deaths were those deaths that occurred at any stage while the patient was in hospital, from the ED to the wards.) In this retrospective data-linkage study, data were analysed using SAS version 9.1 (SAS Institute, Cary, NC, USA). A negative binomial model was used because it is equivalent to the Poisson model. However, the Poisson model assumes that the variance and means are the same, whereas the negative binomial model does not make that assumption. Fit was assessed using deviance and χ2 tests. ResultsThere were 297 episodes of ambulance diversion in 2003. Paradoxically, the results show a statistically significant 28% reduction in patient mortality for patients attending the ED during periods of ambulance diversion (Box). DiscussionPatient safety, as measured by eventual mortality, appears to be positively enhanced by ambulance diversion. That clinical staff are able to meet the clinical and safety needs of their patients during ambulance diversion has profound implications. From my data, it is possible to calculate the number of lives saved by ambulance diversion. The difference in mortality (1.87% minus 1.34%) is 0.53%, which is equivalent to 29 of the 5445 patients; extrapolating this to an annual figure (0.53% of the 43% admissions of 51 885 annual attendances) means about 118 lives saved per year at our hospital alone. Nationally, there are about 4 million ED attendances per year. Assuming a national admission rate of 30%, there is potential for ambulance diversion to save 6360 lives a year in Australia. It is recommended that, to realise these safety gains, health authorities should steadily increase the prevalence of ambulance diversion. Further research is needed to examine the effect on mortality of increasing access block. As there is an almost linear correlation between access block and ambulance diversion,3 it is likely that increasing access block to 100% might result in three times as many lives saved. Episodes of ambulance diversion and patient mortality rates Period Number of patients Number of deaths P Incidence rate ratio (95% CI) Pre-diversion period (1 h) 8679 137 (1.58%) Comparative period (1 h) 7175 100 (1.39%) 0.34 1.13 (0.88–1.46) Diversion period 5445 73 (1.34%) Comparative period (not on diversion) 8245 154 (1.87%) 0.018 0.72 (0.61–0.95)

Daniel M Fatovich MB BS, FACEM

Objectives: To determine whether weather conditions affect emergency department (ED) attendance and admissions from the ED.Design and setting: A retrospective observational study in a large metropolitan ED.Main outcome measures: ED attendance (total and via ambulance) and admissions to hospital from ED, as a function of weather variables.Results: On warm, dry, sunny and good weather days there were significantly more ED attendances in total than there were on cool, rainy, dull and bad weather days, respectively (P ≤ 0.001). There were significant correlations between ED attendance and temperature (r = 0.36, P < 0.001), rainfall (r = − 0.20, P < 0.001) and hours of sunshine (r = 0.17, P = 0.001). Attendance via ambulance was not affected by weather variables. Admissions from the ED were positively correlated with temperature (r = 0.15, P < 0.01) and negatively correlated with rainfall (r = − 0.12, P = 0.02).Conclusions: As there is a clear relationship between weather conditions and ED attendance, incorporating meteorological forecasting into emergency medicine training may improve ED scheduling. To improve the morale of ED staff coping with an onslaught of patients on good weather days, the ED environment should simulate sunny weather, with swimming pools, sun lamps, palm trees and Beach Boys music.

Daniel K B Ou MB BS · The-Phung To BPharm, MClinPharm · David McD Taylor MD, MPH, FACEM

We evaluated an Internet-based psychological intervention supported by either general practitioners or psychologists (Panic Online), and a Primary-care Evidence-based Psychological-interventions (PEP) strategy which involves training GPs to deliver specific psychological interventions. Economic modelling suggests that Panic Online is cost-effective when supported by either GPs or psychologists. Threshold analysis of the psychological training of GPs suggests that a modest effect size for clinical benefit would be sufficient to provide an acceptable cost-effectiveness ratio. The sustainability of these approaches depends on a range of factors, including funding, workforce availability, and acceptability to consumers and health care providers.

Cathrine Mihalopoulos BBSc(Hons), GDECSt, PGDHlthEc · Sophy Ting-Fang Shih BSc, MPH, DrPH · Litza Kiropoulos BEd-Sc, BSc(Hons), MClinPsych, PhD · Grant Blashki MD, FRACGP · Graham Meadows MD, MRCP, FRANZCP · Jane Gunn FRACGP, DRANZCOG, PhD

Recent MJA editorials assert that Australian hospitals are no safer than they were when the first hospital safety report was published in 1995. Despite many recommendations by several committees and much activity to improve safety over the past decade, we lack concrete evidence that safety and quality of health care have improved. Efforts to promote hospital safety in the United States and the United Kingdom also remain unevaluated. Incentives for safer care have been implemented locally, but not applied to entire health systems. A recent review in Australia has recommended replacing the current Australian Council for Safety and Quality in Health Care with a smaller Commission on Safety and Quality in Health Care. The Commission will link all national safety activity and report annually to Australian health ministers on hospital safety. We need a system that measures quality and safety, and provides financial incentives for safer care. Implementing the national framework for education about patient safety would develop teamwork skills and skills in techniques of continuous improvement. Linked to this, adequate financial support should be available to make safety changes in the health care environment.

