Health services administration

Since 1996, an increasing proportion of federal government expenditure has been directed into Australia’s healthcare system via private health insurance (PHI) subsidies, in preference to Medicare and the direct funding of public health services. A central rationale for this policy shift is to increase the use of private hospital services and thereby reduce pressure on public inpatient facilities. However, the impact of this reform process on regional Australia has not been addressed. An analysis of previously unpublished Australian Bureau of Statistics data shows that regional Australians have substantially lower levels of private health fund membership. As a result, regional areas appear to be receiving substantially less federal government health funding, compared with cities, than if these funds were allocated on a per-capita basis. We postulate that the lower level of membership in regional areas is mainly due to the limited availability of private inpatient facilities, making PHI less attractive to rural Australians. We conclude that PHI as a vehicle for mainstream federal health financing has potential structural failures that disadvantage regional Australians.

Buddhima Lokuge MB BS, MPH · Thomas A Faunce LLB(Hons), BMed, PhD · Richard Denniss BCom(Hons), PhD

Kenneth Wong Surgical Registrar, Gosford Hospital, Holden Street, Gosford, NSW 2250. kennethwoATyahoo.com To the Editor: I am writing to offer a registrar’s perspective on the constructive comments by Lack and Cartmill on registrar–intern interactions.1 The same comments would be equally applicable to consultant–registrar interactions. The current strict hierarchical, “militaristic” structure of the hospital system, with a “top down” approach to performance assessment (which, in turn, influences career prospects), is conducive to neglect of junior colleagues, as they are often the most expendable cogs in the wheel. In my experience, the two key selection criteria for hospital appointments and career advancement — namely, impressing senior colleagues and passing postgraduate examinations — bear little correlation to the ability to supervise or instruct junior staff. Training in human resource management is not part of any undergraduate or postgraduate medical curriculum. Yet, negative junior–senior staff interactions can potentially compromise patient safety, as junior colleagues, acting only as acolytes in the professor’s entourage, are not empowered to actively contribute to patient care. So, what are the solutions? A formal circular feedback system that has “teeth” would be a start. Incorporating regular evaluations of senior staff by junior staff as part of the hospital’s quality assurance program and as a condition of continued employment may be effective in identifying those who are unsuitable for supervising junior colleagues. Simple educational measures may alleviate some of the difficulties experienced by interns as highlighted by Lack and Cartmill.1 For example, the difficulties of contacting surgical registrars “hidden” in the operating theatre are cited as a cause of intern distress. But operating theatres are not located on a distant planet beyond feasible means of contact. Most operating theatres are equipped with telephones and are located centrally within the hospital. Educating the intern to telephone through to the operating theatre or possibly even venture inside should enable resumption of contact with even the most evasive surgical registrar. Finally, published guidelines detailing acceptable behaviours and responsibilities towards junior colleagues may benefit senior staff who may not have had appropriate senior role models themselves. Having a junior colleague attached to one’s team is not an assumed right that comes with consultant or registrar status. It is a distinct privilege that carries distinct obligations. Failure to respect these obligations should precipitate removal of this privilege.

Kenneth Wong

Mark Mackay,* Peter Millard† * PhD student, Department of Psychology, Level 4, Hughes Building, University of Adelaide, Adelaide, SA 5005, and Principal Project Officer, SA Department of Health; † Emeritus Professor of Geriatric Medicine, St George’s Hospital Medical School, and Visiting Professor — Health and Social Care Modelling Group, University of Westminster, London. mmbmATiprimus.com.au To the Editor: Gray, Yeo and Duckett used the wrong basis of measure for their analysis of bed trends.1 Bed use per thousand of the population masks the trends in total bed-days or separations and does not address the issue of supply. These issues have important ramifications for policy decision-making. Using the same sources of data,2,3 we compared bed-related statistics and population changes for the periods 1993–94 and 2001–02. What should be of most interest to planners is that the number of multi-day bed-days only declined marginally (from 14 434 to 14 231; −1.4%), despite the significant increase (from 1698 to 3343; + 96.8%) in same-day activity. Although multi-day separations and bed-days did decline (separations, − 4.2%; bed-days, − 14.9%) for those aged 65–74 years, for those aged 75 years or over bed-days and separations increased significantly (separations, + 41.6%; bed-days, +27.7%). Furthermore, same-day activity increased significantly for those aged 65 or more years. Furthermore, the authors failed to highlight the implications of changes in the relative age mix of activity. For those aged 75 years or more, the increase in proportion of separations (+ 5.8 percentage points) and bed-days (+ 1.8 percentage points) was greater than the increase in this proportion of the population (+ 1.1 percentage points). For the 65–74-years age group, the proportion of same-day hospital activity increased (+ 1.3 percentage points), unlike the reduction in that proportion of the population (− 0.2 percentage points). Moreover, the question of whether an ageing population has resulted in the need for more beds can not be answered without considering the supply of beds. From our experience, the growth in same-day activity has been achieved, at least in part, by substituting same-day beds for inpatient beds. The need for increased same-day beds has been considerable. Statistics relating to same-day beds do not appear to be reported for Australia as a whole. However, the increasing implied bed occupancy (including same-day) shown in the Box supports this conclusion. We surmise that the reduction in supply of multi-day beds combined with a marginally altered demand for multi-day beds has led to increasing numbers of bed crises. Given that relative growth in same-day activity can be attributed to people aged 65 years or over, and that the number of multi-day bed-days for those aged 75 years or more has increased, it appears that the ageing of the population, combined with the manner in which the substitution of beds has occurred, has contributed to increasing bed crises. Changes in implied bed occupancy Financial year Change from 1998–99 to 2001–02 1998–99 1999–00 2000–01 2001–02 Total bed-day utilisation (000s) 22 323 22 597 22 467 23 218 + 4.0% Total available bed-days (000s) 28 868 28 540 28 675 28 787 − 0.3% Implied occupancy 77% 79% 78% 81% + 4.3%

Mark Mackay · Peter Millard

Len C Gray,* Stephen J Duckett† * Professor in Geriatric Medicine, University of Queensland, Princess Alexandra Hospital, Ipswich Road, Woolloongabba, QLD 4102; † Professor of Health Policy, Latrobe University, Melbourne, VIC lgrayATsoms.uq.edu.au In reply: Mackay and Millard have raised some important issues in relation to our analysis. Our article was developed to encourage wider reflection and their response is thus welcomed. The primary criticism levelled by Mackay and Millard was that we underplayed the importance of supply of beds in our interpretation of the trends. We agree that bed supply is an important driver of utilisation patterns. We acknowledged this, in part, in the discussion as a possible explanation for rising separation and declining bed-utilisation rates in the older patient population. We are also sympathetic to the hypothesis that there may be a process of substitution of same-day separations for multi-day separations. However, data relating to bed availability are not readily available, and thus could not be included in our study. Our article was designed to highlight different trends between age groups, which have not previously been reported. Now that these trends have been identified, further research and analysis is required to fully explain them, with a view to supporting an intelligent strategy to prepare for future population ageing.

Len C Gray · Stephen J Duckett

Paddy A Dewan Head of Paediatric Surgery, Sunshine Hospital, PO Box 152, Parkville, VIC 3052. Paddy.dewanATwh.org.au To the Editor: Three recent articles in the MJA about complaints by patients attending hospital, 1 attitudes of hospital staff toward incident reporting2 and whistleblowing3 show that complaints are common, that cultural change is needed to allow staff to understand that a complaint from a patient or staff member should be viewed as an opportunity for change, and that quality assurance sometimes relies on whistleblowers but does not always appreciate their efforts. Faunce and Bolsin report on three whistleblower incidents,3 but fail to mention one at the Royal Children’s Hospital, Melbourne, in which I was involved. Attempts to highlight deficiencies in delivery of paediatric surgical care and concerns about the response to adverse events were managed with threatening tactics (of dismissal) by the division of surgery. This was followed by a hospital board investigation that, in my opinion, had neither the skill mix nor the terms of reference to adequately investigate the quality of care or the bullying. The subsequent investigation by the Department of Human Services involved narrowly focused terms of reference and failed to consider outcomes in some circumstances, thereby facilitating the “shooting of the messenger”. Current legislation does not effectively allow for dealing with threatening behaviour in the workplace, particularly when the refusal to look at complaints and adverse events in a productive manner goes well beyond the confines of the hospital involved. The Community Advisory Committee parliamentary enquiry was held in camera, with evidence being kept from the public. Worksafe legislation on bullying does not deal well with the complex situations that arise in the healthcare industry.4 The Colleges and other professional bodies, such as the AMA and the Medical Boards, need to take a proactive rather than a reactive role if further whistleblower incidents are to be avoided. I concur with the statement of Faunce and Bolsin that: “Even after substantiation of their allegations, the whistleblowers . . . received little respect and support from their institutions or professions”.3 From personal experience, I am very aware of the lack of support that stems from an ethos wary of public criticism, and the reactive bullying to which the whistleblower is often subjected. Until the culture of healthcare focuses on quality and caring, whistleblower sagas will continue to occur.

