Health services administration

The problems of staff and funding shortages implicated in this affair may not be confined to the hospitals in question In December 2003, public confidence in New South Wales hospitals was severely shaken by the release of the Health Care Complaints Commission (HCCC) report on the “Cam affair”. 1,2 This had erupted from the allegations of four nurses who had voiced their concern, some 13 months earlier, over questionable patient care, disregard for quality and safety, and an indifferent administration at the Campbelltown and Camden hospitals of the Macarthur Health Service in Sydney’s southwest.3 The HCCC report detailed a raft of symptoms of a sick hospital and administration system, and outlined a blueprint to rid the health service of this sickness.4 It is hoped that something more substantial than yet another list of blameworthy individuals will emerge from the inquiry. The response by the NSW Minister for Health, Morris Iemma, was surgical and swift: two doctors were suspended and another nine were referred to the NSW Medical Board; disciplinary proceedings were commenced against four administrators; 19 deaths examined in the HCCC report were referred to the State Coroner; and the South West Area Health Board, ultimately responsible for the two hospitals, was dissolved.5 To this point, the minister’s actions had the right political resonance and were ostensibly defensible. But then came a decision at odds with the wisdom of focusing on the message, and not the messenger. The minister noted, “The report does detail in great length instances of clinical failure, deficiencies in management systems, and the failure to ensure appropriate supervision. But for an investigation that took 13 months to complete, the HCCC doesn’t go far enough in terms of finding anyone accountable for these failures [my emphasis].”5 He then dismissed the HCCC commissioner, Amanda Adrian. This baffling, and as yet unexplained, decision might reflect information to which the minister alone is privy, or simply poor advice from his minders. In any event, the commissioner went. To drive home the political focus on accountability, the minister announced yet another inquiry.5 Its brief is not only to retrace the HCCC investigation, but also to “make recommendations as to further actions against individuals, and to refer any matter or person for disciplinary action” and to “make recommendations on the regulatory and administrative arrangement of the HCCC.”5 It is hoped that something more substantial than yet another list of blameworthy individuals will emerge from the inquiry. To the casual observer, the Cam affair resembles the United Kingdom’s high profile Bristol case.6 Both were the result of whistleblowers’ altruism, and their frustration when their complaints about unacceptable patient care and safety fell on institutional deaf ears. In both, the whistleblowers (seven nurses in the Cam affair and an anaesthetist in the Bristol case) paid a high personal and professional price for their public stance. 4,7 In both, there were long initial investigations followed by other inquiries. 5,7 But there the similarity ends. The Bristol case revolved around issues of professional competence and self-regulation,6 whereas the Cam affair centres on, among other things, a mismatch between clinical capacity and clinical demand4 — 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.8,9 But what to do? What are the pathways out of this situation? The HCCC remedial blueprint and the recommendations for change made by the Macarthur Expert Clinical Review Team led by Bruce Barraclough, Director of the NSW Institute of Clinical Excellence,10 have much in common. The Macarthur Expert Clinical Review Team, at the behest of the minister, examined the embattled hospitals in August 2003. Its recommendations include the need for: significant leadership in the clinical and administrative spheres; increased clinical service capacities in workforce and resources; involvement of academic institutions and clinical colleges to enhance the professional attractiveness of the hospitals for postgraduate training and senior staff; and an ethos that encourages open reporting, review and remediation of problems — an ethos that is patient and safety centred. These conventional approaches to troubled healthcare systems are laudable, but the Cam affair also provides opportunities to explore innovative approaches that might be transferable to our troubled hospitals in other jurisdictions. These include: confronting the “silo” mentality of our hospitals by appointing staff, not to specific hospitals, but to health areas, so that expertise and services are available area-wide according to need (there is a pressing need to develop more flexible service capacity within healthcare services); developing clinical services on the basis of area-wide need rather than political or academic opportunism; establishing a tertiary care teaching hospital at the hub of the health area, with real and transparent service or training links with the area’s other hospitals; and developing indicators, or clinical “Plimsoll lines”, which signal higher risks to proper patient care and required quality and safety. At a global level, politicians need to be made more individually aware of, and accountable for, health services. This may be achieved by: dismantling the highly centralised and adversarial HCCC and replacing it with local-area health ombudsmen, accountable to an independent panel comprising the area’s state and federal politicians along with community and health-discipline representatives (such a system would be far more responsive to local difficulties and more in tune with concepts of accountability and quality); and increasing the proportion of bipartisan local, state or federal politicians serving on area health boards, along with limited-tenure members selected for professional prowess rather than political patronage. But change and innovation alone will not allay a real anxiety about whether the Cam affair was an isolated incident or is destined to be replayed elsewhere. The unstoppable demand for hospital services during a medical and nursing workforce crisis, compounded by inadequate hospital funding,11 suggests that the latter is more likely. The community, through its politicians, has a confronting choice: either reinvigorate our hospital services by increasing the number of doctors and nurses and attend to our hospitals’ waning capacity and infrastructure through adequate funding, or await the next Cam affair. Ironically, the Macarthur Health Service’s quality policy statement throughout this affair outlined a commitment to the principles of customer focus, strong leadership, striving for best practice, evidence of outcomes, and a culture of improving.12 But the Cam affair illustrates that, for our hospitals, there is more to quality than rhetoric.

Martin B Van Der Weyden MD, FRACP, FRCPA

To boldly go . . . These famous words from Star Trek have current resonance in general practice here in the United Kingdom, although the optimism of the star ship Enterprise’s voyages is balanced with doses of anxiety. While many in the UK believe that the new contract with general practitioners may be the last chance for the profession, it will, as with the Star Trek voyages, take general practice in this country into uncharted worlds. Repeatedly, surveys find a GP workforce that is despondent, demoralised and overburdened by bureaucracy. Although the reasons for low morale are complex, it’s not all about money: there aren’t the same income disparities between GPs and consultants in the UK National Health Service (NHS) as there are in Australia. . . . in UK general practice the goodwill that has sustained the GP workforce is waning. There appears to be a more fundamental shift in UK general practice — the goodwill that has sustained the GP workforce is waning. There is a sense that something important has been lost, and that core commitment to the national public good can no longer be taken for granted. The fabric of Aneurin Bevan’s uncompromising vision for a new, socialised health service in 1948 (to quote: “We know what happens to people who stay in the middle of the road; they get run down.”) may be lost forever in New Labour’s reforms. An average GP here might earn in the vicinity of £70 000, depending on where in the UK he or she practises, and, under the new contract, earnings could rise by as much as £15 000–£20 000. It’s often recalled that Bevan remarked that in order to sell the idea of the NHS to doctors he “stuffed their mouths with gold”. Some of that ethos is alive in the new general practice contract negotiations, but the GP workforce is weary, demoralised and distrustful — and a bit more streetwise than in 1948. They want improved pay and conditions, and to be able to treat their patients unencumbered by bureaucracy. But, instead, they seem to be getting a very complex package in their new contract, and very few people can confidently predict how it will work. There is no doubt that general practice has become more complex over time. There are more meetings, recurring bed-capacity crises, long waiting lists, and the constant struggle with an increasingly dysfunctional secondary care sector. General practice here is facing a workforce crisis, as it is in Australia. Medical students in Edinburgh don’t seem to want to go and work as GPs in the outer Hebrides or rural Fife; they want to be consultants in England! General practice registrars won’t commit to permanency in practices, preferring more mobile, portfolio-style careers. Will the new general practice contract arrest this decline? It may turn out to be the GPs’ saviour, but it has had some unglamorous moments. They reached a peak in April 2003 with the release of the “Carr-Hill” formula (Box),1 which allowed practices to calculate their incomes under the new arrangements. Despite widespread anticipation of 30% pay rises, many practices found to their amazement that their incomes would in fact decrease! Then the GP tabloids had a field day when, at the height of the crisis, the architect of the funding formula, Professor Roy A Carr-Hill, a highly respected economist from York, was sighted in the mountains of Nepal. The contract targets several sacred institutions in UK general practice. Instead of capitation payments being tied to individual principals’ lists, the contract will be between the “primary care organisation” (usually, but not always, a primary care trust) and the entire practice. GPs will be able to “opt out” of certain non-core services, depending on their skills and interests — hence there will be incentives for practices to join up and jointly provide such services. There will be no compulsion to provide after-hours services — it will be the responsibility of the local primary care organisation to make sure there is after-hours cover. Most importantly, incentive payments will be linked to quality targets. In terms of its quality components, the contract has been described as “the boldest such proposal on this scale ever attempted anywhere in the world”.2 There will be 76 quality indicators in 10 clinical domains of care (eg, hypertension, diabetes management), 56 in organisational areas (eg, record-keeping, training, practice management), four in assessing patients’ experiences (eg, satisfaction, consultation length), and others for additional services. For the first time, there is to be a serious attempt to link remuneration in general practice with quality — not a small undertaking. About 80% of GPs voted in favour of the contract, yet many harbour deep suspicions. This stems in part from the perception that GPs will lose their “independent contractor” status — something they’ve always valued highly in a nationalised health service. Critics suggest that the contract is biased towards those areas of primary care for which there is “evidence” — which naturally tends to favour management of hypertension or cholesterol lowering, possibly at the expense of more complex areas of primary care such as mental health and cancer. Many believe that GPs will become administrators of disease management and prevention programs, and the focus on outcomes may undermine the holistic values of general practice. There are inevitably narrow definitions of good performance in the contract, largely centred around achieving certain markers of clinical outcomes. Undoubtedly, there will be a huge administrative burden on practices, and the need for better information technology systems. Further, there has been no attempt so far to measure the health gain that this initiative will offer to the population served. All complex contracts are unavoidably incomplete, and they contain inevitable “gaps, errors and omissions”.3 Many argue that the need for contracts such as these has arisen out of the erosion of the relationship of trust between doctors and their patients. The government has trusted the profession to deliver high-quality care to the NHS — but events such as the Bristol paediatric cardiac surgery inquiry and the long-undetected Shipman serial murders have effectively undermined this trust. However, it is argued that, instead of replacing this old-fashioned trust with complex contracts, there should be greater emphasis on transparency, with “acknowledgement of deficiencies in patient care and clear, incentivised policies for remedying them”.4 So what will happen when the new general practice contract takes effect in April 2004? At one level, the government must surely be anxious, with all the disaffection and criticism that has been expressed. But perhaps politicians don’t care — if the whole thing unravels there are always organisations distant from the centre of government to blame. There are also established, simpler alternatives to escape to such as Personal Medical Services — a scheme by which providers and local primary care organisations can negotiate local service contracts (often quite financially attractive) which encourage better integrated care and multidisciplinary teams. It’s hard to interpret the values behind current healthcare reforms in the UK, and this has been part of the problem in selling the contract. The old Labour principles of equal access for equal need and of universality do not figure highly in the current government’s agenda; for example, foundation trusts seem designed to increase the distance of government from the provision of healthcare. The trend towards selection of patients, treatments and services on the basis of financial risk rather than healthcare needs seems unstoppable.5 At least, though, there is a plan for general practice. This is in stark contrast to the lack of a coherent approach to the problems facing general practice in Australia. There is no doubt that the Divisions of General Practice in Australia have become a significant lever for change, and the investment through the Primary Health Care Research, Evaluation and Development Program is welcome. However, broader developments, such as the ill-fated flirtation with corporatisation, as well as changes to Medicare, give an impression of drift. At the very least, the new UK general practice contract is taking it somewhere — probably “where no man has gone before”, but let’s hope it’s a journey that leads to renewed hope and vision. Key components of the Carr-Hill formula for the new UK general practice contract1 The various payments that make up the new contract are weighted for factors that influence relative needs and costs. The formula includes adjustment for: the age and sex structure of the population, including patients in nursing and residential homes; the additional needs of the population, relating to morbidity and mortality; level of turnover of patients on the practice list; and the unavoidable costs of delivering services to the population, including variations in costs of hiring staff, and rurality.

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

Objectives: To estimate the magnitude of access block and its trend over time in New South Wales hospitals, using different definitions of access block, and to explore its association with clinical and non-clinical factors.Design and setting: An epidemiological study using the Emergency Department Information System datasets (1 January 1999 to 31 December 2001) from a sample of 55 NSW hospitals.Main outcome measures: Prevalence of access block measured by four different definitions; strength of association between access block, type of hospital, year of presentation, mode and time of arrival, triage category (an indicator of urgency), age and sex.Results: Rates of access block (for all four definitions) increased between 1999 and 2001 by 1%–2% per year. There were increases across all regions of NSW, but urban regions in particular. Patients presenting to Principal Referral hospitals and those who arrived at night were more likely to experience access block. After adjusting for triage category and year of presentation, the mode of arrival, time of arrival, type of hospital, age and sex were significantly associated with access block.Conclusions: Access block continues to increase across NSW, whatever the definition used. We recommend that hospitals in NSW and Australia move to the use of one standard definition of access block, as our study suggests there is no significant additional information emerging from the use of multiple definitions.

Roberto Forero MA, MPH, PhD · Lis Young FAFPHM, RCAP · Hai N Phung MD, MPH · Kenneth M Hillman MB BS, FRCAnaes(Eng), FFICANZCA · Mohammed Mohsin MSc(Stats), MSc(Demography) · Adrian E Bauman MPH, PhD, FAFPHM · Sue Ieraci MB BS, FACEM · Sally M McCarthy MB BS, FACEM, MBA · C David Hugelmeyer FAAEM, FACEM

On a per capita basis, Australia spent more than seven times as much on its Sydney Olympic team as did Canada, to win four times as many medals. Compared with Australia, Canada spent an additional amount per capita (standardised to the purchasing power parity rate at year 2000) of US$1605 per life-year gained on healthcare in 2000. Neither country is “right” or “wrong” in making these funding choices, but they highlight the need for more explicit discussion about what is being spent, what is obtained for the given expenditure and what society actually values.