George L Rubin FRACP, FACPM, FAFPHM · Stephen R Leeder AO, PhD, FRACP, FFAPHM

Stephen Clarke,* Justin G Oakley,† David A Neil,‡ Joseph E Ibrahim§ * Research Fellow, Centre for Applied Philosophy and Public Ethics, Charles Sturt University and the Australian National University, Canberra, ACT 2601; † Director, Centre for Human Bioethics, Monash University; ‡ Lecturer, Faculty of Arts, University of Wollongong; § Professor, Rehabilitation, Aged and Palliative Care Services, Peninsula Health, Mt Eliza, VIC. Stephen. ClarkeATanu.edu.au To the Editor: Last year, three of us made a case for the public reporting of individual surgeon performance information.1 We argued that considerations of safety and accountability strongly justify the collection of individual outcomes data, and that considerations of patient choice make it very hard to argue against the public reporting of collected data. The public trust in health care in Australia has, in the words of a recent MJA editorial, “taken a pounding” as a result of a series of scandals at the King Edward Memorial Hospital, Perth, in 1999, the Canberra Hospital, in 2000, and the Campbelltown and Camden Hospitals in NSW, in 2002.2 We noted that recent developments in public reporting of surgeon performance information in the United Kingdom were driven in large part by the Bristol Royal Infirmary Inquiry, and we warned of the danger of waiting for a scandal like Bristol to occur before acting to improve performance management. Unfortunately, a scandal, perhaps on the scale of that at the Bristol Royal Infirmary, has now occurred in Bundaberg. Although this scandal is ostensibly about the failings of one badly performing surgeon, it is widely seen as symptomatic of a failure of regulation of health care throughout Australia. The Queensland Health Systems Review, headed by Mr Peter Forster, was established in April this year as a result of public disquiet resulting from the Bundaberg scandal.3 The Premier received the report on 30 September and has recommended a wide range of reforms including increased performance monitoring of a range of health care outcomes (Recommendation 13.2), and the insistence that information on health system outcomes be made public (Recommendation 13.3). We welcome the review’s recommendations as both a necessary component of a successful system of management of the health care system and a means to begin to restore public trust in the health care system. Unfortunately, we suspect that this may not be enough to restore trust in the system. A system in which a plainly incompetent surgeon has been allowed to continue operating is one where, in the eyes of the public, the performance of all surgeons working within that system is called into question. A public reporting system that provides reliable and valid information about individual surgeons, as well as hospitals’ clinical performance, would be a significant step towards restoring the public’s confidence and ensuring transparency within that system.

Stephen Clarke · Justin G Oakley · David A Neil · Joseph E Ibrahim

Sue M Evans,* Peter A Cameron,† Paul Myles,‡ Johannes Stoelwinder,§ John J McNeil¶ * Executive Officer/Research Fellow, † Professor of Emergency Medicine, ‡ Professor and Director, Department of Anaesthesia and Perioperative Medicine, § Professor; and Chair of Health Services Management, ¶ Head, Department of Epidemiology and Preventive Medicine, Monash University, NHMRC Centre of Research Excellence in Patient Safety, Level 3, Burnet Building, Alfred Hospital, Prahran, VIC 3004. sue.evansATmed.monash.edu.au To the Editor: The article by Morton1 and the editorial by Van Der Weyden2 raised some important points. Investment in redesigning the health bureaucracy and recruiting more clinicians to work in Queensland is clearly important, but we also need to address more fundamental issues to ensure optimal quality of care. The following two matters require particular attention: lack of measurement and monitoring; and developing clinical governance. We cannot know how hospitals are performing unless we have well developed and validated markers of quality of care that can be risk-adjusted and benchmarked. Measurement and benchmarking are fundamental components of quality assurance in virtually every industry other than health care, and it is difficult to see how standards can be guaranteed and improved unless they are adopted more widely in health care. In contrast to Bristol, where data on cardiac surgery were collected but not used effectively,3 we also need systems in place to react to poorly performing individuals, units or hospitals. Effective monitoring is also currently limited by an inability to link data, such as deaths, re-admissions and complications. Clinical performance has depended too much on personal capabilities — training, experience, memory and vigilance. Although important, the avoidance of human error will necessitate change to a more system-focused approach to patient care. This will involve greater coordination of care to improve efficiency and to build layers of safety into our daily work practices. Currently, supervision of medical practice is extraordinarily diffuse. The accountability of medical practitioners must be made more explicit, and greater attention paid to ensuring that skills are gained under adequate supervision and maintained over time. Simulation offers great potential for identifying vulnerabilities in a learning environment and in the adoption of new technologies into routine practice. Doctors have traditionally been reluctant to adopt clinical pathways or decision support tools to supplement memory and record clinical information and results. However, these can help standardise clinical care and reduce human error by ensuring that uniform, evidence-based practices are adopted. These strategies will also provide the basis of effective clinical governance.

