Health services administration

To focus solely on reducing error may inadvertently reduce the quality of care In this issue of the Journal, Wenck and Johnston (page 117) describe the response of a medical indemnity insurer to the potential for claims associated with the contraceptive implant Implanon (Organon).1 The article stimulates reflection on whether the recent increased emphasis on risk management has been at the expense of quality assurance. The “quality movement” began in Australia over 30 years ago. The 1970s and 1980s saw the development of hospital accreditation through the Australian Council of Hospital Standards (now the Australian Council of Health Care Standards [ACHS], www.achs.org.au) and drove the system of credentialling medical staff in hospitals and delineating their clinical privileges that has become the norm. Accreditation of general practices resulted largely from the Australian government’s decision in the late 1990s to tie various government general-practice payments to accreditation. The “safety movement” developed more recently, catalysed in part in Australia by the 1995 report in this Journal of the Quality in Australian Health Care Study,2 and internationally by the report of the Bristol Inquiry3 and the US Institute of Medicine’s article To err is human.4 However, the increased momentum of the safety movement brings with it the risk that “risk management” (avoiding error) will overshadow “quality assurance” (enhancing quality). Further, Wenck and Johnston’s report raises the question of whether the prudential risk management outlined simply imposed financial disincentives to the continued use of Implanon, and increased funding for potential future claims. Or did it stimulate reduced error — clinical risk management? Recently, concern at the escalating cost of public liability insurance in general, and medical indemnity insurance in particular, has stimulated: A wave of tort law reform across Australia. An early reform that directly affected medical accident compensation, and hence medical indemnity costs, was the New South Wales Health Care Liability Act (2001). Reform of the medical indemnity industry. This culminated in Federal Parliament passing the Medical Indemnity (Prudential Supervision and Products Standards) Act (2003) and a number of subsequent bills. Over $300 million in federal subsidies for medical indemnity insurance premiums (the “Premium Support Scheme”) and medical negligence claims (the “High Claims” and “Exceptional Claims” schemes). Over $300 million in federal funding for the UMP (United Medical Protection) Support Scheme, which replaced the IBNRs (“Incurred but not reported” liabilities) Levy Scheme announced in 2002; the Commonwealth will now directly subsidise three-quarters of the IBNRs of doctors who were members of UMP at 30 June 2000. Now that medical indemnity is not directly provided by the medical defence organisations (MDOs), but by the subsidiary insurance companies they registered (“captive” insurers), the quid pro quo demanded by Government for the $600 million “rescue” injection of subsidies was: that the parent MDO or its subsidiary medical indemnity insurer provide enhanced programs of clinical risk management for their clients and that those clients participate in the programs offered, and that the medical indemnity insurers practise much higher standards of prudential risk management than did their MDO parents in the past. (Prudential risk management refers to how insurers set premiums and manage their reserves and business risk to ensure they remain solvent and able to meet liabilities as and when they arise.) In this process, the two meanings of the phrase “risk management” — the prudential risk management of the insurer, and the clinical/medicolegal risk-management services they offer those who are insured — became blurred. The article by Wenck and Johnston highlights the similarities and differences between these two forms of risk management. Prudential risk management can have perverse effects on clinical practice. For example, from around 1990, the MDOs moved away from “mutual” subscriptions (all doctors paid the same) to “differential” subscriptions (higher-risk disciplines paid higher rates). One result was that general practitioner and specialist obstetricians who practised low-volume obstetrics found a powerful reason to cease midwifery: the extra cost of obstetric indemnity far exceeded the income they derived from obstetric work. There were other factors as well, but the number of doctors for whose obstetric services rebates were claimed through Medicare dropped by 29% between 1989 and 1995.5 The sudden spate of claims arising from the use of the implantable contraceptive Implanon saw the MDOs respond in different ways. Prudentially, they needed to ensure that Implanon claims were properly funded. Clinically, they wanted to reduce the number of such claims by encouraging safe use. Some MDOs chose to maintain the status quo — perhaps relying on media reports either to deter doctors from using Implanon or to ensure they reviewed their clinical techniques. Other MDOs, such as MDA National and UMP, moved coverage for matters arising from Implanon use into the more costly “procedural general practice” category of insurance. The latter approach would predictably lead to most non-procedural GPs stopping use of Implanon in their clinical practice. Who would pay up to $10 000 more per year for insurance to cover a procedure they might perform 20–30 times a year for a fee of less than $30 per service? A third approach was adopted by the Medical Defence Association of Victoria (MDAV) in July 2003,6 demonstrating that risk management by an MDO can be vigorous without perversely affecting clinical services. GPs who used Implanon were advised that they might be asked to pay an excess of $5000 if they were unable to demonstrate adequate training and technique should an Implanon claim be brought against them. There was no fixed economic deterrent to using Implanon, but there was an incentive to “risk manage” clinically to avoid the $5000 excess. After monitoring claims in the ensuing period, MDAV announced in May 2004 that the excess would no longer be applied.7 Similarly, United Medical Protection announced on 21 May 2004 that Implanon insertion would revert to being covered in the non-procedural general practice category of insurance, but with ongoing conditions. To quote from UMP’s media release: It will be a condition of cover that members agree to adhere to risk management guidelines based upon the RACGP’s [Royal Australian College of General Practitioners’] guidelines . . . Members using Implanon will be required to undergo a training session in patient selection and counseling and Implanon insertion and removal techniques arranged by the manufacturer Organon. In addition, members will need to perform the first six insertions under the supervision of a medical practitioner experienced in Implanon insertion.8 MDA National had earlier announced, on 25 February 2004, that, with effect from the insurance year commencing 1 July 2004, Implanon cover would be available again in the non-procedural category — subject to adherence to risk-management guidelines.9 Some MDOs now offer premium discounts to members who satisfy specified standards for risk management in their practices or attend risk-management educational seminars and similar activities. I recently reviewed well over a thousand of the applications for MDAV’s RISQ (Risk Identification for Sustaining Quality) program. Some applicants supported the program strongly, saying the application process stimulated a major review of their practice’s policies. Others thought the discount was not worth the time required to complete the application. In my opinion, this latter group missed the point. The premium discount is a relatively minor immediate incentive when compared with the ameliorative effect that effective risk management may have on claims frequency, and hence the potential impact on their future premiums. Further, one member made another, poignant point: I know this is a very worthwhile exercise, but it’s had the effect of making me view every patient as a potential plaintiff. While his comment strikes an empathic chord, he also missed the point. Medical practice requires quality assurance and risk management. It also requires organisational governance — management of personnel, financial efficiency, systems efficiency, and so on — as much as clinical governance. All the various components of practice governance need to be managed. Focusing on any one component to the detriment of the others leads to a mismanaged practice. It is not a choice between risk management or quality assurance, we need both — less error is part of better quality. Saxe’s poem about the blind men and the elephant is apposite.10 Six blind men argue vigorously about the nature of the beast of which each is holding one part — the tusk, the trunk, an ear, a leg, and so on. The poem concludes: So oft in theologic wars, The disputants, I ween, Rail on in utter ignorance Of what each other mean, And prate about an Elephant Not one of them has seen! The elephant is clinical governance (continuous quality improvement). It has many parts. All must be subject to equal focus.

Paul Nisselle AM, FRACGP

Objective: To examine changes between 1991 and 2003 in the characteristics of active recognised general practitioners in Australia.Design: We compared self-reported GP characteristics from the 1990–91 Australian Morbidity and Treatment Survey (AMTS) with those from the 1999 and 2003 Bettering the Evaluation and Care of Health (BEACH) surveys, after standardisation for age and sex to the respective sample frames. AMTS and BEACH are cross-sectional, paper-based, national surveys.Participants: Three random samples of 473 (1990–91), 980 (1998–99) and 1008 (2002–03) GPs who had claimed at least 1500 A1 (ie, general practice) Medicare items in the preceding year (in the AMTS) or 375 general practice Medicare items in the preceding 3 months (in the BEACH surveys).Main outcome measures: Changes in distribution of GP sex, GP age, number of sessions per week, practice size and location, country of graduation, and postgraduate training.Results: Between 1991 and 2003, the proportion of female GPs rose from 19.3% to 35.2%; GPs aged < 35 years dropped from 22.3% to 10.0%, and those aged ≥ 55 years increased from 21.4% to 31.6%. Between 1999 and 2003, the proportion of male GPs working < 6 sessions/week increased from 6.1% to 11.4%, while the proportion working ≥ 11 sessions/week fell from 23.8% to 17.1%. Between 1991 and 2003, the proportion of solo practitioners nearly halved (25.5% v 13.7%); the proportion of GPs in practices of ≥ 4 partners increased from 34.3% to 59.8%; the proportion of Australian graduates fell from 81.4% to 72.2%; and the proportion of graduates from Asia and Africa increased. Over the same period, the proportion of GPs with Fellowship of the Royal Australian College of General Practitioners more than doubled (17.8% v 36.4%). All of these differences were statistically significant (P < 0.001).Conclusion: Changes in characteristics of the practising GP population will affect consultative services and the balance between supply and demand for these services. These changes should be considered in future workforce planning.

Janice Charles BA, MSc(Med) · Helena Britt BA, PhD · Lisa Valenti BEc

Objective: To evaluate whether rural consumer preferences for health services have changed over time or vary across communities with different models of health service delivery.Design: Questionnaire survey replicating a 1989 study, with ranking of seven different healthcare services.Participants and setting: Adult occupants from a 20% sample of private residences, in towns and on farms, in the rural shires of Bogan and Warren in north-west New South Wales. The survey was conducted in September 2002.Main outcome measures: Rank order of preferences for different healthcare services; preference structure intervals showing relative “distance” between preferences.Results: Response rates were 68% (Nyngan town), 78% (Nyngan farms) and 59% (Warren town). The doctor was the most valued health service in rural communities, followed by the hospital. These preferences occurred regardless of age, sex or place of residence, persisted over time, and were similar for residents of towns with different models of healthcare service provision.Conclusions: Rural people, both in towns and on farms, rate acute primary healthcare services provided by the doctor and hospital as the two most important services. These preferences have not changed substantially after a decade of restructuring rural health services and reorienting them towards a primary healthcare approach. The stability of rural consumer preferences may reflect a bias towards the status quo.

