Health services administration

The increasing array of strategies and models for improving clinical practice and patient outcomes can be confusing for clinicians. The Clinical Support Systems (CSS) model has proved to be effective in local environments because it demystifies the design and implementation of evidence-based practice improvement projects. The CSS model is simple and has a wide scope. It provides a broad framework with minimalist specifications, enabling clinicians to design their own systems of care that cut across fragmented organisational structures. Implementing simple rules can be an effective strategy for change in complex care systems. These rules do not impose solutions on clinicians, but rather, help them to find creative solutions that have meaning for them and are contextually relevant.

Robin H Mortimer FRACP · Jillian R Sewell FRACP · Don M Roberton MD, FRACP, FRCPA · Napier M Thomson MD, FRACP · Paul W Long GradDipCommMgt · Jenni A Leigh BA (Hons), BSocAdmin

The Clinical Support Systems Program (CSSP) provided a mechanism for change from the existing entrenched structure and culture of patient care to one based on patient-centred, evidence-based care. The spectrum of change and improvement achieved by the CSSP was extensive, with support from government and active and enthusiastic involvement of clinical champions, practising clinicians, consumers and managers. The CSSP experience confirmed that responsibility for quality clinical care cannot be borne solely by clinicians, and highlighted key areas where improvement in the support clinicians receive is needed. Many barriers to improvement in our complex healthcare system can be removed by recognising the need for accurate data recording and data systems, teamwork, and high-level organisational buy-in, with collaboration between teams and organisations trying to improve the quality of patient care. System-wide improvement has been stimulated and facilitated by the CSSP experience, with mutual flow-on benefits for the activities of the Australian Council for Safety and Quality in Health Care and the National Institute of Clinical Studies.

Jenni A Leigh BA(Hons), BSocAdmin · Paul W Long GradDip(CommMtg) · Bruce H Barraclough AO, FRACS

Steering GroupDr Robin Mortimer, RACP Dr Vin McLoughlin, Department of Health and Ageing Ms Susan Garner, Department of Health and Ageing Ms Mary Draper, Department of Human Services Victoria Ms Maureen Robinson, NSW Health Dr Jill Sewell, RACP Prof Jim Hyde, RACP Mr Paul Long, RACP Evaluators Ms Jenni Leigh and Mr John Pilla, BearingPoint Australia Reference GroupChair: Prof Richard Smallwood, Chief Medical Officer, Commonwealth of Australia Ms Meredith Carter, Health Issues Centre Prof Enrico Coiera, University of New South Wales A/Prof Judith Dwyer, La Trobe University Dr Peter Greenberg, RACP Dr Peter Kennedy, RACP Prof Richard Larkins, Monash University Dr Rick McLean, RACP Prof Jeanette Ward, RACP Mr Robert Wells, Department of Health and Ageing Dr Vin McLoughlin, Department of Health and Ageing Prof Paddy Phillips, Australian Council for Safety and Quality in Health Care Prof George Rubin, Australian Centre for Effective Health Care Prof Nicholas Saunders, NHMRC A/Prof Steven Boyages, RACP Ms Rosemary Bryant, Royal College of Nursing, Australia Mr Lou McCallum, Consumers’ Health Forum Dr Geoffrey Metz, RACP Ms Sally Nathan, Australian Consumers Association Mr Craig G Patterson, RACP Dr Karen Luxford, National Breast Cancer Centre A/Prof Stephen Bolsin, Geelong Hospital Ms Amanda Adrian, NSW Health Care Complaints Commission Ms Fiona Wheatland Tito, Enduring Solutions Prof Bruce Barraclough, Australian Council for Safety and Quality in Health Care Department of Health and AgeingMr Robert Wells, Dr Vin McLoughlin, Ms Susan Garner, Ms Kerrie Murphy, Mr Martin Fletcher, Ms Jenny Thomas, Mr Gerry Van Wyk, Mr Peter Harlow, Mr Julian Hamon Austin Bowel Cancer ConsortiumDr Craig White, Austin and Repatriation Medical Centre Dr Paul Mitchell, Austin and Repatriation Medical Centre Ms Ryhl Gould, Austin and Repatriation Medical Centre Ms Jane Evans, Austin Bowel Cancer Consortium Ms Meredith Carter, Health Issues Centre Prof Susan Long, Swinburne University of Technology Dr John Newton, Swinburne University of Technology Mr Andrew Bui, Austin and Repatriation Medical Centre Mr Andrew Barling, Bendigo Health Care Group Brisbane Cardiac ConsortiumPrincess Alexandra Hospital:Mr Ian Coombes Dr Paul Garrahy Ms Annabel Hickey Prof Thomas Marwick A/Prof Charles Mitchell Ms Daniela Sanders A/Prof Ian Scott Royal Brisbane Hospital:Dr John Atherton Dr Cameron Bennett Mr Neil Cottrell A/Prof Charles Denaro Dr Mark Dooris Dr Alison Mudge Ms Therese Theile Ms Justine Thiele Prof Michael Ward Queen Elizabeth II Hospital:Dr Judy Flores Mr Adam La Caze Dr Malcolm Wright Brisbane North Division of General Practice: Dr Ann McBryde Mr Ian Watts Dr Beres Wenke Dr John Bennett Brisbane Southside Central Division of General Practice:Dr John Aloizis Mr David Gardner Dr John Turnbull Monash University ConsortiumProf Malcolm Horne, Howard Florey Institute Ms Judith Dwyer, Southern Health Ms Julie Andrews, Southern Health Mr Michael Robinson, Southern Health Ms Martine Thompson, Southern Health Ms Jill Peterkin, Southern Health Ms Janelle Finn, Southern Health Prof Chris Silagy (deceased), Monash Institute of Health Services Research A/Prof Jeremy Anderson, Monash Institute of Health Services Research Ms Louise Corben, Monash Medical Centre Ms Cate Wilson, Monash Medical Centre Dr Paul Talman, Monash Medical Centre Mr Neville Kelly, Frankston Hospital Dr Prakash Nayagam, Frankston Hospital Dr Bruce Maydom, West Gippsland Hospital Ms Meredith Carter, Health Issues Centre Dr Judith Frayne, St Frances Xavier Cabrini Hospital Ms Maureen Flaherty, St Frances Xavier Cabrini Hospital Ms Fiona Symington, Project Manager Towards A Safer Culture Consortium (Phase 1 & 2)Prof Katherine McGrath, Hunter Health Ms Robyn Considine, Hunter Health Prof Peter Fletcher, John Hunter Hospital Dr Chris Levi, John Hunter Hospital Dr Julia Lowe, John Hunter Hospital A/Prof Drew Fitzpatrick, Nepean Hospital Dr Rod Bishop, Nepean Hospital Dr Greg Stewart, Wentworth Area Health Service A/Prof Jane Gordon, Wentworth Area Health Service A/Prof Jeff Wasserthiel, Frankston Hospital Dr Carolyn Hullick, Townsville Hospital Dr Christopher Kennedy, Townsville Hospital Dr Andrew Johnson, Townsville Hospital Dr Liz Mullins, Healthcare Risk Resources International Dr Maree Bellamy, Standards Australia Mr Raj Verma, Hunter Health Mr Paul Long, RACP Ms Fiona Wheatland Tito, Enduring Solutions Pty Ltd Mr John Windle, Nepean Blue Mountains Cardiac Support Group Prof Michael Boyer, RACP Dr Ian O’Rourke, NSW Institute for Clinical Excellence Prof Phil Harris, NSW Institute for Clinical Excellence Ms Cate Ferry, NSW Institute for Clinical Excellence Ms Maureen Robinson, NSW Health