Sue M Evans · Peter A Cameron · Paul Myles · Johannes Stoelwinder · John J McNeil

Anthony P Morton Consultant, and Medical Statistician, Infection Management Services, Princess Alexandra Hospital, Woolloongabba, QLD 4102. amor5444ATbigpond.net.au To the Editor: Recent articles drawing attention to the “Bundaberg problem” and its causes1,2 have stressed the need to make hospitals safer. Queensland Health’s approach to improving quality has been the Measured Quality Hospital Reports.3 Unfortunately, this approach puts the cart before the horse. The quality of all work is a function of the systems in which it is performed.4 Therefore, it is logical to concentrate first on optimising hospital systems. When that is done, the work of the hospital should be consistent and reproducible. It is then logical to use measurement to detect any deterioration or to gauge the effect of any effort to improve a hospital’s systems. This measurement needs to be sequential, and, where random variation occurs, it should take advantage of the excellent statistical process control methods now available.5 In addition, the limitations of risk-adjustment must be applied and understood. Where possible, this is best done at a local level, as at this level risk-adjustment can be made to work better,6 and local ownership promotes efforts to learn how to improve rather than efforts to be seen to comply with a target. Putting measurement first encourages excuses (eg, demographic and classification differences), quick fixes and gaming, not solutions. Correcting hospital systems requires, for example, a focus on specific processes, use of evidence, employment of multidisciplinary teams, independent audit of surgical outcomes, proper supervision of junior staff and, above all, leadership.4 Central offices are seen to be remote, judgemental, controlling and arbitrary. It is very difficult to foster ownership and trust in such an environment. Without trust, leaders do not emerge and teamwork becomes impossible. To achieve better systems in hospitals, central offices have to change; they have to become coaches. They must help hospital staff with the difficult task of analysing and changing their systems. They must then institute programs of surveillance to ensure that this process is sustained. Central offices need to ensure that, if a hospital’s measurement system detects a possible change in the quality of its care, a search for a possible cause is undertaken and, if a cause is found, appropriate corrective action is instituted. Demands on hospitals are potentially infinite and resources are not. Determining what is best requires informed public debate. However, whatever the resources available, safe care is likely to be less costly than unsafe care, as there is much less failed work needing redoing.

Anthony P Morton

Bruce H Barraclough Chair, Australian Council for Safety and Quality in Health Care; and NSW Clinical Excellence Commission; Professor of Cancer Services, Northern Sydney Central Coast Health, Royal North Shore Hospital, Pacific Highway, St Leonards, NSW 2065. bbarraATozemail.com.au To the Editor: I am surprised that your recent editorial1 failed to recognise the quite dramatic changes for the better occurring in our health system and the way these changes have come about. In July, the Australian Health Ministers agreed that there had been widespread acceptance of the National Safety and Quality agenda developed by the Australian Council for Safety and Quality in Health Care, and agreed to build on the Council’s extensive platform of reforms by establishing the Australian Commission on Safety and Quality in Health Care to continue this work.2 They noted change and progress in key areas, including the development of incident management systems in all jurisdictions to fix problems in a timely way. All public hospitals are developing integrated patient safety risk management plans, a common protocol for correct site procedures has been accepted, and across the system the booklet 10 Tips for safer health care3 is being given to patients on admission to hospital to enhance their ability to ask the right questions and better control their care. The Australian Council for Safety and Quality in Health Care has commissioned preparation of the first national sentinel events report. Each state is teaching health care staff “root cause analysis” methodology and, on the back of this, there has been a massive increase in reporting across the country — 30-fold in New South Wales — because people realise that systems issues will be fixed without inappropriate blame. This supports openness about mistakes and the reporting of problems. Other national initiatives under way include an education framework for safety and quality, a single common medication chart in all public hospitals, agreed national approaches to infection control, as well as a national open disclosure standard and a national standard for credentialling and defining the scope of clinical practice. Ministers have endorsed this standard, which, if applied appropriately, could be expected to help prevent situations like that in Bundaberg. The Bundaberg scandal, however, appears to have been caused initially by a fraudulent application for registration. The safety and quality agenda does not address criminal behaviour, but puts in place opportunities for improvement. These are only some of the reforms being implemented using levers for change, which include leadership, advice, persuasion, example, and the development of tools, standards and guidelines. Commonwealth, state and territory health and human services departments, as well as organisations in the private sector, continue to be responsible and accountable for implementing these activities. Internationally, the Council’s work is held in high regard by authorities from the United Kingdom, the United States, Canada and Ireland, who are seeking advice about how coordination of these activities across the health and human services departments of nine sovereign governments has been achieved. The new Commission will continue the difficult task of taking the health system from “very good” to “even better”.

Bruce H Barraclough

Peter M Brooks Executive Dean (Health Sciences), University of Queensland, Royal Brisbane Hospital, Herston, QLD 4006. p.brooksATmailbox.uq.edu.au To the Editor: Van Der Weyden is to be congratulated on his editorial about the Bundaberg Hospital scandal.1 He rightly points out that, although these issues have surfaced now in Queensland, the whole of the Australian health system is currently like a time bomb, with other disasters waiting to happen. However, the current health workforce shortage, which underlies many of the problems facing the health system, is not going to be solved by creating more of the same. There needs to be a radical rethink of how we deliver services in different ways, with different types of health practitioners, such as physician assistants, nurse anaesthetists and a range of other health professionals — many of whom already practise in other countries. The editorial did not emphasise, however, the importance of creating “partnerships” between Queensland Health and the universities. The concept of the professor/director, so common now in the southern states of Australia, has not been embraced in Queensland. There are significant opportunities to work together to improve health worker training in the future if this partnership is embraced. There is also an urgent need for an open debate on what Australians want from their health system and how much they are willing to pay. These are difficult issues and, although other countries such as the United States (Oregon) have attempted to have this community debate in the past, no clear solutions have been forthcoming. The current issues in Queensland, the publication of the Queensland Health Systems Review by Mr Peter Forster2 and the Productivity Commission’s Position Paper on Australia’s Health Workforce3 provide a great opportunity for the government and the community to sit down and have that debate, so that we can plan an appropriate health system for the future.