Karly B Smith BA(Hons) · John S Humphreys BA(Hons), PhD · Yuliya Lenard BEd · Judith A Jones BA(Hons), MSPD · Vanessa Prince B Public Health · Gil Soo Han MA(Soc), MA(Hons), PhD

We need evidence that can underpin fundamental change General practice and the rest of the primary care team, rather than specialist or hospital care, deliver the lion’s share (90%) of healthcare.1 They also provide the anticipatory care necessary for early and better management of the chronic diseases that characterise modern industrial societies. A strong, self-reliant primary care workforce increases quality as well as cost-effectiveness.2 Thus, the way a country remunerates its primary care workforce is vital. This is a good time to debate the options in Australia — a federal election year in which healthcare is likely to be a central issue. Changes to the administrative system can have enormous implications for primary care. So far, planned changes in Australia have been tentative, consisting of “add-on” improvements such as payments to general practitioners (GPs) in addition to the traditional fee-for-service arrangements. These include Practice Incentive Payments (PIPs), which pay GPs who can demonstrate using set protocols for managing some chronic diseases (eg, asthma, diabetes), and Service Incentive Payments (SIPs), which are specific payments for certain services such as mental health care and vaccination. The complexity of administering these programs has prompted complaints from GPs, and in response a Red Tape Task Force has been convened.3 Healthcare systems differ hugely from country to country, as we see from the articles that follow. Reimbursement is perhaps its most emotionally highly charged aspect and, however contentious an issue, some system has to be chosen. Strong primary-healthcare-led systems like those in the United Kingdom4 (page 109) and The Netherlands5 (page 110) use capitation systems as the basis of paying GPs: they contract to assume the obligation to provide care for a group of patients, and their financial rewards are independent of the actual service and care delivered. In the former Yugoslavia, with its socialist origins, remuneration took the form of a salary, accompanied by planning (and restriction in the number) of GPs. A more market-driven way of paying GPs is for GPs to “deliver” before payment (fee-for-service), and in competition with each other, as in Australia and the United States (page 113).6 Canada (page 111) has opted for a combination of methods,7 and New Zealand (page 106) is experimenting with a variety of interesting models in quick succession.8 Fee-for-serviceFinancial incentives have a direct influence on GPs’ behaviour. For example, in Belgium, 46% of GP–patient encounters are home visits,9 whereas in The Netherlands this is only a small proportion of GPs’ clinical activities. The population health status and infrastructures of the two countries hardly differ, so the difference can only be explained by incentives: under Belgian fee-for-service, a home visit is chargeable. It also strengthens patient satisfaction with the GP in a competitive environment. On the other hand, the Dutch GP receives a capitation fee irrespective of whether the patient is seen at home or at the practice (or not at all). One problem with fee-for-service payment is that the way GPs are funded is confounded by other innovations that Australia should be considering, such as patient registration. Although theoretically this could be separated from how doctors are paid (capitation, for example), nowhere does this occur. A second problem is that fee-for-service can be inflexible about who is remunerated. This has held back the proper utilisation of nursing in general practice in Australia simply because nearly all services in general practice are ineligible for a Medicare rebate if provided by nurses, even though for many services (eg, preventive10 or protocol-driven chronic care11) nurses may be better suited. A third problem is the need for a business mind with fee-for-service general practice. Many doctors want to practise unencumbered by a “small shopkeeper” role. One consequence was the evolution in the 1980s of “entrepreneurial practices” (those whose owners were more interested in making a profit than serving their communities). These offered greater flexibility for the increasing numbers of doctors who, wanting “just to practise medicine” and happy to abdicate their commercial role, flocked there. “Perverse incentives” reward some clinical activities better than more valuable ones.12 For example, a GP who delivers many short consultations will earn more than one who has fewer and longer consultations — even though longer consultations are associated with better attention to preventive healthcare and psychosocial problems.13 Attempts to address this by providing less reliance on fee-for-service (to the fury of the Australian Medical Association)14 with additional alternative payment systems (so-called blended payments) such as PIPs and SIPs — funded by what might have otherwise gone to increased fees — are probably only partly successful. It is too early to tell if the complexity of administering them is any better than the fee restrictions that arose to discourage entrepreneurial practices. Do we need more fundamental reforms of the GP system? What are the alternatives? CapitationCapitation payment and its associated patient registration (the “list”) feels like clinical freedom for many GPs in the UK and The Netherlands: the GP accepts an obligation to provide care for the patients on the list and do what is in their best interests. It has offered GPs a level platform to counter medicalisation, overdiagnosis, over-referral and spurious prescribing, without the tilt of having to please the patient (something usually miscalculated in any case15). But there are disadvantages. A capitation system can be a haven for laziness, because payment comes irrespective of the quantity (let alone the quality) of care. GP-initiated activities — like anticipatory (chronic disease management) and preventive care — are particularly sensitive to this. Perhaps this is the basis for the reforms currently under way in the UK NHS.16 Disciplinary hearings against GPs in the UK and The Netherlands are, to a large degree, occupied with GP failure to provide enough care — in particular, failure to visit patients in a (perceived) emergency at home. In Australia, the focus of disciplinary hearings is on overservicing. The issue for capitation systems is deciding what is enough care; for fee-for-service, deciding what is too much. The solutionBlended payments (a mixture of fee-for-service and payments for good practice) sound sensible (the best of both worlds), but there is little evidence17 to reassure us we might not get the worst of both: entrepreneurial GPs learning which mix of activities yields the highest earnings, and government reacting by over-regulating the system to avoid this. GPs are at the forefront of evidence-based patient care. It would be good if GPs’ financing systems were established by good evidence, but little exists regarding the effects on service of different payment systems (Box). Thus, we need to trial different systems, not simply enact the latest political ideology. The current flux in the Australian healthcare system is surely an ideal environment for such experiments. Possible alternatives would be payment systems that allow for patient registration, that include the option of salaries for doctors uninterested in running a business, and that encourage doctors to collect and analyse clinical data about the services they provide. There is no doubt that such trials would be hard to conduct politically,17 and perhaps randomised controlled trials would have to give way to the pragmatics of quasi-experiments. But we need changes to the system that are fundamental, rather than the lean-to sheds propping Australia’s current archaic system. The evidence base for different primary care payment systems The best evidence comes from a Cochrane review.18 This is in need of update (last search date was 1997). The review compared four payment systems (fee-for-service, salary, capitation, and mixed), and accepted studies that were randomised controlled trials (RCTs) or controlled before–after (CBA) studies if there were at least two measurements before and two after the intervention (nine studies were excluded for failing this test). Two RCTs (total of 98 doctors) and two CBAs (216 doctors) were included: all had potential biases in their methods. Compared with capitation, fee-for-service was associated with more services, tests and referrals to specialists, but fewer referrals to hospital. Compared with salaried payment, fee-for-service was associated with more services and more continuity of care, but less patient satisfaction with access to care. A more recent narrative review (conducted at an international conference on the subject) reached the same conclusions.19

Chris Van Weel PhD, FRCGP · Chris B Del Mar MD, FRACGP

How general practice is funded in New Zealand depends upon an answer to the question “This week or next?”! General practice, and primary healthcare generally, is currently undergoing a revolution greater than anything since the early 1940s, when government funding of general practitioners was introduced. GPs then successfully argued for the “sacred” right to charge a fee commensurate with their services, making them unique compared with similar countries, including Australia. Substantial patient copayments resulted, rising at times to more than 80% of practice income. In the early 1990s, the government introduced a “community services card” (CSC) for people on below-average incomes. Currently, the threshold for this is NZ$21 913 for a single person and NZ$31 225 for a married couple, and rises with number of children. The CSC entitles holders to higher subsidies, including for prescriptions, but the quid pro quo was the removal of all government subsidies for adults on above-average incomes, including the elderly. However, the government proportion of GP funding remained low, averaging about 30% of practice income.1 With this underfunding, many GPs became Robin Hoods, charging minimal or no fees to patients who could not afford to pay, with some compensation from their well-off patients. Many (understandably) located themselves in more affluent areas.1 Hence, central Aucklanders have 800–900 population per GP, whereas more disadvantaged populations have almost twice as many people per GP.2 Of course, the Robin Hood system did not work for practices serving predominantly poorer and disadvantaged (including rural, Mäori and Pacific Islander) populations. Radical organisational reforms in 19933,4 encouraged GP leaders to voluntarily form independent practitioner associations. Similar to Australian Divisions of General Practice, these primary care organisations (PCOs) rapidly expanded to include 85% of GPs by the end of the 1990s. PCOs took on the financial management of pharmaceutical and pathology services to improve quality use.1,3-5 Savings from this were used to promote other services, such as vaccination, smoking-cessation programs, chronic disease management and terminal-care services. They were also used to remunerate GPs and associated services (eg, free nursing and radiology services for community-based alternatives to hospital admission). This was never called fundholding, the term for a scheme implemented, then abandoned, in the United Kingdom. The real revolution began in 2000, with the New Zealand Public Health and Disability Act. This established 21 decentralised and population-based district health boards (DHBs) providing public hospital services and managing government funding of all health and disability services, including primary healthcare. In 2001, a new government primary healthcare strategy launched the evolution of PCOs into broader primary health organisations (PHOs).6 These are needs funded and serve defined populations enrolled in member GP practices. They provide population healthcare as well as treatment services, involve communities in their governance, and are multidisciplinary. GP membership is voluntary. This strategy is supported by the New Zealand Medical Association and the Royal New Zealand College of General Practitioners, but there is ongoing criticism over the implementation process. Two forms of PHOs have been established, the first (Access PHOs) serving disadvantaged populations. The remainder are called Interim PHOs, in the expectation that Access funding will eventually apply to all PHOs. An alternative strategy, Care Plus, is being launched to fund the needs of individual high users. The different levels of funding are shown in Box 1. Disadvantages of the current systemThe additional funding still covers less than half of the cost of running a general practice. More has been promised after 2005 by the Health Minister, “subject to the availability of funding”. A particular issue is the inequity between the two forms of PHOs, with funding being based upon the level of disadvantage of the enrolled population rather than individual need. Hence, poorer patients in Interim PHOs remain disadvantaged. The Care Plus strategy is an attempt to rectify this. From late 2004, PHOs will be required to manage equitably funded budgets for pharmaceutical and pathology services, commonly called “referred services”,7 in a more formal process than PCOs used. There is clear evidence of serious inequities in current referred-services expenditure.2 This will mean significant shifts of expenditure from practices, PHOs and DHBs serving well-off populations to those below equity, but the funding distribution may be vital to improving the health of the disadvantaged. Relevance to AustraliaIs this relevant to the future of Australian general practice? Almost certainly, given the recommendations of the 2003 Review of Divisions.8 A comparison of primary care in both countries (Box 2) suggests that New Zealand is some 10 years ahead,9 with a more integrated and influential primary healthcare service. Although the organisational upheavals and additional paperwork have been traumatic for many GPs, the prospects of improved care and better outcomes for patients and communities, while yet to be proven, appear to be good. 1 General practice funding in New Zealand, by type of organisation to which GPs belong Non-PHO organisation and individual GPs Access PHOs serving high-need patients Interim PHOs serving other populations Current and expected GP membership 20%–25%, diminishing rapidly 20%–25%, increasing 50%–55%, increasing Current government subsidy for GP (includes practice nurse at $1.70 per consultation) Fee-for-service claims $0–$35 Capitation payments for enrolled population Average $13 per consultation Average $24 per consultation Average $15 per consultation ACC subsidy per consultation* $2.00 $2.00 $2.00 Patient copayment† $0–$45 $0–$20 $0–$45, and reducing Special funding groups Extra funding for low-income and high-need patients Aged under 6 years, $35 per consultation; aged 6–17 years and high users, and (from 1 July) aged over 65 years, $26 per consultation Expected subsidy trends over next few years Expected to diminish to insignificance over next year All to be based on Access formula To become equivalent to Access PHOs over time ACC = Accident Compensation Corporation. PHO = primary health organisation. * ACC funding for treatment of injuries is paid as fee for service, averaging $2 per consultation, or $30 for all consultations. † Patient copayment is paid as fee for service. 2 Features of New Zealand primary health organisations contrasted with Australian Divisions of General Practice Feature Australia New Zealand Organisation Divisions of General Practice Variable, but primary care organisations forming into PHOs Roles Largely GP focused Broad primary health/population focus, multidisciplinary, strong community participation Membership of organisation Based on geographic location Chosen by practice from local options Health services funding Fragmented between federal and state levels Fully integrated through district health boards Government payment/subsidy for services Open-ended fee for service. AMA strongly opposes capitation Rapid progress towards universal capitation Patient copayment Small but increasing Large but decreasing Organisational accountability for primary-care-related expenditure (eg pharmaceuticals) No direct financial accountability and resisted by AMA Well accepted. Expenditure to be in PHO budgets Ability to shift resources (including savings) from low- to high-priority services Nil. No referred-services budgets and hence no incentives or ability to make savings Substantial. Expected to increase with global budgets for PHOs Models of service integration, including primary/secondary Limited to selected high-risk diseases and local initiatives Wide-ranging developments (eg, community alternatives to acute hospital admission) Relative power balance between primary and secondary care Hospitals in a much stronger position than primary care Improving balance through government policy and DHB and PHO collaboration Quality improvements in primary care Largely “top down” and through local initiatives Major improvements driven by clinical leadership AMA = Australian Medical Association. DHB = District health board. PHO = Primary health organisation.