Fairness and compassion are the bases for improving Aboriginal health There is no dispute that Aboriginal health in Australia is both poor and very much worse than that of non-Aboriginal people, and their life expectancy at birth is about 21 years less for men and 19 years less for women. Among Aboriginal and Torres Strait Islander males, 6.8% die in infancy, compared with 1% for the rest of the population. For females the figures are 6.7% and 0.8%. A large array of diseases are much more prevalent among Aborigines.1 Institutional racism in Australian healthcare — some examples Funding inequity: Overall funding of Aboriginal healthcare is not commensurate with extra need.8 Different performance criteria for black and white: For example, in Perth, Derbarl Yerrigan Aboriginal Medical Service funding was cut when an “overspend” arose because of success in attracting clients; at the same time the teaching hospitals’ overspend was 120 times as great as that at Derbarl Yerrigan. The teaching hospitals were given an extra $100 million to cover their overspend.9 “Body part” funding: For instance, separate streams of money for conditions such as diabetes and heart disease for a health service which is intended to be holistic — 26 funding streams (and hence 26 separate accounts and 26 demands for accountability) for the Danila Dilba Aboriginal Medical Service in Darwin. Differences in treatment regimens: Aboriginal people in Western Australia born in the 1940s received low-cost nursing care; in contrast, a white cohort of the same age received higher-cost technological care.10 Inequitable Medicare Primary Health Care (Medicare Benefits Schedule plus Pharmaceutical Benefits Scheme): In Katjungka (a remote Aboriginal community), $80 per head per year; in Double Bay (an affluent Sydney suburb), $900 per head per year.11 Cultural barriers to Aboriginal use of healthcare services: Inadequate funding to reduce these barriers (such as language barrier and lack of recognition of different constructs of health) for Aboriginal people. This is not news. The question is how to improve this situation. The argument presented in this article rests on two core and related ideas: that our health services are “institutionally racist” and that such racism stems from Australia being, or at least having become, an uncaring society. The way forward that we propose is recognising and addressing institutional racism. This would provide a framework for improving Aboriginal health. We believe, however, that acceptance of the need to address such racism can only come about through building a more compassionate and decent society. To suggest that healthcare in Australia is institutionally racist may be confronting for some, but we argue not only that it is institutionally racist, but, more importantly, that such racism represents one of the greatest barriers to improving the health of Aboriginal and Torres Strait Islander people. We will also indicate what might be done to overcome this institutional racism and improve Aboriginal health. Defining institutional racismInstitutional racism “refers to the ways in which racist beliefs or values have been built into the operations of social institutions in such a way as to discriminate against, control and oppress various minority groups”.2 It has been claimed that “Institutional racism is embedded in Australian institutions”.3 Often, institutional racism is covert or even unrecognised by the agents involved in it. In recent years, interest in both the concept and practice of institutional racism has increased. In the United Kingdom, it was sparked by the Stephen Lawrence Inquiry,4 published in 1999. This examined the events which followed the completely unprovoked murder in 1993 of Stephen Lawrence, a young black man, which was “unequivocally motivated by racism”. It found that the investigation was marred by a combination of professional incompetence, institutional racism and a failure of leadership by senior officers. It claimed that “officers approached the murder of a black man less energetically than if the victim had been white and the murderers black”. In the context of racial and ethnic disparities, Camara Jones,5 an Assistant Professor at Harvard University School of Public Health, has called for “a growing national conversation on racism”, one key aspect of which is “institutionalized racism”. This she sees as being “often evident as inaction in the face of need”. An increasing focus on institutional racism in Aotearoa (New Zealand) was prompted by a visit there by Camara Jones in 1999.6 In Australia, institutional racism has been an almost constant feature of our history, from the British designation of the continent as terra nullius, through the 1897 Convention on Federation (where the question of whether Aboriginal people should be counted as “people” in the national census was covered in just 195 words7), to the stolen generations and the failure of the federal government to issue an apology. Examples of institutional racism are shown in the Box. Clash of culturesWe believe that any healthcare system is a social institution built on the cultural stance of the population it serves. It follows that cultural values should provide the value base for health services. Between Aboriginal and non-Aboriginal Australians, there is not only a difference in culture, but a clash of cultures. We think some white people are at least dimly aware of this. However, the extent of their understanding of the difference between a culture based on individualism, where the individual ranks above the community in importance, and a communitarian culture, in which each individual is less important than the whole, is limited. One of us, S H,7 a Gungulu man, has written: “Aboriginal Peoples have built a communitarian solidarity that includes an awareness and affirmation of the [cultural] difference [of Aboriginal people]. Such communitarian solidarity is a form of civic friendship between peoples that is distinguishable from other forms of friendship because it unites people who are members of the same particularistic cultural community — persons who share a common worldview and use the same primary moral vocabulary.” Yet that value base is inadequately recognised in the planning of healthcare services in this country. Where societies or social entities have a greater awareness of and concern for mutuality, reciprocity and sharing, trust in institutions will be fostered and racism will diminish. Many Australians have embraced the individualism of neoliberalism. Uniting as a community around little other than the successes of its sporting teams, today’s white Australia lacks these “communitarian” traits. While communitarianism need not always be a force for good (the Nazi vision of the “master race” is a case in point), it can be and has been a beneficial force in Aboriginal culture. Here it is best seen in terms of what the distinguished public servant Coombs12 describes as “the Aboriginal ethic of accountability to others”. This, he writes, “is required by their commitment that autonomy, at a personal and group level, will be exercised so as to ensure that what is done contributes to the care and nurture of others with whom they are related; so that personal behaviour remains socially grounded”. In current health policy there is little attempt to recognise the differences in culture between black and white. The holism of Aboriginal health involves not just a “wholeness”, but a series of mutual obligations. Aboriginal Medical Services attempt to provide culturally “secure” services (ie, services based on Aboriginal preferences where differences in culture do not create additional barriers to use). Their poor funding levels, however, severely restrict them in this. Mainstream services make almost no effort to understand or provide culturally secure services. To deliver such services might increase primary healthcare costs for Aboriginal people by more than 50%.9,13 This is because, for example, questioning with respect to history has to be indirect, and preceded by time spent in building trust and confidence between the doctor and patient. This process, to be done well, can be time consuming. Also, advocacy on behalf of the client with other agencies, such as those providing housing, is often expected by Aboriginal clients as part of a GP’s role. The prospects for creating a cohesive Australian community, advancing social capital, furthering equity and reducing racism are not bright. For example, the Human Rights and Equal Opportunities Commission conducted a series of consultations across Australia which showed racism to be widespread and institutionally based, especially with respect to Aboriginal people.14 We believe that the current Australian federal government puts at risk our social capital in its pursuit of divisive policies. This applies not only to Aboriginal people, but also to other minority groups, defined racially or otherwise. For example, extending upfront fees for universities gives the affluent greater access compared with the poor; and ignoring the principle of universality (which did not rate a mention in the Prime Minister’s media release as one of his three pillars of Medicare15) on Medicareplus creates yet more of a two-tier healthcare system. The government’s policies on immigration have been severely criticised by many, including Father Frank Brennan, the Jesuit priest and lawyer, who concludes his book on the subject with an appeal to re-create social capital in Australia: “Many of us would like to return collectively to being a warm-hearted, decent international citizen.”16 We believe that Aboriginal people have lost their trust in the institutions of government, including healthcare services. Lack of respect by white Australians for Aboriginal values, the discounting of these values by those who have sought, patronisingly and paternalistically, to “do good” to Aboriginal people (according to a “good” defined by white fellas), leads to further erosion of trust. The lack of trust by Aboriginal people in white people and white institutions is obvious. More tellingly, we believe there is a lack of trust by Aboriginal people in themselves as a people — a lack of confidence in their culture. It is this last, a legacy of colonisation and its aftermath, that has wreaked the greatest havoc of all. We also believe that there is a lack of political will and of leadership to deal with inequalities generally in Australian healthcare. The most glaring example in recent times lies in the government’s schemes to promote private health insurance. The cost of increasing spending on primary healthcare for Aboriginal people to a level which would take into account such considerations as greater health problems, cultural-access barriers and equity (ie, increasing it to five times the per-capita level for non-Aboriginal people17) might be measured by the benefit forgone if the government were to halve the rebate (from 30% to 15%) for private health insurance.18 Progressing from institutional racismCurrently, cultural differences and ignorance create racism, and indifference nurtures it. Cultural differences must be celebrated, rather than denigrated. Former Prime Minister Paul Keating’s Redfern Speech on reconciliation pointed the way forward: “I think what we need to do is open our hearts a bit. All of us. Perhaps when we recognise what we have in common we will see the things which must be done . . . If we open one door others will follow.”19 That was 12 years ago. Today, the converse is true. As we have closed one door, others have followed. So many doors on social justice are closing in this society. We closed the door on a Norwegian freighter carrying abandoned refugees. We close the door on children in detention centres, on poor youngsters trying to get a university place. We close the door on opportunities for Aboriginal people and on the richness of an ancient culture which is potentially there for all Australians to learn from and take pride in. What scope is there for building compassion? Not much, it might seem, in this neoliberal society and this globalising world. Yet, as the social commentator Richard Titmuss remarked 30 years ago about the UK National Health Service, altruism and compassionate acts are infectious not only to other people, but to other events and circumstances.20 Compassion is good for us. What to do?Firstly, white Australia must learn to understand Aboriginal culture, particularly with respect to its fundamental philosophy of “communitarian solidarity”. Only then can social institutions, such as healthcare services for Aboriginal people, be built on a genuine understanding followed by accommodation of the hopes and aspirations of Aboriginal people. More directly, only then can Aboriginal people have the chance to have health services delivered to them that are, by right, as accessible (in the broadest sense) as they are to white Australians. Secondly, those white people who were described (above) as patronising and paternalistic would cease to be so when, in their “doing good”, good was defined by Aboriginal preferences. Thirdly, Aboriginal communitarian preferences must drive Aboriginal health services, their funding and their performance indicators. Unless the governance of Aboriginal organisations is based on Aboriginal cultural values, these services will not function effectively or efficiently. Fourthly, public compassion must be built into the Australian social fabric. The “fair go”, if it ever existed, has gone, but Australia needs a leadership that will articulate that fair go. The philosopher Martha Nussbaum argues against “impoverished models of humanity” with “numbers and dots taking the place of women and men”.21 She continues: “. . . when one’s deliberation fails to endow human beings with their full and complex humanity, it becomes very much easier to contemplate doing terrible things towards them . . . if you really vividly experience a concrete human life, imagine what it is like to live that life, and at the same time permit yourself the full range of emotional responses to that concrete life, you will . . . be unable to do certain things to that person. Vividness leads to tenderness, imagination to compassion.”21 Finally, our call is for a more compassionate society. Attitudes to asylum seekers, to Aboriginal people, to people who are in any way disadvantaged, are linked. Social attitudes need to be more compassionate to all who are disadvantaged, and not just to Aboriginal people. ConclusionAboriginal people merit so much more from white Australia. First and foremost, they deserve white Australia’s trust — trust that Aboriginal people know better than white Australians what is good for Aboriginal people. They deserve (and not just in their music and dancing) recognition of their culture. Two things are necessary — first, Australian society needs to listen and hear the calls of the disadvantaged (and there are so many in Australia today, especially Aboriginal people); then, those who have compassionate voices need to use them. Many people working in healthcare and in universities have social consciences and believe in social justice. They need not only to give voice to the voiceless, but to give themselves voice as decent, white Australians. In this Australia — this divided, divisive, racist, socially unjust society that we have built — we now need institutions and policies that will unbuild it. We need to acknowledge that the “fair go” is struggling to survive, if not already dead. Fairness and compassion need to be once again the guiding principles of our leaders and our democracy. Only then can we build a society where decency can become the fundamental in addressing Aboriginal health. There will be no sudden breakthrough; there is no magic pill. Decency, however, is a good place to start.