Craig R Mitton PhD · H Dele Davies MD, MSc · Cam R Donaldson PhD

There is growing interest in involving the public in decisions about healthcare provision. Citizens’ juries, whose members were randomly selected from the electoral roll (rather than derived from consumer interest groups), have been trialled in Western Australia. When asked to take a community focus, presented with balanced evidence and given time to discuss and deliberate, the juries were able to identify and debate issues of broad principle, such as equity. Such issues seem to be best handled by referring to community values. Any public consultation process should provide sufficient information, opportunity for reflection and deliberation, and recognition of the scarcity of resources.

Gavin H Mooney MA · Scott H Blackwell MB BS

A missed opportunity for improvements to medical practice Medical practitioners in New Zealand are to be regulated by a new piece of legislation — the Health Practitioners Competence Assurance (HPCA) Act. The stated purpose of the Act — “to protect the health and safety of members of the public by providing for mechanisms to ensure that health practitioners are competent and fit to practise their professions” — while laudable, is ambitious and conceptually flawed. The resulting legislation is complicated and undermines professional functioning. Its effect may be exactly the opposite of its intention . . . The initial aims of the Bill, as proposed by the Minister of Health, were widely supported. It was to be an omnibus piece of legislation designed to bring 16 health practitioner groups (including dentists, nurses, chiropractors, midwives, pharmacists, psychologists and other allied health practitioners), regulated by 11 statutes, into line with the registration, competency and discipline provisions of the NZ Medical Practitioners Act 1995. The Medical Practitioners Act was modern, effective and cognisant of societal changes (such as the need for openness by having disciplinary hearings in public). There had been wide consultation and debate associated with its development, and it had the support of major medical professional groups, both in the development phase and in practice. During a long gestation period, however, the initial concept of the HPCA Bill became lost under the onslaught of multiple competing agendas. The resulting legislation is complicated and undermines professional functioning. Its effect may be exactly the opposite of its intention — to make the provision of health services safer and of higher quality. From initial tentative support, the leading medical professional organisation in New Zealand — the New Zealand Medical Association (NZMA) — along with the union representing senior hospital doctors (the Association of Salaried Medical Specialists), and the major medical colleges of surgery and general practice, ended up opposing the legislation in favour of retaining regulation under the Medical Practitioners Act. We were unsuccessful. So how did these changes come about? And how did the New Zealand Government come to pass a law that was actively opposed by organisations representing many of the people who would be bound by it? First of all, there was no doubting that much of the legislation covering other health practitioners was outdated and in need of modernising (eg, laws regulating occupational therapists and physiotherapists dated back to 1949). The advocacy of many of these other health practitioner groups, while publicly supportive of the concerns of the medical profession, was in the end more muted because of issues with their existing outdated legislation. Secondly, Ministry of Health consultation on the Bill was primarily with the statutory bodies that would be administering the new legislation (such as the Medical Council of New Zealand). These bodies do not and cannot represent practitioners, as their statutory role is to regulate them. Professional medical organisations received little consultation. Such consultation that did occur was late and completely inadequate, and despite strong and detailed responses, concerns raised were largely dismissed. Thirdly, there is a political perception that more political and external controls on the professions are what society wants. This runs counter to repeated polls that place professions such as medicine and nursing high in the public trust, with politicians scoring poorly in this regard. It also ignores the growing body of international opinion that competence, quality and safety are better assured through models structured on professionalism rather than state control.1 Consequently, as the legislation developed, it moved substantially away from the concepts and clarity of processes of the Medical Practitioners Act on which it was supposed to be based. The NZMA believes the new Act is a missed opportunity for improvements to medical practice and offers no assurance of further benefits to patients. It will increase political influence and bureaucratic involvement in the practice of medicine, with a consequent decrease in professional self-regulation, which has been at the core of the development of safe healthcare for New Zealanders.2 As Onora O’Neill, Cambridge Professor of Philosophy, as well as teacher, bioethicist and politician, said in her 2002 Reith lectures:3 Plants don’t flourish when we pull them up too often to check how their roots are growing: political institutional and professional life too may not go well if we constantly uproot them to demonstrate that everything is transparent and trustworthy. Perhaps the culture of accountability that we are relentlessly building for ourselves actually damages trust rather than supporting it. The Act, as passed (among other things): provides for additional Ministerial powers; introduces scopes of practice for all health practitioners; introduces restricted activities; and mandates regulatory authorities to set standards of ethical conduct. Along with cumbersome bureaucratic requirements, the HPCA Act significantly increases political control over doctors. The Minister of Health now has powers to resolve disputes over scopes of practice, to designate restricted activities, and to appoint all the members of regulatory authorities (eg, the Medical Council, which currently has four members elected by the profession). The Minister may also allow new health practitioner groups to become regulated under the Act. The introduction of legislation-based scopes of practice is an unproven concept and has the potential to bring about substantial change to the practice of medicine, particularly if scopes of practice are narrow and, as the NZMA fears, become highly codified and prescriptive. Practitioners will be limited in the activities they can practise by the details of their scope of practice, irrespective of possible wider competencies, and disciplined if they step outside that scope. The Minister of Health now has powers to resolve disputes between authorities over scopes of practice, which should be entirely a matter for the professions and not subject to bureaucratic influence or political decisions. Consequent changes in other statutes, the decisions of future authorities appointed by the Minister of Health, determinations by case law, and inclusion in employment contracts, with time, are likely to make scopes of practice more restrictive and task oriented. Restricted activities, which may be undertaken only by specified practitioners or disciplines, are another new and untested legislative concept, with uncertain outcomes. As the process is defined in the Act, the declaration of restricted activities may potentially be responsive less to professional and patient safety realities than to political pragmatism. Another major concern is the mandating of statutory regulatory authorities to set standards of ethical conduct. Effectively, this could mean people appointed by the government setting ethical standards for the profession. For the safety of patients, the independence of medical ethics must be protected from political agendas. William Sullivan, a prominent North American sociologist said: Neither economic incentives nor technology nor administrative control has proved an effective surrogate for the commitment to integrity evoked in the ideal of professionalism.4 Health legislation can actively promote professionalism — or it can discourage it. The NZMA believes that the HPCA Act is a backward step for the promotion of professionalism in medicine. We are establishing a monitoring process to assess the effects of the Act on both doctors and their patients so that we will be prepared for the planned review in 2006.2

Tricia A Briscoe MB ChB, BSc, DipObst

Almost 200 health leaders from Australia, New Zealand, the United Kingdom, Canada and Singapore attended the Health Leaders Network’s conference “Designing the health workforce for the 21st century”, held in Melbourne, 2–3 April 2003. The conference allowed participants to think afresh about healthcare and its current and future demands, and to explore what type of health workforce, especially clinical, is required to meet the demands of the 21st century. Two key themes ran through the conference — recruiting and retaining the workforce, and the need for changed and new roles to meet changing work requirements. 21st century healthcareThe conference theme used the picture of 21st century healthcare painted by Liam J Donaldson (Chief Medical Officer for England):1 The agenda for healthcare in developed countries in the 21st century will be dominated by a vision of quality which seeks to address the deep seated problems of the past . . . The need for health services to give priority to developing health professionals equipped to practise in a new way and thrive in new organisational environments requires a rapid response to reshape curricula and training programmes . . . Health care in the 21st century will require a new kind of health professional: someone who is equipped to transcend the traditional doctor–patient relationships to reach a new level of partnership with patients; someone who can lead, manage and work effectively in a team and organisational environment; someone who can practise safe high quality care but also constantly see and create the opportunities for improvement. The conference explored the development of a sustainable health workforce and the range of new skills that health professionals will require into the future, including: the requirements for the sustainable development of the 21st century health workforce; how various changes are affecting the clinical workforce; the implications of new emerging models of service provision and modes of practice for the clinical workforce; and what challenges these emerging models present for the development of the current health workforce and the training and development of new healthcare workers. International workforce benchmarkingSeveral overseas speakers addressed the conference, providing an opportunity to learn how workforce issues are being handled elsewhere, using comparison as a stimulus for critical reflection and analysis of their own situations. The Canadian speakers, Dr Linda O’Brien-Pallas (Professor, Faculty of Nursing, University of Toronto) and Gail Tomblin-Murphy (Associate Professor, School of Nursing, Dalhousie University, Nova Scotia) indicated that Canada has identified human resource planning for the healthcare sector as the dominant health policy issue for the next 5 years. High-level commitmentThe keynote speaker, Mr David Fillingham (Chief Executive Officer, National Health Service [NHS] Modernisation Agency), identified some healthcare challenges.2 These are not unique to the United Kingdom, and include: the ageing population; the burden of chronic disease; the emergence of information and communications technology supporting new forms of care delivery; the shift in emphasis from services centred on the healthcare professional to patient-centred services; technological advances in healthcare that are prompting changes in the demand for services (eg, increased interest in health and access to health-related information through online services are driving consumers’ expectations of quality and choice, and creating more discerning and demanding patients); and issues in relation to education, training, regulation, accreditation, and pay and reward. Clearly demonstrating the commitment to workforce development and reform in the UK, he discussed the ambitious 10-year program that is underway to transform the NHS.2 This includes establishing the NHS Modernisation Agency, which has been set up to promote improvement within the UK health system, and the funding of a major “Changing Workforce Programme” in 2000. The Programme . . . has been based initially on 13 national pilot sites, which have developed well over 100 new job roles. Each site has focussed on a theme where new ways of working could improve patient care, the aim being to test out job and role changes in a practical healthcare setting and to identify and overcome the blocks to the development of new job roles . . . Some examples of the types of new roles being developed include those of chronic disease practitioners in disciplines such as cardiac care and respiratory medicine. These posts operate on the interface between primary and secondary care, and help avoid unnecessary hospitalisation and facilitate earlier discharge. Challenging work roles and valuesThis conference challenged participants to move away from traditional ways of doing things and to “open their minds and hearts” to different agendas. Training and education were key discussion points by several speakers. Di Lawson (Chief Executive Officer, Community Services and Health Training Australia) spoke about “Changing work roles in the health services industry” and the effect this would have on the workforce of the future. She discussed the vocational education and training (VET) sector, which provides education and training for work, and ways to develop and recognise the competencies and skills of learners. Work is under way in the VET sector to develop better training programs for a variety of health technicians and support workers. She highlighted that it is easy to forget that the work of high-performance healthcare professionals depends on the knowledge and skills of many others in the organisation. Although the health technicians workforce (numbering about 10 000) is a small proportion of the overall vocational workforce in health (about 150 000), it makes a vital contribution to service delivery. Ms Lawson highlighted the constraints on modern healthcare (such as population factors, government policy, quality and safety of services, funding, workplace culture, productivity and staff retention), and challenged participants to consider the three noticeable trends that are emerging in the workforce (across the board, not just in health): People are moving very strongly towards work–life balance models. People are motivated by a complex structure of rewards that are heavily supported by non-financial benefits. People will move quickly if their expectations are not met. These contributions were reinforced by Dr Michael Walsh (Chief Executive Officer, Bayside Health, Victoria), who also stressed that health is facing significant workforce challenges in the near future (Box). The broadcaster Julie McCrossin, who has had a longstanding interest in consumer issues in health, highlighted that benefits will occur if healthcare professionals join with consumers in addressing the many and varied challenges in healthcare. Lessons learnt from other industry sectorsThe conference also explored workforce issues in the banking industry. The paper presented by Greg Barnier (Head of People and Performance Service and Operations Centre, Westpac Banking Corporation), “Effective recruitment and retention strategies in the face of a changing demographic picture”, highlighted the workforce planning implications of Australia’s ageing population, “a global issue which impacts our future business sustainability”. Developing a sustainable workforce for bankingA review of Westpac’s workforce demonstrated a mismatch between its workforce and customer base. Eighty per cent of the future workforce growth will be in age groups 45 and over. Barnier pointed out that the current workforce age profile in banking does not match current Australian labour force projections3 (more than 36% of Westpac staff are aged between 26 and 35 years, whereas the current Australian labour force has only 23% in that age group and the number is declining). Nor do the projections match Westpac’s customer base (39% of its customers are aged 45 years or more, whereas 20% of employees match that age profile). Furthermore, Westpac research shows that older customers prefer to deal with more experienced staff, especially when discussing certain banking issues, such as superannuation and investment strategies. The bank is now actively recruiting older workers. All the evidence internationally and in Australia4 suggests that many of the myths about older workers are wrong. Mature aged workers have a stronger work ethic; higher productivity or work quality; lower absenteeism due to sickness; better corporate knowledge; and an ability to learn new skills. Westpac is also focusing on making itself more competitive in recruitment. All indications suggest that it is increasingly becoming a sellers market for skilled labour, whether in banking or health. Westpac research shows that we already have a multigenerational workforce: Matures/veterans (aged 55–70); Baby Boomers (aged 38–54); Generation X (aged 23–37); and Generation Y (born after 1980). Each generation has different drivers that will attract and retain them in the workforce. The different approach that the four generations in your workforce have to their jobs, careers, families and personal lives means as the labour market shifts we need to adapt our approach to managing people. Barnier questioned whether the healthcare sector faced similar issues with their workforce planning, recruitment and retention. The consensus was that it did. In coming years, the source of new recruits will change significantly for both industry sectors (banking and healthcare), effectively putting them in direct competition in the “war” for talent. Recruitment and retentionIn addition to the banking industry, the conference turned to the airline industry as a model for lessons in safety and quality. Both Dr Darryl Mackender (Gastroenterologist, Erromed, Brisbane — Human Factors in Health Training) and Professor Cliff Hughes (Cardiothoracic Surgeon, Royal North Shore Hospital, and Council Member, Safe Staffing Taskforce, Australian Council for Safety and Quality in Healthcare) highlighted the importance of communication skills and teamwork. They drew from the experiences of the aviation industry and its shake-up in the 1960s after some tragic accident statistics prompted the industry to look at staffing, work practices, rostering and how technology might be able to assist in reducing fatalities, and the reporting and investigation of “near misses”. In 1960, there were 45 major accidents per million departures, but by 1993 this figure had been reduced to two major accidents per million departures.5 Eighty per cent of airline accidents were shown to be due to avoidable human factors. Both presenters urged that health systems take note of these lessons and consider how successful approaches in other industries can be used in health. Of special relevance to health is the information about safe working hours and the effect of fatigue on performance. Health–tertiary education interfaceRecognising the crucial role tertiary education plays in preparing graduates for the healthcare sector, a couple of speakers analysed the benefits of good working relationships between the health system and tertiary education so that graduates are prepared for work in the health system, and the transition to work is smooth. Professor Peter Smith (Dean, Faculty of Medical and Health Sciences, Auckland University) and Dr Judith Clare (Professor of Nursing, Flinders University) both highlighted new approaches to health workforce training. Smith focused on quality and safety issues around systems failures and the benefits of interprofessional learning (“Occasions where 2 or more professions learn from and about each other to improve collaboration and the quality of care”)6 and Clare discussed clinical education in nursing and partnerships for improving patient care, recruitment and retention of registered nurses. Citing the level of dissatisfaction with the models of clinical placement implemented by schools of nursing (long before the transfer of nursing education to the tertiary sector), Clare discussed work at Flinders University in 1997, with the establishment of four dedicated education units (DEUs). There are now 32 DEUs in a range of healthcare agencies, managing 1100 students each year. In these units, optimal clinical learning is driven by practice-based assumptions and activities. ConclusionThe conference identified the issues of current and projected health workforce shortages in Australia and New Zealand. The take-home message was that we are only just touching the tip of the iceberg — and that further exploring and exchanging of ideas on new ways of working and new approaches to healthcare delivery will be crucial as we try to do more with less. Participants were challenged to: Think beyond numbers when considering recruitment and retention issues, and to explore how developing a better understanding of the specific needs of the different age cohorts and new roles and categories of healthcare workers can assist with maintaining a sustainable health workforce; Explore ways of working more effectively with consumers as partners; and Ensure that the health workforce is appropriately skilled for the 21st century, particularly recognising the importance of communication skills and teamwork as specific and identifiable capabilities, in addition to the traditional clinical skills. The conference presentations from the 2003 event are available on the Health Leaders Network website (www.hln.com.au). Workforce challenges that will affect the healthcare sector in the near future Demographic or social Ageing workforce Decline of “careers for life” Recruitment (more choices of career, which compete with health) Professional requirements More pre- and post-practice training More specialisation Safe practice, safe working hours Individual preferences Lifestyle matters and flexibility Retention (mobility in an era of shortage) Pressure, scrutiny and burn-out Nature of work Specialisation and integration Safe practice and audit More time training, retraining and auditing practice, less time practising Place of work Increasingly towards community and home Who you work with Multidisciplinary teams Working across traditional structures New roles, new professionals Machines and the caring professions Information technology “Labour-saving” technology