Laurence A Malcolm MD, FRCPE, FFPHM

The National Health Service (NHS) has undergone fundamental reform since 1948, but the fabric of UK general practice remains more or less intact. Fundholding was probably the most significant change in financial arrangements (Box). Essentially, this was an experiment for the NHS to contain costs, stimulate competition and bring resource allocation decisions closer to the patient — fundholding general practitioners assumed significant roles in local healthcare economies. Nevertheless, there was much debate over whether it was equitable. Many saw it as a basis for partnerships with the private sector and fragmentation of the healthcare service.1 Others showed that it reduced non-emergency medical admissions.2 Fundholding grew from the Thatcher government’s strongly held belief that markets are the best way to achieve efficiency in healthcare. At the same time, fundholding established general practice as the cornerstone of the NHS.3 Further, it brought a questioning of the “status quo” in the NHS, and the prospect of higher standards of care. These expectations remain in the eyes of the public, government and the profession. Reforms aside, under “standard” contracts, UK general practitioners have been rewarded for increasing patient list size, and for providing specific services to achieve target payments. Unlike in Australia, there is no incentive to overservice, but an incentive to limit the availability of appointments, and pressure to keep appointment times to a minimum. Interestingly, salaried GPs in the personal medical services pilots (Box) have similar productivity without affecting other GP behaviours or quality of care.4 The new contractThe new GP contract, operative from April 2004, brings more funding, fundamental structural change, greater regulation and performance monitoring. There are concerns that many of the quality targets (eg, the incentive to diagnose, investigate and treat hypertension) have not been adequately costed.5 Further, this new environment has a strong emphasis on performance management and holding doctors to account. Some people see this as an erosion of public trust in the medical profession, which could undermine doctor–patient relationships; others see it as an essential mechanism of delivering proven, cost-effective care. For patients, NHS general practice is well integrated with the wider health service, and gives access to a multidisciplinary primary care team, including health visitors and practice nurses. On the downside, a non-competitive system means there are not the same incentives to attract patients as exist in Australia’s fee-for-service environment, and there is a culture of demand management, which often takes precedence over making services attractive and convenient to patients. In many ways, the NHS places GPs at the centre of the healthcare service and gives one a sense of being part of a team, with less of the fragmentation and isolation that often exists in Australian general practice. Whether the new GP contract will improve experiences and outcomes for patients, at a cost the NHS can afford, remains to be seen. On the downside, many GPs believe the wider healthcare service has not been able to accommodate the needs of patients in recent years; this may, despite the best efforts of individual primary care teams, lead to a demoralised workforce. Towards the end of New Labour’s second term, the NHS is being pulled in several directions — involving performance management, quality payments, new contracts, and greater engagement with the private sector, including American managed care organisations. The competition and “constructive dissonance” of these changes is very reminiscent of the Thatcher reforms. How general practice will fare in this turbulent environment is unpredictable, but no doubt being a GP or a patient in the NHS will be a very different experience in 2010. How it works Most UK general practitioners are independent contractors with the National Health Service. They own their own premises, hire their own staff, and supply general medical services. Remuneration is based mainly on capitation (ie, a payment dependent upon list size), supplemented by fees for certain specific services (eg, maternity care) and for achieving certain “target” levels of service (a complex system, although it only involves childhood vaccination and cervical cytology). Payments are also made for seniority and postgraduate education activities. Alternatives: the NHS (Primary Care) Act of 1997 allowed GPs to provide “personal medical services” (PMS) on a salaried basis through local service contracts that are designed to meet the particular needs of the locality. More than 35% of GPs are now salaried. Fundholding was a system of general practice purchasing services from secondary care. It operated between 1991 and 1999. Fundholding practices were given greater autonomy over aspects of practice expenditure such as drugs, diagnostic testing and staffing (within defined budgets), and could “shop around” for the best deal on procedures such as hip replacement. A further initiative, “total purchasing”, allowed practices to purchase a wider range of services from both primary and secondary care — for example, community nursing. Primary care trusts were established in 1997 (they began as primary care groups; in England, these became trusts in 2002, but have taken different forms in Scotland, Wales and Northern Ireland). Individual practices were replaced as purchasers by regional organisations, which could assess and plan for local needs. A new GP contract took effect in April 2004, with GP payments more closely linked to “quality targets” for both clinical and organisational activity. This has been coupled with increased funding and structural change — for example, GPs are no longer obliged to provide out-of-hours services, and the contract is with whole practices rather than individual GPs.

David P Weller FRACGP, MPH, PhD · Alan Maynard DSc, FAMS, MFPHM

The strength of Dutch healthcare is that the general practitioner’s role is enshrined in the primary care structure and the personal listing of patients (Box).1,2 Primary care is delivered through a personal working relationship with the patient over time and the payment system reinforces this to some extent. Capitation fee payment encourages delivery of care that is tailored to individual needs, rewarding powerful primary care strategies such as “watchful waiting” and the follow-up of the natural course of signs and symptoms.3 It takes considerations of financial reward out of the consultation. The profession of general practice considers the capitation fee payment as the prevailing frame of reference on which professional standards of care are based. Healthcare policymakers’ attempts to change capitation payment are usually resisted by the profession. Although private insurance and fee-for-service might theoretically invoke different professional behaviour, in practice there are few differences in the care received by privately insured patients and that received by those who are Sickfund-insured. In general, GPs do not like fee-for-service payment, because it does not acknowledge strategies such as “masterly inactivity”.3 Over the years, Dutch GPs have been jealously protecting capitation payment and tried to exclude any financial biases that might affect their performance. Allowances in the actual money received have been made for the number of elderly and migrants on the practice list, compensating for the extra burden of illness and GP care needed. This has maintained relatively equal status among Dutch practices and helped to strengthen the corporate identity of GPs. The most recent proposal by the Minister of Health to change healthcare financing aims to introduce a form of patient copayment for healthcare received, at 25% of GP costs for consultations, and more for secondary care. The objective is to encourage patients to take more responsibility for their own health and consult less often. This proposal is still in its early stage of political decision making, and it remains to be seen if it will be introduced. If it is, it will be interesting to see whether this financial approach rewards valued primary care approaches such as watchful waiting. An alternative form of payment that has developed in recent years is GPs in the salaried service of colleague GPs. Although there has been a long tradition of locum services by young GPs before selecting a practice of their own, more GPs now seem to prefer salaried employment. This indicates dissatisfaction with the combined role of both practitioner and practice manager. As a consequence, practice has to be reorganised to make it more attractive for younger GPs, and salaried employment may become more prominent. Disadvantages of the systemThe trend towards salaried GPs highlights an obvious disadvantage of capitation fee payment, which covers practice costs and GPs’ income at the same time, without conditions attached. For example, the fee covers a full-time-equivalent practice assistant for a standard practice, irrespective of actual hours of employment. Thus, general practice was poorly prepared for the rapid increase in female GPs, who prefer part-time, salaried positions to full-time, private contractor status. The need for general practice to accommodate this change, together with the additional resources needed to train more part-time GPs, is one of the factors leading to increased GP costs. Another disadvantage is that new developments in medicine have to be included in the package covered by the capitation fee. As a consequence, there are few (financial) incentives for GPs and practices to innovate their care. This has particularly affected proactive aspects of care such as illness prevention and high risk screening, and investment in practice support (such as practice assistants and nurses; providing technical equipment). The package of care that the capitation fee should cover is critical. This should be based on the effectiveness of diagnostic and therapeutic interventions. In reality, the package has to flow with the political and economic tides. For a long time, the level of the capitation fee was fixed, irrespective of the patient’s health status. In recent years, the fee has been increased for certain groups (eg, the elderly), becoming an indirect incentive to provide more proactive services (such as preventive home visits) for these groups. However, this is as far as the system has come in enhancing the capitation principle with financial stimuli. ConclusionGiven the lack of financial incentives, it is surprising how strong general practice care is. For a long time, hospital specialists were paid on an item-for-service basis, in conjunction with GPs’ capitation fee. Yet, although this payment system did reward the transfer of patients to secondary care, rates of GP prescribing and referral in The Netherlands were among the lowest internationally.1,4 Furthermore, more than 80% of Dutch practices are computerised in the absence of direct financial support.5 This may indicate that the payment system is not the sole determinant of GP performance, and that corporate identity and healthcare structure may also play a vital role. How it works General practitioner payment is based on a two-tiered system depending on patients’ income: Capitation fee for Sickfund-insured patients (70% lowest income; in 2004, up to €32 600/year for people younger than 65 years. As the insurance includes the period after retirement (“pensioners”), the cut-off income for people 65 years and older is €20 750/year. Fee-for-service payment by the 30% highest-income privately insured patients, who do not contribute to the Sickfund. Capitation fee is the payment a GP receives from the Sickfund for each patient on the practice list, regardless of whether the patient decides to consult the GP. Sickfunds pay the capitation fee out of the insurance contribution received from their insured members. This fee fully covers all GP services for that patient, including the GP’s income and a proportionate contribution for practice costs. The capitation fee is extended to family members who do not generate income of their own. Employee and employer pay 8% of the income for Sickfund contribution (1.25% by the employee, 6.75% by the employer). There is no direct government involvement. Key to access to general practice care is registration of the patient with the GP or practice, establishing continuity of care over time. For Sickfund-insured patients, registration is obligatory for access to care. For privately insured patients, registration is usually not required, but most patients do list with a practice and obtain care from the same GP or practice over time. Through registration with a GP, primary care remains the foundation of healthcare: patients receive their basic medical care through the GP and the primary care team, and specialist care is only available through referral by the GP.