Barbara R Henry GradDipHE · Shane Houston PhD · Gavin H Mooney MA

The modernisation agenda is a valiant attempt to move forwards, but is it real change and will it make a difference? As Australia reflects on healthcare directions after a quarter of a century of Medicare, what has the UK done to update its rather older National Health Service (NHS)? In 2000, the “NHS Plan” (www.nhs.uk/nationalplan/) set out an ambitious attempt at modernisation — “to give the people of Britain a health service fit for the 21st century”. It promised record investment and a number of defined dividends for that investment, such as extra hospital beds and more nurses and doctors. Modernisation became the catchword. A Modernisation Board was convened to oversee the process, a Modernisation Agency created to spread good practice, and a number of other organisations established. These include the National Institute for Clinical Excellence, which reviews drugs, new technology and procedures and then issues guidelines; and the Commission for Health Improvement (already re-engineered once), an independent inspection body that publishes reports, including performance ratings. . . . by the time this Postcard appears, it is likely that further reorganisation may have been put in place. The whole scope of the NHS reorganisation that has followed is not worth reporting in detail here, for, by the time this Postcard appears, it is likely that further reorganisation may have been put in place. But what does the government really mean by “modernisation”? Is it a fundamental shift or just words? Are there lessons for Australia and Medicare? The Modernisation Agency (www.modern.nhs.uk) has its sights on a number of areas: primary care, secondary (hospital) care, mental health services, leadership and workforce, clinical governance, innovation and improvement, and good practice. “3 Rs” have been coined — renewal, redesign, respect — and “5 simple rules” laid down: see things through the patient’s eyes; find a better way of doing things; look at the whole picture; give frontline staff the time and the tools to tackle the problems; and take small steps as well as big leaps. There is an obvious abundance of rhetoric, but is there any substance? One example in the primary care arena is coronary heart disease (CHD): 30 CHD Collaboratives have been established across England to improve cardiac services by bringing together professionals working in primary care and their hospital-based cardiological colleagues. Although these Collaboratives aim “to fundamentally redesign the systems for prevention, diagnosis, treatment and care of CHD”, what has actually been instituted (accompanied by fanatical fervour and exaggerated claims about its value) is a quality-improvement exercise that is difficult to generalise and impossible to evaluate. There is an expectation that modernisation initiatives should be evaluated, and the Modernisation Agency has espoused a commitment to “quick and clean” research to capture and share the learning gained through service improvement activities. Despite this commitment, the resources needed for adequate evaluation of modernisation projects are rarely set aside, and only occasionally are academics who are trained and experienced in evaluation of health services brought into the picture. Simultaneously, closure of the excellent NHS Research and Development Programme, established under a previous Conservative government, has seriously curtailed much of the investigator-initiated health services research. Instead, concerns about the slowness and “relevance” of academic enquiry have seen the ascendancy of change for the sake of being seen to be doing something within the NHS. In a world reminiscent of a kind of Maoist “continuous revolution”, an evaluation report, no matter what its quality, does become irrelevant if things have already changed again before the assessment of the earlier initiative is complete. Since the Modernisation Agency was established, Foundation Trusts have arrived on the scene. Those achieving Foundation status are allowed to set their own salary scales and to raise their own capital. The Bill to create them had a rough ride in the UK Parliament and only just survived. We don’t really know yet what Foundation Trusts will achieve, but, presumably, they are a further step towards encouraging private investment in the NHS. We have recently been told that “targets” (benchmarks of performance used as a management tool leading to the awarding of Michelin-like “star” ratings to individual Trusts) are out — they are not popular, nor usually evidence based. So, it’s change again — but is it real change and will it make a difference? Pieter Degeling and colleagues1 have attempted to cut through the rhetoric and suggested that the modernisation agenda requires healthcare workers and managers to accept loss of clinical autonomy. They need to share power through team-based approaches to dealing with the resource implications of clinical activity. These authors find that the top-down method of performance management is not appreciated — and that this displeasure is shared by clinicians not only in the UK but across continents. The change in work practices of clinicians is, of course, only part of the UK modernisation agenda, but it is fundamental to it. By contrast, “modernisation” in Australian healthcare has progressed through incremental change, which can be more sustainable. It needs to take into account Australia’s complex structures, fragmentation of providers and the idiosyncrasies of the State–Commonwealth divide. Yet, there is probably a stronger recognition of the need for incentives — to motivate clinicians, and to avoid heavy-handed, top-down approaches that can leave a workforce feeling demoralised and out of step. Despite its rather eccentric structure, the healthcare system in Australia manages to produce good outcomes. Surveys reveal reasonable levels of satisfaction with the healthcare sytem among workers and patients in Australia, and among the British public there are high levels of commitment to the NHS. However, the morale of the health workforce in the UK is extremely low. If the sceptics among the readers of this Postcard don’t believe there is a difference, come and work in the UK! The good news about the NHS modernisation agenda is that it exists, and is a valiant attempt to move forwards. It is, however, imposed from above, full of rhetoric, short on substance and poorly evaluated. It does not deal with the fundamental problems of the NHS — decades of infrastructure neglect, low staff-to-population ratios, chronic overload, and a focus on process rather than outcome.

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

The doctors' tale. Professionalism and public trust. Donald Irvine. Oxford: Radcliffe Medical Press, 2003 (ix + 247 pp). ISBN 1 85775 977 X The doctors' tale is an insider's story of recent reforms affecting the British medical profession. Donald Irvine presided over the United Kingdom's General Medical Council (GMC) during this turbulent period (1995--2002) and his narrative explores the challenges he confronted in dragging an insular and imperial GMC into the new millennium. Irvine had been elected to the presidency on a reform agenda. Before his ascendancy, reform had been pursued through blueprints for medical education (Tomorrow's doctors: recommendations on undergraduate medical education. London: GMC, 1993) and for professionalism in practice (Duties of a doctor: good medical practice. London: GMC, 1995). But reform had moved at a snail's pace and remained impervious to societal changes. However, all this became history following the well-publicised events in paediatric cardiac surgery at the Bristol Royal Infirmary. Public trust in doctors' abilities to self-regulate and ensure clinical competence evaporated almost overnight. Politicians and the public perceived the GMC as no longer in control. Further shocks followed with the revelation of the medical murders by Harold Shipman; the gross professional misbehaviour of gynaecologists Rodney Ledward and Richard Neave; and the arrogance displayed in the Alder Hey affair. But the Bristol case, which is central to Irvine's theme, was to become the epicentre for reform and restoration of public trust. The second half of his book covers the post-Bristol efforts to advance revalidation of the profession and to achieve GMC change. There are other subplots: the politics involving the British Medical Association, the National Health Service and the Medical Colleges, and the measured relationship between Irvine and the UK Secretary of State for Health. In the details of these interactions lies the book's only drawback -- it all seems so gentlemanly, without passion or heat! The book is easy to read. It is divided into four parts: Irvine's formative years in general practice and its Royal College; his time as a member of the GMC; his seven years as GMC President; and finally his afterthoughts. It is well referenced, with helpful glossaries and appendices. All doctors interested in medical reform and politics should read The doctors' tale, especially those in our health departments and medical boards. I recommend it for anyone who enjoys a good political whodunit. Martin B Van Der WeydenEditor, The Medical Journal of Australia Sydney, NSW

Martin B Van Der Weyden

Project management in health and community services Judith M Dwyer, Pauline Stanton, Valerie Thiessen. Sydney: Allen and Unwin, 2004 (xxi + 200 pp) ISBN 1 74114 055 2. Would I be interested, the polite letter from the Journal asked, in reviewing a book about project management? I turned the letter over gloomily — I couldn’t think of a less interesting title. The sub-text, however, Getting good ideas to work, was a bit of a pull, as I have a big project just starting. One of the frequent deficits of doctors when they assume levels of seniority is a thorough incompetence at management. We are trained with quite different skills in mind, like caring for individual people. Project management is not always well done, even for medicos involved in research — projects often fizzle out not because of problems with design, or messing up the sample, but because of pragmatic failings. So this book might have relevance to all of us involved with projects, and — look! — written for us health folk, and by true-blue Aussies. The book comes in two parts: some of the research and thinking behind projects, and where they fit in organisations and their strategies. There is quite a bit of theory, but few pragmatic data on what works. The theory is littered with technical stuff: it was good to get my head around things I had come across but wasn’t really sure about, like PERT (Project Evaluation and Review Technique), Gantt Charts, WBS (Work Breakdown Structure) and PMBOK (Project Management Body of Knowledge). There isn’t anything here that is intellectually tricky. Don’t worry, they say, about all the technical stuff. Forget the acronyms, all you really need is buckets of common sense. We are introduced to tools (mostly software) that help manage projects, but the finger is wagged in our faces about not relying on them, and the plans they generate. “Project management is an art not an algorithm” (p63). So does any this stuff work? Empirical research is weak, but suggests the usual suspects for failure: insufficient planning, buy-ins from the organisation, planning and so on… The second part of the book is more of a workshop manual. What to do, and, more pertinently, what not to forget. It suggests telltale signs of things going wrong; how to spot the folk who might cause you problems (like the white-ant); and what to do about them. This is the sort of book in which you might pause, smile in recognition, and read on again. There are examples — some real — from Australian hospitals, community health settings, and also Divisions of General Practice. A good book. I am the better for having read it. I think. Christopher B Del MarDean Health Science and Medicine Bond University Gold Coast, QLD