Paddy A Dewan

Objective: An Australian stroke services study (SCOPES) has developed a framework to compare different forms of acute stroke services, the gold standard being localised stroke units. We aimed to use this framework to assess changes in the quality of stroke care over time as a sequential audit process.Design and setting: A retrospective medical record audit comparing 100 sequential stroke admissions (July 2002 to June 2003) two years after institution of a mobile stroke service (MSS) with 100 historical controls (September 1998 to October 1999) at a 260-bed hospital in Melbourne. The MSS results were also compared with stroke units in SCOPES.Main outcome measures: Adherence to quality indicators and standard measures of outcome (complications, length of stay and discharge disability) after implementing the MSS.Results: Significant improvements were seen in prophylaxis for deep-vein thrombosis, incontinence management, premorbid function documentation, frequent neurological observations and early occupational therapy. The MSS demonstrated fewer severe complications (9% versus 24%; P = 0.004), reduced median length of stay (discharged patients: 12.0 days versus 18.5 days; P = 0.003) and more patients were independent at discharge (32% versus 9%; P < 0.001). Comparison with SCOPES stroke units showed our MSS could improve in incontinence management and appropriate use of antiplatelet therapy.Conclusion: Institution of the MSS was associated with improvements in the quality of stroke care. This study demonstrates application of an audit procedure for quality improvement in hospital stroke management and the potential to improve stroke services in smaller centres.

Anneke van der Walt MB ChB · Amanda K Gilligan MB BS, FRACP · Amy G Brodtmann MB BS, FRACP · Dominique A Cadilhac MPubHlth · Dora C Pearce MIT · Geoffrey A Donnan MD

Objective: To assess differences in trends for prostate cancer mortality, radical prostatectomy and prostate-specific antigen (PSA) testing for Australian men aged 50–79 years living in capital cities compared with regional and rural areas.Design: Descriptive, population-based study based on data from official sources from 1985 to the 2002/03 financial year (depending on data availability).Main outcome measures: Age-standardised rates per 100 000 men aged 50–79 years of mortality from prostate cancer, incidence of prostate cancer, PSA tests and radical prostatectomy.Results: We found a statistically significant and increasing (age-standardised) mortality excess for prostate cancer in regional and rural areas. In 2000–2002 the excess (compared with capital cities) was 21% (95% CI, 14%–29%). Rates of radical prostatectomy in rural and regional Australia were 29% lower (95% CI, 23% lower to 35% lower) than in capital cities. Although PSA testing is common across the whole of Australia, age-standardised rates in 2002/03 were 16% lower (95% CI, 15% lower to 17% lower) in regional and rural areas than in capital cities.Conclusions: Our results show that the probability of a man having a PSA test and the management of his prostate cancer depend on where he lives. The cause or causes of the prostate cancer mortality excess in regional/rural areas cannot be established in a descriptive study, but fewer radical prostatectomies in regional and rural areas, perhaps associated with less PSA screening, remain among the several competing hypotheses. Other possibilities are related to other differences in management, perhaps associated with access to urologists. Governments and other budget holders need good evidence about the effectiveness of prostate cancer screening and early treatment, but also about the best strategies for providing equitable access to cancer services in both urban and rural areas.

Michael D Coory MB BS, PhD, FAFPHM · Peter D Baade BSc, MMedSc, PhD

Change for the sake of change is not real improvement, and distracts from providing consistent high-quality care Who could possibly question the value of continuous improvement in any service or other collective human endeavour? It is not surprising, then, that modern management across the developed world has taken up continuous improvement as a central theme and turned it into a management strategy, which I refer to below as “Continuous ImprovementMS”. Here, I wish to compare continuous improvement, as a generic entity, with the newer Continuous ImprovementMS. Continuous improvement has been around since prehistoric times. In its best form, it flowed from a particular attitude, shared by many people, ordinary and otherwise. Such people went about their work or other activities with a mind open enough to recognise better ways of doing things, or ways of doing better things, and they were prepared to try them out. Their improvements were mostly minor, but added together over time to transform tasks. These people listened to others — especially the young, who often had a fresh, new approach, and the old, who could remember changes which had not been good, and who had seen useless fashions come and go. Occasionally, an open mind, inventiveness and serendipity would coincide to produce a spectacular advance, but the continuous improvement was generally evolutionary, not revolutionary. It took its time; it came in “fits and starts”. Old continuous improvement had the wisdom to distinguish real improvement from change for the sake of change. It valued and retained the traditional and the “tried and tested”, at least until the “new” was truly proven to be better. I believe Continuous ImprovementMS, on the other hand, is a corporate, multinational systems approach. It is a management tool, aimed at achieving specific targets and outcomes. It has become a mantra, a fundamentalist plank of modern managerialism. To me, it is a stick, not a carrot. It is like a clanking military tank set on autopilot. It assumes that improvement can be introduced by “force-feeding”. Continuous ImprovementMS is supported by Strategies and Action Plans — if you don’t have these in place, then you aren’t ImprovingMS. Modern management believes there is no activity that cannot benefit from Continuous ImprovementMS. It insists if change is not happening continuously then something is wrong. I believe Continuous ImprovementMS is particularly frustrating and disheartening when it is required to be applied to standard clinical practice, where the ongoing challenge is to maintain a high standard, day after day, patient after patient, often with limited resources; history-taking and physical examination, for instance, don’t require continuous improvement — they just need to be done to the best standards that were taught and performed decades ago. Continuous ImprovementMS ascribes no value to the substantial achievement of maintaining a high standard, and, as far as I am aware, modern managerialism has no category to recognise it. Needing to repeatedly demonstrate compliance with Continuous ImprovementMS is additionally problematic for busy clinical services, because it fails to recognise the essential, central work of such units. Continuous ImprovementMS, by its very own words, implies that this essential, central work is not good enough — no wonder that it demeans hard-working, earnest people, damaging their morale. Critics have said to me: “You just don’t understand Continuous ImprovementMS and quality management generally.” But they do not seem to be aware of the extent and depth of adverse feelings to these systems approaches experienced by the people doing the work. What of the future? Continuous ImprovementMS — itself a sort of reincarnation of Total Quality Management — will disappear, only to be reincarnated as another corporatised, systematised, jargonised entity — perhaps “Non-Selective Non-Stop Upgradance (NSNSU)”? Notwithstanding this, it would be good if modern managerialists could consider adding “Working Systems Maintenance Tracking (WSMT)” to their systems approach, if only to recognise the importance of the need to acknowledge and value good work done well, irrespective of further improvement. And clinicians will continue to dream of a system that recognises the best of what we do at the same time as questioning everything — from what people really need through to how that can be provided — then making changes with due care. In line with current global trends, I expect reactions to what I have written will be polarised. So I will put out some challenges: To those who feel some empathy with what I have said — speak up! Express your concerns, and make suggestions for some real continuous improvement in quality and other management. To those who object to what I have written — pilot and perfect new management strategies on a small scale to show they have the potential to produce substantial, real benefits for real people. Only then, “roll them out”. Additionally, accept the same standards of evidence and accountability that you demand of others.

Henry A Kilham FRACP

Stephen N Bolsin Director, Division of Perioperative Medicine, Anaesthesia and Pain Management, Geelong Hospital, Ryrie Street, Geelong, VIC 3220. stevebATbarwonhealth.org.au To the Editor: Two recent articles in the Journal highlight the need to re-evaluate the collection of performance data in Australian healthcare, as well as the uses and analysis of these data.1,2 Individual report cards are an extremely good and ethically mandated means of monitoring performance, especially when the information is given to patients as part of an informed-consent process.2 However, it is possible to provide more valuable analyses than simple crude complication or mortality rates. Cusum (cumulative summation) analysis was developed for industrial quality assurance to monitor production processes and detect subtle deviations from a preset, defined level of achievement. It can be applied to clinical practice to identify statistically significant improvements (or decrements) in performance, using agreed definitions of “acceptable” and “unacceptable” performance levels.3,4 It can be risk-adjusted if necessary. Cusum analyses are routinely undertaken by the Geelong Hospital Department of Anaesthesia for monitoring performance of College-accredited trainee anaesthetists, and have been suggested by surgeons as a method for monitoring performance of a series of procedures.5 Although cusum analysis may seem highly threatening to many senior professionals, the support it provides and the cultural change it achieves in trainee anaesthetists have already been well documented in a unique Australian initiative.4 Modern regulatory theory describes three levels of regulation: the individual (micro), organisational (meso), and state or national (macro) levels. The personal professional monitoring program based on personal digital assistants (PDAs) and cusum analysis that was introduced for accredited trainee anaesthetists by Geelong Hospital operates at all these levels. It encourages reflection on individual performance by accredited trainees in a supported environment; organisational review by the supervisor of training within a clinical governance framework; and College supervision, collation and endorsement as part of a national training program. The fact that the reporting structures inherent in this PDA-based model conform to these highest standards of regulatory theory and clinical governance confirms that the required professional change recommended by Irvine1 can be easily achieved through mechanisms already operating in Australian hospitals. The model also achieves cultural change in the trainees and the highest incident reporting rate in modern healthcare (96.7%–100% voluntary reporting of critical incidents occurring in their practice). 6 These two factors should mandate the wider introduction of the PDA-based program in Australian hospitals if the profession and the industry are to be taken seriously on this issue.

Stephen N Bolsin

Objective: To identify and explore behavioural characteristics of registrars that interns find helpful in their working relationships and workplace learning.Design, setting and participants: Semistructured interviews with 18 interns at Nepean Hospital, Penrith, NSW, at the end of their first working year as doctors. The survey was conducted between December 2003 and February 2004.Main outcome measure: Desirable and undesirable behavioural characteristics in registrars, as reported by interns.Results: Overall, interns’ opinions of registrars were positive. Desirable characteristics in registrars included approachability, availability, good communication skills, and a willingness to teach. Undesirable characteristics included an unwillingness to listen, unreasonably high expectations, a condescending attitude, apathy and rudeness.Conclusion: The behavioural characteristics of registrars that interns find helpful are identifiable, and there is significant room for improvement in the quality of clinical mentoring by registrars. The next step is to facilitate regular feedback from interns on registrars’ performance, and to develop ways to encourage desirable behaviours in registrars while actively discouraging undesirable behaviours.