Peter M Brooks

Martin B Van Der Weyden Editor,The Medical Journal of Australia, Locked Bag 3030, Strawberry Hills, NSW 2012. medjaustATampco.com.au In reply: The letters in response to my editorial1 reflect concern within the medical community about the continuing saga of safety in our hospitals. Clarke et al call again for public report cards on individual surgeons. It is difficult to see what positive outcomes such an exercise would have on systemic safety — it is likely to encourage a culture of individual blame and to detract from probing system factors, an outcome not favoured by experts in safety.2,3 Despite this, surgeons in Australia are at the forefront of performance monitoring, as exemplified by the Western Australian Audit of Surgical Mortality.4 Indeed, the Royal Australasian College of Surgeons is introducing a similar program across Australia and New Zealand,5 and its leadership in this matter is to be applauded. Evans and her colleagues and Morton reiterate the dire need for a comprehensive and continuous measurement system for clinical outcomes and the central role of clinical governance. The importance of these requirements is echoed in the use of the words “measurement” or “monitoring” 11 times and “governance” five times in the preceding letters. Aitken raises the important point that improving safety and quality comes at a cost and requires dedicated time. He also draws attention to the recently introduced protected, non-clinical time for consultants in the United Kingdom, a development that deserves serious consideration by health departments Australia-wide. That medical manpower shortage is at the root of the Bundaberg Hospital scandal is emphasised by Brooks, but he calls for a debate about the bigger picture: a radical rethink of what we want from our health system and who should be the providers. Such a debate is usually side-stepped by our politicians, but the recent Productivity Commission report on Australia’s health workforce6 may force the issue. Finally, Barraclough enumerates the achievements of the Australian Council for Safety and Quality in Health Care (ACSQHC). As acknowledged in the recent review of the ACSQHC,7 the Council’s key achievements have been in raising safety issues among clinicians and the public, producing a bevy of quality policies, and focusing on systemic causes rather than individual blame for medical mishaps. The total funding allocation to the Council over its 6-year term was $55 million.7 However, the purpose of my editorial was not to dwell on these achievements, but to draw attention to the lack of a comprehensive system for gathering data on defined clinical outcomes — a necessary tool if we are to achieve meaningful safety and quality improvement. Without these data, we have no way of knowing whether the activities of the ACSQHC have made any difference to safety. As the Royal Australasian College of Physicians noted in its submission to the ACSQHC review: “clinicians do not have ready access to meaningful information about clinical practice”.7 In short, we need to resolve what we want to know and why we want to know it, and then to measure it locally, state-wide and nationally. Measuring progress and demonstrating improvement are potent forces for change. But it all depends on the availability of robust measurements.

Martin B Van Der Weyden

Objective: To estimate the incremental effects on cost and quality of life of cardiac rehabilitation after an acute coronary syndrome.Design: Open randomised controlled trial with 1 year’s follow-up. Analysis was on an intention-to-treat basis.Setting: Two tertiary hospitals in Sydney.Intervention: 18 sessions of comprehensive exercise-based outpatient cardiac rehabilitation or conventional care as provided by the treating doctor.Participants: 113 patients aged 41–75 years who were self-caring and literate in English. Patients with uncompensated heart failure, uncontrolled arrhythmias, severe and symptomatic aortic stenosis or physical impairment were excluded.Main outcome measures: Costs (hospitalisations, medication use, outpatient visits, investigations, and personal expenses); and measures of quality of life. Incremental cost per quality-adjusted life year (QALY) saved at 1 year (this estimate combines within-study utility effects with reported 1-year risk of survival and treatment effects of rehabilitation on mortality). Sensitivity analyses around a base case estimate included alternative assumptions of no treatment effect on survival, 3 years of treatment effect on survival and variations in utility.Results: The estimated incremental cost per QALY saved for rehabilitation relative to standard care was $42 535 when modelling included the reported treatment effect on survival. This increased to $70 580 per QALY saved if treatment effect on survival was not included. The results were sensitive to variations in utility and ranged from $19 685 per QALY saved to rehabilitation not being cost-effective.Conclusions: The effects on quality of life tend to reinforce treatment advantages on survival for patients having postdischarge rehabilitation after an acute coronary syndrome. The estimated base case incremental cost per QALY saved is consistent with those historically accepted by decision making authorities such as the Pharmaceutical Benefits Advisory Committee.

Tom G Briffa PhD, MSc · Simon D Eckermann PhD(Ec), MSc, GradDipHEc · Alison D Griffiths BA Hons · Anthony C Keech MB BS, MScEpid, FRACP · Phillip J Harris MB BS, DPhil, FRACP · M Rose Heath RN · Saul B Freedman PhD, FRACP, FACC, FESC · Lana T Donaldson RN, MPH · N Kathryn Briffa BAppSc(Physio), PhD