Christopher B Del Mar

Objective: To evaluate changes in quality of in-hospital care of patients with either acute coronary syndromes (ACS) or congestive heart failure (CHF) admitted to hospitals participating in a multisite quality improvement collaboration.Design: Before-and-after study of changes in quality indicators measured on representative patient samples between June 2001 and January 2003.Setting: Nine public hospitals in Queensland.Study populations: Consecutive or randomly selected patients admitted to study hospitals during the baseline period (June 2001 to January 2002; n = 807 for ACS, n = 357 for CHF) and post-intervention period (July 2002 to January 2003; n = 717 for ACS, n = 220 for CHF).Intervention: Provision of comparative baseline feedback at a facilitative workshop combined with hospital-specific quality-improvement interventions supported by on-site quality officers and a central program management group.Main outcome measure: Changes in process-of-care indicators between baseline and post-intervention periods.Results: Compared with baseline, more patients with ACS in the post-intervention period received therapeutic heparin regimens (84% v 72%; P < 0.001), angiotensin-converting enzyme inhibitors (64% v 56%; P = 0.02), lipid-lowering agents (72% v 62%; P < 0.001), early use of coronary angiography (52% v 39%; P < 0.001), in-hospital cardiac counselling (65% v 43%; P < 0.001), and referral to cardiac rehabilitation (15% v 5%; P < 0.001). The numbers of patients with CHF receiving β-blockers also increased (52% v 34%; P < 0.001), with fewer patients receiving deleterious agents (13% v 23%; P = 0.04). Same-cause 30-day readmission rate decreased from 7.2% to 2.4% (P = 0.02) in patients with CHF.Conclusion: Quality-improvement interventions conducted as multisite collaborations may improve in-hospital care of acute cardiac conditions within relatively short time frames.

for the CHI Cardiac Collaborative*

There are concerns that Australia is facing an impending shortage in the medical workforce, and there are significant changes occurring in key determinants of medical workforce supply and demand. To date, workforce planning has not taken into account the full range of dynamic variables that are involved, nor accounted for their inherent uncertainty and complex interactions. Future planning will require more careful monitoring and dynamic modelling within a full healthcare system perspective.

Catherine M Joyce BA(Hons), MPsych · John J McNeil PhD, FRACP, FAFPHM · Johannes U Stoelwinder MD, FRACMA, FAFPHM