Jennifer A Alexander MB BS, MHP, MComm · Sue M Thomson · John A Ramsay

Re: Lowering blood pressure in 2003, a Clinical Update article by Chalmers JP and Arnolda LF in the 15 September 2003 issue of the Journal (Med J Aust 2003; 179: 306-312). On page 308, second column, under the heading ANBP2, an error in the editorial process led to an incorrect statement: “ANBP2 was an open-labelled randomised study with blinded endpoints, a design in which study doctors knew whether the patient was on active treatment or placebo . . . ” ANBP2 is clearly a comparative study, not a placebo controlled study, as is made plain in the other sections of the article. The html and pdf versions of the article published online were corrected on 14 November 2003.

John P Chalmers MD, FRACP · Leonard F Arnolda PhD, FRACP

The UK’s National Health Service (“the NHS”), with 1.3 million employees, has now become the world’s second largest employer after the army of the People’s Republic of China. How can anyone drive anything that large? The former UK Secretary of State for Health, Alan Milburn, tried doing it for 6 years and, within days of his resignation, was instead defending tobacco industry jobs in his own constituency. At least he wasn’t driven to drink; to us, as newcomers to the United Kingdom trying to make sense of this unwieldy bureaucracy while surviving the deep midwinter, a drink looks pretty good. What NHS managers appear to excel at is meetings. They have dozens of them, often attended by literally dozens. A relic of the Milburn era is a profusion of performance targets, not only for hospitals, but for general practice and primary care as well. Someone has reckoned that across the NHS there are at least 1200 targets. A basket of 34 of them determines whether hospitals and Primary Care Trusts attract no, one, two or three stars — the NHS equivalent of Michelin ratings. These are important drivers, because the star rating determines access to funds — those who do well are rewarded with more public money to do even better; laggards are left to limp along: “The fault, dear Brutus, is not in our stars, but in ourselves, that we are underlings”. A great many of the targets relate to the processes of health care and precious few to its outcomes. Waiting lists for elective surgery, and “trolley waits” in accident and emergency departments are part of public discussion in the UK now, while particular institutions are lambasted for poor medical records or general cleanliness. The focus on targets reflects a belief in the benefits of centralisation and a lack of trust in those at the coalface. This has led to demoralised health professionals. Furthermore, the emphasis on process rather than outcome is partly due to a perception that the public is unable to understand more than waiting times. The UK lacks the health consumerism of Australia; while the NHS remains part of the social fabric, there are often low public expectations, and medical issues remain mysterious to most people. The public-health community is driven by a health inequalities agenda, which is remote enough from service delivery to make it irrelevant to the health service. Thus, there is no one to help set priorities to improve public health and prevent the agenda being driven by how care is delivered rather than by what it achieves. While the system is awash with forms and information, it is totally unable to link records. It took long enough to recognise the excess short-term mortality in the paediatric cardiac surgical service in Bristol; there is no hope of routinely measuring clinically important long-term outcomes. Meanwhile, targets are responsible for distorting NHS activity on a day-to-day basis. Hospitals shift their staff around to reduce “trolley waits” during the week when the inspectors from the Commission for Health Improvement are visiting, and accusations of waiting-list fiddling are heard regularly. More profoundly, the orientation of many people in the middle layers of the NHS has undergone an about-face. Instead of attending to problems reported from below about barriers to delivering high-quality care in a timely fashion, the focus of most middle managers is on meeting targets imposed from above, from levels even more remote from the delivery of service. In the early days of the NHS, there is no doubt that doctors called the shots. This lasted for several decades, until the development of Thatcher’s internal market (consisting of large numbers of “business units”, each of which needed a manager); the focus on targets and performance; and, most recently, the clinical governance agenda. Oddly, both doctors and managers feel disempowered and believe that someone else is in charge. So, are the managers themselves part of the problem (it’s not the driver that’s bad, but the transmission that’s broken)? The Tory Party says that managers now outnumber beds in the NHS. Good clinicians from the whole spectrum of health professions have moved sideways into comfortable, well paid administrative roles that could be fulfilled during sociable hours, significantly depleting the ranks of those actually delivering healthcare and making the difficult clinical decisions that this involves. What NHS managers appear to excel at is meetings. They have dozens of them, often attended by literally dozens. If you add up the wages and the travelling times, a single meeting can cost the same as a whole week of clinical care, but rarely will it take a decision that measurably affects anyone’s health. Even when someone is brave enough to try a novel idea, managers further up the line are likely to impose a reorganisation long before enough time has passed to see if the new way is better. And that presupposes that adequate provision was made for a proper evaluation of the initiative, which is all too rarely the case. Not that people are unaware of the problem; the divide between management and the frontline underpins much of the current disaffection and malaise within the NHS. It’s just that solutions to such complex problems don’t come easily.1 Some commentators become despondent, and suggest that the only effective strategy for managing a huge complex machine like the NHS is to muddle through. Meanwhile, on the wards, in the outpatient clinics, and out in the practices, scores of dedicated health professionals and other staff struggle on. There are half the number of doctors per head of population compared with Australia, and the slice of gross domestic product dedicated to the NHS is at least a third less. One does not have to be driven, there is always someone waiting to be seen. Enjoy the sunshine this Christmas; your comrades over here may also be feeling the heat.

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

We’ve downsized and upgraded, We’ve amalgamated too. We’ve splurged, and surged, and urged, and merged From here to Timbuktu. There’s just one little problem, With all that we’ve been through, We can’t remember what it is That we were trained to do. (Anonymous administrator) The hospital system the world over is in turmoil. The burgeoning cost of healthcare is ignored by governments more concerned with weapons of mass destruction than trivial matters such as the health of the nation. Even the perpetual smile on the faces of the Public Relations Department personnel has become fixed into a risus sardonicus. Is there no cause for optimism? Of course there is. When things look particularly grim, we should never neglect the past. There is always the option to look back to the future. As patients increasingly turn to alternative medicine, we suggest embracing a combination of the ancient philosophies, such as feng shui (a belief that energy can either flow or stagnate according to the shape of one’s surroundings, determining success or failure in any endeavours), and the contemporary, holistic approach to medicine. Holism is the concept that, in the function of complex systems, the whole is greater than the sum of its parts. Until now, hospital medicine has lacked a holistic approach. Indeed, it might be suggested that hospital administration has adopted the opposite approach, in which the whole is less than the sum of its parts. Consequently, in this article we propose a hybrid model for changes to the hospital milieu, incorporating practices inspired by ancient philosophies and holism, in the pursuit of improved healthcare delivery for patients, clinicians and administrators alike. This model will be known as the Hospital Intergenerational Transcultural Solution, or “HITS”. Hospital AdministrationBefore HITSThe Hospital Administration’s main role is to write a Mission Statement. This should not be confused with the Vision, which is in the realm of the Almighty (see Box). The Vision, usually shared by a select few, transcends the immediate tangible concerns of clinicians and, indeed, transcends reality. Mission Statements resound with platitudes, even though it is widely acknowledged that platitudes are the last resort of the intellectually destitute. For example, the standard children’s hospital Mission Statement aims to “improve the health and wellbeing of all children”. The major advantage of such statements is that it is impossible to argue with their sincerity and impossible to evaluate them. After HITSIt has been said that leaders are born and not made. But why not both? The genetically modified administrator (GM-A) of the future will have all genes for empathy deleted and replaced by genes for transcendental obfuscation. All members of the executive will be dressed along the lines of the Raelian cult, pending the first successful cloning of an administrator. For the inner spirit to escape the confines of the daily routine, the hospital boardroom will be refurbished with futons and a small but tasteful jacuzzi in the corner. The Vision will be placed in the hands of a new Department of Iridology. Finance DepartmentBefore HITSThe modern Finance Department aims to correct the archaic notion that a hospital’s primary role is patient care, and re-direct it to revenue raising. The MD should defer to the MBA. When revenue raising proves too difficult, the modern Finance Department turns its hand to revenue recycling: each department bills other departments for services rendered, ensuring the circulation of imaginary money to the extent that rational budgeting is impossible. This cleverly hides the fact that the Finance Department is incapable of rational budgeting. Any clinical department hoping to achieve an increase in its working budget is advised to read Beckett’s Waiting for Godot. After HITSAs all hospital departments will be created equal, there will be no need for a Finance Department. Instead, there will be a Community Chest, shared on the basis of harmony and mutual goodwill. Over the Chest will be a framed photograph of the Director of Finance, clad in saffron robes, with a garland of rose petals. Candles and incense will be available for purchase, all profits going to the Community Chest. A barter system will be introduced for staff. For example, staff may elect to be paid in kind with offers of coronary artery bypass graft surgery instead of long service leave. In an innovative strategy, patients will be charged on a step-by-step basis once they enter the hospital. Those in wheelchairs or on trolleys will be charged per wheel rotation. This is considered a revolutionary approach to finance. Service Improvement UnitBefore HITSPreviously known as the Quality Improvement Department, the Department of Continual Improvement, or the Department of Perpetual Audit, this fashionable construct of redeployed middle management thrives despite the fact that none of the quality improvements can be quantified. Put simply, Quantity begets Quality. After HITSThe Service Improvement Unit will confine its activities to helping executive staff play better tennis. Public Relations DepartmentBefore HITSPublic Relations is believed by those working there to be the most important department in the hospital, responsible for Corporate Image, which necessitates changing the hospital logo with bewildering frequency and pestering the press to a greater extent than the press pester anyone else. After HITSThe PR Department will be painted beige to emphasise calm, belying the turmoil of bed shortages. A glass “ideas box” will be situated on each Departmental member’s desk, and emptied annually, if necessary. Photographs of the smiling “Fundraiser of the Month” will become mandatory screensavers on the computers in all departments. SummaryOur advocacy of the introduction of HITS to the hospital represents an attempt to meet the needs of the modern patient and adhere to the expectations of clinical governance using a root-cause analysis approach in a no-blame culture. Notwithstanding these ever-present administrative mantras, we would implore you to embrace the concept of holism whole-heartedly. Academic and General Misinformation, and Staff Re-Education 1: Current operational model of devolved responsibility

Dominic A Fitzgerald MB BS, PhD FRACP · David Isaacs MD, FRACP, FRCPCH

To the Editor: The 25th Australian Conference of Health Economists was held in Canberra on 2–3 October 2003. This conference used to be held in shabby university seminar rooms, with dry biscuits and instant coffee. This year it was held in a modern facility — the SAS Visions Theatre at the National Museum — with all the usual conference embellishments, including brewed coffee and fresh pastries, plus an evening dinner at the lakeside restaurant within the museum. The conference was sponsored by Medicines Australia; Pfizer Pty Ltd; Bristol-Myers Squibb Australia Pty Ltd; AstraZeneca Pty Ltd; Sanofi-Synthelabo Australia Pty Ltd; Schering-Plough Pty Ltd; Bayer Australia Limited; and Merck Sharp & Dohme (Aust) Pty Ltd.1 Why are those traditional sponsors of medical gatherings, the pharmaceutical companies, subsidising the health economists’ conference? The immediate explanation is simple. Applications to the Pharmaceutical Benefits Advisory Committee for listing of a drug on the Pharmaceutical Benefits Scheme must now include a formal cost-effectiveness study. This requirement has generated a boom in this narrow technical aspect of health economics. Thirteen of the 32 papers presented to the conference reflected this area of interest.1 But are we seeing something more fundamental here? Are the canny pharmaceutical companies directing their largesse away from the once autonomous doctors to the dry bean counters who now make the real decisions? Or have the economists proved one of their own famous maxims wrong by demonstrating that there is such a thing as a free lunch?