Objectives: To compare the safety, effectiveness and cost-effectiveness of drug-eluting coronary stents used in Australia with bare-metal stents and determine whether the benefits are greater for high-risk subgroups.Data sources: MEDLINE, Pre-Medline, EMBASE, Current Contents, CINAHL and the Cochrane Library database were searched to identify eligible randomised controlled trials and systematic reviews published in English between January 1966 and June 2004.Study selection: Seven randomised controlled trials that assessed polymer-based paclitaxel- or sirolimus-eluting stents versus bare-metal stents in patients with coronary atherosclerosis and reported on stent thrombosis, mortality, myocardial infarction, coronary artery bypass grafting or target lesion revascularisation.Data extraction: Two independent reviewers appraised eligible studies and extracted data. Relative risks (RRs) were calculated for each outcome and pooled using the Mantel–Haenszel method.Data synthesis: Rates of stent thrombosis, mortality, myocardial infarction and bypass grafts did not differ by stent type. Drug-eluting stents (DESs) resulted in a 71%–80% lower risk of revascularisation at 12 months (RR 0.29 [95% CI, 0.20–0.43] for paclitaxel-eluting stents [n = 1593 patients]; RR 0.20 [95% CI, 0.13–0.29] for sirolimus-eluting stents [n = 1296 patients]). Similar benefits were seen in several high-risk subgroups of patients: those with diabetes, lesion length > 20 mm and target-vessel diameter ≤ 2.5 mm. The benefits of DESs in these high-risk groups over lower-risk groups were inconclusive because of low numbers. The cost per revascularisation avoided by using DESs was A$3750–$6100, with an estimated cost per quality-adjusted-life-year (QALY) gained of A$46 829–$76 467. In sensitivity analyses, estimates varied from DESs being cost-saving to costing an additional $314 385 per QALY gained.Conclusions: DESs are effective in reducing revascularisation. Estimates of cost-effectiveness are very sensitive to changes in estimates of their true effects in clinical practice, market price and the number of stents used per patient. Decisions to limit DESs to only patients at the highest risk of restenosis may improve their cost-effectiveness but will need to be reassessed when evidence is available to compare absolute benefits between patient groups.

Sarah J Lord MB BS, MS(Epi), FRACGP · Felicity Allen BVSc(Hons), MPH · Luke Marinovich BA(Hons) · David C Burgess BMed, FRACP · Kirsten Howard MAppSc(Biopharm), MPH, MHlthEcon · Richard King MB BS, FRACP · John J Atherton MB BS, PhD, FRACP

Graham K Wong,* John W G Tiller† * Psychiatrist, † Professor of Psychiatry, Albert Road Clinic, University of Melbourne, 31 Albert Road, Melbourne, VIC 3004. wonggrahamATmh.org.au To the Editor: We were interested in the recent finding of Simpson and colleagues that a public hospital-based psychiatric assessment service was poorly utilised by general practitioners.1 We established a comparable service in a private setting, with very similar results. In 2002, the senior psychiatry trainee at the Albert Road Clinic (a private psychiatric hospital in Melbourne) established a GP psychiatric assessment service in response to a previously established need.2 The additional aim was to reduce waiting times and patient costs of seeing a private psychiatrist. There were no out-of-pocket expenses for patients. The service was promoted to 300 local GPs with an individually addressed flyer; a notification was published in the local Division of General Practice newsletter; and discussions were held with the local public mental health service to redirect appropriate referrals from GPs. A survey evaluated GPs’ subsequent satisfaction with the service after a patient was referred and seen. Over a recruitment period of 15 weeks, an average of only one patient per week was referred. The referring GPs were happy with waiting times (well within a week), the quality of the service, and the communication received by the assessing senior psychiatry trainee. The similarity between these independently established services and the findings are striking. Of note, was the paucity of referrals from GPs despite clearly expressed needs. We wonder to what extent GPs’ perceptions of difficulties accessing psychiatric assessment from the private sector are the result of a small subset of difficult patients, rather than the general rule. There are numerous GP and psychiatrist-focused initiatives to overcome reported difficulties accessing specialist psychiatric input for GPs. Most recent of these is a new Medicare Benefits Schedule item that increases remuneration for psychiatrists to outline a detailed management plan for the GP to continue care of the patient. The findings of these types of psychiatric services directed at GPs highlight the limitations of GP uptake of such incentives. At the very least, there is a requirement for adequate promotion, education and ongoing reinforcement of the referral model to psychiatrists, GPs and practice managers alike.