A recent editorial looked at the way the problems at Camden and Campbelltown hospitals were managed, and has attracted a range of opinions Be very afraid Brad Frankum,* Duane Attree,† Andrew Gatenby,‡ Sandy Eagar,§ Anthony Aouad¶ * Director of Medicine, and Conjoint Associate Professor, University of New South Wales; † Clinical Decision Support Manager; ‡ Chair, Division of Surgery; § Nurse Manager, Professional Development; ¶ Chair, Clinical Advisory Council, and Physician; Macarthur Health Service, PO Box 149, Campbelltown, NSW 2560. Brad.frankumATswsahs.nsw.gov.au To the Editor: In reply to your question as to whether the crassly phrased “Cam Affair” was “an isolated incident or destined to be repeated?”,1 doctors and administrators throughout our healthcare system should be very afraid. They may be next; this was no isolated incident. We who continue to work in Macarthur Health Service (MHS) expect a daily dose of ill-informed and inaccurate “revelations” about our hospitals in the media. Our despair increases, however, when we read similar superficial comments from your esteemed publication. For the record, before the leaking of the draft Health Care Complaints Commission (HCCC) report, some of the following systems and solutions had already been put in place at MHS (implementation date in parenthesis): Performance management of all staff — including 100% of all senior medical staff — with focus on Key Performance Indicators and implementation of the Clinician’s Toolkit (March 2003). Capital development at a cost of over $100 million (ongoing). Appointment of 45 new consultants across a variety of specialties (2000 to September 2003). Appointment of an academic full time Director of Medicine (January 2003). Establishment of new and innovative services in ambulatory care, acute medicine, emergency short stay, paediatric emergency, stroke, palliative care, cancer therapy, rehabilitation/geriatrics, radiology, community maternity and paediatrics, and mental health. A local graduate nurse program with over 85% retention rate (1998–2003). Rigorous identification of all adverse events from acute settings by having dedicated staff and weekly multidisciplinary team review of cases (2001–2003). Weekly multidisciplinary grand rounds (January 2003). An active partnership with members of the community through a Community Council, community review of complaints handling and inclusion in MHS committees (2002). A functional and well represented Allied Health Council and Discipline Seniors Committee. Well attended and widely represented (including community) Clinical Advisory Council (December 2002). Multidisciplinary team meetings and quality review in all specialty departments (July 2003). Increase from one to three Royal Australasian College of Surgeons accredited surgical registrar positions since 2000. Successful Postgraduate Medical Council accreditation (2003) and recruitment of 6 additional Junior Medical Officers. Are these the actions of an “indifferent administration”? Was there any attempt to place these adverse outcomes in the context of an extremely busy health service; one with historically the poorest staffing levels of any metropolitan hospital in New South Wales (Box) and a health service existing in a population with one of the highest growth rates in Australia?7 No one wishes to minimise the impact on the families of those who suffered adverse outcomes. However, anyone who works in a public hospital knows that adverse events occur. The established rate internationally ranges from 3.7%–45.8%.8 Applying the accepted rate in Australia (16%), Camden and Campbelltown hospitals should have had 26 667 adverse events in the years 1998–2003. The number of cases highlighted in the various investigations (71) represents an adverse event rate of 0.043%. The only appropriate way to deal with these events is through a rigorous quality framework making use of the expertise of staff at the coalface. The handling of our hospitals’ adverse events by various bodies has set this quality agenda back many years. In its report, the HCCC showed that it is a completely inappropriate body to be investigating a health service. It investigated and passed judgements on clinician performance without ever consulting individual clinicians. It convened expert panels unsuitable for the nature of the cases reviewed (eg, no Visiting Medical Officer [VMO] involvement on a panel that investigated over 30 cases of patients under the care of VMO physicians). Our State Health Minister shares this opinion.9 In 2003, MHS achieved 2 years’ accreditation with the Australian Council on Healthcare Standards.10 What, then, does this mean? In 2004, significant numbers of senior clinicians have resigned, the administration has been decimated, and there is widespread bewilderment among the hard-working, skilled and dedicated staff. The media and politicians on both sides have behaved poorly. Ironically, staff now fear to speak out publicly, because to do so may jeopardise the assistance and resources we may finally be afforded. Obviously the government and bureaucracy would prefer the general public to believe that MHS is the only “sick hospital(s)” in the healthcare system, find some individuals to blame, play catch-up with resources, and watch the problem evaporate. Furthermore, a new threat is emerging: if you undertake investigation into adverse events, you risk confidential cases being easily identified and passed on to the media and regulatory bodies. If you are a clinician and you treat enough patients, one day you will make a mistake. Be very afraid. The precedent is set — blame is back on the agenda. Occupied bed-days, emergency department presentations and staffing levels at Sydney public hospitals Hospital Bankstown St Vincent’s Macarthur Sutherland Hornsby Admissions in 2002/03 26 2252 29 6813 29 4092 19 3963 16 9644 Emergency department presentations (for November 2003)5 2 710 2 755 3 713 2 590 1 922 Salaried medical officers (FTE)6 128.61 266.7 70.83 93.26 108.87 FTE = Full-time equivalent. Staff goodwill is running out David Rosenfeld Chairman, Liverpool Health Service Medical Staff Council, Liverpool Hospital, Locked Bag 7090 Liverpool, Sydney, NSW 1871. d.rosenfeldATunsw.edu.au To the Editor: In response to your recent editorial,1 I would like to point out the following. The Sydney Metropolitan Area Health Services, comprising Northern Sydney, South Eastern Sydney, Western Sydney, Central Sydney, South Western Sydney and Wentworth, had a budget expenditure for 2001/02 of $4581 million (information from internal Department of Health documents). The combined population of these health service areas was 3 887 142, and dividing this expenditure by the population gives annual expenditure of $1178.66 per person. In 2001, South Western Sydney Area Health Service (SWSAHS) had a population of 797 510,2 making it the most populous of all these health areas. Dividing SWSAHS’s expenditure by its population gives an annual expenditure of only $920 per resident. Population projections (an increase of 14.9% from 2001 to 2006) show SWSAHS to be the fastest growing of all, which means the funding per resident will continue to deteriorate. To spend the 2001 average on SWSAHS residents would require increasing this health service’s budget by $205 million. This is the crux of the whole problem. For far too long, residents of SWSAHS have lagged far behind their metropolitan neighbours in healthcare expenditure. These figures do not even take into account the marked disparity in research funding flowing to other metropolitan areas compared with SWSAHS, nor all the private hospitals and level of privately insured patients in other health areas, which would probably more than double the health expenditures already listed. Further, SWSAHS has the highest ethnic population in the country and is the most socioeconomically disadvantaged; our expenditure on interpreter services and social workers consumes a disproportionate percentage of our funding. The state Department of Health has long recognised this disparity, and has been trying to redress the problem. However, unless significant additional funds can be generated, resources will need to be redistributed from other Area Health Services. This can be extremely difficult — long-established teaching hospitals have very well resourced support networks and links that go back many years. SWSAHS includes Liverpool Hospital, which is a tertiary referral service still funded as a district hospital. Unfortunately, the only real surprise to staff working there is that the recent problems have not happened before, and that they have not happened at more of the hospitals in SWSAHS. Medical research in SWSAHS is extremely limited. We struggle to appoint advanced trainees. We are trying to teach our undergraduates in an environment with shrinking teaching resources, and the promise of $5 million is a couple of zeros short of what is needed. It is only through the goodwill of staff, and their extraordinary commitment, that we have survived this long. Senior medical staff are now leaving in significant numbers because of “burnout” and overwork. The solution is not money alone, and it is certainly not “working smarter”. Colleges need to make rotation compulsory for advanced trainees so that they can be exposed to a wider variety of clinical cases. There need to be inducements locally to attract staff — including not charging them more for parking than any other hospital! There are no simple answers, but blaming inadequately trained and resourced staff, who are placed unwillingly in situations beyond their competence, is severely damaging to all SWSAHS staff. Diagnosis before treatment: don’t blame funding Paddy A Dewan Paediatric Urologist, PO Box 152, Parkville, VIC 3052. Paddy. DewanATwh.org.au To the Editor: In your recent editorial, you make the statement “it is hoped that something more substantial than yet another list of blameworthy individuals will emerge from the inquiry”, and then blame funding shortages for substandard care,1 highlighting how pervasive blame and guilt are! Nonetheless, your suggestion that we have a sick, politically motivated health-care system is accurate. Improvement will occur if we, as medical service providers, take responsibility for the deficiencies and accept that we and our system are inadequate for a whole host of reasons, including less-than-perfect science, and competition rather than collaboration between specialties and specialists, to name just a few. Even more importantly, we are constrained by an unfriendly work environment in much of the public hospital system, for which we blame the budget. Money never made anyone happy! Unfortunately, hospital administrators are usually not “in for the long haul” and often seem poorly focused on the needs of the patients, let alone the emotional needs of staff — an administrator’s career is more dependent on meeting “targets”. The workplace environment is further marred by the limited ability of some of our clinical colleagues who have been “elevated” to management positions, where they manage budgets, complex interpersonal issues and patient complaints. Strategic planning, root-cause analysis and staff satisfaction are terms without real meaning to many of these doctors, who appear to be set up to fail. Once in the clinical administrative position there seems little in the way of “staff caring” performance review. Interpersonal conflict and politics often predominate, and bullying is facilitated by these high-stress environments, exacerbated by the threats of litigation from patients, some of which occur because unhappy staff lash out at consumers. As we tend to view adverse events as something for which families will seek legal solutions rather than seeing such events as opportunities for change, we are frightened. Because we are stuck in a culture of fear and blame, we avoid these patients rather than try to share the hurt that comes from an adverse outcome. Thus, minor imperfections are dismissed as inevitable, and for more major adverse catastrophes we seek qualified privilege to feel protected. However, we are not protected by hiding; we are protected by dealing with a complaint as a challenge to improve rather than a reason to abuse the person who points out a deficiency. At the Royal Children’s Hospital, Melbourne, a senior clinician expressed concern about quality of care, for which he was progressively marginalised, put through an unjust request for resignation, and exposed to a hospital board review conducted with no clinical expertise and little understanding of bullying. The clinician’s appointment was then terminated because he went to the media, and his termination was justified by a clinical review with restrictive terms of reference. The circumstances were similar to those of the “Cam affair” in the Macarthur Health Service. The public and the medical community can only conclude that politics, and not standards, drive the health agenda, a view that was confirmed during a recent Victorian parliamentary inquiry into community advisory committees of hospital boards that did not allow major concerns of selected people to be heard by the public. This lack of transparency, and lack of partnership, at all levels, should be replaced with a more open, trusting culture with greater accountability, less blame and less hollow jargon. When will we ever learn! In support of the HCCC John H T Ellard Psychiatrist, 29A Almora Street, Balmoral Beach, NSW 2088. manstumATtpg.com.au To the Editor: Your recent editorial1 raises some very interesting questions. The Health Minister commented in his press release that the “HCCC [Health Care Complaints Commission] does not go far enough in terms of finding anyone accountable for these failures”.2 He could have set his mind at rest by consulting the relevant articles in the Encyclopaedia Britannica. In essence, in the system of government that we have, with Cabinet responsibility, he is the person with the ultimate responsibility. If his departmental and administrative heads did not keep him properly informed and advised, then surely their heads should roll rather than that of the HCCC Commissioner, whose report demonstrated that there were big problems. I believe that one of your suggestions — that of dismantling the “highly centralised HCCC” and replacing it with regional panels — is very likely to make things worse rather than better. The first question to be answered in an inquiry of this kind is whether or not there was medical error, incompetence or impropriety. This involves a careful and detailed examination of the information available about the event or events in question. There are allegations and responses, and there is often a large body of clinical notes, hospital records and laboratory results to be read most carefully and considered. Sometimes the issues are simple, and sometimes they are complex, requiring the assessor to have considerable experience, detailed specialist knowledge and to make literature searches. Not every local area will have a sufficiently wide range of expert assessors. The capacity to find competent, experienced, unbiased assessors diminishes as the geographical and administrative areas to be considered become smaller. Remember that the HCCC has to deal with all the registrable healthcare professions — not only medical practitioners, but psychologists, nurses, physiotherapists, osteopaths and the like. Consider the amount of time and effort required to set up the panels in all these activities in each local area. I will conclude by indicating what I believe to be the fatal error in your suggestion. Imagine that the preliminary inquiries strongly suggest that the problems in question arose from a lack of resources and that the government of the day is substantially responsible for what happened. I have the greatest difficulty in believing that the area’s state and federal politicians would be capable of coming to an opinion which laid the fundamental blame on the government of the day, if it happened to be that of their party. I believe that the “Cam affair” provides an indication of what would happen. I have been associated with the present system since it began as the Complaints Unit and then became the HCCC. I do not suggest that it has reached perfection, but long observation convinces me that it has played a valuable role and that many errors and improprieties in medical practice have been much diminished because of its good work. No profession has ever welcomed scrutiny from outside its ranks, and there are still those in medicine who hold that position. I am in firm disagreement. The healthcare complaints commission needs reform, and politicians must accept ultimate responsibility Martin B Van Der Weyden Editor, The Medical Journal of Australia, Locked Bag 3030, Strawberry Hills, NSW 2012. editorialATampco.com.au In reply: We at the Journal welcome criticisms as treasures from which we always learn. The recent editorial on the “Cam affair” has certainly provoked responses from a number of our readers. Let me state from the outset that I fully understand the tension so evident in the remarks of Frankum and his colleagues from the Macarthur Health Service. However, I am not sure why our choice of the phrase “Cam affair” has caused so much apparent distress. The Concise Oxford Dictionary defines an affair as: “1 a concern; a business; a matter to be attended to (that is my affair). 2 a a celebrated or notorious happening or sequence of events. b colloq. a noteworthy thing or event (was a puzzling affair). 3 = love affair. 4 (in pl.) a ordinary pursuits of life (current affairs). b business dealings. c public matters.” The unfortunate events within the Macarthur Health Service over the last year certainly constitute “an affair” which will be remembered for some time; whether its use is “crass” is in the eye of the beholder. I am heartened to read the administrative and clinical progress listed by Frankum et al. However, as late as August 2003, the Macarthur Expert Clinical Review Team recommended, among other things, the need for significant leadership in the hospitals’ clinical and administrative spheres, and the involvement of academic institutions and clinical colleges to make the hospitals more professionally attractive for postgraduate training and senior staff. Central to all this is the importance of doctors in training in Sydney’s south- west to be seen to successfully withstand the scrutiny of our clinical colleges, on par with other metropolitan hospitals. This will only come with an enhanced academic presence in all major clinical disciplines of the Macarthur Health Service. Again, I am heartened to read that this is happening, albeit slowly. Rosenfeld’s data reinforce one of my editorial’s contentions, that the Cam affair was a system failure, a “mismatch between clinical capacity and clinical demand — a mismatch exacerbated by the chronic ‘poor country cousin’ status of Sydney’s outer metropolitan hospitals compared with their ‘rich city cousins’, the established inner city hospitals”. However, transfer of resources alone will not solve the problems. Our public hospitals are 19th-century institutions at sea in the 21st century, and they need reform. This will require urgent short-term and long-term solutions to meet the obvious funding and workforce deficiencies, but also fundamental system reform. How long do doctors and other healthcare professionals have to send out SOSs that the public hospital ship is sinking before bureaucrats and their political masters respond? Dewan’s comments are apt; our healthcare culture is not good at confronting criticism. Witness the experiences in Bristol1 and Winnipeg.2 We desperately need an open, blameless and depoliticised environment which allows individuals to speak frankly about individual or systemic shortfalls and failures, and clear pathways for these to be addressed. Finally, Ellard is not certain that dismantling the highly centralised Health Care Complaints Commission is a good idea. Modern management principles eschew top-down, people-insensitive systems as appropriate quality improvement tools, and the HCCC allegedly has all these attributes. Further, the Commission provides politicians, as aptly noted by Ellard, with another means of dodging their responsibilities. It is evident that the healthcare complaints system needs reform. Thus, my suggestion for local complaints panels headed by an ombudsman, and involving local health professionals and politicians, was meant not only to promote debate, but also to engage an inclusive, bottom-up approach. I am not rigidly committed to the local entity, but whatever strategies and recommendations emerge from current parliamentary enquiries they must ensure the integrity of systems and locate these close to where the healthcare action is played out. It is also imperative that local politicians on both sides of politics are involved along with healthcare professionals, and that the current emphasis on investigation of individuals is shifted to investigation of systems. Finally, it is crucial that any reporting undertaken is directed, not to health bureaucrats or the Minister for Health, but to Parliament as a whole. Our politicians must take collective responsibility for healthcare in the communities they purport to represent. Anything else is political bastardy.