Christopher S Lack BA, BM · John A Cartmill MB BS, BSc(Med), FRACS

To the Editor: Cokis and Faris describe an intraoperative complication detected by transoesophageal echocardiography (TOE).1 Their letter is interesting in that it describes a rare complication during aortic valve surgery, and it is provocative in that it is critical of the Department of Health and Ageing decision not to rebate TOE (except in valve repair or replacement) to anaesthetists. A rare complication is not an argument for routine monitoring. Justification for monitoring requires detailed analysis of complication rates. The number needed to monitor for this and other complications is not known. Cokis and Faris do not discuss the rate of complications from TOE, which could be similar to that of the rare complication they describe. That there is a link between efficacy and the likelihood of a Medicare rebate is yet to be shown, and the authors themselves allude to this. TOE can be performed without a rebate. This is good for patients and also for a healthcare service which is strapped for funds. There are arguably other pressing needs for Medicare funds in the healthcare system. Presumably, both doctors were remunerated for their presence at the operation. Eligibility for a Medicare rebate can be a “perverse incentive” leading to overservicing. I have seen this with monitoring with TOE. Procedures have a clinical and financial cost as well as perceived benefit. I have seen other diagnoses missed or misinterpreted because of routine use of TOE, and it has occasionally led to prolonged intensive care unit stays and other complications. None of my arguments should deny TOE a place as a useful monitoring tool. It may become as routine during cardiac surgery as central venous pressure and arterial pressure monitoring is now. Whether that happens should not depend on whether TOE is eligible for a Medicare rebate. The use of TOE during surgery should depend on whether there is evidence of a meaningful benefit, and it is well to remember that the routine use of any procedure is hard to justify and can sometimes be dangerous. Early in Australian cardiac surgery, it was argued that the rebate for coronary bypass surgery should be related to the number of grafts. This argument was rightly not accepted. Similarly, the rebates for cardiac anaesthesia should not be related to the number of monitors used. Cokis and Faris should be commended on their excellent care of the patient. However, their argument for a rebate is not compelling.

John W Stokes FANZCA, FJFICM

In reply: Stokes raises a number of relevant issues, but we would like to make the following points. The case we reported occurred in a teaching hospital and neither of us undertakes routine transoesophageal echocardiography (TOE) in a private capacity. While a Medicare rebate is not directly relevant to the clinical usefulness of a medical procedure, the Medicare Benefits Schedule functions as a surrogate marker for clinical legitimacy. Stokes quotes anecdotes of occasional misuse or overuse of TOE. We agree that single cases neither justify nor give cause to reject a particular kind of monitoring. However, case reports, although lacking a denominator, are a start. The main point of our letter was, in fact, to report the complication of surgery and the vital role played by TOE in achieving a good outcome. Nevertheless, many of us who routinely use TOE consider that its advantages over other kinds of monitoring regularly benefit patients. We agree there is little “hard” evidence to support this, but detailed risk–benefit analysis for many of our routine monitoring devices is similarly non-existent. The Swan–Ganz catheter is a classic example. We suspect that if a group of cardiac anaesthetists and surgeons was asked to review the usefulness of TOE in routine cardiac surgery, the decision of the Department of Health and Ageing might be different.

Chris Cokis MB BS, FANZCA · John Faris MB ChB, DAvMed, FFOM, FANZCA

We need improved primary care, access to expert multidisciplinary services, and appropriate coordination of the two More than a third of Australians live outside major cities, with 3% living in remote or very remote areas.1 The health disadvantage of rural and remote Australians is well documented, and includes poorer survival after a diagnosis of cancer.2 Both more advanced cancer at diagnosis and poorer treatment appear to contribute.3 Documented instances of poorer cancer care in rural and remote Australia, though not necessarily all with survival implications, include less “state of the art” diagnosis, staging and treatment of prostate cancer;4 less breast-conserving surgery for breast cancer;5 and an apparently lower probability of completing treatment when referred for radiotherapy for rectal cancer.6 Surprisingly, there appears to be little difference in women’s use of breast and cervical screening by area of residence.7 Remoteness of residence is not the only axis of disadvantage that may contribute to poorer cancer outcome in remote areas. Indigenous Australians account for 26% of the population in these areas, and have poorer survival from cancer than other Australians.1,8 Lower socioeconomic status is also associated with rural and remote residence and poorer survival.2 Poorer treatment may explain these worse outcomes. Analysis of linked cancer registry and hospital inpatient records in Western Australia suggests that Indigenous cancer patients are less likely to have surgery for lung cancer or radical surgery for prostate cancer,9 but there was no significant difference in breast-conserving surgery for breast cancer.9 Although that study could not address the possibility that differences in stage at diagnosis explained the observed treatment differences, a Sydney study has shown, after adjustment for size and stage of cancer, that socially disadvantaged women with breast cancer are still less likely to have breast-conserving surgery.10 Factors that underlie Indigenous and socioeconomic disadvantage in cancer survival, and possibly treatment, may go beyond just remoteness of residence and inability to pay. They could include knowledge, attitudes and beliefs about cancer (which may influence presentation for and acceptance or completion of recommended treatment), communication difficulties, and discrimination on the basis of race or socioeconomic status for access to travel support or more expensive care.9,11 In principle, tackling rural inequality in cancer care and outcome requires a combination of improved primary healthcare, access to expert multidisciplinary services, and coordination of the two. Evidence that could guide investment decision-making is limited. Present rural health policy is underpinned by the principle that patients should have access to high quality services as close to their homes as is clinically and geographically feasible. This policy should improve access to primary healthcare and aid in obtaining earlier diagnosis of cancer and quicker referral to expert care. That these factors will improve cancer outcomes is, however, more an article of faith than supported by evidence. Increasing specialist healthcare services in rural areas may also run counter to evidence that, for some cancers at least, the best outcome is obtained by practitioners and institutions that have high caseloads.12 Specialist medical services of all kinds are rare outside cities and large rural centres in Australia and are likely to remain so, and cancer surgery caseloads are low in a high proportion of hospitals in rural New South Wales and Victoria.6,13 Problems of low caseloads can be overcome to some degree by specialist outreach services and shared-care arrangements, in which initial treatment often requires travel to a major centre, but subsequent treatment can be delivered effectively closer to home and partly by local healthcare practitioners. Available evidence suggests that specialist outreach services can increase the proportion of patients receiving breast cancer care consistent with evidence-based guidelines.14 More generally, it appears that specialist outreach services that interact in a shared-care model with primary healthcare providers, such as Aboriginal health workers, can improve healthcare access for remote Aboriginal communities.15 A trial of breast cancer nurses in rural settings has also shown clear psychological and physical benefits to women and more coordinated care among practitioners.16 Developing the role of specialty oncology nurses in care coordination and administration of chemotherapy in rural areas is supported by oncologists, but has not been fully evaluated.17 Moves have been made to define a more coherent approach to cancer service delivery,18 but there is little evidence of successful implementation. So what, in principle, do we need? Conceptually, a well-defined pathway, appropriately tailored to needs, that each person with cancer can easily follow to timely expert care. Practically, this requires that the person and their primary care provider know how to access the pathway, that the person’s journey along it is carefully guided to ensure he or she does not get lost, and that there is effective communication between all places visited. Successful development of such pathways would require innovative information systems, effective interaction between the many services involved in cancer care, and cooperation between governments. The challenge in establishing them will be greatest in rural and remote areas. Distance and low service density may make them more difficult to operate; the social and cultural adaptations required may be a hurdle; and they will need to draw more on special provisions, such as shared and outreach care. But the broad principles will be the same. The additional costs, for pathway creation and maintenance, information provision, journey coordination and communication, should not be great, and would probably be repaid by more efficient care and a better outcome. Food for thought?