William Coote

Most of the solutions lie beyond the emergency department Hospitals represent essential infrastructure. Engineers who run an essential community resource such as the water supply system at 100% of capacity might expect to lose their jobs the first time consumers had to queue to use a tap. In contrast, some hospital funding models include activity targets that reward administrators who run at 100% of capacity — a level that guarantees queuing in the emergency department for coronary care beds and other critical inpatient services. The community accepts the use of price and denial (eg, restrictions of hours or allowed uses) as a rationing mechanism for the water supply, but not for hospital beds — queuing is the only rationing method currently accepted in the hospital system. Rationing is an essential feature in modern medicine,1 and queuing has long been used to ration elective services. But queuing is fundamentally an inefficient means of rationing care for time-critical illness. Access block — the inability of patients in the emergency department (ED) to access hospital beds — is the major issue currently facing emergency medicine in Australasia2 and, indeed, the whole Western world. Given a fixed physical resource and a relatively fixed labour force, increased average total ED time,3 also called ED length of stay (EDLOS), will decrease the resources available for providing care to acutely ill patients. Access block decreases access to emergency care (eg, measured as waiting time),4 and the resultant overcrowding is associated with adverse outcomes for ED patients.5,6 It is certainly in the interests of ED staff and patients to decrease EDLOS. . . . restricting the access and quality of initial care because of inability to provide timely later care is ethically dubious . . . The article by Liew et al in this issue of the Journal 7 adds to the growing evidence for an association between EDLOS and outcomes beyond the ED.8 The authors used a multivariate approach to study the relationship between EDLOS, other confounding factors, and subsequent inpatient length of stay in three Melbourne metropolitan hospitals. They found a positive association between EDLOS and inpatient length of stay after adjusting for casemix, time of presentation, and patient age. Whether this relationship is causal is a subject for further study. The Australasian College for Emergency Medicine has committed resources to such research through the Emergency Medicine Research Foundation. From an administrative perspective, the underlying mechanism is less important than the result. Increased inpatient length of stay after correction for casemix is financially undesirable: it is in the interest of hospital management to reduce both EDLOS and inpatient length of stay. Emergency departments are specialist multidisciplinary units with expertise in managing acutely unwell patients for the first few hours in hospital. Neither the facilities (generally poor privacy, small trolleys, 24-hour lighting) nor the staff are appropriate for providing longer term inpatient care. Very few patients who require an inpatient bed benefit from staying in the ED longer than 4 hours, and no ED benefits by caring for patients beyond this time. If the 30% or so of patients who are admitted spend twice as long in the ED, this represents a 30% increase in workload for ED staff with no change in conventional measures of activity (presentations, admission rate). Steadily worsening delays in accessing inpatient beds have been documented in many EDs over the past decade,9 suggesting there might be an underlying incentive such as increased efficiency in a different part of the health system. This research demonstrates an association with increased opportunity costs rather than any benefits. There is a clear need to reduce EDLOS for patients, but most of the solutions lie beyond the ED.10 Changes within the ED can mitigate the effects of increased workload, but, because of access block, they cannot shorten EDLOS. Much can be done to improve our hospital systems, including use of protocols for common conditions, transparent bed-management processes, and a focus on efficient use of the available beds, particularly through admission and discharge planning. Clinicians must be willing to trial different methods of management, such as treatment in the home and accelerated discharge, and to evaluate the outcomes rigorously.10 The study by Liew et al identifies the elderly as a group with the greatest potential for effective intervention. There have been significant achievements and more can be expected, but process change will not completely address the underlying mismatch between demand for inpatient beds and resources available. The primary problem is the lack of acutely available beds.11,12 The scarcer those empty beds become, the more difficult they are to access. Queuing for care at the entrance to ED is managed by triage, which stratifies patients by urgency — the most time-critical cases have the shortest queues. Queuing for a bed at the exit of ED is managed by bed allocation, which tends to stratify patients by their nursing load — the least intensive cases generally have the shortest queues. Elementary queuing theory predicts the accumulation of patients, but the daily variation in emergency medical activity has for too long allowed both emergency staff and others to assume the ED has “rubber walls” and that the marginal cost of the ED absorbing additional care to inpatients is low. The study by Liew et al7 and other studies on the effects of overcrowding5,6,13 now provide clear evidence that this is not the case. Emergency departments are expert at triage to achieve “the greatest good for the greatest number”, but, when prioritising, even emergency physicians are reluctant to consider denying care to patients with whom they have begun a therapeutic relationship. EDs are faced with the ridiculous situation of providing many hours of care to patients whose conditions were urgent on arrival but stable after treatment, while potentially unstable patients of similar initial urgency languish in the waiting room or in an ambulance for want of an ED trolley and nurse. It is time that hospitals addressed this inequity: restricting the access and quality of initial care because of inability to provide timely later care is ethically dubious14 and is likely to lead to adverse outcomes and medicolegal exposure. These weighty issues cannot be addressed by EDs alone. Demand for emergency services has increased9 while bed numbers have decreased,15 and demographic projections indicate that these trends are unlikely to reverse. Unless practices change, our EDs will cease to function in their designated role, and will instead inappropriately spend most of their resources providing care to patients who should be in inpatient beds. Hospitals, communities, and government must debate and decide the allocation of resources to EDs and wards and agree on a sensible approach to providing appropriate care in both environments. The debate is no longer about the level of resources our EDs deserve, but rather about how to ensure that ED resources are directed to those who need them — the patients in the waiting room.

Drew B Richardson MB BS(Hons), FACEM

Failure to provide public funding for clinical trials may come at a high cost to the community in the long term Large-scale morbidity–mortality trials have become fundamental to the evaluation of most new drugs intended for long-term administration. Such trials have the unique ability to determine the net balance of positive and negative outcomes from the long-term use of drugs and allow consumers to feel confident that long-term therapy is safe in otherwise healthy individuals. A randomised controlled trial is the only study design that can provide reliable and unbiased estimates of the moderate treatment effects of interventions for most chronic diseases. Smaller studies measure surrogate outcomes or are underpowered to answer important clinical questions. If underpowered, they may be unethical and also squander the community altruism that underpins trial participation. Large-scale trials are major logistical exercises. They involve several thousand people allocated randomly to different treatment groups and monitored for 4–6 years. Depending on the recruitment strategy and the mode of follow-up, the cost is typically $20–$50 million.1 Past attempts to interest Australian research organisations in funding such studies have floundered because of this cost. In spite of this, there are a number of groups in Australia with an excellent track record in initiating and running high-quality large-scale clinical trials (many of the “public good” variety), indicating local capacity to conduct this type of research. However, these trials have largely been the province of the pharmaceutical industry. Although industry-funded studies have yielded firm scientific foundations in many areas of clinical practice, they are almost all directed towards testing superiority or equivalence of specific products, or other aspects such as greater convenience of new agents or technologies over the existing ones. Indeed, it is naïve to believe that the interests of industry will align with broader societal interests in securing effective and affordable care.2 The failure of non-industry concerns, including governments, to fund large-scale clinical trials leaves some conspicuous gaps in evidence where the consequences may be forgone savings for the public purse. In other cases, the result may be prolonged community exposure to older agents whose long-term risks have not been adequately assessed. Some recent examples highlight the importance of this problem. Antihypertensive drugs make up a large component of the Australian pharmaceutical budget — $516 million for the Pharmaceutical Benefits Scheme (PBS) for the newer agents in the financial year 2002–03 alone.3 For many years, there has been a trend towards these newer, more expensive agents replacing older, cheaper drugs for first-line management of mild hypertension.4 The justification was provided by small trials involving surrogate endpoints, such as effects on blood pressure control, vascular changes, and other risk factors. However, clinical trials with surrogate endpoints do not provide an appropriate basis to underpin long-term drug therapy: they can not provide reassurance of the drug’s long-term safety or determine the balance of desirable and undesirable effects of new agents. When the necessary studies of antihypertensive drugs were finally undertaken, they demonstrated that the advantage of newer agents over diuretics was marginal, at best.5,6 In this instance, a lack of appropriate trial data on management of hypertension probably led to years of unnecessary expense to the PBS that greatly outweighed the cost of a large-scale trial. It is clearly in the public interest to ensure that PBS funds are not being spent on expensive therapies when much cheaper agents are just as effective. We recently estimated that the failure to provide funding for trials probably cost Australian taxpayers between $45 million and $108 million in 1998 alone.4 Another example of the false economy of failing to fund clinical trials is the recently reported Women’s Health Initiative study.7 Before the results of this trial were published, a generation of women was prescribed hormone replacement therapy (HRT), despite the lack of rigorous long-term safety data that could only have been obtained from a large-scale trial. There was little commercial imperative to fund such a long-term trial when large markets of regular users existed. Eventually the US National Institutes of Health (NIH) recognised the importance of funding such a study, as indeed they have funded a number of other “public good” studies. Release of the study results has led to a sharp drop in the use of combined HRT, except for short-term use to relieve significant perimenopausal symptoms. The “dividend” for the Australian government was $16 million less expenditure on HRT in the financial year 2002–03.3 A failure to learn from these experiences may cost the community in the future. For example, low-dose aspirin is an effective antiplatelet agent whose use has recently been advocated in the United States for people with a 10-year risk of coronary events and stroke of 10% or more.8 This recommendation may lead to widespread use of aspirin for primary cardiovascular prevention in the elderly, despite a lack of data to indicate that its benefits in this age group outweigh the risk of haemorrhage.9,10 There is little likelihood that commercial interests will supply the funding to overcome this lack of data. It is more likely that industry would fund a study using a newer, more expensive antithrombotic agent in the hope of establishing it as standard therapy. The means must be found to identify and target strategically important research questions that require public funding. A budget (in the order of $100 million) for national research funding of these large “public good” trials should be established and administered by the National Health and Medical Research Council (NHMRC). This sum, representing 12% of the NHMRC budget and 0.2% of the recurrent health expenditure of $60 billion, is commensurate with the importance of such trials to clinical medicine and public health. Using the NIH as a model, trials would involve a mix of requested and investigator-initiated research. Research groups, either alone or (more likely) collaboratively, would apply for competitive funding. Although this would be administered by the NHMRC, a number of other stakeholders would benefit, including federal and state governments and their agencies, departments of health, the Health Insurance Commission, and the PBS. New funds should be made available from these sources. States should contribute to this initiative as large-scale trials are usually multicentred, allowing research capacity building and employment in both metropolitan and rural areas throughout Australia. Failure to develop a policy that supports such strategic research may well lead to waste of public funds and a delayed recognition of unfavourable risk–benefit ratios.

John J McNeil PhD, FRACP · Mark R Nelson PhD, FRACGP, FAFPHM · Andrew M Tonkin MB BS, MD, FRACP

Objective: To examine the association between emergency department length of stay (EDLOS) and inpatient length of stay (IPLOS).Design: Retrospective review of presentations and admissions data.Setting: Three metropolitan hospitals in Melbourne, 1 July 2000 to 30 June 2001.Main outcome measures: Mean IPLOS for four categories of EDLOS (≤ 4 hours, 4–8 hours, 8–12 hours, >12 hours); excess IPLOS, defined as IPLOS exceeding state average length of stay; odds ratios for excess IPLOS adjusted for age, sex and time of presentation.Results: 17 954 admissions were included. Mean IPLOS for the four categories of EDLOS were ≤ 4 hours, 3.73 days; 4–8 hours, 5.65 days; 8–12 hours, 6.60 days; > 12 hours, 7.20 days (P < 0.001). The corresponding excess IPLOS were 0.39, 1.30, 1.96 and 2.35 days (P < 0.001). Compared with EDLOS 4–8 hours, odds ratios (95% CIs) for excess IPLOS associated with the other three categories of EDLOS were ≤ 4 hour, 0.68 (0.63–0.74); 8–12 hours, 1.20 (1.10–1.30); and > 12 hours, 1.49 (1.36–1.63), after adjusting for elderly status, sex and time of ED presentation.Conclusion: EDLOS correlates strongly with IPLOS, and predicts whether IPLOS exceeds the state benchmark for the relevant diagnosis-related group, independently of elderly status, sex and time of presentation to ED. Strategies to reduce EDLOS (including countering access block) may significantly reduce healthcare expenditure and patient morbidity.