Chris Van Weel PhD, FRCGP

Family physicians (FPs) in Canada undergo specialised training, often in a Family Medicine Residency, and complete the College of Family Physicians of Canada (CFPC) national certification examination. Their payment is negotiated and administered separately by the 10 provincial governments and three territorial governments, using different funding arrangements in different settings. Under the Canada Health Act, provinces will be financially penalised if they permit private billing by physicians or copayments by provincially insured patients other than for certain services funded by third parties, such as insurance medical examinations, reports and travel services. In 2001, FPs reported practising in private offices/clinics (73.1%), community health centres (7.1%), emergency departments (6.7%), hospital in-patient units (3.3%), walk-in clinics (3.1%), and family medicine teaching units (2.5%).1 National surveys confirm that fee-for-service continues to be the main form of remuneration for physician services (Box), with little apparent change between 1997 and 2001.1 The drive towards alternative payment methodsUnder the current healthcare system, 12% of Canadians (with considerable geographical variation) report having unmet healthcare needs.2 Millions do not have access to an FP, and emergency department waiting times are long. FPs have identified high levels of dissatisfaction with current workloads and working conditions.1 Governments appear to believe that alternative funding arrangements will address these problems and are the key to involving FPs in primary healthcare reforms.2,3 Alternative payment approaches combine fee-for-service, capitation (lump sum payment per patient managed over a given period), salary, sessional and other funding arrangements.4 Other, less common funding arrangements include block funding and service agreements. In block funding, annual budgets are negotiated for a group of physicians, usually associated with an academic medical centre. Service agreements are often used to recruit and retain physicians in rural areas and take the form of: funding to regional boards for clinical services under arrangements by which boards have discretion regarding specific uses of the funds; contractual payments; and payment arrangements that incorporate both alternative remuneration and fee-for-service. Both the Canadian Medical Association and the CFPC advocate that all FPs should be able to choose the practice model that best meets their patients’, their co-workers’ and their own needs.5 In Canada’s largest province, Ontario, both the Ontario College of Family Physicians and the Ontario Medical Association (OMA) support FPs working in practice networks (Family Health Networks) funded through a blended payment model (which combines different methods), but recommend physicians have a choice. The remuneration model for Family Health Networks (FHN) preferred by the Ontario Ministry of Health is based on: a capitated rate for all registered patients; fee-for-service payments at a rate of 10% of the provincial schedule for most services; bonuses for targeted preventive care (theoretically up to C$8800/FP); payment for taking new patients; continuing medical education allowances; practice management fees; and some access to nurse practitioners paid by the government. This model encompasses on-call arrangements 24 hours a day, 7 days a week, and evening and weekend clinic access. Working in such networks with blended capitation payment is thought to provide incentives for promoting preventive healthcare and chronic disease management, and to improve professional satisfaction.1 However, uptake of the FHN model has been slow, prompting the Ontario government, in conjunction with the OMA, to introduce a simpler model, the Family Health Group. This model, based on virtual patient populations (either from the ministry health insurance database or patient registration), is paid on a fee-for-service model, with requirements to provide on-call arrangements 24 hours a day, 7 days a week, and after-hours clinic access. The Primary Health Care Transition Fund3 policy to shift physicians to a blended capitation model aims to improve access to care, quality, integration, health outcomes and cost-effectiveness. There is a strong desire that the most appropriate (least expensive) person deliver the service to the patient, invoking passionate debate about whether this means substituting for or supplementing FPs. The current policy position is that a collaboration of FPs with nurse practitioners, pharmacists and other professionals is more feasible with blended and capitation models than with the current fee-for-service arrangements. However, it is yet to be seen if blended payments and new models, with their additional administrative burdens on the FP and the practice, will add costs to the healthcare payer or improve health outcomes. Remuneration* among Canadian family physicians, 20011 Physicians receiving remuneration type† Mean (SD) proportion of total income accounted for by remuneration type Fee-for-service 23 070 (90.8%) 85.4% (24.9) Salary 3 775 (15.0%) 50.5% (37.4) Sessional 8 171 (32.5%) 35.0% (33.7) Capitation 469 (1.9%) 69.9% (31.0) Other 4 567 (18.2%) 14.1% (20.9) * Remuneration for clinical services other than on-call services. Based on a census survey of Canadian family doctors (n = 13 088) weighted to estimate the total population of Canadian family doctors. † The combined percentage may exceed 100% as some respondents checked off more than one answer.

Carmel M Martin PhD, MSc, FRACGP · William E Hogg MD, MClSc, FCFP

Underperformance of the healthcare system at great expense is the situation in the United States. The results are great inequity, problems with access, missed opportunities for prevention, fragmented rather than integrated care, relatively poor chronic disease care, and high expenses without commensurate improvements in health as compared with what would be expected from a well-functioning primary care system.1 Indeed, “. . . the need to manage escalating health care costs while maintaining reasonable access to care is becoming the salient challenge in US health care policy”.2 The diversity of healthcare arrangements in the US precludes a single, reliable answer as to how family physicians are paid. However, using national reports,3 including surveys done by the American Academy of Family Physicians,4 a generally accurate idea of “how it works” in the United States can be derived (Box). It is stunning how much is spent to accomplish occasionally spectacular results for some, but overall so little, for so few. Family physicians are not satisfied with the results of current payment arrangements in the US, as they undervalue family medicine and primary care in general; too often family physicians are unable to provide the care they think their patients need.5 Through research and deliberations by their national organisations, family physicians have concluded that, without significant changes in both the way they practise and the way family medicine is financed, family medicine in the US will probably become untenable in 10–20 years.6 In aggregate, the current payment systems are believed to contribute to a deterioration of primary care, with market forces rewarding commodity production and use of technology, while punishing sustaining relationships, listening to people, and sorting out and responding to troubles that may or may not be amenable to technological medical care. The solutionsFee-for-service payments alone are not sufficient, as this approach rewards doing more, not necessarily doing best. Capitation is no panacea, because it is subject to rewarding underservicing and may deter care for the sickest patients unless payments are adjusted for greater need. Paying for performance (outcomes) is intuitively attractive, but subject to factors well beyond the control of individual clinicians, or even, in many instances, an entire practice. A system of payment that blends these different approaches to capture their respective strengths while minimising their weaknesses is conceptually attractive, but difficult to define and implement. Such a blended system would presumably be based on capitation adjusted for population characteristics, additional premium payments based on services provided, and incentives based on achieving particular policy objectives.6 Currently, in the US, calls for a new model of family medicine, with a robust “basket” of services and the intelligence and performance attainable through information technology, have created an urgent sense that payment reform is necessary. A classic “chicken-and-egg” problem exists — the new model is not feasible until there is payment reform, and payment reform is not realistic without demonstrated improvements inherent in the fully implemented new model. Fortunately, both public and private payers recognise that steps need to be taken to assure entry to timely healthcare, health promotion, disease prevention, and care of chronic conditions.7-13 As a spokesperson for the US Medicare program (which provides health insurance for people aged 65 and older) noted at a recent policy forum in Washington, DC: “With very little friction, we will probably approve expenditures in the billions of dollars for biventricular pacing, yet we still don’t know how to pay for someone to have their own doctor.”14 A task force chartered by the Future of Family Medicine collaborative project is now at work, estimating the full cost of the proposed new model of family medicine and the amount and sources of revenues necessary to cover its cost and leave a margin sufficient to pay family physicians fairly and competitively. As concluded at the Keystone III Conference in 2000, family medicine in the US needs to spend less time justifying itself and more time acquiring the practical means to achieve its objectives.15 Indeed, another time to revise family medicine in the US is at hand — this begs for reform in how family physicians are paid. How it works (or not!) * Based on 35 965 respondents to American Academy of Family Physicians Survey.4 † Medicare is a federally funded national insurance program for people ≥ 65 years. ‡ Medicaid is a state-based insurance program (with federal and state funding) for people on low incomes. § Based on 32 321 respondents to American Academy of Family Physicians Survey.4