Katharine E Jong MPH · Paula J Vale GradDipIHP · Bruce K Armstrong AM, FAA, FRACP

Linda Mann, a Sydney GP, proposes ways of potentially enhancing patient care and reducing hospital stays, without increasing overall healthcare costs. Her suggested solutions include making it simpler for all healthcare practitioners involved in caring for the same patient to share (rather than not share) all patient information by applying the information technology of today (rather than tomorrow). Also, pooling some funding from state and federal sources could allow for further “seamless care” at areas of reasonable overlap between the current “silos” of hospital-based and community-based care. The type of scenario described in Box 1 is not uncommon. Contemporary healthcare cuts patient care into separate events by erecting barriers at the boundaries of what we have come to see as “hospital practice” and “general practice”. As a result, Mr A and his doctors face several barriers to optimal care: Patient information can be found in many places. Individual carers may not be aware of all the other places where patient information is held; Information about patients may not be shared within, let alone outside of, an institution; If a practitioner is not “within” an institution, the institution has no easy way of sharing care with the practitioner. It may be easier to duplicate not only clinical notes, but also tests and procedures, rather than look for information kept elsewhere; Institutions guard their healthcare resources and limit access to them. This is because they cannot afford to provide all the healthcare needs of all of their patients, irrespective of whether the care is delivered in the hospital or the community. Fragmentation of healthcare leads to poorer patient outcomesThe claim that patient care suffers because of the fragmentation of healthcare delivery is not new. In 1994, the US Primary Care Policy Fellowship observed: “Three barriers to health care are shared by all vulnerable populations: inaccessibility of care, fragmentation of care, and cultural insensitivity on the part of care providers”.1 Patients can get different forms of treatment from institutional sources or community sources (each funded from a different arm of government) for the same condition, with the same outcome but different costs.2 Fragmentation of care, which occurs even within institutions, is inefficient.3 Care is often discontinuous,4 with knowledge, culture and activity being housed in separate “silos”.5 Institutions guard their resources for good reasons: they must account for every dollar and relate the money spent to health activity and occasions of care of the patients within their boundaries. We are all required to “do more with less”. As a result, in order to benefit from resources provided by an institution, a patient must become a patient of that institution — leading, inadvertently, to potential fragmentation of healthcare. Communication between an institution and other people or organisations is sometimes distorted, leading to errors such as prescription critical incidents. For example, hand-written medical instructions can be misinterpreted, with 12 units of insulin being misread as 120 units if the prescriber uses the abbreviation “u” instead of writing out the word “unit”.6 Different funding sources for curative care (usually institution-based) and chronic care (usually community-based) create tension in the provision of medical care and in decisions about how that care should be funded.7 I believe general practitioners (GPs) are willing to provide whole-patient care, but are frustrated by barriers dictated by the “origin” of funding. In New South Wales, for example, interpreters are available in person for a patient attending a hospital clinic after a sexual assault, but not for a patient attending a GP or a sexually transmitted diseases clinic. In my own experience, patients who have been seen and diagnosed with a fracture in a general practice had to be seen by junior staff at a central Sydney teaching hospital before they could gain access to the hospital fracture clinic, because the clinic did not accept GP referral. I fully acknowledge that while some patients are well served economically and socially with care provided outside an institution, achieving the same clinical outcomes,2 certain forms of care can only occur inside institutions. We know that many conditions (eg, breast cancer, acute stroke and diabetes in pregnancy) respond better to care provided by a dedicated team.8 However, medical advances do allow care for some conditions to be appropriately resited from one side of the institution/community barrier to the other. For example, Doppler diagnosis of thromboembolism and the availability of new anticoagulants have allowed some patients to be diagnosed and treated in the community without requiring hospital admission, and community-acquired pneumonia is now most usually diagnosed, assessed clinically and treated out of hospital, facilitated by the use of small, portable oximeters. However, once care occurs outside an institution, patients with such conditions lose their access to institutional services such as specialised physiotherapy (eg, of the hand), social work and occupational therapy. How can we change this scenario for the better?I think we could reduce this fragmentation of healthcare by improving communication and sharing resources within the healthcare system. It would involve the patient, rather than interventions or healthcare practitioners, becoming the centre of care; however, it would not involve increased overall funding but rather a funding readjustment. And yes — even shorter hospital stays would result. Make it simpler to share (rather than not share) informationThe late Dr John Paterson, former Secretary of the Victorian Department of Health and Community Services, dreamed of a unified medical record and patient-centred medical economics. Paterson envisioned three important principles for streamlining the healthcare system:9 Develop a longitudinal patient record for each patient. At each contact, the provider would add new data to a centralised patient record and get paid for the service. Thus, a cumulative record would build up for each patient. Gradually roll funds into one budget pool. Cap pooled funds as a whole and then regulate entitlements at the patient end, rather than at the source of funding. Along similar lines, the concept of teams that deliver “seamless care”, overcoming gaps in information sharing and making the duplication of tests or medical effort unnecessary, has arisen. Genuine seamless care10 depends on a host of characteristics, including the culture of the “actors”,7 their previous investment in knowledge management processes11 that encourage movement (rather than hoarding) of knowledge, and the promise of access to new funding sources. If we could change the emphasis from “craft”-centred teams (eg, with a melanoma social worker and an orthopaedic physiotherapist and so on) to a patient-centred team (made up of an in-hospital specialist, a GP, a pharmacist, and a physiotherapist — either within or outside the institution), we may find workable new combinations of teams that benefit the patient by crossing current boundaries. Current examples of this are the “smart card” trial for patients with heart disease in Brisbane Waters12 (where hospital discharge records provide core information that is accessible on-line by GPs and other health providers), and trials of information sharing in central Sydney.13 In Sydney, use of an existing web platform (Ozdocsonline) allows patients, carers and institutional outreach nurses and GPs to develop interactive management for patients with heart failure. Coordinated care trials are under way to assess whether such “seamless care” is cost-effective and whether it delivers equivalent health outcomes.14,15 (The results from the second round of these trials, which began in 2001, are awaited.) The trials involve service providers working in public, private, and non-government organisations; community and institutional healthcare settings; community support services (such as Home and Community Care); and residential aged care. The trials “will be supported by improved data systems between participating services, and more flexible funding arrangements to enable movement of funds between services as required by an individual’s care plan”.14,15 Use information technology to enhance communicationExisting hospital and state area sector intranets, currently protected by firewalls, could be changed to Internet-based systems using PKI (public key infrastructure) or some other secure entrance to the platform. This would permit off-site, secure access to notes, results, messaging and communication. Such access systems are already being introduced in the United Kingdom.16 Health workers on home visits could use handheld devices to download patient information from a central source, allowing each and every team member caring for a patient to have access to all available information. Information Technology Online grants, from the Commonwealth Department of Communication, Information Technology and the Arts, were given in 2004 to support three separate trials of various methods of caring for patients whose conditions require treatment in the community, then in hospital, then back in the community.13 Subsets of such a process are being rolled out via HealthConnect17 in Tasmania and South Australia. Overlap healthcare boundaries to allow for “seamless care”Overlapping the line where primary care begins and institutional care stops could be achieved without insult to any medical craft — specialists are, and can remain, the designated “bed-holders” and technologists,18 while medical generalists3 (often GPs, but also geriatricians and, especially in rural areas, physicians and surgeons) maintain patient health before and after intervention, and “stream” patients for specialist care. However, patients receiving primary care from medical generalists should be included in the definition of those entitled to access services from state-funded hospitals. This intersection should be made a common ground, not a boundary to be fought over. Patients who are receiving a state-funded phase of healthcare should be guaranteed access to federally funded care, if needed — for example, via their GPs or federally granted allied healthcare. Patients would then have better-targeted services, allowing specialists to do more for patients at their level, while liberating funds to provide resources in the community. Specialists’ and GPs’ legal and fiscal responsibilities should be re-delineated, as is already done in shared-care programs. Doctor and patient satisfaction, costs and clinical outcomes should all be audited to assess whether the desired outcomes are being achieved. Pool some funds and then apply the “health bunyas” conceptState departments of health have suggested pooling of funds19 to allow healthcare activity to follow patients regardless of where they receive care. Fund pooling has been advocated internationally to support intersectoral service supply.11 Although not a health economist, I have found myself wondering whether one effective way of using pooled funds would be to apply the concept of “health bunyas”. A bunya is a unit of goods or work used in a “local energy transfer system”, such as the one currently being used in Maleny, Queensland.20 In that town, an individual’s work or goods are exchanged in local units or tokens (called “bunyas” — after the local pine tree) which can be traded for needed goods or services organised via a directory listing of what is wanted and what is available. In the healthcare setting, an item of care, or the complications of that item of care, could be valued in health bunyas, which would then be redeemable in either the state or federal arena. The money value of health bunyas in this system could be set at levels already calculated for medical care activity — for example, the Medicare rebate for the medical component of care, or the private insurance rebate for items of allied healthcare in the community. A similar system proposed for community-oriented “shopfront” projects21 already blurs the boundaries between state and federal funding. One such project is the NSW Community Options Project, providing case management services for individuals who need services across the state/federal divide not provided by home and community care services. “Silo”-type boundaries would be re-formed to allow for “seamless care”, and might look something like those presented in Box 2. Using the alternative healthcare model I have outlined in this article, Mr A’s care could follow a very different and, I believe, more desirable path (Box 3). 1 Scenario: “How things are today” Mr A, a 70-year-old Maltese migrant with limited English, has diabetes and vascular compromise of his right foot. He also has a longstanding but stable mental illness, managed by his Maltese-speaking psychiatrist, Dr B, and his general practitioner, Dr C. Mr A attends the combined diabetic, surgical and foot clinic at the nearest teaching hospital. The clinic sends its reports about Mr A to Dr C, who scans them into her paperless patient record, but she has no direct access to the results of Doppler imaging or pathology tests. Dr C continues standard diabetes monitoring between Mr A’s clinic attendances, sending results to the clinic. The various consultants at the hospital clinic decide that Mr A needs to have a below-knee amputation. Although Mr A tells Dr C of the planned surgery, the relevant letter does not arrive until three weeks after the operation. Only then does Dr C learn that Mr A was referred to a rehabilitation hospital. Dr C does not get a discharge summary from the rehabilitation hospital, as it goes to the referring surgical registrar from the vascular team at the hospital. Mr A spends 6 weeks in the rehabilitation hospital. The patient’s family asks Dr C to intervene because Mr A is becoming depressed. Dr C contacts the rehabilitation registrar, who tells her about an impending psychiatric referral with an interpreter. The registrar is surprised to learn of the existing arrangements for Mr A’s psychiatric care, as the referral from the hospital made no mention of this. As Mr A is still in the rehabilitation hospital, the decision to continue with the new, separate stream of psychiatric care stands. Long-term effect of fragmented healthcare delivery Because of increasing allied health costs and lengths of stay when healthcare delivery for individual patients is fragmented, the wait for hospital beds for patients with vascular conditions doubles, within the space of a year, from 3 weeks to 6 weeks. 2 A suggested patient-centred model of healthcare delivery and funding 3 Scenario: “How things could be today” Mr A (the patient with diabetes and a mental illness, described in Box 1) sees his general practitioner, Dr C, regularly. On each visit, using a smart card,12 Dr C accesses a database of hospital-derived results via the Internet. Dr C adds to the Internet-based history she maintains for Mr A. She receives email notification of Mr A’s attendance at the diabetes clinic, and sends email notification to his hospital team leader when he is seen at her surgery, so that the team leader can access her information and, if desired, add it to the hospital notes. The hospital clinic consultants decide that Mr A needs to have a below-knee amputation. When alerted by email of Mr A’s latest hospital assessment, Dr C learns of the decision to amputate. She undertakes preoperative testing as per the hospital protocol (detailed on its website), and sends all results directly to the hospital — downloaded from the private pathology company. This care is funded through the federal government (via Medicare). When Mr A is admitted for his operation, the “health bunyas” system commences as part of discharge planning. Money previously dedicated to late postoperative care by nurses, occupational therapists and physiotherapists in the hospital is now pooled in a health bunyas fund. (Pharmaceutical Benefits Scheme funding of Mr A’s usual medications is also pooled into this fund during his hospital stay.) The area discharge planner adds up the bunyas that Mr A’s condition attracts, consults her list of community bodies that take part in the bunya system, and advises them of Mr A’s hospital admission. As he progresses through his stay, she writes up the plan. Dr C warns Dr B, Mr A’s psychiatrist, of his admission and makes an early appointment for him to be seen after discharge. Mr A goes home on the early discharge program to have care at home. Money from community health services, local government and Medicare is added to his bunya pool. He is attended by hospital-in-the-home nurses, who record their visits on hand-held devices and download their data daily to the Internet-based patient record, which is also accessible to Mr A’s specialist and GP members of Mr A’s team. Community resources are costed at community rates. Bunyas buy home-visit physiotherapy, a prosthesis, community transport to the day hospital rehabilitation gym and to Dr B, dressings, medications, social worker support for accessing benefits, regular specialist follow-up consultations in the hospital outpatient department or the specialist’s rooms, and postoperative home-based medical care from Dr C. Dr C works together with Mr A’s specialist via the Internet and phone to manage Mr A’s progress. Long-term effect of integrated healthcare delivery Because of cost sharing, care in the community and use of private allied health workers, the wait for vascular beds falls, within the space of a year, from three weeks to one week.

