Health services administration

“Illness is the night side of life . . . Every one who is born holds dual citizenship, in the kingdom of the well and in the kingdom of the sick”. — Susan Sontag Were we too successful in the 19th and 20th centuries? Public health and medicine vanquished many infections and injury as causes of death and disability in the developed world. But a “burden” of chronic disease now rises to challenge us: chronic disease affects at least one in ten Australians,1 and cardiovascular disease, chronic obstructive pulmonary disease and depression are endemic.2 It would be heartening to think that a Polypill might be the answer to our (chronic) ills.3 But the problem lies in the fundamental mismatch between 21st century morbidity and 20th century management — and a better match for the former is unlikely to be simple. We’re coming to realise, as the World Health Organization has, that “as long as the acute care model dominates health care systems, health care expenditures will continue to escalate, but improvements in populations’ health status will not”.4 Take Zajac’s provocative statement on page 250 of this issue, that “if supermarkets offered the same level of customer service as . . . public hospital(s), they would not survive”.5 His unique master proposal will turn hospital organisation (and staff leisure activities) on its head. MacDonald (doctor and BMJ Assistant Editor, who has scleroderma; page 267)6 and Fels (ex-chairman of the Australian Competition and Consumer Commission, who cares for a daughter with schizophrenia; page 268)7 eloquently attest to the deficiencies of our system in this special issue. How would a revamped healthcare system attuned to chronic illness look? Well, we have a dream. It is that Australia’s healthcare system will provide: quality Care that is Centred on the patient, Community-based, Coordinated, Continuous and Cost-effective, and utilises Clinical information systems Can the dream do any better than our current system?The dream is an evidence-based reality, albeit patchily applied, in several parts of the world. A systematic review of trials testing such chronic care models for people with diabetes showed that these improved health outcomes and lowered healthcare costs or use of health services.8 A comparison between Britain’s National Health Service and Kaiser Permanente, a Californian non-profit health maintenance organisation (HMO), showed that, although per capita costs were similar, patients in the HMO received more comprehensive and convenient primary care services, faster access to specialist services and inpatient treatment, and used acute hospital services less.9 These advantages were attributed to an integrated system (including chronic disease management programs and partnerships between physicians and administrators) that efficiently managed hospital use, competition and greater investment in information technology.9 The chronic care paradigm encompasses preventive and therapeutic care, and both must incorporate risk-factor management. As many of the top risk factors for disease burden (such as smoking and physical inactivity)2 involve behavioural change, working in continuous partnership with patients to find common ground is crucial. Such patient-centred care is not a new concept, says Bauman on page 253, but is becoming more evidence-based and can increase adherence to management, reduce morbidity and improve quality of life.10 Evidence is mounting, too, that well-coordinated interdisciplinary teams (intuitively desirable but only recently supported by evidence) can actually benefit people with chronic illness, if team members have the right training, clearly defined roles, and clinical and behavioural skills.11 The evidence that a healthcare system modelled on chronic care benefits its users is compelling. So what will it take to overhaul the system?That nothing succeeds like largesse is a belief dispelled by those who argue that it is the methods of health financing that must change for appropriate healthcare delivery.8,12 Visionary professional and political leaders are vital to the process. For beleaguered healthcare professionals at the frontline, Brooks weighs in with “task substitution” (page 260), freeing up some to focus on their particular expertise.13 Turf-threatening anathema to some, but perhaps it is more important to ensure that our patients get the best care possible. No one can be all things to all patients with chronic illness. Nair and Finucane explore the reforms needed for this postmodern approach on page 257.14 The quest requires a shared vision that echoes