Don Liew MB BS, FACEM · Danny Liew MB BS(Hons), FRACP · Marcus P Kennedy MB BS, FACEM

The current “Pharmaceutical Benefits Scheme (PBS) community awareness campaign” explicitly links the difficulties facing the PBS to patient behaviour and “waste”. The campaign suggests that patients are taking advantage of affordable access to prescription medicines, and emphasises that patient responsibility is “the prescription for a healthy PBS”. By neglecting to inform the public that the pressures facing the PBS also include doctors’ prescribing habits and intensive pharmaceutical industry marketing, the campaign has missed an opportunity to initiate a balanced and constructive debate about the future viability of the PBS. It has become something of an axiom that increasing cost is endangering the Pharmaceutical Benefits Scheme (PBS), and that something must be done about it. Typically, policy responses have been to target the prescription end-user — the patient. Successive governments have increased patients’ out-of-pocket charges as a means of containing drug costs. The present federal Government, thwarted thus far by the Senate in its attempt to increase the patient co-payment, is trying an alternative — appealing to patients’ moral sensibilities rather than their hip-pocket nerve. The current “PBS community awareness campaign”,1 an initiative of the National Strategy for Quality Use of Medicines (QUM)2 has been launched at a reputed cost of $27 million through a nationwide advertising strategy.3 The objective of informing the Australian public about the operation, strengths and costs of the PBS is laudable. However, the tone of the campaign is morally charged, with the suggestion that many Australian patients are not acting responsibly in their use of prescription medicines. The two main mediums of the campaign — a series of television advertisements and an information booklet — emphasise an association between patient behaviour, “waste”, and the increasing financial pressure on the PBS, a pressure which imperils the future viability of the scheme. It appears that patient responsibility is “the prescription for a healthy PBS”. As part of the National Medicines Policy, the strategy for QUM is underpinned by a set of principles, the first of which is “the primacy of consumers”. The strategy claims to recognise “the wisdom of consumers” and states “consumer involvement in all aspects of the Strategy is critical”.2 Far from incorporating the wisdom of patients, the present campaign appears to selectively choose more extreme examples of misuse of medicines to establish a moral position and place the responsibility for increasing prescription demand on patients. The campaign booklet states “some people like to get a prescription every time they visit a doctor”. This statement implies that patients drive the demand for prescriptions and that the low cost of prescription medicines promotes wasteful behaviour. The campaign repeatedly advises patients to take note of the full cost of the prescription that is borne by the Scheme (this is now highlighted on prescription labels). With such information, patients can “use the PBS responsibly” and minimise “waste”. Patients are also exhorted to consider their need for repeat prescriptions, but are not advised of the dangers of stopping treatment for some serious disorders (eg, diabetes and heart failure). The National Medicines Policy document raises the concern that “easy access can work against the quality use of medicines”, offering the common anecdote of patients’ stocking up unnecessarily on prescription medicines “. . . because they are available free or at low cost”. While patients probably do initiate a certain amount of unnecessary prescription demand, the relationship of this to the cost of a prescription is not clear in the available evidence.4 Further, there is no substantial evidence to show that such behaviour is common enough to be a major contributor to rising drug expenditure. The emphasis on patient responsibility reveals a conviction that prescription subsidy through the PBS results in significant “moral hazard”. In other words, low out-of-pocket cost generates unnecessary prescription demand or “waste”. Arguments for the operation of a “moral hazard” rest not on direct observations of patient behaviour, but on studies of aggregate prescribing data.5 Rather than drawing on the wisdom of patients, fluctuations in use of prescription medicines after changes to out-of-pocket costs are used to make inferences about patients’ motivations. Differences in rates of use of “essential” therapies compared with “discretionary” therapies are taken as proxies for “necessary” and “unnecessary” patient behaviours.6 However, prescribing data cannot show whether the changes in pharmaceutical use reflect appropriate or inappropriate patient responses to increased cost; nor can they reveal the motives of patients who have received prescriptions. Increased demand when drugs are affordable does not itself mean that patients are using medicines unnecessarily.7 The increasing cost of the PBS does, however, mean that Australians are being given more prescriptions, often for newer or novel therapies. Australians, like the citizens of other developed nations, live in a society where prescription medicines are central to the provision of healthcare and increasingly prominent in how we prevent and manage illness. The pharmaceutical industry devotes considerable expense and effort to promoting drugs directly to doctors and less directly to patients.8 Australian doctors’ preferences for prescribing newly released medicines, often neglecting older cheaper alternatives, have long been noted.9-13 Patients may sometimes ask their doctor to prescribe the latest available drug for their condition; however, there is no evidence to indicate that low cost is a prime motivator in this demand. The diminishing numbers of general practitioners willing to “bulk-bill” their patients means that seeing a doctor requires an increasing out-of-pocket expense for many patients.14 Most Australian patients do not undertake the cost and inconvenience of consulting a doctor lightly. It is unlikely that many visit their doctor to unnecessarily access affordable medicines. Even with affordable access, the underuse of prescription medicines is a commonly acknowledged problem. While some patients may “like to get a medicine every time they visit the doctor” (quote from the Strategy), other patients don’t seek a medicine when it is necessary, do not always accept a necessary prescription, nor do they always adhere to their prescribed therapy. Despite the PBS providing affordable access, medicine costs can still present a barrier for some Australian medicine users, particularly the chronically ill and those on lower incomes but not eligible for government concessions.15 While the strategy has parallel initiatives aimed at enhancing QUM among health professionals and the pharmaceutical industry, the notion of pharmaceutical “waste” is not a prominent feature of these. In contrast to the message about “waste” that is communicated to consumers, health professionals and industry staff who visit the PBS Web home-page receive a brief outline of the PBS drug-listing process. The strategy and its current awareness campaign give the impression that whatever waste exists is largely driven by consumers taking advantage of affordable access. Related phenomena such as prescription “drift” (the tendency to prescribe newer more expensive medicines for common conditions) and “leakage” (prescribing to a broader population than was intended in the subsidy decision) and aggressive industry marketing are left out of the public gaze.13,16 This restricts the community’s awareness about the PBS, the pressures it faces and its future viability. An opportunity has been missed to provide the public with a comprehensive and balanced view of the problems facing the PBS. The Strategy, as presented to the public, has selectively focused on the role of affordable access in creating “waste” and in contributing to the pressure on the PBS. Because of the complexities of prescription drug use in the community, this will have little impact on quality use of medicines overall. Further, this focus potentially alienates patients from information on the other important factors contributing to increasing PBS expenditure, such as intensive promotion by pharmaceutical companies and doctors neglecting to prescribe older, cheaper therapies. Accepting that most prescription use is necessary begs the question of what proportion of medicine use is unnecessary and what factors combine to generate such use. These questions are still to be coherently answered, and what current knowledge exists is insufficient to justify elevating “moral hazard” to a primary cause of difficulties facing the PBS. A more balanced approach to informing the community about these problems would be to acknowledge the role of patients, health professionals and the pharmaceutical industry in creating demand, and to initiate an informed debate on how to sustain the PBS.

Evan Doran PhD · David A Henry FRCP

William J Glasson,* Robert A Bain† * Federal President, † Secretary General, Australian Medical Association, PO Box E115, Kingston, ACT 2604. To the Editor: The workforce article by Brooks et al1 identifies key factors causing the medical workforce shortage and notes, correctly in our view, that: “The full impact of these factors is yet to be felt, but might occur very rapidly”. However, the authors fail to address why this has occurred and what should be done. The answer as to why is quite simple. In the 1990s, the Labor and Coalition federal governments introduced a series of measures to ration the supply of doctors and the provision of services in order to restrain the health budget. Measures such as restrictions on medical student places, reduced training places, restricted provider numbers, failure to properly index the Medicare Benefits Schedule or introduce the Relative Value Study, and the move away from fee-for-service with the rapid expansion of red tape, were all designed to restrict services that cost the government money. The current doctor shortage, falling participation rates (the trend to doctors retiring early or working part-time) and demoralisation of significant sections of general practice are a tribute to the success of these policies. As the recent Australian Medical Workforce Advisory Committee careers study shows, the much-discussed feminisation of the GP workforce is as much a consequence of a declining number of young male doctors considering general practice to be a rewarding career as it is the result of a need by both male and female doctors for an occupation that allows a flexible work and family lifestyle.2 Nevertheless, the outcome — the falling participation rate among current and future general practitioners — is at the heart of the problem. The solution will require a total shift in policy direction from sticks to carrots. It will need to cover Medicare, training, working conditions, and the removal of red tape and all forms of restrictions not required to ensure good clinical practice. Attempts to use regulations or commercial levers to enforce bulk-billing in an already depleted workforce will only serve to exacerbate the current situation.