Larry A Green MD

Reducing error is an ongoing process, always in need of fine-tuning A crucial challenge in efforts to prevent or reduce the occurrence of medical error is obtaining information about the diverse types of medical mishaps. “Mishap” is a useful term — it is neutral and broad enough to encompass the wide range of things that can go wrong in clinical practice. The types of medical mishaps include the “near-miss”, the “incorrect procedure or treatment which does not harm the patient”, the “adverse event” (either anticipated or unanticipated), and, finally, the “sentinel event” (a blatant error, such as a blood transfusion error). All these forms of mishap have the potential to provide important information to help minimise or prevent patient harm and enhance standards of medical practice. The need for a flow of information far outweighs fingerpointing There are arguments about the definitions of medical error, and my assertion — that lessons can be learned from all forms of medical mishap — deliberately cuts a broad swath. Close examination of each of these types of mishap provides different learning opportunities. Near-misses, or errors that cause no harm, can trigger a re-evaluation of correct procedures to prevent these events; Adverse events, both “anticipated” and “unanticipated”, can help clinicians develop more rigorous thinking about evidence and standards; and Sentinel events can show how the protective systems put in place can be breached. Collecting extensive information in all these mishap categories not only leads to interventions to minimise and prevent harm, but also allows detection of patterns of error. For example, if an inordinate number of errors occur during night shifts, or when the change of shift occurs, organisational changes may be required. Information about mishaps also provides material for teaching medical students, residents and community practitioners, with the aim of preventing future errors. If the information prevents errors then there will be impressive cost savings for hospitals and healthcare systems, as well as for patients and their families.1 Finally, information about errors and patterns of errors forearms clinicians to avoid patient injury, thus reducing the stress involved in suspecting or knowing their actions may have caused harm. But there remains an ongoing impediment: can healthcare data systems provide timely information for risk management and reducing medical mishaps? In the book Medical mishaps. Pieces of the puzzle contributors from several countries identified “multiple overlapping and faulty mechanisms for the revelation, investigation and mitigation of errors”. There was “clearly considerable scope for greater collaboration, integration and coordination”.2 And the situation in Australia appears to be no exception. One of the key priorities of the Australian Council for Safety and Quality in Health Care (ACSQHC) is enhancing processes for measuring local quality improvement and aggregate-level reporting of performance and outcomes.3 A report in this issue of the Journal by Kingston and colleagues (page 36)4 explores the attitudes of the two main health-professional protagonists involved in reporting medical error. It analyses the differential use of incident reporting by doctors and nurses, and attributes this to the different cultures of the two professions. This finding has been well substantiated. Nurses work in a culture that responds to directives, including the directive to report incidents; doctors work in a culture that values intragroup action and professional–cultural definitions of error or mistake.5 Other, systems factors also influence the decision to report incidents: time constraints, dissatisfaction with the process, inadequate feedback, and failure to value the process.5 In addition, there may be confusion about what should be reported, feelings of fear of retribution and doubts about the possibility of remediation. Finally, what are the views of healthcare consumers? In a study published in the 7 June issue of the Journal,6 a random sample of Australians supported vigorous reporting of errors, and 68% of those surveyed also wanted disclosure of the identity of the healthcare worker involved. While this is understandable, it shows the need to educate the public about the importance of a “no-blame” culture to ensure that reports will be made in the first place. The need for a flow of information far outweighs fingerpointing. Clinicians want error reduction, and favour anonymity. Patients and the public want error reduction and are likely to accept anonymity in the name of this goal. The ACSQHC supports the principle of “no blame”, and has recently published a document Open disclosure standard: a national standard for open communication in public and private hospitals, following an adverse event in health care. This provides clear guidelines for patients, healthcare professionals and organisations confronting and dealing with medical error, and the legal issues attending such events. Its major message is an open, blame-free culture.7 Despite the human and systems factors impeding reporting of medical error, many of these can be overcome by adequate incident-reporting systems. These have the following characteristics:8 they are anonymous and easy to use (computerised); they acknowledge receipt of a report and confirm that it is being investigated; they report back the results of the investigation in a timely manner; they use the information for programs of reduction; they provide feedback about successful reduction efforts; and they receive continual public support from key physicians in leadership positions. The process of error reduction involves long-term effort. There needs to be consistent and persistent emphasis on a cycle of attention to information, patterns revealed by information, error-reduction efforts, evaluation, more information and more reduction efforts. These efforts now also include producing informed patients, who are coached to ask the questions that might avoid errors. We should think about this cyclic process to reduce error as an ongoing one, always in need of fine-tuning. Its effectiveness depends on clinical leadership providing a continuing example in error reporting.

Marilynn M Rosenthal PhD

The health service reforms fuelled by whistleblowing continue In 1995, the tragedy in paediatric cardiac surgery at the Bristol Royal Infirmary, exposed by a whistleblower, ended the laissez-faire approach to patient safety, management of clinical quality and professional self-regulation in the National Health Service (NHS). Indeed, the impending impact of the Bristol case was poignantly captured by an editorial in the British Medical Journal, entitled “All changed, changed utterly”.1 Britain may not be alone in whistleblowing. In this issue of the Journal, Faunce and Bolsin report on three such recent events in Australia2 (page 44). These show an uncanny commonality with the Bristol case. What has happened in the NHS since 1995? In the immediate aftermath of Bristol, the then Health Secretary, Frank Dobson, took urgent action to place a duty of quality of care on chief executives of NHS Trusts, effectively ending any doubt about where responsibility would lie. In 1998, the new Labour government introduced two white papers, The new NHS: modern, dependable3 and A first class service: quality in the NHS.4 Although these described the regulatory framework for a quality-oriented healthcare service in England, the principles were to apply across the UK. Subsequent policy papers have added many refinements — including some 42 quasi-autonomous regulatory bodies in healthcare. These have just been pruned after criticisms of overly oppressive regulation. The following are key elements of change in England: The National Institute for Clinical Excellence (NICE) is tasked to develop evidence-based clinical guidelines and to assess and evaluate new technologies and pharmaceuticals for the NHS. Complementing the clinical guidelines, National Service Frameworks were created to map out the essential ingredients of good clinical service provision. Originally, there were three — for coronary heart disease, cancer and mental health. Paediatric care was added after the report of the Bristol Inquiry.5 However, the focal process for the delivery of clinical care is clinical governance, which is defined as “a framework through which NHS organisations are accountable for continuously improving the quality of their services and safeguarding standardised care by creating an environment in which excellence in clinical care can flourish”.3 To monitor compliance, the government established the Commission for Health Improvement, which was superseded this year by the independent Commission for Health Audit and Inspection, to regulate institutional quality in both the public and private healthcare sectors. Adding to all this bureaucracy and control are bodies with more specific functions. For example, the National Patient Safety Agency manages the reporting and analysis of “near misses”. The National Clinical Assessment Authority advises NHS Trusts and complements the work of the General Medical Council (GMC) in assessing and retraining poorly performing doctors. In addition, there is a new, overarching body for coordinating the regulators of the individual health professions — the Council for the Regulation of Health Professionals. For the citizens, the Commission for Patient and Public Involvement in Health, together with local Patients’ Forums, is to champion and promote public participation in the direction of local health services. This is a breathtaking array that even the distant observer in Australia might find daunting. For doctors, the regulatory landscape has also changed dramatically. The recent consultant and general practitioner NHS contracts increase employers’ control over the organisation of medical work, incorporate performance incentives and strengthen accountability. But it is the GMC’s proposals for doctors’ registration, training and discipline that are potentially most far reaching. The GMC changes began in 1992 with a new approach to basic medical training — Tomorrow’s doctors.6 Even more radical was the publication, in 1995, of a patient-centred code of practice, Good medical practice.7 If embedded successfully in the medical culture, the code will lead to positive changes in attitude on matters such as communication with patients and colleagues, teamwork, risk management, transparency, and whistleblowing. To strengthen compliance, the GMC tied the code directly to registration in 1998. The full effect will begin to be felt in 2005, when all UK doctors in active practice will have to have a licence to practise that must be revalidated every 5 years. Revalidation will require doctors to submit evidence of their continuing competence and performance (assessed against the template of Good Medical Practice) regularly for review. So where do things stand now? Two recent reviews of the NHS show a picture of patchy performance through clinical governance, particularly in the workplace.8,9 Data quality and some other systems issues are still a serious problem. But the central questions are about the medical and healthcare culture, and therefore medical leadership. Have the GMC and the Royal Colleges the will to see revalidation — and with it clinical governance — implemented as rigorously as required to give patients the assurances of the quality and consistency of medical care they are entitled to expect? Such questions are likely to be aired publicly again later this autumn when the Shipman Inquiry reports. All these changes raise the question: will the need for whistleblowing ever pass away? I believe this will only happen if the medical profession is prepared to put the task of embedding, demonstrating and communicating patient-centred professionalism at the heart of its vision for the future.10 This task has to become central to our professional practice, our teaching and our research. It is the object on which our mutual leadership should be focused. The public expect no less.

Donald Irvine CBE, MD, FRCGP

Objective: To describe complaints by patients and compare rates of complaint in demographic subgroups of patients and hospital departments.Design and setting: Retrospective analysis of complaints made by patients attending 67 hospitals (metropolitan, 25; rural, 42) in Victoria, and lodged with the Victorian Health Complaint Information Program (January 1997 – December 2001).Main outcome measures: Demographic characteristics of patients lodging complaints and the hospital department involved; nature and outcome of complaints.Results: From a total of over 13 million patients presenting to hospital during the study period, 19 156 patients or their representatives (mostly their parents, children or spouses) lodged 26 785 “issues” of complaint (overall complaint rate, 1.42 complaints/1000 patients). Significantly more complaints (P < 0.001) were lodged by (or on behalf of) female patients (complaint rate ratio, 1.3; 95% CI, 1.2–1.3), public patients (rate ratio, 2.1; 95% CI, 2.0–2.2) and Australian-born patients (rate ratio, 8.9; 95% CI, 8.3–9.6). The complaint rate for general wards was 6.2/1000 patients (95% CI, 6.1–6.3). Intensive care units had a similar rate of 5.9/1000 (95% CI, 5.4–6.5), but aged-care departments had a significantly higher rate of 45.2/1000 (95% CI, 39.5–51.7), while emergency departments (1.9/1000; 95% CI, 1.8–2.0), operating theatres (1.0/1000; 95% CI, 1.0–1.1), day-procedure units (0.5/1000; 95% CI, 0.5–0.6) and outpatient departments (0.4/1000; 95% CI, 0.4–0.4) had significantly lower rates. Complaints relating to communication (poor attention, discourtesy, rudeness), access to healthcare (no/inadequate service, treatment delays) and treatment (inadequate treatment and nursing care) accounted for 29.2%, 28.5% and 22.5% of complaints, respectively. Most (84.5%) complaints were resolved. Apologies or explanations resolved 27.8% and 27.5% of complaints, respectively.Conclusion: Interventions to decrease the number of complaints in the areas of communication and access to healthcare need to be implemented. The active use of complaint data for quality-improvement activities is recommended.

David McD Taylor MD, MPH, FACEM · Rory S Wolfe BSc, PhD · Peter A Cameron MD, FACEM

Objectives: (i) To examine attitudes of medical and nursing staff towards reporting incidents (adverse events and near-misses), and (ii) to identify measures to facilitate incident reporting.Design: Qualitative study. In March 2002, semistructured questions were administered to five focus groups — one each for consultants, registrars, resident medical officers, senior nurses, and junior nurses.Participants and setting: 14 medical and 19 nursing staff recruited using purposive sampling from three metropolitan public hospitals in Adelaide, South Australia.Main outcome measures: Attitudes and barriers to incident reporting; differences in reporting behaviour between disciplines; how to facilitate incident reporting.Results: Cultural differences between doctors and nurses, identified using Triandis’ theory of social behaviour, were found to underpin attitudes to incident reporting. Nurses reported more habitually than doctors due to a culture which provided directives, protocols and the notion of security, whereas the medical culture was less transparent, favoured dealing with incidents “in-house” and was less reliant on directives. Common barriers to reporting incidents included time constraints, unsatisfactory processes, deficiencies in knowledge, cultural norms, inadequate feedback, beliefs about risk, and a perceived lack of value in the process.Conclusions: Strategies to improve incident reporting must address cultural issues.