Brad Frankum · Duane Attree · Andrew Gatenby · Sandy Eagar · Anthony Aouad

Patient care and outcomes could be significantly improved if the knowledge gained from health research was better translated into practice. This is the message from studies suggesting that 30%–40% of patients do not receive treatments of proven effectiveness and that 20%–25% have treatments that are unnecessary or potentially harmful.1,2 Three years ago, the Australian Government established the National Institute of Clinical Studies (NICS)3 to improve healthcare by helping to close important gaps between the best available evidence and current clinical practice. The NICS aims to do this by working with clinicians to support evidence uptake, helping to increase knowledge about the science of evidence uptake in clinical care, building national capacity for evidence uptake, and advocating for systemic change that will improve the use of evidence in clinical practice. The Institute was initially chaired, before his untimely death, by Chris Silagy, a world leader in promoting better use of evidence in healthcare. In its first years it has worked with a range of partners to identify important gaps between evidence and practice and to develop and test approaches for assisting clinicians to improve evidence uptake in these areas. Priority areas for initial work were chosen to reflect a range of disciplines, issues and settings, and to develop methods and tools that could be used in other clinical areas or settings with similar barriers to evidence uptake. Current projects focus on improving emergency care, heart failure management, pain management in cancer care, and prevention of deep vein thrombosis. In 2002, the NICS funded a targeted grants program for investigators seeking to improve appropriate use of interventions over a broader range of areas. Since then, the Institute has invested in a longer-term capacity-building program by developing evidence implementation fellowships. The NICS has also been identifying which measures are known to improve evidence uptake and which are seemingly ineffective, and is seeking advice on ways this knowledge might be best applied in Australia. In November 2003, the Institute held a meeting in Hobart at which a wide range of healthcare professionals, social scientists, policymakers and consumers met to discuss possible approaches to improving evidence uptake across the Australian healthcare system. Two working groups convened by the NICS, one chaired by Jeffrey Robinson and one by Chris del Mar, developed initial proposals for the meeting participants to discuss. The meeting was addressed by two overseas experts in knowledge translation approaches — Martin Eccles, from the United Kingdom, and Jeremy Grimshaw, from Canada. These acknowledged experts are the first visitors brought to Australia by the Institute to help inform its work program. This Supplement presents a report of this meeting.4 It also draws together a number of articles on ways to promote clinical change from people who contributed to the strategies discussed at the meeting and from other experts who will be visiting and providing advice to the NICS in the coming year. Many of these articles highlight the limitations of current studies and emphasise the need to learn more about the ways to promote and sustain behavioural, organisational and system change in healthcare. Research that builds understanding about diffusion of innovation and factors influencing knowledge uptake comes from a broad range of disciplines, many of which lie outside the traditional areas of focus for healthcare research. Grol and Wensing (page S57) outline theories and models of change and emphasise the need to address barriers at different levels when complex changes are required to improve care.5 They illustrate their argument with an analysis of the lessons for improving diabetes care, but the same principles could be applied in other areas. The article by Eccles and Grimshaw6 (page S52) focuses on the quality of guidelines and on features that might enhance their use. The article by Davis and colleagues (page S68) on the work of the Ontario Guidelines Advisory Committee7 shows the way one group supports clinicians by finding and appraising the quality of available guidelines and by developing practical implementation strategies. Factors influencing the adoption of innovations, and the difficulties and potential facilitators of sustainable change, are discussed in contributions from Australian experts in the field of behavioural change (see pages S55, S66).8,9 Other issues relevant to achieving successful change are discussed in articles by the Chairs of the working groups that developed strategies for the workshop participants to consider (see pages S63, S61).10,11 Grol and Grimshaw have commented elsewhere that, while sometimes the step from best evidence to best practice is simple, most of the time it is not12 — research so far shows that none of the many different approaches to changing practice is superior for all changes in all situations. The potential strategies for evidence implementation suggested at the Hobart meeting incorporate a variety of features and approaches. The “bare bones” of these strategies will be developed for consideration by the NICS Board. Further discussion with stakeholders will examine the feasibility of various approaches, leading to a decision about which strategies might be developed further, tested, and taken forward in 2004.

Heather Buchan MB ChB, MSc, FAFPHM · Jillian R Sewell MB BS, FRACP · Melissa Sweet BA, MA

Your brief is to develop innovative strategies which will encourage the widespread, sustainable and systemic adoption of evidence-based practice, with the goal of improving patient care. These strategies must be capable of being tested in different healthcare settings and of involving both private practitioners, including general practitioners, and the public sector. You should also suggest plans for their evaluation, including impact on patient outcomes, cost-effectiveness, and contribution to the knowledge base about change implementation in healthcare. This was the set of challenges given by the National Institute of Clinical Studies (NICS) to a multidisciplinary group of more than 70 strategic thinkers who attended a 2-day workshop in Hobart in November 2003. Workshop participants were not there to represent their organisations, but to lend to the task their individual expertise, creativity, and pragmatic knowledge of Australian healthcare systems. Summary of draft strategies developed by the two working groups to encourage the adoption of best evidence into practice in Australia General practice/community focus 1. Finding and plugging evidence gaps for common problems in general practice. Clinical data on the most common clinical reasons for encounter would be collected from general practitioners who had been recruited through Divisions of General Practice. This information would identify areas in which best evidence could be applied and would form the basis of an intervention to be tested through a randomised controlled trial, with Divisions as the unit of analysis. 2. An “evidence SWAT team”. The team would raise “evidence literacy” and counter the impact of unreliable information by strategic entry into health debates through the media, general practices and pharmacies. The team would act as a media “watchdog” and produce media releases, a website, briefing notes for GPs and pharmacists, and patient information. 3. A national network of dedicated evidence-based general practice sites for information transfer evaluation. Ten exemplary general practice sites would implement evidence-based practice. They would incubate and test new evidence-based tools and training. These sites would also have a teaching and training role and provide education for patients. Hospital focus 1. Creating and sustaining the evidence-based hospital. An evidence-based practice support unit would promote organisational change. The unit would regularly review the evidence for best practice, support guideline development and implementation, conduct audits and evaluation of practice, and develop close relationships with clinical units. 2. A stepwise approach to changing behaviour. Volunteer hospital units would be recruited to participate in a pilot study before a national implementation plan was rolled out. Units involved would identify what best evidence would be the focus of implementation and use interventions in stages of increasing cost and complexity to change practice. 3. Clinical research implementation networks. These teams would implement best clinical practice and evaluate its use. They would set clear objectives, form a central steering group, identify relevant evidence and priorities for implementation, and identify relevant process and outcome measures. SWAT = special weapons and tactics. Forward planningIn preparing for the workshop, the NICS convened two working groups — one to focus on general practice/community care and another on hospital care — to develop potential strategies to encourage adoption of best evidence, which could then be considered and further developed by the workshop participants. The two working groups were asked to develop generic change strategies to encourage implementation of evidence. It was specified that the strategies should: be appropriate to the Australian environment; produce positive outcomes for the greatest possible number of Australians; include ways of identifying and incorporating new evidence over time; be feasible and implementable by the NICS and partners from 2004; and be affordable. The detailed draft strategies developed by the two working groups are briefly summarised in the Box. The processWorkshop participants were given an overview of current knowledge by two international authorities in the area of evidence uptake: Professor Jeremy Grimshaw, Director of Clinical Epidemiology at the University of Ottawa, and Professor Martin Eccles, Professor of Clinical Effectiveness at the University of Newcastle upon Tyne. Professor Grimshaw said there was increasing interest in knowledge translation activities to promote evidence-based practice. However, there were many barriers to this occurring. The evaluation of guideline dissemination and implementation strategies had been flawed, with the result that there was an imperfect evidence base to guide decision-makers. They would have to exercise considerable judgement about how best to use limited resources for implementation. Professor Eccles said guideline developers traditionally have not taken the crucial extra step of spelling out the implications of the guidelines for practice. He described an intervention that successfully reduced ordering of lumbar spinal x-rays in the routine investigation of back pain in primary care in England and Scotland. It involved identification of local influential people, dissemination of guidelines, education of key stakeholders (including radiologists), and audit and feedback. A key component was instructing radiologists to attach a reminder note about the appropriate ordering of lumbar spinal x-rays when reporting back to GPs. However, it could not be assumed that such an intervention would be effective in other settings — for example, in Australia, the fee-for-service environment might be a barrier. Workshop participants then considered the strengths and weaknesses of the six draft strategies (Box) and further developed the proposals. Some participants also wished to develop other, new approaches. Workshop outcomesDiscussions highlighted the complexities surrounding the design and evaluation of systems to promote evidence uptake. They also reflected the challenges posed by this novel strategy-development process in engaging the expertise and perspectives of a variety of disciplines and stakeholders. In the end, it was not possible within the format of the workshop to address all of the challenges posed to participants at the outset. It is noteworthy that participants strongly valued the process of the workshop as well as its outcomes, judging by the post-workshop evaluation survey completed by participants. Group work and discussions led to some of the original proposals being built on, modified, rejected and/or amalgamated. The overall approaches that participants worked on included: establishment of clinical networks, using a variety of approaches and in a variety of settings; establishment of a media “watchdog”; and development and implementation of point-of-care interventions to promote evidence uptake. The common thread to these approaches was the notion that strategies may be more effective at encouraging evidence uptake if they target communities rather than individuals. The following is a brief summary of the workshop outcomes. 1. Establishing clinical evidence uptake networks, using a variety of approaches◆ Defining a networkA network has been described as a linked group of professionals and organisations from primary, secondary and tertiary care, working in a coordinated way that is not constrained by existing organisational or professional boundaries to ensure equitable provision of high quality, clinically effective care. The emphasis . . . shifts from buildings and organisations towards services and patients. Another view was that a network is “a group of people with a common interest”, existing because of the need to accomplish a real practical purpose. Networks could be pre-existing or new, national or local, and could extend beyond the hospital setting into primary care. Existing networks would need to identify evidence uptake as an additional core goal. The workshop group thought networks would work in most situations and settings, except where there was no evidence available or no organisational willingness to be involved, or where there were other constraints such as geographical limitations. Generally, networks would be patient-, discipline- or problem-based, rather than organisationally based. Examples of services and clinical areas in which evidence uptake could be a key feature of a network include pregnancy and newborn services; a diabetes network; a network forming around acute stroke management; maternity services; and intensive-care units. In other words, they must have strong service structures with multidisciplinary care and multiple interfaces. Desirable features of networks would include commitment to implementing evidence-based practice and sharing lessons with the NICS and other bodies; capacity to measure practice and change in practice; strong clinical leadership and sustainable infrastructure, such as colleges/hospitals — ie, a strategy for continuation once NICS support is no longer available; intention to include consumers and other professionals working in the same field; capacity to engage a majority of healthcare providers; capacity to be applied across settings; coverage of an area that is important and has national relevance (eg, chronic disease such as heart failure); willingness to develop a strategy for national adoption — one that goes beyond the pilot project and beyond the NICS’ specific support; capacity to access evidence of effective care — there must be evidence available of a gap, of a useful intervention, and of a significant, measurable, modifiable problem; a supportive body or partnership; effective governance and project management; expertise in the behavioural sciences. ◆ Views on how networks might operateIdentifying and supporting potential networks. The NICS could publish its criteria for an evidence-based clinical network and call for expressions of interest from networks to undertake a clinical-change program in areas identified as having gaps between best available evidence and current practice. The networks would source reliable evidence, have explicit criteria for selecting priority areas for action, develop an understanding of the situation and the relevant behaviours (including barriers and incentives to change), develop strategies for change, negotiate issues related to the interface between hospitals and other care environments, have a risk-management process, and measure clinical behaviours. The Institute could provide funding and support and could have a strong role in ensuring there was independent evaluation of the process. The Institute could also develop and provide tools for defining problems, identifying and reducing barriers, measuring, changing management, redesign, organisational development, quality improvement and team building. Plugging the gaps in primary care. This approach would focus not on individual GPs, but on Divisions of General Practice and other primary-care providers. The community would be involved in identifying areas of action and developing intervention strategies. The NICS and other organisations could help the Divisions drive this forward. Developing a broad-based approach. The NICS could take a “macro” approach, linking in with existing general practice and primary-care groups and increasing the uptake of evidence-based practice in general practice through capacity building of the whole practice team. There would be focus on a protocol-driven approach in chronic-disease management. The use of pooled practice data and feedback after analysis, together with chronic-disease registers to capture data, would help drive evidence use. Developing a “home base” of expertise. The NICS could convene a taskforce to develop a discussion document outlining a “home base” model for promoting evidence uptake through Divisions of General Practice. The home base would provide expertise in change strategies, biostatistics, systematic reviews, communication and qualitative research. Clinical priorities would be established, evidence sourced, and change strategies developed. Using an integrated systems approach. The NICS would encourage an integrated general-practice systems approach focusing on both the practice team and patients, using a “plan–do–study–act” cyclical model. This approach might target areas such as cardiovascular disease, diabetes and “SNAP” (smoking, nutrition, alcohol, physical activity). Strategies for the practice team could include incentives, practice development workshops, skills-building and networks. The patient-based intervention would “skill up” patients so that they could stimulate GPs to better adopt evidence-based practice. The role of the NICS could be to act as a catalyst by providing GPs with evidence and guidelines and getting information to patients. 2. Establishment of a media “watchdog”A media “watchdog” initiative would aim to increase individuals’ awareness and ability to be critical about the validity of health-related claims by raising “evidence literacy” and countering the impact of unreliable information, through strategic entry into health debates via the media. The project would be providing information about evidence — not definitive health advice. It would aim to encourage people to be more questioning of health information, to make greater use of reliable information sources, and to reduce the use of non-evidence-based interventions by the public and clinicians. A further aim would be to improve the quality of media reporting. The brief of the media watchdog would be to respond to information in news media and other forms of media (including advertising, promotions and Internet campaigns), as well as breaking scientific news and information. It would also be proactive, through “horizon scanning”, being prepared, reviewing the past for recurring issues, and reinforcing positive messages. This initiative would require considerable strategic planning and risk management. As an initial step, the NICS could establish a pilot project. 3. Development and implementation of point-of-care interventions to promote evidence uptakeEvidence provided at point of care can influence practice, and there is a need to tailor evidence for local practices. Different types of clinical environments require different types of point-of-care information. To inform decision-making, evidence must be limited to the essential. The NICS could support development of a kit that helps identify need, practice/evidence gaps, evidence, barriers and opportunities, appropriate strategies, information needs of decision-makers at point of care, strategies to ensure that information is used (such as checklists), feedback mechanisms for users, and evaluation. This approach would work well with existing and future clinical networks for specific issues and problems. Risks include overlap/duplication with other information systems, a perceived threat to professional autonomy, and obsolescence. As an initial step, the NICS could undertake a systematic review of point-of-care interventions and a stocktake of current developments in this area and identify a few priority areas in which lack of immediate information is the cause of the practice/evidence gap. Where to next?The suggested strategies will be further explored by the NICS Board with the aim of developing suitable ideas for implementation in 2004.