William J Glasson · Robert A Bain

In 1988, I attended a workshop of healthcare service managers sponsored by the King’s Fund of London. Participants included such managers and the odd academic from the United Kingdom, the United States, Canada, Australia and New Zealand. We were discussing resource allocation, and frustration mounted during the first 2 days. Ideologically, participants had divided into two teams — the US and the Rest. On the third day, the leader of the US team said, “The difference between us is that you guys believe in equity and we don’t. In the US, people are less interested in making sure everyone gets care than that those who can get it get great care. They accept not getting care now if they can see the opportunity to improve their position and succeed, so that, when they get the money, they will be able to buy great care the minute they want it. It is all about opportunity. People in the US want opportunity, not equity. That’s what they think is fair.” It was important that the US delegate said what he did. It cleared the air. It reminded us that not all societies, and not all people within a society, share a common view of what is fair. In the US, fairness means that you will be encouraged to seek personal success without having to worry much about anyone else. In the UK, Canada, New Zealand and Australia, there is a general interest in the well-being of others. I doubt that Robert Putnam could have written his book Bowling alone1 about Australia. Putnam’s book mourns the loss of social capital, a resource that grows from community trust and participation. Putnam especially laments its replacement with a fierce individualism. The meaning of equityEquity conveys a sense of fairness, but sharpens fairness by adding equality and fellow-feeling. Equity it is not the same as equality, which simply implies similarity of status, capacity, or opportunity. Indigenous Australians, whose life expectancy is shorter than that of non-Indigenous Australians, represent the pre-eminent example of an inequality that is also an inequity. Equity is an ethical value. US health and human rights academics Braverman and Gruskin defined equity as it applies to health: “. . . An ethical concept grounded in the principle of distributive justice . . . Equity in health reflects a concern to reduce unequal opportunities to be healthy [which are] associated with membership in less privileged social groups, such as poor people; disenfranchised racial, ethnic or religious groups; women and rural residents. . . . Pursuing equity in health means eliminating health disparities that are associated with underlying social disadvantage or marginalisation. Equity . . . focuses [our] attention on socially disadvantaged, marginalised or disenfranchised groups within and [among] countries, but not limited to the poor.”2 This definition emphasises that individuals’ need for healthcare services is based on both their medical condition and their social situation. Of course, the problem of inequity in health is not due only to the healthcare system. According to Matthews, the poor health of Indigenous Australians is linked inextricably to social, cultural and educational as well as more classically medical causes.3 She reminds us that, when addressing the health needs of the less socially privileged, we must do much more than just provide equitable access to healthcare. Australia’s health economists have also written and spoken frequently about equity in healthcare, but none has done so more consistently, clearly and passionately than Gavin Mooney. He accepts that there are many definitions of equity, but the one that he endorses is “equal access to equal care for equal need”.4 That is fine for people on the same income and living in the same suburb. Nevertheless, as do Braverman and Gruskin, Mooney extends this definition by recognising the additional needs of underprivileged people. These people may need more access to more care for the same health problem than those with more money, better social support and better opportunities. Ring and Brown5 and Deeble6 observe that current healthcare service funding for Indigenous Australians does not match their severe and special needs. The extent of the positive discrimination we make in favour of such people will reflect how caring our society is. In New South Wales, the resource allocation formula that guides the distribution of funding among geographical regions includes a loading that recognises the greater needs of Indigenous people by multiplying the allocation for Indigenous populations by 2.5.7 This is a good start, but we need to do more. When equity is at work, sick individuals who seek help have their needs met. There is no compulsion or competition. No one is told, “Your need is too great; we can’t afford to treat you — unless you can pay for it yourself.” Patients in need of a heart transplant or expensive long-term therapy for HIV have the same degree of access — equitable access — to medication and care as patients with hypertension or mild asthma. Nor are sick people told, “Because you are old or poor or receive a pension, the government will pay for your healthcare, but will pay the doctor only half or three-quarters of what he or she would receive from treating a younger, rich person.” So the care provided under this definition is impartial. Who you are or how much money you have does not determine your care. Equitable care does not depend on your fame, fortune, or your ability to pay. The principle of universality, on which Medicare has been built, takes seriously the reality that sickness and accidents happen chaotically to any of us, and that a humane and caring society wishes all its citizens to have the same access to the same standard of care, according to need, and unrelated to their financial status. This principle should apply to all public expenditure on healthcare in this country. At present, many Australians do not have equitable access to good quality healthcare. The reasons for this are as follows: Some general practitioners have closed their books, healthcare services are scarce in poorer areas, and, in rural towns, “up-front” payments for consultations are increasing while bulk-billing is in decline.8 Indeed, there were recent reports of some patients having received more speedy attention because they were willing to pay a surcharge (Professor J Richardson, Director, Health Economics Unit, Monash University, personal communication). All these things tear us away from equitable primary healthcare. Public hospital infrastructure is growing old and needs replacement. Access to high technology is patchy. Richardson (see personal communication, above) has shown that investigation and treatment of heart disease is three times more common among privately insured patients. Access to timely surgery is uneven, with private patients getting it quickly and public patients often waiting for a long time. Access to dentistry and ancillary healthcare services is inequitable — better access to high-quality services is offered to those who are privately insured and/or wealthy.9 Public funding for healthcare and equityI want to examine two aspects of the relationship between public funding for healthcare and equity. The first follows from the observation that rich countries apply more public funding to healthcare (as a percentage of GDP) than do underdeveloped countries.10 Investment in healthcare is a sign of a country’s economic strength, and a reflection of its democratic values. Government investment in healthcare is both ethically desirable and economically rational. This has some clear implications. To honour equity, as a nation, we must set aside enough resources to buy appropriate, quality services and safe treatments, and make these accessible to our citizens based on their need. If the level of remuneration to doctors and other health professionals is lower than is economically or socially appropriate, or if the funds do not allow procurement of the most appropriate treatments, problems follow. Deeble estimated that the consumer-price-index-adjusted Medicare rebate for a standard general practitioner consultation (Item 23) has declined by $6 since 1984.6 The recent fall in bulk-billing by general practitioners has led to reform proposals from the Commonwealth Government and the Opposition. While these proposals are different, both would cost an extra $300 million per annum, and neither would apply the funds equitably. General practice is by no means the most expensive item in the healthcare system. As well as supporting general practice, we must ensure that our public hospitals are adequately funded. It is disappointing that the federal budget surplus has been used to fund a tiny personal tax cut when $2.4 billion, or thereabouts, would greatly help in raising our public hospital infrastructure to acceptable standards. Canadian social commentator John Ralston Saul has suggested that governments which are committed to corporatism, rationalism and cost cutting as means to achieve greater efficiency can make beliefs such as “publicly-funded healthcare services cannot cope” come true. The failure of publicly funded healthcare services is an inevitable consequence of insufficient investment or disinvestment. Indeed, the Romanow Commission, set up to review Canadian Medicare, recommended an increase in its funding.11 I am convinced that, as a nation, we need to spend more public money on healthcare services, and that much of the strain on Australian healthcare in recent years is the result of underfunding. Furthermore, there is room to improve the effective, safe and efficient use of the allocated money, thus assuring its support for equitable access. The second aspect of the relationship between public funding of healthcare and equity that I want to discuss is the observation that high levels of government funding for healthcare do not guarantee equity. A strong investment by government in healthcare may be necessary, but is not sufficient, to achieve equity. Big private-sector contributions bias the government contribution in favour of the rich. This is the case in India12 and the US, and is increasingly the case in Australia. About 14% of GDP goes on healthcare funding in the US, compared with about 9% in Australia. The difference is the result of healthcare spending in the private sector, not the public sector. The public sector accounts for 44% of US healthcare spending,13 and the proportions of GDP spent on public-sector healthcare are similar in the US and Australia. However, US public-sector healthcare expenditure is distributed preferentially to middle-class Americans because of the huge additional expenditure from private sources which drags government funding in its train. In Australia, the private health insurance rebate actually increased overall government spending on healthcare.14 However, the rebate tends to distribute government expenditure preferentially to those with private health insurance — that is, the wealthier members of the community. Moving forwardTo place equity on the agenda in the public funding of healthcare for Australia, we need two things: Greater clarity as to what Medicare and other public money for healthcare actually fund (clearly, where the nature or means of funding is inadequate or inefficient, we should develop new funding mechanisms); and A way to determine funding priorities that has equity as its centrepiece. On the first of these, we should consider a few funding additions and redistributions. First, we should extend the principles of the Pharmaceutical Benefits Scheme and the Commonwealth Medical (previously Medicare) Benefits Schedule to cover other essential services in our healthcare system. We currently support dental and allied health professional services with public money, but preferentially for those with private insurance. We pay for a third of private health insurance premiums from public funds. From the 1998 Australian Bureau of Statistics Health Insurance Survey and AXA/National Mutual data for NSW, Spencer estimated that each year we give some $300 million of public funds for dental care of those with private insurance.9 I believe that we should subsidise basic dental services for all Australians, as dental health is not a luxury. Private health insurance rebates for physiotherapy, podiatry and other support services also channel public-sector funds to those who are privately insured. This runs counter to the principle of Medicare. If we consider dental and ancillary services justifiable areas of public expenditure for those with private health insurance, then we should assess what public funds provide to all other citizens in respect of these services. We should focus on equity in what we do and do not fund. Second, the disparity in the payments that general practitioners receive from bulk-billed versus non-bulk-billed patients needs to be redressed. The Commonwealth Government is about to increase this disparity through its “Fairer Medicare” proposals.15 This is unacceptable. I understand the complexity of the issues, and the need to increase remuneration for general practitioners, but the present proposal widens the gap between those who are bulk-billed and those who are not. We must be able to come up with something better. Third, the Australian Health Care Agreements should take account of chronic disease management. For example, we could make more use of casemix methods in funding chronic disease management, although the AR-DRGs (Australian refined diagnosis-related groups) would have to be expanded to encompass continuing care and reflect the growing burden of chronic disease. The care of the chronically ill is an aspect of Medicare arrangements that requires substantial revision, including a full exploration of capitation rather than fee-for-service funding. Funding of healthcare provided by all professionals, not just doctors, is critically important for people with multiple chronic health problems. Models of care for chronic illness urge team approaches with good leadership and management. Extended and coordinated care is difficult to achieve if we only pay doctors at bulk-billing rates, or, indeed, if we continue to rely on a fee-for-service basis. Fourth, we need a coordinated plan to improve public hospital infrastructure in Australia. We need substantial additional capital funds, as well as ongoing funding. In the meantime, public hospital waiting lists, which disproportionately apply to those without private health insurance, constitute a real problem of equity. How do we move forward? Our healthcare services change incrementally, and from time to time we need to review and consolidate them. Yet it is easy to overlook the importance to us of equity in such reviews. This requires that we establish a process of determining what we should pay for through Medicare. For this reason, I propose the formation of a National Council for Equity in Healthcare, accountable to the Australian Parliament, with a mission to make the healthcare system more equitable. Its terms of reference would concentrate on the extent to which the resources available for healthcare are used equitably. As part of its charter, the Council for Equity in Health Care should support community debate leading to the development of a national healthcare charter containing principles for a more equitable healthcare system. The debate would provide an opportunity for citizens, patients and carers to state their expectations clearly, and might produce some surprising results. When Gavin Mooney recently asked a citizens’ jury in Perth to set priorities, it voted for equity and public health. When asked to set priorities within equity, Aboriginal health came first in the jury’s agenda, ahead of rural and remote health and aged care.16,17 The proposed Council for Equity in Health Care could also review the contribution of the taxation system to healthcare. This is especially timely now that the GST is in place. The Australian economy is in good shape and it could sustain an increase in public spending on healthcare and health. Although some say that there would be strong resistance among voters, a small progressive increase in the Medicare levy, to be used for the provision of more equitable healthcare, may well be acceptable. Opinion polls conducted by the major political parties have found that such an increase would be acceptable to most people in the way I have described.18 There are barriers to the achievement of equity that are not financial, and these deserve the careful attention of the proposed Council for Equity in Health Care. In remote Aboriginal communities, the absence of basic services compromises the universality of Medicare, and equity suffers.19 People who live a long way from a city do not have equal access to equal care for equal need, and may never fully do so. A previous federal Health Minister, Dr Michael Wooldridge, was correct when he said that Medicare was not the instrument to address the special needs of rural Australia. The Australian Institute of Health and Welfare has documented that Australians in large cities are bulk-billed for general practice services much more frequently than those living in remote areas.8 One description of Medicare is that it is a metropolitan system.20 On the positive side, the Commonwealth Government has been energetic in seeking to improve healthcare services in rural areas. It has funded programs for medical student education and registrar training, and provided enhanced funding for services. These efforts are laudable, as are the levels of dedication of many healthcare professionals who have worked hard under less than ideal circumstances. The government is also working to open up access to Medicare and the Pharmaceutical Benefits Scheme for many rural and remote Indigenous Australian communities, and this is commendable. There are also cultural and language barriers to equity in healthcare that can limit access to quality care. If there are not enough interpreters available in public hospitals, those who do not speak English fluently are disadvantaged. The cultural norms of the medical profession may easily prevent doctors from treating working-class patients in appropriate ways. Apart from underfunding, lack of cultural security is a major block to improving Aboriginal health.20 The proposed National Council for Equity in Health Care should include these issues in its remit. With increasing affluence, we can choose to invest more as a nation in the healthcare of our citizens. We can do much more to improve the degree of equity in healthcare in Australia. This is the course of a humane, caring nation with a belief in the value of civil society. We can apply business principles with benefit to many parts of healthcare. There is also a strong case for investing more in innovation and the evaluation of healthcare, and more in improving its quality and safety. At its core, though, healthcare is about sharing and caring — sharing the load of illness and caring about ensuring access to the privilege of hope that humane medical care offers. We need political leadership, both lay and medical, that will seek to strengthen, not weaken, worthwhile achievements, and build on what this country has achieved over recent decades in providing equitable healthcare for all Australians.

Stephen R Leeder PhD, FRACP

Burden-of-disease and cost-effectiveness studies will help us realise better population health Over the past decade or so, there has been increasing demand for greater clarity about the major causes of disease and injury, how these differentially affect populations, and how they are changing. In part, this demand has been motivated by resource constraints and a realisation that better health is possible with more informed allocation of resources. At the same time, there has been a change in the way population health and its determinants are quantified, with a much closer integration of the quantitative population sciences (such as epidemiology, demography and health economics) to strengthen and broaden the evidence base for healthcare policy. As demand for healthcare grows, decisions about resource allocation and priorities for the healthcare sector will fall under increasing scrutiny. The first coordinated efforts to provide more relevant and comprehensive data on the health (as opposed to survival) of populations and on specific strategies for disease control were led by the World Bank, culminating in two seminal reports in 1993 on the state of global health and priorities for improving it.1,2 These reports have subsequently had a great influence on debates about health sector priorities and healthcare research needs. A fundamental outcome of this World Bank research has been a change in the paradigm for health accounting, from measuring death to measuring population health, using a single summary index that simultaneously incorporates information about age at death and the incidence and prevalence of disease and injury. A time-based metric, the disability-adjusted life-year (DALY), was used to capture both fatal and non-fatal health outcomes affecting populations. DALYs for over 100 specific diseases and injuries have been assessed within a “burden-of-disease” framework which constrains individual estimates and preserves epidemiological plausibility.3,4 The burden-of-disease approach gives estimates of DALYs from risk factors (eg, smoking) as well as diseases caused by known risk factors (eg, ischaemic heart disease related to smoking) and from other, unrelated conditions (eg, road traffic accidents, which have nothing to do with smoking).5 Thus, a single metric (the DALY) can be used to compare disease burden across a range of diseases, injuries and risk factors. Certainly, the data and information requirements for adequate measurements of the burden of disease in a population are not inconsiderable. They need information on age at death and cause of death, the age-specific incidence of disease and injury, the typical duration of life lived with the sequelae of diseases and injuries, and some quantification of the severity of disability assessed according to a commonly agreed framework. The ethical, philosophical and conceptual issues involved in quantifying states of health other than perfect health are still very much a matter of debate, and rightly so.6 However, the reliability, and hence the utility, of burden-of-disease studies for public policy depend much more strongly on the quality and availability of the underlying epidemiological data. A principal advantage of the burden-of-disease approach is that it entails a data “audit”, whereby the completeness, reliability and consistency of routinely collected data are assessed, and critical gaps in health data collection are identified. One implication is that periodic quality assessments of, say, routine cause-of-death data ought to be carried out to ensure their continued relevance and reliability for public policy. Another might be the need for a more rational assessment of priority data for the healthcare sector, placing greater emphasis on data collection and data linkage to facilitate burden-of-disease studies, rather than on routine collection of statistics of limited public health relevance. The burden-of-disease framework, based on the estimated epidemiological path of incident cases, would benefit greatly from wider availability of linked data sets on health outcomes and further research into health-state transition probabilities (ie, the probability that patients with a given illness or disability will get better or worse, and the severity of their current compared with their previous health state) from longitudinal studies.7 In parallel with the increased emphasis on more reliable and comprehensive assessment of population health, there has been a rapid expansion in knowledge about the cost-effectiveness of interventions for reducing the burden of disease. Packages of interventions to optimise health in populations at different levels of development were among the major research outcomes of the World development report 1993.1 Subsequent work by the World Health Organization identified evidence of cost-effectiveness as a key health research priority worldwide.8 The findings of a large international study of the cost-effectiveness of 170 interventions, primarily to reduce health hazards from unsafe water and hygiene, childhood undernutrition, tobacco use, unsafe sex, and high blood pressure and blood lipid levels were recently reported by WHO.9 The evidence base for setting health priorities is thus rapidly expanding. Yet, as the WHO report points out, there is still a large potential for realising better health through more informed and systematic application of this knowledge.9 As demand for healthcare grows, decisions about resource allocation and priorities for the healthcare sector will fall under increasing scrutiny. This is likely to lead to demands for more reliable and useful evidence about population health problems, and for affordable and effective measures to address them. Australian researchers have been at the forefront of these international developments, and have carried out local burden-of-disease studies that have been used to support policy development by the federal and state governments, particularly in Victoria.10,11 Australia is also well placed to provide technical support to neighbouring countries that are undertaking burden-of-disease and cost-effectiveness research to improve the efficiency of their healthcare systems. More than 5 years have now passed since the first Australian burden-of-disease study was undertaken, and much could be gained from a renewed appraisal of Australian healthcare information based on the methodological advances in burden-of-disease measurement in the interim. The School of Population Health at the University of Queensland has established a Centre for Burden of Disease and Global Health Research which has a mission to provide the technical and strategic leadership for priority-setting research in Australia and the entire Asia–Pacific region. Strong links to WHO, the World Bank, the National Institutes of Health in the United States, and other leading health research institutions worldwide, will ensure that efforts to improve the evidence base for healthcare reflect global advances in health research and development.

Alan D Lopez PhD

Regulatory and ethical guidelines require clinical trial sponsors to disseminate clinical trial adverse event reports to involved investigators and human research ethics committees. Compliance with these guidelines has resulted in a major administrative burden for ethics committees. This burden does not necessarily contribute to the protection of clinical trial participants. Rationalisation of the adverse event reporting might allow better use of the data and might benefit human research ethics committees.