Marilyn J Kingston RN, RM, BAPsych(Hons) · Sue M Evans BN, GradDipClinEpi · Brian J Smith MB BS, GradDipClinEpi, PhD · Jesia G Berry BHSc(Hons), GDPH

The protracted and costly investigations into Camden and Campbelltown hospitals (New South Wales), The Canberra Hospital (Australian Capital Territory), and King Edward Memorial Hospital (Western Australia) recently uncovered significant problems with quality and safety at these institutions. Each investigation arose after whistleblowers alerted politicians directly, having failed to resolve the problems using existing intra-institutional structures. None of the substantiated problems had been uncovered or previously resolved by extensive accreditation or national safety and quality processes; in each instance, the problems were exacerbated by a poor institutional culture of self-regulation, error reporting or investigation. Even after substantiation of their allegations, the whistleblowers, who included staff specialists, administrators and nurses, received little respect and support from their institutions or professions. Increasing legislative protections indicate the role of whistleblowers must now be formally acknowledged and incorporated as a “last resort” component in clinical-governance structures. Portable digital technology, if adequately funded and institutionally supported, may help to transform the conscience-based activity of whistleblowing into a culture of self-reporting, linked to personal and professional development.

Thomas A Faunce BA LLB(Hons), BMed, PhD · Stephen N C Bolsin MHCA, FRCA, FANZCA, MRACMA

Now we know these services are widely used, we need to know how best to support them The Australian government has recently released the report of the independent National Review of Tele Counselling and Web Counselling Services.1 Initiated by the Office of the Prime Minister in 2001, the review aimed to “take stock of the expanding and dynamic sector” and to describe the use, management, financing and role of web and telecounselling services. The report was commissioned in response to the recognition that the rapid expansion of these services created ethical, legal, funding, service delivery and education issues. The main findings of the review are summarised in the Box. In Australia, telecounselling (communication by telephone between a counsellor and a caller) is a large, diverse industry provided by 131 not-for-profit organisations and an unknown number of commercial organisations or individuals. The largest provider, Lifeline, consists of a federation of 42 centres, employs 5000 volunteers and provides 24-hour service 7 days a week. Web counselling (synchronous and asynchronous communication online or through email between a counsellor and a user) is a smaller, newer industry, with 17 not-for-profit agencies providing services mostly directed at youth. Two key points emerged from the review. First, many Australians use telecounselling services, although the benefits of the services have not been evaluated. Two of the largest service providers answer a combined total of about 850 000 telephone calls annually. (Precise estimates of numbers of users cannot be provided because individuals do not identify themselves, and may visit many times to the same or other agencies.) Despite this extensive use, the review confirmed that no randomised controlled trials (RCTs) have been conducted of the efficacy of web or telecounselling either in Australia or internationally.2 However, telecounselling as an adjunct to professional care has demonstrated effectiveness in RCTs3,4 and has been associated with changes in suicidality and mental health in uncontrolled evaluations.5 A second finding was that mainstream healthcare professionals, including general practitioners, refer patients to web and telecounselling services, although these services are not a formal part of the healthcare system. More than 20% of web and telecounselling agencies estimated that at least half their caseload was referred by healthcare providers, and reported that many calls relating to mental health were answered in the evenings or at weekends. Moreover, although crisis intervention is a component of the caseload, telecounselling agencies report that they are increasingly responding to a core group of individuals with ongoing mental health needs and loneliness. For Lifeline, less than 25% of callers were first-time callers, and across all of the agencies that were surveyed nearly 40% of callers had rung 20 times or more. Different counsellors in different locations talk to these individuals and are not privy to their concurrent medical service use. These key findings suggest three directions for action. First, better integration of telecounselling within mainstream mental health services may be desirable. A core group of users will be better served by being linked to healthcare and other services (for example, accommodation) and by information being shared about concurrent service use. Although telecounselling and mainstream services may have different locations, one solution is to link Lifeline web or telecounselling directly to telepsychiatry services. Telepsychiatry provides consultations with formal healthcare services (either face-to-face using technology, or through email). Although telepsychiatry may be costly and difficult to implement in practice, the advantages are the potential for geographical reach, accessibility, responsiveness, Medicare cover for users, the provider’s attention to evidence-based care and the provider’s duty of care. Software that records user contacts with major community agencies and the healthcare system would be a great step forward, although issues of anonymity, consent, privacy and, importantly, user preference and acceptance need consideration. Access for rural users to affordable telephone and internet services also requires attention. A second direction to consider involves implementing strategies for improving mental healthcare delivery within a web or telecounselling framework. There is a range of educational initiatives that allow high quality, evidence-based interventions to be delivered by non-specialists.6,7 This direction may involve integrating web or telecounselling with internet therapy and psychoeducation. A third clear direction is the need to evaluate the effectiveness of web and telecounselling. Fee-based web counselling with specialists and non-specialists is readily available to users, and these services are likely to accelerate, driven by a body of consumers who use internet resources. There is now the opportunity to test the usefulness and effectiveness of web counselling before this proliferates further. The emerging managed-care models delivered by an engaged and organised workforce of experienced telecounsellors is an exciting research opportunity not to be missed. Before the web and telecounselling review, no one knew the extent, quality or standards of delivery of these services, or even who used them. Now we know that these services are used frequently, both by the community and by healthcare agencies, and that they play a major role in managing vulnerable individuals with mental health problems. If telecounselling services are found to be effective, there is an urgent need to adequately support the sector and improve continuity of care between the systems. To date, telecounselling has been seen as non-core — a poor cousin to mental health services. However, given the development of communication technology, consumer empowerment, and the infrastructure, workforce, and capacity in the web and telecounselling sector, we foresee a central role for these services in delivering flexible, evidence-based, cost-effective help to the community. The National Review of Tele Counselling and Web Counselling Services Method Survey of 131 agencies in July 2002. Analysis of caller data from Lifeline, Kids Help Line and Care Ring, using statistics collected since 1999. Surveys of 80 interviews with web and telecounsellors and allied service providers. 20 focus groups of industry stakeholders. Telephone surveys of 125 users of web and telecounselling. Results Few national services exist, although there is a proliferation of state and regional services. Between 62% and 90% of calls are not answered because of under-resourcing and poor routeing of calls among centres. Nearly 80% of services relate to a specialist issue, such as sexual assault, domestic violence or cancer. Most calls concern mental health. Major telecounselling providers perceive themselves to be increasingly supporting highly vulnerable people rather than offering crisis intervention. Many callers ring repeatedly. More than 20% of services estimated that more than half their caseload was referred by main sector healthcare providers. Most telecounsellors are formally trained, with almost two-thirds being paid professional rates. Research team Urbis Keys Young. Advisors to Urbis Keys Young: Professor Trevor Waring and Dr Nick Kowalenko. Reference group Mr Dermot Casey, Mr Conrad Gershevitch, Professor Matt Sanders, Dr Margaret Tobin, Dr Bronwen Harvey, Mr Gordon Gregory, Professor Helen Christensen, Mr Des Graham, Ms Dawn Smith, Mr Trevor Carlyon, Ms Barbara Hocking, Mr Jack Heath.

Helen Christensen PhD · Barbara M Hocking BSc (Hons), DipEd, Dip H Eed, GAICD · Dawn Smith MBA

Ware, Francis and Read (page 627) express some concerns about the processes used in the Australian government’s decisions about funding for positron emission tomography (PET). We appreciate the Journal’s invitation to comment. I will briefly describe the workings of the Medical Services Advisory Committee (MSAC), the particular processes that have been undertaken in respect of PET, and the recommendations and funding decisions that flowed from those processes. MSAC advises the Minister for Health and Ageing on the strength of evidence pertaining to new and emerging medical technologies and procedures. In doing so, the committee considers safety, effectiveness and cost-effectiveness, and under what circumstances public funding should be supported. MSAC consists of eminent surgeons, physicians, health economists and experts in epidemiology and medical research, as well as representatives of consumers and of the Australian Health Ministers’ Advisory Council. In addition, for each technology under review, MSAC appoints experts in the relevant fields to supporting committees to help interpret the evidence. Since its inception in 1998, MSAC has established a reputation as one of the foremost sources of advice to government on new healthcare technologies. The processes surrounding the consideration of PET, including MSAC’s assessment, have been as follows: In 1999, PET first came to MSAC’s attention through applications from the Peter MacCallum Cancer Institute (Melbourne) and the Wesley Hospital (Brisbane). In August 1999, the then Minister for Health and Aged Care asked the department to conduct a broader review of PET to determine its proper role in the Australian clinical setting. The review incorporated an assessment by MSAC of PET in six clinical indications, but also considered a range of other matters, including the distribution of services, and workforce and accreditation issues. The review was guided by a steering committee comprising representatives of the medical profession, state and territory governments, and consumers. It received submissions from professional associations, states, hospitals, technology suppliers and medical service providers.1 In May 2000, MSAC concluded that there was insufficient evidence to draw definitive conclusions about PET’s clinical effectiveness and cost-effectiveness for the six indications.2 However, it did recommend that interim funding be made available on condition that facilities collect data to inform longer-term decisions about the role of PET in Australian clinical practice. In August 2000, the Minister agreed to implement the recommendations of the broader review, incorporating MSAC’s findings. This included a limited expansion of funded PET facilities through a tendering process. In May and August 2001, MSAC published further assessments of PET in respect of seven additional indications.3,4 MSAC again concluded that there was insufficient evidence to warrant unrestricted Medicare funding, but that interim funding should be provided under certain conditions, including that data should be collected to aid further assessment. The PET tendering process was completed in September 2001. By April 2003, eight facilities were receiving Medicare funding to provide PET services: three in Victoria, two in New South Wales, and one each in South Australia, Western Australia and Queensland. Funded facilities are participating in a data collection and evaluation program, as recommended by the PET review. This is expected to be completed in 2006. MSAC considered PET within the context of a broader review of the technology, but it applied its normal methods and evaluation criteria. The committee recommended funding for PET both in its initial report in 20002 and in subsequent reports in 2001.3,4 The Minister accepted that advice, and a wide range of PET services now attracts a Medicare benefit. This will continue until MSAC next reviews the technology. In addition to offering Medicare benefits for PET services, the government is funding the collection of data by service providers to improve the evidence base relating to the use of PET in a wider range of indications. The government does not routinely fund such data collection, but has done so in this case in acknowledgement of the potential impacts of PET on patients and the Australian healthcare system. Finally, one of the concerns that has been raised about the PET reviews is that the government did not follow the views of individuals who were involved in the processes. But that is by no means unusual. It is common for advisers appointed to MSAC supporting committees to bring a range of views to the table. Indeed, the supporting committees and MSAC itself are constructed to enable a diversity of perspectives to contribute to constructive and rigorous debate and decision making. MSAC’s challenge is to marry the published evidence with a diverse range of opinions and come to a definitive conclusion. The examinations of PET have been no exception. Having provided significant interim funding for PET, and substantial support for further data collection to build the evidence base, the Australian government has accepted MSAC’s advice to leave the door open, and will consider further evidence of PET’s safety, effectiveness and cost-effectiveness as it emerges in 2006.