Linda Mann FRACGP

Health statistics say we’re doing well, but our healthcare system is in crisis; we need more than just another report Australians have never enjoyed such good health as they do now. Our life expectancies reach well beyond the biblical ideal of “threescore and ten”, and we rank among the top four in the world’s longevity league.1 However, there is a caveat: the poor health and short lives of Indigenous Australians continue to be a blot on the nation’s psyche. The quality of our healthcare also ranks highly. In a recent comparison of selected health indicators in five nations — Australia, Canada, New Zealand, the United Kingdom and the United States — our survival rates for breast, cervical and colorectal cancers were high, as were our performances in screening for breast and cervical cancer.2 Furthermore, Australia’s mortality rates for asthma and acute myocardial infarction were the lowest among the nations. Our vaccination rates for polio and influenza were exemplary, but the incidence of pertussis in Australia was the highest among the five nations.2 We could do better. Australia’s general practitioners also perform well.3 Most Australian adults reported being with the same doctor or place of care for more than 5 years, and most received appointments on the day they were ill, although after-hours access to primary care remains an issue.3 Core features of the patient–doctor relationship and communication also rated highly: 71% of patients related that the quality of the care they received was excellent; 71% felt that their GPs listened carefully; 73% believed that medical matters were explained in an understandable way; 63% were satisfied that their doctor spent enough time with them; and 61% claimed that their management plans had been clearly outlined.3 With all these good tidings, you may well ask why Australia’s healthcare is beset by a pervasive sense of negativism? Our citizens are losing confidence, troubled by long hospital waiting lists,4 increasing hospital access block,5 and crises such as those at the King Edward Memorial Hospital6 or at Campbelltown and Camden hospitals.7 Our doctors are also unhappy — battle-weary from working in resource-poor and unpredictable environments. Furthermore, there is a swell in public impatience with the inability of politicians to confront the chaos. Playing the cost-shifting and blame-shifting game is more their forte. The causes of discontent were sought in a recent survey of medicopolitical leaders (see Box), and the perceived problems fell predominantly in the domains of funding, organisation and bureaucracy. Indeed, even the Chairman of the National Productivity Commission concurs with these views. In launching the draft Review of National Competition Policy Reforms in late October 2004, he noted: “It is now generally accepted that Australia’s health system is beset by structural problems that require nationally coordinated action. But there is less agreement on the best way forward. An independent review of the whole system is needed to provide a roadmap for reform.”8 Another review? Please! Australia’s healthcare has had more reviews than The Lord of the Rings epic. Our citizens and healthcare professionals want solutions to the problems that they experience and which have been enunciated ad infinitum. The possibility of a National Productivity Commission inquiry into health has been temporarily deflected by the activation of a small taskforce in the Department of the Prime Minister and Cabinet. It will examine the operations of the Australian healthcare system to: ensure optimum efficiency and effectiveness of healthcare service delivery for all Australians across the primary, acute, rehabilitative and aged-care sectors, and, in doing so, clarify responsibilities; ensure best use of the funds all jurisdictions put into healthcare, as well as improve accountability and transparency in healthcare funding; and identify barriers to seamless service delivery for patients and recommend options to address them. The taskforce will present its report early in 2005. As its members contemplate solutions, they may well keep in mind that: We need more time. Modern healthcare reforms have drastically eroded time — time for care, time for teaching and time for learning.9 In an ageing society, we need to provide the means for healthcare professionals to spend time with people. We need greater efficiency. Given our limited health dollars, we need to spend wisely. We can no longer afford unnecessary duplication and waste. We need a greater investment in and coordinated strategies for preventive healthcare. Incentives for “good health” will yield dividends for the future.10,11 We must support our greatest asset — the healthcare workforce. Above all, the taskforce needs to remember the “public” in public service. In this year’s federal election, the public endorsed Coalition majorities in the House of Representatives and the Senate. Having placed such trust in the government, the public is now looking for political leadership in tackling the chronic problems in healthcare. They certainly don’t want yet another report to gather dust in the Council of Australian Governments archives. In this task it may be apt to recall the words of John F Kennedy: “Those who make small revolutions impossible will make violent revolutions inevitable.” Will we have three more years of political rhetoric or will there be purposeful reform? What is wrong with Australia’s healthcare system At a recent meeting, 36 high-level medicopolitical leaders representing all states and territories as well as selected clinical craft groups were independently asked “In one sentence what do you consider to be wrong with our health system?”. Thirty-four participated. The top three responses were: Funding (8 respondents) Lack of indexed funding; inadequate funding; funding inappropriately targeted or managed; maldistribution of government benefits in the community — “money in wrong place” mismatch between funding and expectations. Healthcare system organisation (8 respondents) Demand exceeds capacity; lack of same standards nationally; system is fragmented; poor coordination; access problems; compartmentalisation; system silos and the gap in between; duplication. Bureaucracy (8 respondents) Jurisdictional divides; duplication of function; mismatch between bureaucratic and patient priorities; faceless; costly and inefficient; poor coordination; poor forward planning.