Melissa Sweet BA, MA

Overseas studies that aim to quantify the evidence base of conventional medical care give varying estimates, but many of these studies have potential for bias. We do not know how much of the total healthcare Australians receive is based on the best available evidence; studies of a number of specific conditions show that there are gaps between what is known and what happens in practice. The National Institute of Clinical Studies aims to identify and test systemic approaches to embed ongoing review and uptake of evidence into routine clinical care.

Heather Buchan MB ChB, MSc, FAFPHM

Traditional approaches to disseminating research findings have failed to achieve optimal healthcare. In a systematic review of 235 studies of guideline dissemination and implementation strategies, we observed the following: there was a median 10% improvement across studies, suggesting that it is possible to change healthcare provider behaviour and improve quality of care; most dissemination and implementation strategies resulted in small to moderate improvements in care; multifaceted interventions did not appear more effective than single interventions. The interpretation of our systematic review is hindered by the lack of a robust theoretical base for understanding healthcare provider and organisational behaviour. Future research is required to develop a better theoretical base and to evaluate further guideline dissemination and implementation strategies.

Jeremy M Grimshaw PhD, MBChB, FRCGP · Martin P Eccles MD, FMedSci, FRCGP

There are internationally agreed optimal methods for developing clinical practice guidelines. The quality of published guidelines varies. A validated assessment instrument should be used to identify well developed guidelines that can be used with confidence. There are multiple ways of presenting guidelines, including computerised systems. Computerisation of guidelines can cover a range of formats, from brief prompts through to complex decision-support systems. Integrating guidelines into computerised reminder systems has been shown to be effective in improving patient care, but there is less evidence to support the effectiveness of guidelines integrated into computerised decision-support systems.

Martin P Eccles MD, FMedSci, FRCGP · Jeremy M Grimshaw MB ChB, PhD

Maximising the adoption of evidence-based practice has been argued to be a major factor in determining healthcare outcomes. However, there are gaps between evidence-based recommendations and current care. Bridging the evidence gap will not be achieved simply by informing clinicians about the evidence. One theoretical approach to understanding how change may be achieved is Rogers’ diffusion model. He argues that certain characteristics of the innovation itself may facilitate its adoption. Other factors infuencing acceptance include promotion by influential role models, the degree of complexity of the change, compatibility with existing values and needs, and the ability to test and modify the new procedure before adopting it. The diffusion model may provide valuable insights into why some practices change and others do not, as well as guiding those who try to effect adoption of best-evidence practice.

Robert W Sanson-Fisher PhD

To bridge the gap between scientific evidence and patient care we need an in-depth understanding of the barriers and incentives to achieving change in practice. Various theories and models for change point to a multitude of factors that may affect the successful implementation of evidence. However, the evidence for their value in the field is still limited. When planning complex changes in practice, potential barriers at various levels need to be addressed. Planning needs to take into account the nature of the innovation; characteristics of the professionals and patients involved; and the social, organisational, economic and political context.

Richard Grol PhD · Michel Wensing PhD

We propose the formation of evidence-based clinical practice support units in hospitals and clinical research implementation networks. The purpose of these initiatives will be to increase the uptake of beneficial forms of care and remove harmful or ineffective practices. They will bring together clinicians and other professionals to improve clinical care across the healthcare system.

Jeffrey S Robinson FRANZCOG · Deborah A Turnbull MPsych(Clin), PhD

Concern about risks associated with medical care has led to increasing interest in quality improvement processes. Most quality initiatives derive from manufacturing, where they have worked well in improving quality by small, steady increments. Adaptations of quality processes to the healthcare environment have included variations emphasising teamwork; large, ambitious increments in targets; and unorthodox approaches. Feedback of clinical information to clinicians is a central process in many quality improvement activities. It is important to choose feedback data that support the objectives for quality improvement — and not just what is expedient. Clinicians need to be better educated about the quality improvement process to maintain the quality of their care.

Chris B Del Mar MD, FRACGP · Geoffrey K Mitchell MB BS, FRACGP

Few studies have monitored change in professional practice over time to determine the sustainability of change. Research from other behavioural change literature shows that initial change is difficult to maintain, with reported relapse rates as high as 80%. Interventions most likely to succeed are based on a clear understanding of target behaviours and the environmental context. Facilitators and barriers are usually multifaceted and occur at a number of interrelated levels. The issue targeted for intervention must be clearly defined at the outset, so that antecedents, determinants and supporting mechanisms can be defined, suggesting points for intervention and strategies for initial and sustainable change. The target population’s readiness to change is an important factor at both an individual and organisational level. In most cases, a combination of different interventions will be needed to achieve lasting change.