Philip Davies MSc

Understanding the rules of the game appears to be as important as the quality of the research “The role of the good civil servant,” said Sir Humphrey Appleby, “is to find a problem with every solution.”1 In mainstream British life, this appears to translate into a paralysing fascination with complexity. . . .“reseach-led” universities are afraid to show too much interest in teaching, as it will not gain RAE points. The greatest of all sources of complexity of current academic life in the UK is undoubtedly the Research Assessment Exercise (RAE), introduced by the Higher Education Funding Councils in 1992. Ratings in the RAE feed directly into the funding formula for higher-education institutions. Run episodically at unpredictable intervals of between 5 and 7 years, the RAE takes into account an eclectic mixture of indicators: papers published (up to four per academic in the 2001 cycle); grants awarded; research students, staff and strategies; and “measures of esteem” (which are not defined on the principal RAE website). Higher-education institutions in the UK devote millions of pounds’ worth of senior academics’ time to preparing their submissions to the RAE, choosing which members of staff to include in their shop window, and weighing every syllable that goes into a document of a precisely prescribed size. In parallel with this, academe temporarily becomes a giant intellectual meat-market as higher-education institutions vie with each other to buy in staff with impressive CVs in time for them to be included on their RAE return, while experienced individuals whose special skills and vocation lie in university teaching are simultaneously in grave danger of “going under the cleaver”. All this because the key principle of success in the RAE, at least in 2001 (the most recent RAE), was to enter for judgement the maximum possible proportion of academic staff with the highest possible average level of performance in research. And who are the judges? Panels of one’s peers in individual disciplines are the judges, and their task is to pore over research inputs and outputs that have already been through the peer-review process. Many more hours of academic time are devoted to this rereview of research and to the determination of criteria by which each particular specialty is to judge itself. Moreover, the rulebook changes each time the RAE is run. In 2001, academics were considered in cognate groups called “units of assessment”, and the maximum possible score was five star (all individuals entered for consideration four published papers of undisputed international quality), as opposed to five (on average, half of the papers entered for consideration were of international quality and the other half were nationally significant). In the end, many higher-education institutions increased their ratings, but the government declined to expand the overall funding cake. Thus, the big fish now consume an even larger share and the little fish are given even less. The rulebook for the next RAE, in 2008, is still being written by a committee chaired by Sir Gareth Roberts, President of Wolfson College, Oxford, but it seems likely that the unit of assessment will be the individual and the highest possible score six stars. Going into the RAE is like entering a football World Cup, but not knowing the number of players, the shape of the ball, the field or the goalposts, or whether there is an offside rule. Worst of all, university life is dominated by the exercise. While papers of international relevance are required to achieve a five-star rating, work of local relevance, such as most health services or policy research, cannot achieve this standard. Nor can most studies on the impact of new discoveries and implementing new methods in health services or other industries. Methods, rather than their application, are favoured. Particular study designs are deemed creditable in a somewhat arbitrary way, depending on the composition of the discipline panel. Those of us who work in “research-led” universities are afraid to show too much interest in teaching, as it will not gain RAE points. Thus, the whole direction of university life is affected, with the emphasis on research — or, at least, on certain types of research — rather than teaching. Although this is a research assessment, the implications flow on to teaching, both through the funding available to departments and the interests of people recruited to academic posts. In a recent meeting with the higher-education minister of a Middle Eastern country, one of us was told that this country now sends its students only to university departments with an RAE rating of at least four. Understanding the rules of the game appears to be as important as the quality of the research. Should your submission favour breadth or depth? Who should be “returned” (ie, put forward by the institution for scrutiny)? Since the result of the process is directly translated into funding, making the right decisions is crucial. Of course, there are benefits. There is a much smaller possibility for non-productive academics to hide; there is greater transparency about what are the values governing academic success; and there is a real need for individuals, departments, faculties and universities to define their goals and to measure performance. But the price paid for these gains is increasing disgruntlement in the academic workforce and direct lobbying of parliamentarians for a better, less disruptive system to be devised and imposed. For the record, the Australian equivalent of the RAE, which also affects university funding, combines routinely available data on various kinds of publications with information on grants awarded and PhDs completed. Publications are weighted by “impact factors”, a rating method with many shortcomings, but at least it is in the public realm and known in advance. The system is cheap, because most of the data are already available; it is unselective, because all academics and all of their outputs are considered; and it is simple, transparent and fast — fast enough to be run annually, so that the lag between effort and reward is relatively short, and fast enough to avoid causing a mass moonlight flit of university staff! Doubtless, some British civil servant found a problem with this “colonial” solution.

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

Objectives: To seek public opinion on the reporting of medical errors and the anonymity of healthcare workers who report medical errors.Design and participants: A random, representative survey of 2005 South Australians in April 2002, using telephone interviews based on a vignette provided.Main outcome measures: When a medical error occurs (i) whether the incident should be reported, and (ii) whether the report should disclose the healthcare worker’s identity.Results: (i) Most respondents (94.2%; 95% CI, 93.0%–95.2%) believed healthcare workers should report medical errors. (ii) 68.0% (95% CI, 65.5%–70.5%) of those in favour of reporting believed the healthcare worker should be identified on the report, while 29.2% (95% CI, 26.7%–31.7%) favoured anonymous reporting.Conclusions: Most respondents believed that, when a healthcare worker makes an error, an incident report should be written and the individual should be identified on the report. Respondents were reluctant to accept healthcare worker anonymity, even though this may encourage reporting.

Sue M Evans BN, GradDipClinEpi · Jesia G Berry BHSc(Hons), GradDipPublicHealth · Brian J Smith FRACP, PhD, DipClinEpiBiostat · Adrian J Esterman MSc, PhD, AStat

Dale W Hanson,* Herbert R Sadlier,† Reinhold Muller‡ * Tom and Dorothy Cook Research Fellow, James Cook University; † Director, Emergency Department, Mackay Base Hospital, PO Box 5580, Mackay Mail Centre, Mackay, QLD 4741; ‡ Associate Professor, School of Public Health and Tropical Medicine, James Cook University, Townsville, QLD. dwhansonATmackay.matilda.net.au To the Editor: It has been argued that reduced levels of bulk billing have resulted in emergency department (ED) overcrowding due to an increase in non-emergency, primary care ED presentations.1 In the 2001–02 financial year, Queensland EDs experienced a 7.1% growth in caseload compared with 2000–01 (Mr D Searle, Surgical Access Team, Queensland Health, personal communication, Nov 2002). During the same period, there was a 1.5% decline in the proportion of general practice services bulk billed in Queensland. Before December 2000, no dedicated general practice bulk-billing clinics existed in Mackay. The opening of two bulk-billing clinics, one within 1 km of Mackay Base Hospital, provided an opportunity to assess the effect of the increased availability of bulk-billing services on ED presentations. The Mackay region had a full-time-equivalent GP : patient ratio of 1 : 1648 in 2002, compared with a Queensland average of 1 : 1143.2 In the September quarter of 2000, 58.4% of GP consultations were bulk billed in Mackay, compared with 85.7% in Brisbane (Ms D-A Kelly, Federal Member for Dawson, personal communication, Jun 2003). The Mackay Base Hospital ED provides 24-hour, 365-day emergency medical services to the Mackay region, and managed 34 558 presentations in the 1999–00 financial year, admitting 15% of its caseload. On the Australasian Triage Score (ATS) classification, 0.2% of presentations were category 1, 4% category 2, 20% category 3, 54% category 4, and 21% category 5. Since the bulk-billing clinics were established, there has been an average of 237 extra bulk-billing consultations per day, with a resultant 7.3% increase in the proportion of GP consultations bulk billed in the federal electorate of Dawson (Ms D-A Kelly, Federal Member for Dawson, personal communication, Jun 2003) (91% of the electorate lives in the Mackay region). However, ED presentations have remained stable, with a median 93 presentations per day (Box). Changes in the proportion of ATS 3, 4 and 5 presentations were observed (25%, 55% and 14%, respectively), but were associated with internal organisational changes (shifting surgical and orthopaedic dressing clinics out of the ED and into the outpatient department, and a review of triage policy), and cannot be reliably attributed to the influence of the bulk-billing clinics. In Mackay, the implementation of two bulk-billing GP clinics did not result in a measurable reduction in the absolute number of ED presentations. These results are consistent with previous studies that suggest that non-emergency, primary care ED presentations are not a major determinant of ED overcrowding.3 Effect of general practice bulk-billing presentations on average daily emergency department presentations, Dawson electorate, Queensland

Dale W Hanson · Herbert R Sadlier · Reinhold Muller

Ian F Knox President, Australasian College for Emergency Medicine, 34 Jeffcott Street, West Melbourne, VIC 3003. iknoxATgil.com.au Comment: The report by Hanson et al1 comes at an important time in the debate regarding emergency departments, especially at the onset of winter, a time of high demand and stretched resources. The authors describe the effect of the opening of two bulk-billing clinics on attendances at the emergency department (ED) of a provincial Queensland hospital. Despite the clinics seeing 2.5 times the number of patients seen at the emergency department each day, this resulted in no reduction in ED attendances. This should give pause for thought to those who maintain there is a simple and direct relation between the level of bulk billing of general practitioner services and ED workloads. The nature of the relation between GP services and ED attendances has never been clearly defined, but it is likely to be complex. Similarly, the nature of ED workloads is also complex, and more than just a matter of the total attendances.2 In the Journal last year, Cameron and Campbell cited the major causes of access block and overcrowding as being the reduction in hospital beds and aged care facilities, along with changes in workforce and community attitudes.3 In that issue, the Journal published a series of articles that essentially represented a national audit of responses to ED overcrowding. Only one article described the opening of a GP clinic as a response; the authors noted that this was unsuccessful in reducing access block.4 Thus, the findings of Hanson and colleagues are neither new nor surprising. Overcrowding is the single most important barrier to quality in ED care. It is a symptom of a serious and growing mismatch between demand and supply for acute healthcare services. Solutions require a whole-of-systems approach. Efforts to improve the flow of patients through acute-care hospital beds are needed, as are strategies to divert some current inpatient flow to community-based subacute services. There is an important role to be played by GPs in coordinating the management of patients with chronic and complex health problems, to reduce the demand for acute-care admissions to hospital, and in working in partnership with the acute-care sector in coordinating community-based subacute alternatives to hospital care. Such initiatives will only come about if state and Commonwealth governments and health departments work together.