our dream: to serve society; to foster generalism and decrease fragmentation; to address the changing nature of illness and the changing nature of practice.15 But, as Nair and Finucane observe, reform will be difficult where health education systems are diffuse, divided and embedded in high-tech, acute or curative medicine, while low-tech chronic and caring medicine is left to drift.14 The supremacy of curative medicine also spills into our research agenda, where reductionist research currently holds sway. According to Professor A Pettigrew, CEO of the National Health and Medical Research Council (NHMRC) (personal communication), more than 60% of the objectives of current research supported by the NHMRC fall within our National Health Priority Areas (asthma, cancer control, cardiovascular health, diabetes, injury prevention and control, mental health, and arthritis and musculoskeletal conditions). Yet much of the supported research is likely to lead to high-tech curative paths. Considering its burden, chronic illness must shoulder its own defined and targeted research agenda: to identify the factors necessary for successful primary and secondary prevention, then evaluate community-tailored programs arising from these data; to explore integrated health delivery systems that embrace our C’s for chronic care management; to be scientifically rigorous and have meaningful performance indicators, allowing evidence-based decision making. The Box recounts the experiences of a man with complex chronic problems being let down by the current health system. In stark contrast is his treatment in a dream system evincing the seven C’s we espoused above. Our biggest success with chronic disease will be to live the dream by dragging our healthcare system into the 21st century. After all, “when you cease to dream you cease to live” (Malcolm S Forbes, publishing mogul and founder of Forbes magazine). Care for a man with chronic illness: as it is and as it could be The reality Lee, a 44-year-old retrenched bank teller, presents with lethargy and heartburn to his GP, Dr Bilius. The GP orders blood tests (normal, apart from mildly raised serum γ-glutamyl transferase levels) and refers Lee to a gastroenterologist for an endoscopy. This confirms mild reflux oesophagitis. Lee is prescribed proton pump inhibitors, which he ceases as soon as his symptoms resolve. One night, he presents to hospital with a sore neck after a minor car accident, and tells the medical officer, Dr Stressius, that his perpetual tiredness contributed to the accident. Dr Stressius notes that Lee smells of alcohol, his blood pressure is raised and there is no serious injury. Blood tests (duplicating previous tests) are performed, and Lee is discharged with a letter for Dr Bilius. Lee loses the letter, but returns to Dr Bilius, who spends 10 minutes chasing the hospital test result by phone. They run out of consultation time, and Lee is advised “not to drink too much”. He does not return until injured in a brawl a month later. The alternative: We have a dream . . . As Lee presents with a “new” problem, Dr Harmonius takes a full history and examination. A picture emerges of someone with dyspepsia, possible depression, alcohol misuse, high blood pressure, and financial difficulties. Dr Harmonius asks Lee to express his biggest problems (“feeling worthless”, “being tired all the time”) and goals (“to get a job”), then explains how his problems may be linked; a few of their adverse effects may obstruct his goals. Together, they decide on a management plan to meet his goals: appropriate tests (including a breath test instead of endoscopy,16 as per Dr Harmonius’s ESP — Evidence Support Program), cycling instead of driving, reducing alcohol intake, and possible medication. Lee is happy to return for regular review by Dr Harmonius. Lee is also referred to a community mental health worker for problem-solving skills and strategies to handle his alcohol problem. He chooses to have his blood pressure monitored by the practice nurse (instead of home telecare17 or ambulatory monitoring) while he’s unemployed. Each time Lee visits Dr Harmonius, the practice nurse initially checks his blood pressure, medications and adherence. Each healthcare professional involved in Lee’s care charts findings and interventions in a central electronic database, which they can access with Lee’s consent. At hospital after Lee’s car accident, the medical officer, Dr Dextrous, notes from the database that Lee has had the appropriate tests to exclude organic causes of tiredness. Dr Dextrous’s own database entry is emailed to Dr Harmonius.