Martin B Van Der Weyden MD, FRACP, FRCPA

Medical researchers have a moral responsibility to communicate their findings to the public There is no greater commitment than a government’s investment in the healthcare of its citizens. If we, as medical researchers and practitioners, are to preserve public trust and support for our scientific enterprise, we need to pay more attention to translating the benefits and grandeur of science into the common language of the general community.1 Although educators and journalists also communicate the achievements of medical science, doctors and scientists have a greater responsibility to increase the availability and salience of science to the public. I believe we can move further towards realising this goal by keeping several key questions in our minds. How have and how can biomedical breakthroughs benefit humanity? The development of vaccines and immunotherapies is at the top of my list of major medical advances that have changed humanity’s lot for the better. During the past year, the medical crises created by epidemics of Ebola virus and SARS have demanded the creation of new vaccines, which are now poised for clinical trials.2 Other developments in medicine include antibiotics to combat infection, organ transplantation to extend life, high resolution imaging that has reduced the number of invasive surgical procedures and, most recently, the global Human Genome Project, which is revealing secrets about the basis of life. In April 2003, the world simultaneously celebrated the 50th anniversary of Watson and Crick’s description of the DNA double helix and the International Human Genome Sequencing Consortium’s completion of the human genome sequence. However, the completion of the human genome sequence represented only the beginning in genomics research; it has led to the unveiling of a bold new vision for its future.3 Translating genome-based knowledge into health benefits will be a major focus of future genomics research. Virtually all diseases, with the exception of trauma, have a genetic component and an environmental component. One of the projected outcomes of the Human Genome Project is the development of personalised medicine. All patients who share the same diagnosis for a certain disease do not respond the same way to treatment. In some cases, we are already able to determine, based on genetic profiles, which patients will be responsive to specific drugs, and then to specifically deliver the most appropriate to eradicate the disease.4 We have entered a new era of multigeneration, population-based research. This will facilitate innovative genetic studies to identify the paediatric precursors of specific adult diseases, based on the comparative analyses of genetic profiles of children, their parents, and grandparents. Imagine the possibility of identifying genes in newborns responsible for cardiac disease, or diabetes, or arthritis, or specific cancers — and then managing and/or preventing the onset of these diseases. The overall improvement in quality of life would be extraordinary, and we are closer than you might think to achieving this goal. Many scientists have suggested the concept of newborn genetic “passports” in which the complete genetic profiles of newborns will be documented in medical files at birth. On the one hand, this sounds quite exciting, but the social implications are profound. As doctors and scientists, we must act now and we must act together to establish rigorous guidelines and boundaries for the use of genetic informatics with respect to: health insurance; genetic information and the workplace; genetic privacy and confidentiality; and, the forensic use of genetic information. Accordingly, the US National Human Genome Research Institute in Bethesda, Maryland, has developed the Ethical, Legal and Social Implications Research Program to ensure that genetic research is conducted in an ethically sound manner; that genetic technologies are integrated appropriately into clinical and non-clinical settings; that genetic information is correctly interpreted and appropriately used; and that health professionals and the public become more genetically literate.3 How important is advocacy in supporting the mission of research and addressing critical social issues? John Porter, former Illinois Congressman and Chairman of the US Subcommittee on Labor, Health and Human Services, and Education, stated: Since most members of Congress are not scientists, citizen scientists must individually inform, educate, inspire, and direct their representatives regarding public policy decisions affecting science.4 When Americans were polled by Research!America about who they believe should have the most influence on how government medical research funds are spent, they indicated that patients (first) and scientists (second) should have the most influence.4 (Research!America is a not-for-profit, membership-supported public education and advocacy alliance for medical and health research.) Scientists must continue to remember that it is a privilege to be engaged in research, and that the relationship between science and society is growing ever more intimate. The spirit of enquiry behind science is not self-sustaining — it is increasingly dependent on societal support. Thus, we have a moral responsibility to be good stewards of this support and to communicate our findings to the public in order to build on that trust and seek broad input. It is critical for greater success that advocacy groups work together for better healthcare and biomedical research. Typically, in the US, joint advocacy on many issues will involve the Association of American Medical Colleges (AAMC), research institutes, academic institutions, hospitals, state and local organisations, voluntary health associations, philanthropic foundations, individuals, and business and industry, as well as biomedical professional societies. As a representative of American scientists, I have valued opportunities to work closely with the US Congress. From 2000–2002, I was privileged to serve as President and Immediate Past-President of the Federation of American Societies for Experimental Biology (FASEB) — over 70 000 scientists speaking with one voice. Through directed advocacy effects of “acting now and acting together” we were successful in: doubling the NIH budget (1999–2003), from $13.6 billion to $27.2 billion; securing federal funding for human embryonic stem cell research; supporting genetic non-discrimination legislation to protect the use of private, genetic information (a work in progress); and developing debt-relief programs for physician–scientists to encourage this endangered species into the pipeline. What are the economic benefits of investing in research? Simply put by the Lasker/Funding First Foundation, “Investment in research saves lives and money”. Increases in life expectancy have contributed to national budgets. For example, in Australia between 1960 and 1999, longevity improved from 73.9 years to 81.8 years for females and from 67.9 to 76.2 years for males, at an estimated worth of $5.4 trillion.5 With respect to government support of biomedical research, the statistics when comparing the US with Australia were astonishing to me. I have recently learnt that in the 2000–2001 budget year, whereas the budget for the NIH was $17.8 billion, the Australian Commonwealth budget for health and medical research was a more modest $665 million.5 This represents a fourfold difference per citizen, with the US government spending about $130 per person and the Australian government about $33. I felt humbled, acquiring a more profound respect for my world-class Australian medical research colleagues, who, with truly limited resources, have made significant contributions to the field. Among these contributions are the discovery of lithium in treating bipolar disorder, as well as major advances in childhood diseases of spina bifida and sudden infant death syndrome. Australian researchers have also discovered a powerful secret to success — working collaboratively in interdisciplinary teams towards a common goal. Researchers around the world could all learn a lesson from Australian scientists; as the US budget for research begins to shrink, American scientists will have to adopt the Aussie philosophy in order to survive in the “business”. With competing demands on government resources, who will pay for tomorrow’s discoveries? I believe that projects leading to future discoveries will be paid for by creative partnerships between academic, philanthropic, corporate and government agencies. I also believe such projects should be guided by advocacy, led by scientists, to advance treatments and cures. We should always remember the wise words of Paul Rogers, Chair of Research!America: “Without research, there is no hope.”

Mary JC Hendrix PhD

Absence of coherence in the way Australia employs overseas-trained doctors is a problem for our healthcare system and for the doctors themselves In the 1880s, the head of the statistics unit of the Registrar-General’s office in London noted that the shortage of medical practitioners in England was such that there was “imminent danger” that qualified medical care might become “quite inaccessible to vast numbers of people”.1 This shortage was a direct outcome of the Medical Act of 1853, which prescribed strict criteria for the education and registration of medical practitioners. Its effect was to reduce recruitment into the profession because of more formidable courses while concomitantly phasing out unqualified practitioners.1 Now, at the beginning of a new century, we find that the predicament of Victorian England has become a global problem. There is a shortage of doctors worldwide, and Australia is no exception.2-4 OTDs must not be seen as a long-term solution to our doctor shortage. A number of factors have contributed to our doctor shortage. Prominent among these is federal government policy in the 1990s, which limited the number of medical school places in Australia, as all the while the Australian Medical Workforce Advisory Council maintained there was no shortage of doctors.5 Having miscalled policy, the federal government is now rapidly seeking to remedy its gaffe. Five new medical schools have recently been established6 and the number of bonded medical places (requiring graduates to work for a minimum period in districts of workforce shortage) in our existing medical schools has been increased by 234.7 The projected outcome of these initiatives is that the number of Australian medical graduates will increase from about 1200 in 2004 to about 2200 in 2014 (Warwick Hough, Director of Workplace Policy, Australian Medical Association, Canberra, personal communication). Whether this number will meet society’s demands a decade from now is anyone’s guess, but one thing is certain: Australia’s healthcare will be dependent on overseas-trained doctors (OTDs) for some time to come. Our increased dependence on OTDs is reflected by recent bureaucratic activity attending the government’s announced Strengthening Medicare package, with its additional 725 OTDs working in Australia by 2007.8 One consequence has been the generation of a report on OTDs submitted to the Medical Training Review Panel of the Australian Department of Health and Ageing in February 2004. It outlines a bewildering array of Australian policies and guidelines, and differing surveillance and stewardship of OTD programs. The report identifies: enormous inconsistencies in terminology; lack of national coordination in collection of data on OTDs; inadequacy of data held by different agencies and departments; differing entry points of OTDs controlled by different jurisdictions (eg, through the state and territory Areas of Need program or the federal Districts of Workforce Shortage program); a multitude of stakeholders, all focusing on their individual programs, with poor communication among themselves; doubts about the adequacy of assessment and supervision of OTDs entering Australian medical practice by medical boards and about the adequacy of the Australian Medical Council (AMC) examination. Finally, the report on OTDs found there were inadequate resources for orientation, ongoing training and supervision of OTDs, and suboptimal support for their families. Some progress has been made, such as the recruitment of OTDs through contracted recruitment agencies, reduced “red tape” in the assessment and recognition of OTDs, some flexibility in immigration arrangements to allow OTDs to stay longer,8 and fast-tracking of selected applicants to provisional registration and assessment by the AMC. However, the reality is challenging. The data on birthplaces of OTDs in the article by Birrell in this issue of the Journal () reflect the reality of the global village we now live in.9 Yet, while the backgrounds, knowledge and skills of OTDs are diverse, evaluations of competence may be bypassed when employing OTDs in Australia, and formal assessments of communication skills (as distinct from linguistic proficiency) and cultural awareness are not included in current assessments.10 This has the potential to compromise patient care. To facilitate an orderly integration of OTDs into the Australian healthcare system, McGrath () calls for a national body to establish uniform standards in licensure, to review and, where needed, to boost training resources and capacity. He argues that these are the minimum requirements to meet our duty of care to both the public and OTDs.11 We would also argue that recommendations by this body and coherent, relevant OTD data should be regular agenda items for the Australian Health Ministers’ Conference. Focusing on OTDs as the primary short-term solution to our doctor shortage has serious ethical and global implications. The “brain drain” of healthcare professionals from many developing countries compromises their healthcare systems and demoralises their healthcare workforces already struggling to cope with major public health problems such as HIV and malaria. It constitutes a major loss in financial as well as human capital — particularly as any remittances sent back by emigrants (estimated at US$72.3 billion in 2001 and the second-largest source of external funds for developing countries) are not necessarily reinvested in healthcare.12 Unless recruiting countries like Australia adopt policy options such as creative employment contracts that also subsidise the country of origin, it is likely that “borrowing” OTDs will continue to broaden the gulf between developed and underdeveloped countries. OTDs must not be seen as a long-term solution to our doctor shortage. The Australian Health Ministers’ Conference’s recent National Health Workforce Strategic Framework states: “Australia should focus on achieving, at a minimum, national self sufficiency in health workforce supply, whilst acknowledging it is part of a global market.”13 In the meantime, OTDs make a valued and essential contribution to our society and to the provision of healthcare to Australians. We should respect their contribution with the attention and care it deserves.