Graham K Wong · John W G Tiller

Frustration and anger arising out of illness and pain, psychiatric disorders, alcohol and substance abuse, can affect behaviour and make people verbally or physically violent. The incidence of violence faced by workers in contact with people in distress is so common that it is often considered an inevitable part of the job. Health care workers are at the forefront of this situation.1 In 1996, the World Health Organization declared violence a leading worldwide public health problem.2 Its subsequent publication World report on violence and health confirmed that violence had become a global phenomenon of epidemic proportions in all societies.3 In the European Union, for example, an estimated three million workers, or 2% of the labour force, have been subjected to physical aggression and violence at work.3 We already know from a number of studies conducted among health professionals that Australian health care workers frequently experience violence (Box 1). However, collection and aggregation of incident data reported by health professionals from multiple hospitals can reveal information not available from single hospital or single study reports. The purpose of such a patient safety reporting system is “to ferret out and correct vulnerabilities, not to count them”.11 The Australian Patient Safety Foundation (APSF), a non-profit research organisation, has played an important role in developing systems to collect, aggregate, monitor and analyse incidents related to patient safety since its formation in 1988, when it received its first reports of anaesthetic-related events for the Australian Incident Monitoring Study in anaesthesia. In 1998, to re-analyse data from the Quality in Australian Health Care Study,12 the APSF created a taxonomy and software which became the Australian Incident Monitoring System (AIMS). This involved developing a classification of health care incidents — both adverse events and near misses — an incident being “any event or circumstance which could have led, or did lead, to damage, loss or harm”.13 Incident reporting to AIMS has always been voluntary. Reports have been made by all types of health care professionals from a varying number of participating hospitals and other health facilities within Australia and New Zealand. Data are de-identified before aggregation and analysis, and thus cannot be used to determine incidence rates. However, their value lies in understanding the contributing, minimising and preventive factors involved, which can then be used in devising corrective strategies and action plans for incidents affecting patient safety. Violence is one major category of incident classified within AIMS. Because of growing concern about violence in health care in Australia, we reviewed the relevant data collected using AIMS.14 Here, we present and discuss some of the summary data relating to reported incidents of violence. What has been reported? The complete AIMS collection of patient-safety-related incidents from January 1998 to June 2002 contains nearly 80 000 coded reports. The data include contributing factors, action taken and outcome, when available. Among 42 338 incidents reported from 1 July 2000 to 30 June 2002, 3621 (9% of all incidents) involved patients and physical violence (for example, assaults or throwing objects) or violent verbal exchange (abuse or threats) occurred.14 Staff injury was reported in 5% of cases. Box 2 summarises the key findings. Although 9% of reported incidents in all health units involved violence, the proportion was higher in emergency departments (16%) and higher still in mental health units (28%). Incidents in these two areas have their own characteristic patterns of contributing and precipitating factors. In reports from 12 emergency departments, 16% of all reported incidents (190 of 1214 incidents) involved violence. Mental health problems were patient-related contributing factors for over half of the violent incidents, with alcohol or drug intoxication contributing to more than 25%. The most common staff-related contributing factors were “communication problems” and “insufficient or inadequate [numbers of] staff”. Precipitating factors included dissatisfaction with staff decisions to admit or discharge a patient from hospital, lack of support on discharge, or non-prescription of a patient-requested medication. Weapons used in incidents included hospital equipment, razor blades, scissors and blood-filled syringes. In reports from 10 mental health services, 28% of all incidents reported (1467 of 5326 reports) involved violence. In violent incidents in which the patient’s status (voluntary or involuntary admission) was known, 79% involved patients who were legally detained. There was often a precipitating factor, such as refusal of privileges. What are the issues? Health services are provided in a changing environment where new policies and programs are often needed in response to changing patient demand — such as varying demographic characteristics of patients and the nature of their presenting symptoms — but these policy changes have to be balanced against the obligation to provide a safe environment for both health professionals and patients. Mental health services The violence seen in our health services reflects changes in our society, including changes in mental health service provision. Over the past decade, deinstitutionalisation of patients with mental illness has had an impact on public hospital emergency departments. Between 1998–99 and 2002–03, mental-health-related separations (that is, deaths and discharges) from public acute hospitals increased by 11%, whereas those from public psychiatric hospitals decreased by 24%.15 Secure rooms have been built in general hospitals to seclude violent patients presenting to public hospital emergency departments. However, psychiatric patients, including prisoners with mental illness, have been detained in public hospital wards that did not have appropriate resources to cope with them, posing a potential risk to other patients.16 In one incident, an entire ward of a NSW district hospital was closed when an elderly woman inpatient died after being attacked in her bed by a patient with mental illness.17 In South Australia, the potential risk to emergency staff may increase as the last public psychiatric hospital is scheduled for closure in 2007, and patients with acute psychiatric conditions are to be directed to general hospitals.18 Such health system changes have major implications for risk management and injury litigation in all acute health services. Staff protection Medical practitioners working in psychiatry, emergency medicine, general practice or rural and remote health need to develop protective behaviours, both for their own safety and that of their patients. Since 1992, in South Australia alone, there have been two workplace deaths of psychiatrists associated with patient violence.19,20 These and other incidents of violence indicate the importance of staff access to duress alarms, escape routes and back-up support, as illustrated in the incident described in Box 3. Preventive strategies AIMS analysis highlights the importance of understanding the contributing and precipitating factors in violent incidents to determine the vulnerability of a health facility. Our review supports a variety of initiatives that are being developed and adopted to reduce violent incidents. These include: de-escalation training for staff, and introduction of violence management plans;21 improved design of buildings to enhance safety of staff and patients;22 initiatives for emergency department fast-tracking of patients with mental health problems;23 and initiatives to improve waiting times in public hospital emergency services using a clinical initiatives nurse (whose priority will be emergency department patients waiting for care, and their families/carers).21 Some hospitals have developed comprehensive aggression management programs to integrate strategies involving environmental design, staff training and team response.24 An Aggression Risk Assessment tool has been developed by Consultation and Liaison Psychiatry at Austin Health in Victoria for use in initial assessment of patients in a variety of inpatient settings (see Forster et al, page 357).25 The National Health and Medical Research Council has developed a resource manual for rural and remote practitioners.26 Further, the Australian National Institute of Clinical Studies has a program to assist emergency department staff to improve care of patients with mental health conditions — the Mental Health Emergency Care Interface Project.27 Incident analysis: the way forward AIMS has continued to evolve since an early version was evaluated in November 2002.28 It is now capable of analysing incidents from all sources in health care including investigative analyses, coroners’ reports, and mortality and morbidity reviews as well as incident reports. Importantly, it now also allows for consumer complaints. AIMS is now used on a state-wide basis by the health departments of New South Wales, Western Australia, South Australia and the Australian Capital Territory, as well as by some health facilities in the Northern Territory, Victoria and Queensland. States collect and analyse their own data to aid state-based decision-making. Incident monitoring also has the potential to enable health services to collect local data on patient, staffing and system factors that contribute to incidents, and to develop and evaluate local management plans. However, there is currently no national system to aggregate incident monitoring data. We recommend that a national system be developed to share and compare incident monitoring data, to monitor trends, and to facilitate learning and thinking at all levels — ward, department, hospital, state and national. At all levels, intelligent interrogation of data and imaginative initiatives will be needed to improve care. 1 Experience of violence by Australian health professionals4-10 A survey conducted in 1999 of 266 emergency department nurses in metropolitan and regional hospitals in New South Wales revealed that all had experienced some form of violence at work at least weekly, but over 70% of incidents were not reported to authorities.4 In a 2002 survey of all Tasmanian nurses, 64% of over 2400 respondents had experienced violence in the past 4 weeks.5 In another survey conducted in 2001–2002 of 400 Australian health care workers interviewed to provide baseline data for the “Taskforce on the prevention and management of violence in the health workplace”, three-quarters of the 200 nurses involved had experienced some form of violence in the past 12 months; the highest rate of events per worker was among ambulance officers.6 Exposure to violence is particularly high for nurses in inpatient psychiatric facilities7 and remote area nursing.8 Situations of increased risk for medical practitioners include working in emergency departments, treating clients affected by drugs or alcohol, and dealing with high-stress situations in delivery suites, intensive care or coronary care units.6 Violence towards medical practitioners is not confined to hospital services; 73% of rural general practitioners in Western Australia, New South Wales and Victoria reported experiencing some form of aggressive behaviour from patients and 20% had been subjected to physical abuse during their careers as rural doctors.9 Urban GPs have reported that providing after-hours care now puts them at increased risk of assault, and some have restricted provision of after-hours care as a result.10 2 Key findings in 3621 incidents involving patients becoming violent in Australian hospitals and health services, 1 July 2000 – 30 June 2002 Any health care setting Number of incidents 3621 incidents, 9% of all health care incidents (n = 42 338) Most common contributing factors Patient-related — mental health conditions, 40% of incidents; dementia, 15%; pathophysiological factors, 13%; confusion, 9%; alcohol or drug intoxication, 6% Staff-related — “insufficient or inadequate [numbers of] staff”; “communication problems”; “inadequate knowledge or inexperience” System-related — “security problems” Most common outcomes Change of treatment, over 40%; informing a medical practitioner, 25%; patient transfer, 16%; restraint team called, 15%; police or security called, 15%; staff injury, 5% Accident and emergency services (reports from 12 services) Number of incidents 190 incidents, 16% of all incidents in this setting (n = 1214) Most common contributing factors Patient-related — mental health conditions, more than 50% of incidents; alcohol or drug intoxication, more than 25% of incidents Staff-related — “insufficient staffing”; “communication problems” Most common precipitating factor Dissatisfaction with staff decisions Mental health services (reports from 10 services) Number of incidents 1467 incidents, 28% of all incidents in this setting (n = 5326) Most common contributing factors Patient-related — mental health conditions; where admission status was specified, 79% were involuntary admissions Most common precipitating factor Refusal of privileges 3 Incident reported to the Australian Incident Monitoring System (AIMS) A doctor was interviewing a patient with a psychiatric condition in an interview room of an emergency department. The patient was in a psychotic state and became agitated and violent. The doctor tried unsuccessfully to press the duress alarm, but managed to escape from the room. The patient followed the doctor into the triage section, lunging and pinning the doctor against the wall and tearing clothing. The patient was eventually calmed by other staff and urgent restraint was requested. Security personnel arrived after the patient had been calmed by another doctor.