Ian F Knox

Practice based on the best available evidence and the quality and safety of healthcare have become a major focus for governments, healthcare providers and consumers. This increased awareness comes at a time when new heights have been reached in the technical sophistication of care, healthcare systems have become incredibly complex, and there is a potential for patients to be harmed by healthcare interventions.1 Adverse events can seldom be attributed to a single human error and are usually associated with the complex system interactions.1-3 The Quality in Australian Health Care Study,4 published in 1995, served as a catalyst in Australia for promoting system-based approaches to safety and quality improvement. The Clinical Support Systems Program (CSSP)5 is a practical example of this. The CSSP emerged through collaboration between the Royal Australasian College of Physicians (RACP) and the Australian Government Department of Health and Ageing (the Department), and was subsequently sponsored and managed by the RACP. The Department provided most of the funding, with the Victorian Department of Human Services and NSW Health each contributing $500 000, resulting in combined funds of $5.5 million. The formal funded phase of the Program ran from 2000 to 2002. The Program sought to assist the routine uptake of best evidence within clinical practice through a Clinical Support Systems (CSS) model. This model combined the principles of clinical practice improvement (CPI)6 and evidence-based medicine (EBM)7 into a broad framework to enable clinicians to embed best practice routinely in clinical care. It had the following broad specifications (see also Box 1): involvement by clinical teams, health managers and consumers in design, development, implementation and evaluation; establishment of organisational and management structures and tools necessary to develop and maintain capacity for CPI; systematic use of evidence within clinical settings; systematic clinical work practices to reduce inappropriate variation; development of data and analysis systems to support CPI; and routine measurement and review of clinical practices. The CSS model was tested through four consortium-based projects that collectively involved 17 clinical sites across three states. The four projects were selected through a competitive tendering process, based on specific criteria: the projects should involve areas of care that were high cost, high volume or high risk; and for which there was a significant level of evidence relating to diagnosis and treatment, and tangible indicators for a difference between this evidence and current practice. The successful consortia and their projects were: Austin Bowel Cancer Consortium — implemented National Health and Medical Research Council guidelines for colorectal cancer care,8 spanning multiple episodes of acute care (surgery and oncology) in three hospitals: metropolitan, regional and private. Brisbane Cardiac Consortium — adapted national guidelines for management of acute coronary syndromes9 and congestive heart failure10 and systematically implemented the evidence within three hospitals and in general practice. Monash University Consortium — developed local protocols based on the best available evidence (in the absence of national guidelines) for managing patients with acute stroke (first 7 days) and implemented them in four hospital sites: tertiary, regional, rural and private. Towards a Safer Culture (TASC) Consortium — focused on management of acute coronary syndromes9 and stroke (for which there were no such guidelines). The principal area of interest was the emergency department. This program was subsequently extended to the inpatient setting of four hospitals in New South Wales, Queensland and Victoria. The primary aim of each project was to embed the best available evidence into local routine clinical practice. The focus was not on generating new evidence or on proving that evidence-based care improves outcomes for patients. Instead, the projects focused on the structural and cultural dimensions of care, with tangible outcomes such as developing information systems, protocols, tools and organisational pathways necessary to support evidence-based care and influence clinicians to use evidence routinely and sustainably. There was considerable variation between the projects. This heterogeneity included the clinical focus, the amount and type of evidence available and the tasks required to implement the evidence; the environment in which changes were sought; and the number, type and geographical spread of project partners. Projects also varied in their interpretations of the CSS model, change management strategies, project objectives and methods. Each project evolved into a unique, integrated combination of these defining features. The 2-year time frame, and local and wider health system issues over which projects had no direct control, resulted in the projects experiencing varying success. Nevertheless, the consortia all increased their capacity to provide evidence-based care for their patients. The details of their achievements are described in this Supplement (pages S79, S83, S89 and S92).11-14 These projects illustrate the changes required in the structural and cultural dimensions of care to progress towards evidence-based practice becoming routine (Box 2). The projects also uncovered many issues relating to the clinicians and the environments involved, as well as the underlying strategies needed to support implementation of both EBM and CPI. Aspects of the CSSP projects have continued beyond the 2-year funding phase in each of the participating hospitals. In two instances, important project components were taken up by state governments. The Brisbane Cardiac Consortium data sets for acute coronary syndrome and congestive heart failure have been adopted by Queensland Health for wider application. The TASC methodology for management of patients presenting to emergency departments with acute coronary syndromes and stroke is now in use in public hospitals in NSW, funded by the NSW Institute for Clinical Excellence. The RACP has actively promoted uptake of the CSS model in other settings. There is a TASC stroke project in Western Australia, a project targeting otitis media in northern South Australia, another in rural Victoria focusing on community-acquired pneumonia (CAP), and three projects in New Zealand. Clinicians around Australia are now implementing various forms of the CSS model. The CSSP has generated a unique web-based tool that provides a practical introduction to the CSS model and draws heavily on the experiences of clinicians involved in the CSSP.15 An overarching outcome of the CSSP is that it has confirmed that healthcare providers are committed to improving the quality of care. Participants have welcomed the opportunity to reflect on their practice in the light of the best available evidence and CPI. Indeed, the CSSP has created a learning laboratory for its participants and contributed to an increased system capacity to improve healthcare. Further information about the CSSP can be found by visiting the RACP website www.racp.edu.au/bp The Clinical Support Systems model 2: The CSSP projects’ achievements in targeting the structural and cultural dimensions of care Effective teams crossing entrenched structural and professional boundaries Improved care systems across interfaces Improved attitudes towards clinical practice guidelines, clinical practice improvement and consumer involvement Improved staff morale and sense of empowerment Evidence-based tools for clinicians and consumers Information systems providing clinicians with timely, meaningful feedback Improvements in many clinical and organisational outcome indicators

Jenni A Leigh · Paul W Long · Paddy A Phillips · Robin H Mortimer

The concept of the Clinical Support Systems Program (CSSP) was transformed from an idea into reality through the efforts of representatives of the Australian Government Department of Health and Ageing and the Royal Australasian College of Physicians. This collaboration involved developing common ground between two different perspectives: those of the funder/policy/administrative sector and those of the clinical practice world. Bridging these differences to establish an agreed approach to moving forward was a lengthy and difficult process. The process is aided by tension for change. Compromise, persistence and commitment to the end-goal by the parties involved were important features in building and maintaining the momentum of the change process. Many of the difficulties experienced could be traced to differences in decision-making processes between the clinical and the administrative paradigms. Knowledge brokers can assist in bridging the different languages and perspectives of the groups involved.

Jill Sewell FRACP · Paul W Long GradDip (CommMgt) · Jenni A Leigh BA(Hons), BSocAdmin

The Austin Bowel Cancer Consortium aimed to identify drivers of clinical decision-making so as to inform a continuous practice improvement approach to the use of evidence. Strategies for engaging clinicians included a direct clinician–clinician approach, gaining the support of opinion leaders and using the clinicians’ desire for patient outcome data. Interviews with clinicians identified barriers to using evidence in practice. These included poor integration of medical and surgical disciplines, different learning styles, negative attitudes to guidelines and pathways, and no consensus as to what is an effective multidisciplinary team. A clinical implementation group provided a forum for interaction between disciplines. The group agreed on management pathways covering the continuum of care and developed decision-support software for use in the clinic. Interviews with patients and carers highlighted psychosocial and communication difficulties and prompted greater clinician awareness. Consumers developed patient information resources with minimal assistance from project staff. The clinical encounter is the prime site for change for putting evidence into practice, rather than trying to change individual clinicians.

Paul L R Mitchell MB ChB, FRACP, MD · Craig A White MB BS, MBus

As part of the Clinical Support Systems Program, the Monash University Consortium conducted a project to identify factors influencing the implementation of clinical evidence into routine hospital practice. Training was required in the process of clinical practice improvement (CPI) and the nature of evidence. One of the most helpful instruments for change was to point to active models of quality assurance as exemplars. Staff can be trained to be good managers, but leadership is less susceptible to training and is better obtained by selective recruitment. CPI requires rapid feedback on the effectiveness of the implementation. Access to this information and the confluence of management skill, an ability to translate research evidence into routine clinical behaviour and an understanding of the process of quality assurance are central. Effective CPI is only possible when the larger hospital administrative culture is committed to providing the necessary resources.

Malcolm K Horne MB BS, PhD, FRACP

Objective: To quantify the burden of disease and injury for the Aboriginal and non-Aboriginal populations in the Northern Territory.Design and setting: Analysis of Northern Territory data for 1 January 1994 to 30 December 1998 from multiple sources.Main outcome measures: Disability-adjusted life-years (DALYs), by age, sex, cause and Aboriginality.Results: Cardiovascular disease was the leading contributor (14.9%) to the total burden of disease and injury in the NT, followed by mental disorders (14.5%) and malignant neoplasms (11.2%). There was also a substantial contribution from unintentional injury (10.4%) and intentional injury (4.9%). Overall, the NT Aboriginal population had a rate of burden of disease 2.5 times higher than the non-Aboriginal population; in the 35–54-year age group their DALY rate was 4.1 times higher. The leading causes of disease burden were cardiovascular disease for both Aboriginal men (19.1%) and women (15.7%) and mental disorders for both non-Aboriginal men (16.7%) and women (22.3%).Conclusions: A comprehensive assessment of fatal and non-fatal conditions is important in describing differentials in health status of the NT population. Our study provides comparative data to identify health priorities and facilitate a more equitable distribution of health funding.

Yuejen Zhao BMed, MBiostats, PhD · Steve Guthridge MB BS, MTH, FAFPHM · Anne Magnus BEc, BEd · Theo Vos MD, MSc