Winston S Liauw MMedSci, FRACP · Richard O Day AM, MD, FRACP

It’s time to stop applying bandaids and get on with real change Despite their protests that it was a “hold-up” and that it “may tragically be the death warrant for some people”,1 last month our state premiers capitulated and signed the 2003–2008 Australian Health Care Agreements (AHCAs). Since then, the healthcare crisis has all but disappeared from the front pages of newspapers and television screens, but, for the community, the crisis remains a daily reality. The desire for healthcare reform, so evident at the recent Australian Health Care Summit,2 will continue, and the demand for the AHCA’s reform blueprint3 to be implemented will only increase in the face of the ongoing inertia of our health ministers. In short, there is now widespread expectation of less political rhetoric and more action. However, sustainable reform requires a change in the political and professional landscape of Australian healthcare. In a keynote address at the Australian Health Care Summit, leading health reform expert John Menadue diagnosed the ailments of our healthcare system, and proffered some cures. His address, Healthcare reform: possible ways forward, appears in this issue of the Journal (page 367)4 as the first in a series of selected addresses to the Summit. Menadue’s diagnostic skill comes from his role in promoting healthcare reform as chair of the New South Wales Health Council,5 and, more recently, as chair of the South Australian Generational Health Review.6 It would seem that Australia’s healthcare system is not at all well. In the upper echelons of healthcare, Menadue has identified a multitude of ailments, including: endemic political buck-passing across jurisdictional divides; lack of public honesty by governments as to what the healthcare system can provide given its limited funding; and a preoccupation on the part of health ministers and their advisers with media management and health micromanagement, much to the detriment of more significant healthcare issues. In essence, our health system is overpoliticised. Short electoral cycles, constant ministerial turnover and the body politic’s demand for instant solutions are not compatible with reforming a large and complex system.7 At a middle level the ailments include: isolated healthcare professionals who run insider debates with little involvement of the community; a system that is hospital-centred at the expense of primary care, population health and community-based care; and a pervading executive ethos of decision paralysis. Menadue’s diagnosis of Australian healthcare is that it is institutionalised, introverted, and wary of innovation and change — a system constantly crying out for “more money please”.4 However, all is not doom and gloom. Menadue also offers possible cures. Most prominent among these is to have Commonwealth and state governments involve the community in setting priorities in healthcare spending. After all, it is about their health and their tax dollars! Reform means change, and change is always difficult to achieve, but a real life example of healthcare reform and change management has been in train in NSW since 1999 (see Box). In that year, the then NSW Minister for Health, Craig Knowles, initiated a major review of the state’s health system by two independent bodies comprising health and other experts, consumer representatives, and headed by prominent individuals from outside the health system. After an extensive and consultative process, the overarching recommendations from one of these bodies, the NSW Health Council, were the need for metropolitan-wide planning of clinical services (including the role of district hospitals in clinical networks) and increased engagement of senior clinicians in planning and administering health services.5 The NSW government promptly accepted the major thrust of the report, and the health minister initiated a cascade of processes to improve healthcare delivery in the greater metropolitan region (see Box).8 The change process is driven by the Greater Metropolitan Transition Taskforce (GMTT), an independent external body established to monitor progress and facilitate progress (see Box). The principles for achieving reform and managing change evident in this NSW experience include: a health minister with vision and political clout; use of respected outsiders to lead independent bodies in exploring frameworks for reform through extensive and inclusive consultation; timely acceptance of major recommendations by the government; delegating implementation of change and progress monitoring to an independent body, outside the bureaucratic stream, but with “buy in” of professional expertise; and, most importantly, giving “experts” the freedom and time to achieve the task. Overriding all of this, however, is the need for a collective political will for meaningful reform. The AHCAs have been signed and our health ministers have an interlude of no more than 4 years. Over a year ago, all our health ministers agreed on an agenda of reform and change.10 If there is no meaningful movement within the next year or so, patients, doctors, nurses and other health professionals have every right to say “a plague on both your houses”.11 Healthcare reform in New South Wales July 1999: The NSW health minister initiated an extensive independent review of the NSW healthcare system which included establishing the NSW Health Council to examine the way the NSW healthcare system delivers care. March 2000: The NSW Health Council recommended developing a single, coherent, long-term, organised plan for metropolitan Sydney.5 May 2000: The Greater Metropolitan Services Implementation Group (GMSIG) was convened by the health minister to examine hospital services. June 2001: GMSIG report, incorporating 162 recommendations related to a broad range of acute hospital services,8 was accepted as NSW government policy. November 2001: Health minister established the Greater Metropolitan Transition Taskforce (GMTT) to implement the GMSIG recommendations, specifically to examine hospital services in the greater metropolitan region, including Sydney, the Central Coast, Hunter and Illawarra. July 2002: $64.5 million annual recurrent enhancement funding ($30.9m to the 22 smaller “District” metropolitan hospitals) targeted to areas that clinicians considered the highest priority.9 December 2003: GMTT to report on achievements in 15 clinical program areas identified by GMSIG and seven additional clinical programs reviewed at the request of clinicians. GMTT convened working groups across these 22 specialty areas, and held open meetings at hospitals across the greater metropolitan region. Over 2000 doctors, nurses, allied health professionals and consumers were involved in the working groups. Selected outcomes to date Establishment of collegiate approach between doctors, nurses, allied healthcare professionals and consumers, and of clinical networks to coordinate services. Sustainable clinical governance with consumer involvement established in 24 hospital disciplines in the greater metropolitan region. 300 new clinical positions established in metropolitan hospitals; 19 stroke units with common treatment protocols established; three new cardiac units established on the periphery of the metropolitan area to provide cardiac angiography; five computed tomography scanners and staff provided; and interhospital transport upgraded. Statewide services coordinated in severe burns, spinal cord injury, brain injury rehabilitation and major trauma.

Martin B Van Der Weyden MD, FRACP, FRCPA

There is little disagreement about the directions public health reform should take — greater emphasis on primary and preventive care, workforce reform, community participation, improved governance and better application of information technology. It is clear that there are gaps and duplication in clinical services that reflect outdated population patterns and jealously guarded clinical territories. There is concern about the health disadvantage of certain groups, and particularly Aboriginal and Torres Strait Islander people. In quality of life measured by life expectancy, Australia ranks number two in the world, but in healthcare equality we rank number 17.1 If all Australians had the same health experience as Aborigines, we would rank number 140 in the world, alongside Bangladesh. These issues are common to many advanced healthcare systems. This is confirmed by almost any healthcare enquiry or commission. One doesn’t have to be a rocket scientist to know where we need to head. But there is considerable disappointment and disillusionment about the ability of the leaders of our health systems to lead and manage the change. And the public is right about the failure of health leadership — political, clinical and managerial. In the two inquiries I headed in New South Wales2 and South Australia,3 the cynicism I encountered was abundant and depressing. I was continually told that “your inquiry may be well and good, but nothing will really happen”. I understand their cynicism. It is part of a larger issue of alienation, which the community feels towards all our major institutions — parliament, political parties, the media, trade unions, companies, and churches.4 We so often feel that they are not honest and open with us, and that they try to manage and manipulate information to protect their own interests. Major institutions have lost touch with their natural constituencies. It is true in healthcare. I would like to identify briefly some of the major underlying problems and then suggest some possible ways forward. My comments are very much influenced by observing, at close hand, the NSW and South Australian health systems and the way they relate and react to Commonwealth health funding. There is clearly a failure of the Commonwealth and states to cooperate in the funding and delivery of healthcare services, with resulting inefficiencies, buck-passing, cost-shifting and poor integration. It was made clear to me in NSW and SA that the public wants change here, but doesn’t see any leadership through the impasse. There is a lack of honesty by governments as to what the healthcare system, with limited funds, can reasonably provide. As a result the public has unrealistic expectations and the health workforce is under great pressure. In this situation, political mischief by Oppositions is easy. Unless governments face this issue of limited funds and rationing, and are honest with the public, they will always be under pressure and in crisis, with numerous bandaids applied, but no system change. The healthcare system is remarkably inward looking. The debate is between insiders. The community is not enfranchised or involved. If I have been able to contribute anything to the health debate, I believe it is because I am an outsider. There is clearly waste in the present system, with a $2.5 billion private health subsidy that produces few obvious health dividends. There is widespread overhospitalisation, overservicing in some areas, duplication of clinical services and large central health bureaucracies. We have a very institutionalised, medicalised and hospital-centric system, rather than a health system. The debate and resources are pre-empted by hospital interests at the expense of, for example, primary care, prevention, clinical support in the home, more appropriate facilities for the aged, and hospital avoidance programs. Hospitals should be the last resort, but, in the current system, they are often the first. There is the problem of the quality of healthcare, and avoidable adverse events as a result of spreading our skilled clinical services too thinly. In attempting to tackle these issues, the plea invariably is “more money please”. More money is clearly necessary in key areas, but more investment in doing the same things the same way will only delay reform. It encourages just the attitude that is at the centre of our problems — that resources are unlimited and that choices do not have to be made. It will be the same old treadmill. Governments and taxpayers rightly insist on value for money. Reform will not be successful unless we can persuade treasuries that the money will be better spent in the future. In achieving that, I believe some or all of the following elements need to be in place. A Commonwealth/state health commission should be established in any state that agrees to cooperate with the federal government in the joint funding and operations of public healthcare services in that state. Which state will break the impasse and be the first to put its hand up? Will the Commonwealth respond? We need to move beyond Commonwealth/state pilots and demonstration projects to real system change. I am sure that a joint service would deliver better quality and efficiency of care, even if no additional funds were provided. So let us put that joint Commonwealth/state health commission on the agenda, put the case as compellingly as we can, and hopefully within 3 to 5 years we would have started to break the wasteful impasse and buck-passing of the present divided jurisdictional system. The roles of ministers, health executives, boards and health institutions, particularly in the states and territories, must be clearly defined and accountabilities established. The micromanagement of healthcare systems by ministers and their private offices must be stopped. I have heard and seen at first hand endless cases of private ministerial staff members who suppose that, as the minister’s alter egos, they can hector quite senior clinical and non-clinical staff. Some members of ministerial staff even think it is appropriate to try to micromanage external and independent committees of review. This is not a new problem, nor is it restricted to one government. It is a very serious problem. Certainly, ministers and their offices need to manage short-term crises and they need to get on top of some of the detail, and there is a lot of detail in healthcare, but so often they allow themselves to be submerged by the detail, lose their way and allow the nightly TV news to set the agenda. So, ministers spend disproportionate amounts of time putting out brush fires. Media management and micromanagement by ministers and their offices go hand in glove. This preoccupation with daily crises and micromanagement has many unfortunate consequences — long-term issues, such as the reform agenda we are discussing at this summit, are put on the back-burner. Senior executive officers are confused and reluctant to make decisions. They become gun-shy. They manage upwards to the minister. The minister becomes the client, and not the public. Disproportionate resources and energy are spent serving the minister, and particularly his or her staff. The central department also becomes too close to the political agenda of the minister, with the emphasis on news management. In my experience, private staff of ministers are petrified at the prospect of robust discussion and debate. This issue must be addressed, or confusion and frustration at senior levels will continue to paralyse the system. Only ministers can lead this change and forgo their micromanagement. It is not only in the interests of a well functioning system for them to do this, but it would seem clearly in their own interests to break out of the daily political cycle of calls for more beds and complaints about ambulance bypasses. The healthcare system would greatly benefit if they would use their political credit and influence to win the debate and change the system — to achieve, for example, better primary care, improved mental healthcare and putting us on track to remedying the most disastrous problem of all, poor Aboriginal health. In speaking of micromanagement, I know I am treading on toes, but if I could paraphrase the words of Confucius when asked “how to serve the minister”, the sage replied “tell him the truth, even if it offends him”. Not only must there be clearer definition of roles, and clear accountabilities, there must also be close linkages between corporate, clinical and community governance. Each role must be clearly defined within an overarching governance structure. Clinical governance in the end must be subject to corporate governance. Managers must recognise the professional responsibility and skills of clinicians. Clinicians must understand the financial and political constraints under which the system operates. It is they who admit patients to hospitals — not patients themselves or even hospital managers. Nothing is ideal, but improvement is possible. Great care is also necessary in choosing boards of governance, for getting the governance structure right will not be sufficient if ministers appoint political or personal extensions of themselves. Similarly, board members must carefully and determinedly assert their duties to ensure good governance, and not knuckle under to short-term pressures. Governance boards are not the same as advisory committees. They must be structured and appointed with full regard to the overarching responsibilities which governance boards have — financial, ethical and legal probity, adherence to occupational health and safety standards, high standards of professional conduct and competence and efficiency. The health agenda must be changed and the community is the key to doing that. I believe that in SA, we have recently made significant progress in presenting a compelling case to the public for change — the main change being a public understanding that we can’t have everything in healthcare. However, the status of the new agenda may be precarious, and could easily revert to the daily political cycle of media headlines about hospital beds and new high-tech equipment. There must be major and successful communication campaigns to establish what are the clear priorities in healthcare spending. Expenditure on healthcare in Australia has increased from about 6% to 9% of GDP (gross domestic product) over the last 40 years. While healthcare demands are almost unlimited, resources are finite. The health budgets of Commonwealth and state governments are clearly not sustainable into the future. I have seen numerous surveys of community priorities in health. They all tell very largely the same story. Whilst the community appreciates the important role of hospitals, they see mental health as today’s top priority, followed by the health of children (particularly children subject to violence), and Aboriginal health. The community speaks very clearly and consistently on these issues, but they do not shape the priorities in spending. Insiders make the decisions. Ministers give lip service to community participation, but many quite seriously believe that they represent the community, so do not see the need for another level of community participation. Unless the Commonwealth and state governments involve the community in setting priorities in health spending, we will not make real progress in systemic reform. We called our South Australian report “Better choices, better health”.3 Choices cannot be avoided. Unless the community is locked in through appropriate structures and processes, health reform will not happen. The public must be connected. Health leaders must acquire and demonstrate proven capabilities in managing change in large organisations. For large-scale change is necessary, and, if I was a minister, I wouldn’t be confident that I had the senior executives who were capable of leading the process. In my experience, the public sector has superior analytical and policy development skills compared with the private sector. But there is a big difference when it comes to being prepared to take risks. Change management is now a significant feature of leadership in major companies in Australia and around the world. It is desperately needed in healthcare systems. While change in healthcare systems must be driven from within, it requires major help from outside experts. The healthcare workforce is composed largely of people of great professional commitment and skill, but they know little else but health. So change is hard to visualise if healthcare is the sum total of one’s work life. Nowhere is the healthcare system in greater need of external expertise than in human resources and industrial relations. These are essential if we are to see a restructuring and rejuvenation of the healthcare workforce, which is, frankly, more appropriate to the needs of the 19th than the 21st century. Training and work are in separate compartments, and work demarcations abound. Restrictive work practices and denial of career prospects, large central offices and shortages in critical areas are rife. There is little linkage between workforce plans (if they exist at all) and budgets, infrastructure planning and delivery of services. The labour market is supply-driven, with little effective linkage between the supply through training and educational institutions and the demands of a changing healthcare system. We are rightly proud in Australia of the workforce renewal that has helped transform the Australian economy. But that workforce renewal has not really touched the professions, and particularly the healthcare sector, where jobs need substantial redesigning and work processes must be significantly re-engineered. Over a period, this could deliver major productivity gains and enhanced job satisfaction, particularly for nurses. New people with resolution, new ideas and new attitudes are essential if workforce renewal is to occur. The solutions to many “health” problems will not be found only within a highly medicalised healthcare system. The greatest cause of poor health is poverty. This is abundantly clear with Aboriginal people. Their poverty and associated bad health are compounded by a lack of hope. I recall in SA an Aboriginal elder telling me that young Aboriginal people say to her “with our grim prospects, what is the point of being healthy”. So a response must be holistic. It requires whole-of-government action, with targets set across a range of portfolios — employment, education, water supply, police and health. And this can only be driven by the Cabinet. Interdepartmental committees will not do the job. Aboriginal health is a national emergency that requires ministerial leadership by every Cabinet minister in Australia, not just health ministers. Because the health system is so inward-looking, an independent and external monitoring body to report publicly on implementation of a change program is essential. Change will be hard, and every day there will be those with vested interests who will want to beat back the change. Not surprisingly, the leaders within the system are likely to lose heart. That is why an independent and strong external group is essential in checking progress and helping to chart the way forward. In this work, that monitoring body needs to focus on a few simple and clear measures of progress. Healthcare produces reams of reports and statistics, but these are not used to measure and drive reform. The Canadians have something to teach us, as in so many healthcare areas, about what are the really important measures of success in health systems.5 Finally, I guess all this comes down to leadership — political, clinical and managerial. My recent experience in SA is that the public wants to be engaged, and responds very positively to a well argued case for change. That case requires leaders prepared to take risks.