Jill Cockburn MSc, PhD

Doctors are inundated with medical information, some inadequately evidence-based, much of it captured in clinical practice guidelines (CPGs). The Ontario Guidelines Advisory Committee (GAC) selects topic areas, searches for all CPGs on the topic, and reviews them using the AGREE Instrument. Based in large part on the AGREE score, the GAC summarises one guideline in each topic area and mounts it on its website, with links to other information (eg, clinical algorithms) where possible. Two topic areas have been selected for implementation — the reduction of unnecessary preoperative testing and the rational management of acute low back pain. Implementation strategies include performance feedback, training of opinion leaders, development of algorithms and reminders, and communication through journals and continuing medical education activities.

on behalf of the Ontario Guidelines Advisory Committee*

Robert N Atkinson Orthopaedic Surgeon, 135 Hutt Street, Adelaide, SA 5000. wattle135ATozemail.com.au To the Editor: In response to Leeder,1 there is no community in this world that can provide free, at the point of contact, healthcare for all its citizens to the current limits of modern medical technology. This problem will in fact become greater as the technology increases and becomes more expensive. Within the available healthcare resources, there is some medical treatment that is essential and there is some that is quality-of-life treatment; where the two merge depends on one’s point of view. If you choose to play sport and injure your knee, the question of who should pay for the treatment arises. If you smoke or have any other lifestyle risk factors, how much should be funded by you, and how much by others? And, within a healthcare system where there is patient contribution, does this contribution empower and encourage individuals to adopt a healthy lifestyle? In essence, I believe the debate in healthcare should be about accessibility of limited resources. Who draws the line, how is the line drawn, and at what level is it drawn? Pouring money into the public health sector may well parallel the analogy of adding another lane to the motorway. We must be careful to share the responsibility of healthcare between the individual and the healthcare providers in an inclusive and not exclusive manner.

Robert N Atkinson

Elizabeth Harris,* Sarah J Simpson,† Rosemary Aldrich,‡ Jenny Stewart Williams§ * Director, † Program Manager, Centre for Health Equity Training Research & Evaluation (CHETRE), University of NSW, LMB 7103, Liverpool BC, NSW 1871. ‡ Conjoint Academic, School of Medical Practice and Population Health, § Research Officer, Newcastle Institute of Public Health; University of Newcastle, Newcastle, NSW. elizabeth.harrisATswsahs.nsw.gov.au To the Editor: Leeder rightly points out that increased funding of the healthcare system does not necessarily result in improved equity within the health system or better health outcomes for the population.1 This challenges us to develop ways of systematically examining how current healthcare practices either increase or decrease equity. The following two Australian initiatives illustrate how we might work to achieve equity in health — that is, provide opportunities for all Australians to achieve their full health potential.2 Clinical practice guidelines (CPGs) are one mechanism frequently used to facilitate improvements in the quality of clinical practice and healthcare. However, the evidence on which CPGs are based often excludes, or does not consider, the needs of relatively disadvantaged populations.3-5 Recognising this gap, the Health Advisory Committee of Australia’s National Health and Medical Research Council published a handbook for developers of guidelines about ways to access, review and collate evidence of the effect of socioeconomic position on health, and apply that evidence when developing CPGs.5,6 At the policy level, Health Impact Assessment (HIA) is gaining increasing recognition as a tool for assessing the potential effects of a policy or program on health. Health Impact Assessment that systematically addresses equity may also offer a way of incorporating equity concerns into the decision-making process. However, HIA is a comparatively new field, and decision makers are not usually trained in assessing the impact of policy decisions on equity. Through the Public Health Education and Research Program, the Australian Government has commissioned the development of an HIA framework to assist decision makers in systematically identifying potential health equity impacts of policies. This equity-focused HIA framework is currently being tested (through case studies in Australia and New Zealand) to assess whether and where it adds value to the decision-making processes. These two examples illustrate practical ways in which decisions by practitioners and policy makers can routinely incorporate equity issues in the Australian healthcare system. Ongoing investment and commitment is required to evaluate whether such initiatives make a real difference in achieving equity in health.

Elizabeth Harris · Sarah J Simpson · Rosemary Aldrich · Jenny Stewart Williams

Alan Rodger Director, and Professor of Clinical Oncology, Beatson Oncology Centre, Western Infirmary, Dumbarton Road, Glasgow, Scotland G11 6NT, UK. alan.rodgerATnorthglasgow.scot.nhs.uk To the Editor: In their amusing Postcard from the UK, Jamrozik, Heller and Weller1 paint a picture familiar to most of us in the National Health Service (NHS), but, as with most art, some licence has been permitted. Comparing the size of the UK NHS workforce with that of the Chinese army is unfair: there are, as they know, four different health services in the UK (England, Scotland, Wales and Northern Ireland), which function separately and distinctly. The NHS Jamrozik et al describe is much more the English model. In Scotland, targets for cancer care have been set, although they will not be applied for over a year yet. In the meantime, NHS Scotland has awarded the three Scottish regional cancer networks an extra £25 million (A$62.5 million) to improve and enhance agreed cancer services to assist them achieve the agreed targets on waiting times, etc. Another example of the difference between the Scottish and English NHS can be found in the detail of the new consultant contract. Scotland is offering its consultants a sabbatical and England does not. I am reliably informed by one of the negotiators that the seed of that idea was sown by me when I was recounting enthusiastically some of the better experiences of working in Australia’s own, if complex, national health service. Finally, those of us who laboured during the 1990s at the coal face of Victoria’s health service will not be unfamiliar with targets. Infringement of targets set for the upper levels of the waiting list (no one in Category 3 could ever expect treatment, so no target was set), and for 12-hour waits in the emergency department, carried huge financial penalties for the institution. The good old NHS is far from unique in its fondness for targets.

Alan Rodger

Behavioural sciences can make a substantive contribution There is continuing evidence of the failure to translate clinical research findings into existing practice: it is thought that 30%–40% of patients do not receive treatments of proven effectiveness and, more disturbingly, 20%–25% of patients receive care that is not needed or is potentially harmful. 1,2 However, the mere existence of evidence is not sufficient to ensure the adoption of best practice into routine clinical care.3 It is not surprising, then, that there is a growing interest in making knowledge transfer from research into clinical practice more effective.4 Many approaches to changing clinical practice revolve around idiosyncratic beliefs and tradition rather than scientific evidence.5 Evidence is needed on which interventions are the most cost-effective for changing clinical practice and healthcare delivery. A recent systematic review of 235 evaluations of guideline dissemination and implementation strategies concluded that “the majority of interventions observed modest to moderate improvements in care”.4 However, the quality of reporting of important aspects of the studies reviewed (such as details of the study interventions and contextual factors) was poor, and often the rationale for the choice of intervention was obscure. Further, only 30% of studies provided any economic data. The results of this review should therefore be interpreted cautiously, as the methodological quality of many of the contributing studies, and of research in this area more generally, is poor.4 There is growing interest in developing strategies to encourage the adoption of best evidence into practice, including efforts to change behaviour. The effectiveness of these efforts is likely to depend on a complex interaction between the nature of the clinical activity to be changed and the costs and benefits of adopting the change for the healthcare professionals, patients and organisations involved. At a recent National Institute of Clinical Studies meeting, involving multidisciplinary experts in the field of promoting the uptake of research evidence,6 these issues were discussed. Delegates agreed that behavioural scientists, working within multidisciplinary teams of researchers, are important players in the process of understanding how change in healthcare providers’ behaviour may be achieved. Behavioural science refers to a broad range of disciplines, including psychology, sociology, management science and education. This disciplinary group may contribute in several ways to the scientific study of changing healthcare providers’ behaviour. Use of behavioural change theories. Behavioural scientists have developed a number of theoretical frameworks to explain how behavioural change is achieved. These include persuasive communication, diffusion of innovation,7 social influences, adult learning theory8 and social cognition.9 Such models can provide useful overviews of issues to be considered when attempting to change healthcare providers’ behaviour. The development of theoretical models for predicting when targeted individuals are likely to respond to different types of intervention would be of considerable benefit. The development of accurate and acceptable measures. Without adequate measurement of relevant clinical behaviour it is difficult to provide accurate feedback to health professionals and to evaluate the effectiveness of any interventions. Behavioural science has addressed issues about how human behaviour can be effectively, accurately and acceptably measured. Techniques include the use of direct observation, examination of the accuracy of self-report by healthcare providers and patients, as well as more controversial strategies such as the use of “simulated” patients. The discipline has also been involved in developing a wide range of other potentially relevant outcome measures, such as satisfaction scales, patients’ perceived needs, quality of life and other indices that may be used to measure the quality of healthcare delivery. Examination of the prevalence of certain behaviours, and the incentives and barriers to the adoption of best-evidence practice. Behavioural science has a long history of exploring variables that may explain why individuals and groups may or may not engage in specific behaviours. There has also been a substantive examination of variables correlated with the performance of behaviours of interest. Strategies to determine the potential prevalence of different behaviours include the use of qualitative group methods such as focus groups, self-completed questionnaires, open-structured interviews with key informants, and a wider representation of the target group. Behavioural science has also examined methodological strengths and weaknesses of the various approaches designed to determine barriers and incentives. Development, implementation and evaluation of interventions designed to change human behaviour. Strategies effective in changing human behaviour have been derived from educational research, health promotion, and other fields in behavioural science. Change strategies that have been evaluated include modifying individuals’ knowledge, attitudes and skills; the social environment surrounding the individual; and the organisational or sociopolitical structure in which individuals operate. The last includes changes in the financial costs and benefits, organisation structures, and more effective ways of communicating information. While the majority of this research has not focused specifically on healthcare providers, many of the principles are likely to be generalisable to healthcare providers. In essence, the behavioural sciences can make a substantive contribution to our understanding and implementation of behavioural change in healthcare providers. This is critical to the process of translating evidence into clinical practice. To achieve the potential that the behavioural sciences can offer to this process, we need to actively involve behavioural scientists in efforts to change provider behaviour and evaluate such interventions. As in other areas of healthcare research, the involvement of multidisciplinary teams working on a common problem is more likely to achieve positive results.

Robert W Sanson-Fisher PhD · Jeremy M Grimshaw PhD, MB ChB, FRCGP · Martin P Eccles MD, FMedSci, FRCGP