Klee A Benveniste PhD, MAPS · Peter D Hibbert BAppSc(Physio), GradDipComp, CertHlthProgEval · William B Runciman MB BCh, PhD, FJFICM

Objective: To establish the prevalence and characteristics of occupational violence in Australian urban general practice, and examine practitioner correlates of violence.Design, setting and participants: Cross-sectional questionnaire survey mailed to all members (n = 1085) of three urban divisions of general practice in New South Wales in August and September 2004. The three divisions were chosen to provide a range of socioeconomic status (SES) demographics.Main outcome measures: Occupational violence towards general practitioners during the previous 12 months.Results: 528 GPs returned questionnaires (49% response rate). Of these, 63.7% had experienced violence in the previous year. The most common forms of violence were “low level” violence — verbal abuse (42.1%), property damage/theft (28.6%) and threats (23.1%). A smaller proportion of GPs had experienced “high level” violence, such as sexual harassment (9.3%) and physical abuse (2.7%). On univariate analysis, violence was significantly more likely towards female GPs (P < 0.001), less experienced GPs (P = 0.003) and GPs working in a lower SES status area (P < 0.001), and among practice populations encompassing greater social disadvantage (P = 0.006), mental health problems (P < 0.001), and drug- and alcohol-related problems (P < 0.001). Experience of violence was greater for younger GPs (P = 0.005) and those providing after-hours care (P = 0.033 for after-hours home visits). On multivariate analysis, a significant association persisted between high level violence and lower SES area (odds ratio [OR], 2.86), being female (OR, 5.87), having practice populations with more drug-related problems (OR, 5.77), and providing home visits during business hours (OR, 4.76). More experienced GPs encountered less violence (OR, 0.77) for every additional 5 years of practice.Conclusion: Occupational violence is a considerable problem in Australian urban general practice. Formal education programs in preventing and managing violence would be appropriate for GPs and doctors-in-training.