Martin B Van Der Weyden MD, FRACP, FRCPA · Mabel Chew FRACGP, FAChPM

Since the late 1990s Australian employers have recruited an increasing number of overseas-trained doctors (OTDs) to hospital and “area of need” general practice positions. While assessment standards vary by state and field of medicine, most OTDs are appointed without a formal assessment of their medical knowledge and clinical skills, with registration to practice being conditional only on their working in hospitals and “areas of need”. By comparison, formal assessment is required before an OTD can practise medicine in the United States, the United Kingdom and Canada. Most of these doctors hold temporary resident visas, but a minority are permanent residents who have not completed their Australian Medical Council accreditation examinations. In 1997–98, most OTDs arriving under temporary resident visas were from the United Kingdom and Ireland, and by 2002–03 this had dropped to under 50%; OTDs now come from a greater diversity of countries.

Robert J Birrell PhD

Australian healthcare is greatly enriched by its overseas-trained doctors (OTDs). There is no national approach to support the integration of OTDs into the workforce. The problem areas are well defined — the need for better information access; better orientation to our healthcare systems and the workplace; improving communication with patients and healthcare workers; standardised assessment of knowledge and skills; and education and training support —so, let’s get on with it.

Barry P McGrath MD, FRACP

Weeks after beginning its winding journey, a redirected letter finally finds its destination. In our eagerness to open it, we almost tear in half the neatly folded crisp white sheet that lists a series of results: angina, pass; asthma, pass; preeclampsia, pass; bulimia, fail, could not elicit history of vomiting; croup, pass. The list continues to a dispassionate conclusion that the candidate has demonstrated adequate knowledge at the examinations of the Australian Medical Council (AMC) to secure a passing grade. The accompanying card graciously thanks us for our tutoring 1 year ago. We stare wordlessly at the sheet, our joy obliterating its sterility. So far, he has fled state persecution, worked 10 years in a factory, and supported a family of four on a minimum wage. The iatrogenic death of his father served as a powerful impetus to return to his calling in life, medicine. Forty years old, he has juggled swimming and soccer lessons, school homework and, lately, running a small business to steal time to prepare for his own examinations. “I promised myself at my father’s bedside that I would go back to medicine. Every day in the factory, I used to dream about becoming a doctor again, but we needed that job to survive.” Now he will forever be known as an “AMC”. As we exuberantly write him a congratulatory note, a vision of his journey ahead involuntarily crosses our mind. As he begins his quest for a job, he will quickly learn that, although all foreign graduates seeking to enter the Australian medical system must take the AMC exam, the term “AMC doctor” automatically carries the connotation of inferiority. Irish, American and German doctors will be identified by country, while he and his peers from the developing world will be separated by an invisible, but distressingly tangible, line. Deeming himself unsuitable for the elite hospitals, he will apply instead to those considered more “foreigner-friendly”, their reputation earned not necessarily for their greater tolerance of foreign graduates, but because of their inability to attract the more aspiring. These hospitals too will first select local graduates before yielding the leftover spots to the AMCs. At the scant interviews he secures, he will be summarily discarded at some on account of his thick (yet understandable) accent and his slow (yet considered) speech. At others, he is unlikely to receive ticks in the boxes that say “team player”, “enthusiastic” and “makes good eye contact”, because he is unfamiliar with the buzzwords and gestures (although not the inherent concepts) that interviewers seek. His first job is almost certain to be in a hospital staffed largely, if not almost exclusively, by foreign doctors. Collegial support will be tentative, the focus being on surviving each day without raising the staff’s ire. He will be greeted cautiously, unaware of an unspoken probation, and he might only enjoy a few days’ grace before barbed remarks escape their loose restraint. Despite his commitment, he will be slow, never having had the benefit of observing local protocol as a student or a subintern. Despite having passed his exams, he will hesitate with most tasks, including the essential ones of documenting directions, checking blood tests and making a physiotherapy referral, because he is a stranger to them all. Some doctors and nurses might lend a kind and guiding hand, but he is more likely to (over)hear the following: “You are the resident — it’s your job!” “Why do I always end up with the AMCs?” “He might be a nice person, but he doesn’t have a clue!”. Occasionally, the remarks will be deliberately hurtful: “Excuse me, this desk is for doctors only!” “Why don’t they just go back where they came from?”. He is most likely to miss tutorials because of unfinished work, and, when he does get to one, he is the diminutive figure in the corner, too self-conscious to ask a legitimate question. He is the one you will see biting on a stale sandwich most evenings as he ploughs through piles of paperwork between braving phone calls to the registrar, irate at his inability to articulate a problem in 30 seconds. When the desperately needed interpreter is hours away, he will meekly announce his grasp of two other languages. Relief and gratitude on the part of the staff will be somehow inexplicably replaced by righteousness. “At least he can do that!” He will often wonder why his best attempts to contribute meaningfully seem antagonistic, why there is such a glaring lack of encouragement, and why he is finding this initiation harder than he had ever imagined. In a private wish list, he craves for a little more understanding and a little less hostility; then, scoffing at such imagined luxuries, he returns to face another day. Slowly, one unit then another shares the AMC burden, each one “preparing” the next, so that his perceived shortcomings always precede him. Soon he must think about the following year’s jobs. What should he do? Who knows him well enough to provide the references? Who are his role models? Should he follow the majority of his AMC peers and enrol in general practice training or should he make a concerted attempt to pursue a long-desired specialty? The obstacles seem magnified in advanced training. Even if he manages to enter a specialty program, who will supervise the children’s homework? Who in the hospital appreciates the needs of an older foreign doctor, also a son, father, husband and small business owner? The conflict between personal aspirations and life’s larger concerns routinely ravages his mind. In the course of our own training, we have been frequent witness to, and no doubt creators of, the hurdles that the medical community puts in the way of foreign medical graduates. These hurdles are not only academic, but also personal, based on our uninformed and unchallenged perception of their culture, education and work ethic. Every foreign graduate we have taught has understood the rationale for an Australian exam, but, after attaining the very standard demanded by the profession, it is the indignity of working in an unsupported and hostile environment as a second-class doctor that turns out to be the insurmountable hurdle. Although the issues surrounding foreign medical graduates are genuinely difficult and bear no glib resolutions, we suggest the following considerations. Integrate foreign medical graduates preparing for the AMC exam into hospitals by allowing them to observe educational seminars, outpatient work and grand rounds. Knowledge of local medical practice is far more accessible in this manner than by spending countless lonely hours in the library in search of assimilation. Access should not be limited to peripheral hospitals, which are often difficult to travel to and lack consistent teaching programs. Expand the educational program for foreign graduates by encouraging local physicians to teach. (With the assistance of just one other colleague, each of us spent just 2 hours a week to adequately address the exam syllabus.) It is crucial that program directors sanction such activity rather than be dismissive of its goals — a volunteer teaching program will enjoy success only if personal gain is sometimes set aside. Assign a specific mentor for foreign doctors at each institution. Such a mentor must be sensitive to the different goals and needs of foreign doctors compared with those of their local counterparts. Neither excessive pressure to conform nor total immunity from compliance with local standards should take the place of a deliberate process of integration. Practise what we preach. Medical students are taught from inception about the value of empathy and communication. We repeatedly examine their grasp of such skills, yet, once they are doctors, these skills are perceived to be an optional extra. Apply the open-ended question to foreign doctors: “Tell me how you feel.” Appreciate the worth of foreign doctors as a pillar of our increasingly cosmopolitan society. The very doctors we may deride will go on to serve entire populations, which the average Australian graduate is ill-equipped, and hence uncomfortable, to serve. The statistics on migrants, ageing populations and chronic illnesses do not bear repetition, but the overwhelming need to help our foreign doctors to help us take care of all our patients does. In medicine, the road is long for us all, but for the foreign medical graduate it is inevitably more winding and rough. It is our obligation to not abandon our colleagues along the way, but to seek to ease their journey with small, personal gestures and larger, administrative measures. While they tend our society’s sick, we must not deny them their own bruises that often lie just beneath the surface. It is only then that as physicians we can truly call ourselves healers.