John Menadue AO

The recording process needs to become more efficient, more useful to clinicians and multipurpose Medical records serve a variety of purposes: they reflect the care process, provide a line of communication between clinicians and health services, and constitute legal evidence of referral, presentation, assessment and care given. If it is not in the medical record, it did not happen! They are also used for quality assurance, casemix funding, deriving statistics on diseases and procedures, and research. However, many clinicians seem to regard record-keeping as a chore. Why is it important and how can it be made more efficient and exciting? In this issue of the Journal, the report by Lee and colleagues (page 289) demonstrates an important use of medical records.1 Their study of survival of patients after stroke in Western Australia was made possible by linking morbidity data derived from hospital medical records with death reports using unique patient identifiers. This data linkage project and associated efforts to improve the quality of hospital data are well known in Australia and internationally for their contributions to understanding outcomes of care. Moves to introduce data linking over time and place using probabilistic matching or unique patient identifiers are gathering momentum throughout Australia.2-4 Studies such as that of Lee and colleagues depend on accurate, consistent coding of information on diseases and procedures from patient medical records. The coding process is multifaceted, involving: abstracting from the patient record the diagnoses and procedures to be coded; choosing codes for each diagnosis and procedure; and “sequencing” (ranking) of codes to identify the principal diagnosis, which determines the diagnosis-related group5 for that episode of care. In Australia, considerable effort has gone into developing standards for the coding process. The National Centre for Classification in Health (NCCH), with input from clinicians and clinical coders in all states and territories, has developed an Australian modification of the World Health Organization’s classification of diseases, The international statistical classification of diseases and related health problems, and an accompanying Australian classification of procedures, originally based on the items in the Medicare Benefits Schedule — together making up the ICD-10-AM.6 This publication also includes the Australian coding standards, the “rules” for applying and interpreting the ICD codes. The NCCH maintains these systems, updating not only the categories within the ICD-10-AM, but also colloquial clinical terms, so that coders can match the language in patient records with that in the classification. The NCCH also produces the ICD-10-AM chronicle,7 which maps categories and terms from one ICD-10-AM edition to another, so that coded data can be used for longitudinal studies. Use of the morbidity coding process as the foundation for casemix grouping, and in turn casemix funding or contracting, has turned the spotlight on the accuracy of the coding process. While the emphasis has been on obtaining the “correct” diagnosis-related group, this is possible only if the coding is a true reflection of patient characteristics and care. However, coders can only work with what they are given. To produce quality data, they require accurate, comprehensive medical records that are clearly and concisely expressed and in predictable format. Yet, the quality of many medical records leaves much to be desired, with little change in format or content in the past 40 years. In 1995, the Quality in Australian Health Care study found that over half the medical records reviewed were missing one or more key elements, such as assessment, progress notes, discharge summary, or diagnostic and therapeutic procedures, and that adverse events are less likely to be detected if documentation is missing.8 All this points to the need for revolution rather than evolution. There have been many attempts to improve the quality of medical records, such as the development of problem-oriented medical records9 and, more recently, the move towards electronic medical records. The Clinical Casemix Committee of Australia recently commissioned the NCCH to produce the Good clinical documentation guide10 to help clinicians understand the process of coding and to enhance the quality of coded data. This guide reflects the change in focus from coding for casemix to reinforcing the conjunction between good clinical care, good recording and good morbidity data. To promote a uniform approach to information and communication technologies in the health sector, the federal government has initiated Health Online, a national strategic plan for health information management.11 One Health Online project, HealthConnect, proposes a national approach to electronic health records, with patient “event summaries” collected in standard electronic format at the point of care (eg, hospital or general practice) for retrieval and exchange with other healthcare providers.12 Although this project holds out hope, so far health information has not seen the technological advances that have occurred in other information intensive industries. Much clinical time is devoted to recording the care provided to patients. It is our challenge to make that recording as efficient as possible, to free as much time as possible for clinical rather than administrative functions, and to make the data work for clinical care and for research. Clinicians need to feel that the recording process is useful to them, tied to decision support and the literature, including information about drug interactions and evidence of treatment outcomes. Data extraction should not be an after-the-event exercise but a continuous, real-time process and an intrinsic part of care, occurring at the bedside and integrated with ordering of investigations and prescribing. While electronic health records will impose more discipline on how information is recorded, they will not be a panacea for poor recording practices. We must get our collective act together to promote the goal of recording information once at the point of care for the many subsequent uses, with research a by-product of clinical care. While techniques of data linkage, such as those used in Western Australia, already make a major contribution to this, there is still a long way to go in rationalising record-keeping by clinical staff within and between health services.

Rosemary F Roberts MPH, MBA · Ralph M Hanson FACEM. MPH. MRACPA, FRACP

All is not well with Australia’s health system Internationally, Australia’s health system is held in high regard. Our citizens enjoy life spans second only to those in Japan.1 The World Health Organization measures a nation’s health attainment as a composite of the average level of population health and the general distribution of population health or health equality, the level and extent of the health system responsiveness, and the fairness of contributions to health financing by households. According to the WHO’s benchmark — the overall health system attainment index — in 1997, we ranked 12th among 191 nations.1 But all is not well with Australia’s health system. Its edifice is cracking under the strains of a growing mismatch between its capacity to deliver quality healthcare and the changing demands of our communities. Symptoms of the system’s stresses include: the free fall in the number of general practitioners who bulk bill,2 and the consequent threat to Medicare’s principles of universality and equity of access; the short supply of health professionals, particularly nurses3 and general practitioners;4 the increasing occurrence of hospital access block and hospital ambulance bypass,5 and the growing elective surgery queues; the problem of hospital exit block, reflecting the short supply of community-care services, particularly for older people,6 and the breakdown in social networks; the inherent inability of a system organised for acute, episodic care to efficiently provide continuous long-term care;7 and finally the conflict between society’s increasing demand for health services, the high cost of technology-driven medicine and new pharmaceuticals, and the political and fiscal imperatives of the guardians of the public purse. Critical to the viability of our health system are the Australian Health Care Agreements (AHCAs). These 5-yearly political pacts define the joint funding responsibilities of federal and state or territory governments in providing free public hospital services.8 One of the drawbacks of the AHCAs is their impotence in promoting reform. And our health system is sorely in need of reform! This imperative was recognised by Australian ministers of health in April 2002, when they collectively adopted a reform commitment, underpinned by the principles that the federal and state or territory relationship in health funding should ensure that: the provision of optimal care and health outcomes be independent of jurisdictional boundaries; the respective jurisdictions work cooperatively to improve the health and wellbeing of the community; and the next round of AHCAs (2003–2008) be outcome-oriented.8 Suddenly, the winds of change were stirring in Australian healthcare and fanning expectation of reform. The ministers promptly established nine reference groups to address and advise on issues affecting current healthcare. These briefs included the continuum across preventive, primary, chronic and acute care; improving the interface between aged care and acute care; cross jurisdictional cooperation on workforce training and education; the interaction between hospital funding and private insurance; improving Indigenous health, mental health and rural health; quality and safety; and, concluding this impressive and inclusive list, was information technology and research.8 The nine expert groups met, deliberated, and, in record time, in September 2002, presented to Australia’s health ministers a comprehensive agenda for reform.9 The ministers considered the road maps for reforms, and highways were identified for their implementation, but, to date, the reform vehicles have remained locked up in bureaucratic and ministerial garages. In the meantime, the ministers have resumed their adversarial political rhetoric, punctuated as always by fiscal bickering and buck-passing. This return to tiresome political form has undoubtedly fuelled widespread mistrust and cynicism among health professionals and consumers. One outcome of this despair and discontent has been the Australian Health Care Summit held in Canberra on August 17–19, 2003. The Summit was attended by more than 250 delegates, drawn from across the healthcare spectrum. They included academics; administrators; allied health and other professionals; clinicians; consumers, economists; experts in health policy, mental and public health; politicians; and people and health professionals from Indigenous, rural and remote communities. Despite the Summit’s claim to be an independent, bipartisan gathering, the absence of the Federal Minister for Health and Ageing, Senator Kay Patterson, and the minimal representation of the Australian Department of Health and Ageing, were duly noted. Furthermore, the Summit’s claim of independence did not deter lightning forays by the Premier of New South Wales, Bob Carr, and the Leader of the Federal Opposition, Simon Crean. Despite the politics, what did the Summit achieve? It reaffirmed the egalitarian and socially cohesive principles underpinning Australia’s healthcare (Box). It identified inhibitors of and promoters for health reform, which are detailed in the Summit Communiqué.10 The Summit’s sixteen workshops spawned detailed suggestions for reform. Finally, there was a recommendation for an independent national body to drive health reform.10 However, the real message emanating from the Summit was the depth of desire for healthcare reform among consumers and professionals, and the wealth of innovative ideas and solutions that the healthcare community has to offer when committed to the cause. If only one message comes from the Summit it is that Australian healthcare reform is in dire need of political champions and cooperative federalism to harness the people and professional power so evident at the Summit. Without the spirit of cooperation, future health ministers may well look back to 2003 and say “we did nothing”. And that would be a shame. Australian Health Care Summit Statement of principles We believe the following principles must underpin our Australian health system: Universal access – in a timely fashion, to an appropriate service, available because of health needs, not one’s ability to pay; Equity of health outcomes – irrespective of socioeconomic status, race, cultural background, disability, mental illness, age, gender or location; Health care services must be focused on the needs of patients and their carers and the needs of Australians wishing to avoid illness; Health promotion – preventing disease and maintaining health must be appropriately emphasised and balanced with our duty of care to those already unwell; Personal and corporate tax contributions should fund our health care. This is the way we wish to provide health insurance to each other; A fair balance of public and private resources and investment is needed [to] ensure equitable health outcomes for all Australians; The health outcomes of Aboriginal and Torres Strait Islander Australians must be improved so that they match those of other Australians; Health services must be appropriate, safe and of high quality; The community – especially consumers and carers, must play an integral part in the development, planning and implementation of our health services; The health workforce must be valued and appropriately supported.

Martin B Van Der Weyden MD, FRACP, FRCPA

The foundation of treatment for patients with hypertension is ongoing use of lifestyle measures such as physical exercise, weight reduction, and salt restriction. There should be emphasis on reduction of total cardiovascular risk, including smoking cessation and achievement of goal blood pressures. There are now five classes of first-line blood-pressure-lowering drugs — diuretics, β-blockers, angiotensin-converting enzyme inhibitors, angiotensin receptor blockers and calcium antagonists. In most patients, the choice of drug will be guided by the clinical situation in the individual patient, including the presence of target organ damage, diabetes, established vascular or kidney disease, or other comorbidities. In the absence of such clinical indications, start drug therapy with a low-dose diuretic. Combination therapy will be needed in around two-thirds of patients, and a diuretic will normally form one element of most combinations, with the second or third drug coming from among the remaining four. Consider the use of fixed-dose combinations to improve adherence to therapy. Use long-acting, once-daily preparations.

John P Chalmers MD, FRACP · Leonard F Arnolda PhD, FRACP

In response to the increasing use of complementary and alternative medicine (CAM), governments are exploring ways to ensure patients’ safety and respond to complaints. One solution is to establish registration boards and procedures based on the model of existing health practitioner Acts. Registration will require defined minimum standards for competence, which will have to be based on scientific evidence. As scientific evidence accumulates, these modalities are likely to lose their identities as “alternative” and become assimilated into Western medicine.

Malcolm H Parker MB BS, MLitt