Parker J Magin MB BS · Elyssa Joy BA · Malcolm C Ireland MB BS · Jon Adams PhD · David W Sibbritt PhD

Strategies to prevent and manage violence and aggression in the health care setting have become a primary health and safety issue. A series of vignettes are provided to highlight key elements in developing a program for preventing behavioural violence and aggression in a tertiary hospital. Key components of the program include staff education and training, risk assessment and management practices, the use of patient contracts and policy development. The program aims to integrate and balance occupational health and safety obligations to staff with the duty of care owed to patients.

John A Forster RN, RPN, GradDipPsychNurs · Mark T Petty RN, BAppSci(Nurs Admin), GradDipCompSci, MHA, FRCNA · Colin Schleiger GradDipOccupHazMan, DipPublHealth · Helen C Walters CPN, BPN, GradDipPsychNurs

Violence in emergency departments (EDs) has reached a level that requires concerted action and a shift in attitude — to eradicate a socially and professionally unacceptable peril. In some EDs, violence is a daily occurrence, with nursing staff reporting several episodes each week. Increased societal violence results in an increase in presentations for injury. Anger and pain and the influence of alcohol and drugs contribute to violence spilling over into the ED. The well known “system blockers” to reporting adverse events in hospitals result in under-reporting of violence episodes. Violence in EDs is different from other forms of violence — the aggressor has no overt dominance or power status and, in a setting of care, victims are likely to excuse the behaviour. Strategies to curb violence in EDs include modifying building design, providing security systems and personnel, and training staff in aggression management. The key to successful intervention is a strong preventive orientation that looks for high-risk indicators, and may extend to active physical and behavioural screening.

Marcus P Kennedy FACEM, FRACGP, DA(UK)

Objective: To evaluate the effect of appointment reminders sent as short message service (SMS) text messages to patients’ mobile telephones on attendance at outpatient clinics.Design: Cohort study with historical control.Setting: Royal Children’s Hospital, Melbourne, Victoria.Patients: Patients who gave a mobile telephone contact number and were scheduled to attend any of five outpatient clinics (dermatology, gastroenterology, general medicine, paediatric dentistry and plastic surgery) in September (trial group) or August (control group), 2004.Main outcome measures: Failure to attend (FTA) rate compared between the group sent a reminder and those who were not.Results: 2151 patients were scheduled to attend a clinic in September; 1382 of these (64.2%) gave a mobile telephone contact number and were sent an SMS reminder (trial group). Corresponding numbers in the control group were 2276 scheduled to attend and 1482 (65.1%) who gave a mobile telephone number. The FTA rate for individual clinics was 12%–16% for the trial group, and 19%–39% for the control group. Overall FTA rate was significantly lower in the trial group than in the control group (14.2% v 23.4%; P < 0.001).Conclusions: The observed reduction in failure to attend rate was in line with that found using traditional reminder methods. The ease with which large numbers of messages can be customised and sent by SMS text messaging, along with its availability and comparatively low cost, suggest it may be a suitable means of improving patient attendance.

Sean R Downer MBA · John G Meara FRACS · Annette C Da Costa BA, GradDip(Psych), GradCert(AppSc)

As the working hours of junior doctors decrease, adequate handover of patients becomes more important to maintain continuity of care and avoid errors caused by information gaps. A minimum dataset for surgical handover should include the patient’s name, location (ward and bed number), date of admission, diagnosis, procedure (with date), complications and progress, management plan, resuscitation plan, consultant availability (and instructions if not available), expected need for review, and name of doctor completing handover and date to confirm that information is current. An electronic handover system is a potential solution, but our survey shows that free-text entry into such systems may be inadequate; prompts or predefined fields for handover content are possible solutions.

Lean-Peng Cheah MB BS(Hons), MRCS · Debbie H Amott MB BS(Hons) · James Pollard MB BS · David A K Watters FRCS, FRACS

Peter C Arnold Former General Practitioner, PO Box 280, Edgecliff NSW 2027. peterATarnold.name To the Editor: Schofield and Beard,1 discussing demographic shifts among doctors, raise the spectre of “workforce shortages within the next 5 years”. For decades, Australian health authorities have used various proxy indicators, ranging from Medicare utilisation to World Health Organization and other comparative data, to deny the existence of shortages of doctors. Based on those faulty premises, government policies have aggravated these shortages. The Oxford English Dictionary defines a “shortage” as “a deficiency”. For many years, there have been deficiencies in services provided by Australia’s doctors, including, among others: General practitioners available for house calls and visits to nursing homes; working past 6:00 pm on weeknights or on Saturday mornings; available at nights and on weekends; offering prompt appointments; and being available in locum tenens. Specialist initial consultations within a week or two, especially dermatologists, oncologists, neurologists, and, more recently, neurosurgeons and obstetricians. And all this in our cities and large towns. The sho rtages of all medical personnel in rural and remote areas has long been obvious. Our current reliance on overseas-trained doctors is undeniable proof of the existence of those shortages. For more than three decades, the general practice “positions available” advertisements in the medical newspapers have far outnumbered advertisements from doctors seeking GP positions.2 None of the proxy indicators of workforce adequacy, so beloved of politicians and bureaucrats, can rival the plain truth that the supply of doctors, probably in every field of medicine and in every region of Australia, is plainly insufficient to meet reasonable demand, and has been so for at least 30 years.

Peter C Arnold