Ranjana Srivastava MB BS(Hons) · Declan J Green MB BS(Hons)

To the Editor: Hays notes that international medical graduates on temporary residency visas are “an almost invisible workforce”.1 This invisibility results partly from a lack of data, but it also stems from a lack of coordination and consistency between agencies which do hold relevant data. In the main, these doctors hold conditional registration (rather than general registration) with state and territory medical registration boards. However, there are inconsistencies between jurisdictions in how data on conditional registrants are treated in relation to national medical workforce data collection (namely the annual national medical labour force surveys overseen by the Australian Institute of Health and Welfare [AIHW]), and in how statistics relating to this group are reported. Available data from four medical registration boards indicate that, in 2003, conditional registrations of overseas-trained doctors comprised over 10% of all medical registrations in Western Australia and Queensland (see Box). Percentages have increased since 2001 in WA, NSW and, to a lesser extent, in Queensland, while remaining steady in Victoria (2001 figures were WA, 8.2%; Qld, 9.3%; Vic, 6.5%; NSW, 2.3%).2-5 The invisibility of this group might be ameliorated to some extent if existing data on conditional registrants were reported and collated in a consistent manner. The AIHW is the obvious candidate to oversee such collation, and the question of why the state and territory medical registration boards do not provide the data to enable this to occur is a puzzling one. The primary function of medical registration boards is, of course, administration of registrations in their jurisdictions, and their workload has been increased by growth in conditional registrations, which involve time-consuming processing. In this context, it is perhaps understandable that the boards are not focused on the potential value of their data to medical workforce planning. If better use is to be made of the existing data for national medical workforce planning, the boards will need to commit to consistent and more detailed reporting practices for conditional registrants. This would probably occur easily if boards were convinced of the value of national medical workforce planning, and recognised the value of their unique contribution to it. It is a stated principle of national health workforce strategy that Australia should aim to achieve national self-sufficiency in its health workforce supply.6 If this is to be achieved, the numbers, characteristics and movements of international medical graduates on temporary visas must be monitored more carefully. All registrations and conditional registrations for overseas-trained doctors in four states, 2003 State Total registrations Conditional registrations* Western Australia2 6 854 718 (10.5%) Queensland3 12 531 1263 (10.1%) Victoria4 17 603 1115 (6.6%) New South Wales5 25 481 1211 (4.7%) * These include overseas-trained conditional registrants only. It excludes conditional registrants who are interns, who have passed all Australian Medical Council examinations or who are registered conditionally for health or disciplinary reasons.

Catherine M Joyce

Increasingly, the NHS is dependent on overseas-trained health professionals The British are past masters at harnessing the energy of their Anglo-Celtic offshoots. The names of the battles on the tombstones of returned servicemen interred in the cemetery in Halifax, Nova Scotia, are very familiar to any Australian with some knowledge of the Western Front of 1914–1918. And in the Commonwealth War Cemetery in Kraków, Poland, Australians, New Zealanders, South Africans and Canadians lie side by side, linked in death, so very far from the sunburnt country, the long white cloud, the burnt-brown veldt or the rolling prairie. Britain has been habitually suspicious, even untrusting, of the quality of [overseas] medical degrees . . . Today, Australians, New Zealanders, South Africans, and occasionally Canadians, continue to serve side by side as doctors, nurses and other health professionals in the United Kingdom’s modern, dependable National Health Service. They are renowned for their energy, excellence of care, and exuberant intolerance of persisting with the old, outmoded UK approaches, justified only by “that is the way things are done here”. Partly, this is a result of selection bias — those who come to the UK want to see the world, to see how things are done elsewhere, and to challenge this and themselves — and partly it is the lazy monolinguality of many native English-speakers, the air routes (and the shipping routes before them) that terminate in London, and the reciprocity of recognition of basic qualifications in the relevant professions. However, the greeting extended here to “foreigners”, even white, English-speaking foreigners from far-flung corners of the former Empire, is paradoxically patchy. Australians are welcome to pay taxes, and even to vote. They are happily accepted as lecturers and tutors of home-grown doctors for the NHS, but those without patriality (at least one grandparent born in the UK) or “indefinite leave to remain” will have considerable difficulty obtaining a mortgage. In other words, you are free to cure our sick, pay into our public purse, teach our children and participate in our parliamentary process, but we do not guarantee that you will be allowed to own the roof over your head. “Foreign”, of course, has connotations of the unfamiliar, even the unnatural, and certainly something against which a hostile immunological response should normally be raised. Like Australia, Britain has been habitually suspicious, even untrusting, of the quality of medical degrees obtained in countries that were not part of the former British Empire. Even Commonwealth countries can be problematic if their inhabitants are not white. On the one hand, there are reasons for having a single, demanding standard applied uniformly to all, even if that arrangement does oblige highly specialised, very experienced practitioners to go back and learn their general medicine all over again. On the other hand, in the big British cities, there are large populations of refugees and asylum-seekers, for whom the languages, cultures and endemic medical problems of their places of origin are completely unknown to practitioners trained in comfortable countries at high latitudes. Dealing with these patients is extraordinarily time-consuming, not just because of their different backgrounds, but also because of the continuing medical and psychological consequences of events surrounding their leaving their homelands and the ongoing economic, social and legal disconnection experienced after their arrival. Only recently have pilot schemes begun that allow overseas-qualified health professionals (including doctors) in these communities limited rights of practice, under supervision, to help alleviate their compatriots’ burdens. A number of people in the UK are now raising the issue of the dependence of the NHS on overseas-trained health professionals and the detrimental consequences for the source countries. Many of the suppliers of this workforce are low- to middle-income nations that can ill-afford to lose significant numbers of their graduates. The NHS is also a source of emigrants as well as a mecca for immigrants. Remote Australia has its fair share of British graduates manning the medical frontiers — one British practitioner in rural Western Australia famously evacuated an extradural haemorrhage using a brace-and-bit borrowed from the local carpenter and guided telephonically by a neurosurgeon in Perth. But, however interesting these individuals and their experiences, they tend to be itinerants who ultimately return to the “Mother Country” (just as most Antipodeans here eventually return to their “dominions of origin”). This pattern differs sharply from the sizeable cohort whose opposition to the creation of the NHS, in the late 1940s, was sufficiently strong that they “upped stumps” and moved permanently to less socialist settings in the English-speaking world, including Australia and New Zealand. Arguably, one result of this efflux has been a significant and lasting divide between the internal medicopolitical cultures of the NHS and the Australian healthcare system. Although acrimonious occasionally, and feeling disgruntled and downtrodden for much of the rest of the time, most of the medical profession in the UK openly supports a system that is almost always free at the point of care and in which every citizen and most residents have been nominally tied to a single general practitioner. This is the paradigm (and attitudes) that we see passed down to our British students and withstanding the test of time. Beyond the commonality of the GP as gatekeeper to specialist services, Australia’s healthcare system has long had higher levels of entrepreneurialism and market forces, and the publications of medical organisations that reach us here in the UK are forever reporting clashes with governments. A little reflection reveals that the young, pre-Thatcherite émigrés of 1948 would have been at the peak of their medical and political powers when the Whitlam government wanted to introduce Medibank in 1974. They were as trenchant in their opposition to what they saw as the intrusion of government into the sanctity of the doctor–patient relationship in Australia in the 1970s as they had been in Britain in the 1940s, perhaps kindling, or certainly entrenching, a tradition of energetic awkwardness that has bred true in every succeeding generation of Australian practitioners. Both the UK and Australia are the more interesting, then, for the consequences of their medical slave-trades.

Konrad Jamrozik DPhil, FAFPHM, MFPH · David P Weller MPH, PhD, FRACGP, FAFPHM · Richard F Heller MD, FRCP, FRACP, FAFPHM

Re: “The potential for tobacco control to reduce PBS costs for smoking-related cardiovascular disease”, by Susan F Hurley, Michelle M Scollo, Sandra J Younie, Dallas R English and Maurice G Swanson in the 6 September 2004 issue of the Journal (Med J Aust 2004; 181: 252-255). The vertical axis on the graph in Box 5 was mislabelled during the production process. The values should be reduced by a factor of 10. The correctly drawn figure is reproduced below. The html and pdf versions of the article published online were corrected on 15 November 2004. 5 Smoking-attributable PBS costs for drugs to treat cardiovascular disease

Susan F Hurley MS, PhD · Michelle M Scollo BBSc, GradDipCommHlth · Sandra J Younie P/GDipHealthEc · Dallas R English PhD · Maurice G Swanson BSc, MPH

To the Editor: We write in response to the article by Faunce and Bolsin on the lessons to be drawn from three Australian whistleblowing sagas.1 Their summary of events at King Edward Memorial Hospital, Perth, deserves comment. Michael Moodie, the Chief Executive Officer (CEO) of King Edward Memorial Hospital, was also CEO of Princess Margaret Hospital for Children (PMH). He was stood down from PMH because of the concerns of workers in response to events at PMH unrelated to those at King Edward Memorial Hospital, as Faunce and Bolsin implied. Moodie was the senior administrator charged by the government with ensuring that appropriate standards were in place and were being met. Staff at PMH believed he was unable to fulfil his brief, culminating in votes of no confidence from the PMH Clinical Staff Association, the PMH Medical Advisory Committee, and a petition signed by 80 PMH doctors.

Francis Lannigan · Geoff Knight · Gary C Geelhoed · Alan Duncan · Peter Chauvel · Ian Hewitt · Peter Le Souëf

In reply: Our reference to Michael Moodie as a “whistleblower” merely reiterates his description as such in the report of the Inquiry into Obstetrics and Gynaecological Services at King Edward Memorial Hospital by the Australian Council for Safety and Quality in Health Care.1 That report states: “Both the Bristol and King Edward case arose from ‘whistle-blowers’ reporting serious problems rather than from established safety and quality monitoring systems. In Bristol’s case, the whistle-blower was an anaesthetist and, in King Edward’s case, it was the recently appointed Chief Executive. In both cases, either directly or indirectly, the department of health received information about management and clinical performance problems that had not been addressed over a significant period of time.” The report then lists nine examples of problems established at both institutions, ranging from a “closed culture and environment unsupportive of openly disclosing errors and adverse events” to “poor clinical and emotional outcomes for patients and families”. The report continues: “However, there were differences in the Hospitals’ response to the inquiries. Bristol welcomed an inquiry and actively supported the process. In contrast, King Edward tolerated the process and the Western Australian branch of the Australian Medical Association actively and publicly fought it.”

Thomas A Faunce · Stephen N C Bolsin