Mabel Chew · Martin B Van Der Weyden

Public hospitals designed for the past are not changing rapidly enough to meet the needs of the future. Changing work practices, increased pressure on bed occupancy, and greater numbers of patients with complex diseases and comorbidities will determine the functions of future hospitals. To maximise the use of resources, hospital “down times” on weekends and public holidays will be a distant memory. Elective surgery will increase in the traditionally “quiet times”, such as summer, and decrease in the busy winter period. The patient will be the focus of an efficient information flow, streamlining patient care in hospital and enhancing communication between hospitals and community-based health providers. General and specialty units will need to work more efficiently together, as general physicians take on the role of patient case managers for an increasing proportion of patients. Funding needs to be adequate, and system management should involve clinicians. Safety will be enshrined in hospital systems and procedures, as well as in the minds of hospital staff. If these changes are not implemented successfully, public hospitals will not survive in the future.

Jeffrey D Zajac MB BS, PhD, FRACP

The patent system has been seen as a critical factor driving innovation in clinical medicine, particularly in medical devices and diagnostic assays. The licence terms and business model proposed by Myriad Genetics Inc. for testing the hereditary breast cancer susceptibility genes BRCA1 and BRCA2 could stifle innovation (particularly if other companies adopt similar business models), and are likely to limit the ability to provide high quality public genetic testing services in Australia. Under the Myriad model, testing for the BRCA1 gene would be undertaken by an organisation removed from the integrated public healthcare system. Based on overseas experience, Australia can expect a 2–3-fold increase in the cost of this testing, which will provide only partial information on the hereditary breast cancer status of the patient. Commercial exploitation of gene patents needs to be regulated to balance the patent holders’ right to profit from their inventions (necessary to drive further innovation) and the public policy objective of high quality, equitable healthcare.

Ian R Walpole FRACP · Hugh J S Dawkins PhD, Senior Project Officer · Peter C O’Leary PhD · Peter D Sinden LLM

The Australian medical workforce, like those of most developed countries, is increasingly “feminised” and exposed to the global market for doctors. Demand for healthcare services is increasing in the Australian community. Concern in relation to doctor shortages is increasing, particularly in rural areas. There should be greater flexibility for entry of highly-trained overseas doctors. There is an urgent need to increase medical school student intake. Issues of workforce practice, including “task” substitution, should be explored.

Peter M Brooks MD, FRACP · Helen M Lapsley MEc, FCHSE · David B Butt MBA, AFCHSE

David Simmons,* Amanda Fieldhouse,† Leslie E Bolitho,‡ Grant J Phelps,§ Rob Ziffer,¶ Gary J Disher** * Professorial Fellow, Department of Rural Health, University of Melbourne, Shepparton; and Professor of Medicine, University of Auckland Waikato Clinical School, Waikato Hospital, Hamilton, New Zealand; † Health Care Consultant, South Yarra, VIC; ‡ Physician, Wangaratta, VIC; § Physician, St John of God Hospital, Ballarat, VIC; ¶ Physician, Sale, VIC; ** Deputy Director – Health Policy, Royal Australasian College of Physicians, Sydney, NSW. simmonsdATwaikatodhb.govt.nz To the Editor: Rural Australia has a substantial shortage of specialist physicians. In 1999, Victoria had 52 specialist physicians for 1.3 million people (a physician to population ratio of 1:25 000).1 The Australian Medical Workforce Advisory Committee recommendation is 1:10 000.2 Although much has been written about the shortage of rural general practitioners, there is little about rural specialist physicians. However, evidence from Western Australia showed that advanced trainee physicians interested in rural practice were diverted to city-based practice during their training.3 Here, we outline a state-wide approach to encourage advanced trainee physicians to complete their training in rural Victoria. The University of Melbourne Department of Rural Health in Shepparton provided support for rural Victorian physicians to develop a state-wide network, the Victorian Rural Physicians Network, under the Victorian State Committee of the Royal Australasian College of Physicians (RACP). A pilot survey in the 14 major rural Victorian centres demonstrated capacity for at least nine Advanced Physician Trainee positions across rural Victoria. The RACP accredited five positions initially, with others to be reviewed for accreditation if required. These positions were funded largely by the joint Federal–State Government Advanced Specialist Training Program in Rural Australia. Four trainees completed 12 months of rural training in 1999–2000, and three are now working as rural physicians. These trainees were recruited through advertisements in the RACP newsletter and personal contacts. The trainees provided substantial benefits, both in service delivery, as their presence reduced the load on other doctors in the same hospital, and in medical education, as they provided more education and supervision for junior doctors and doctors from overseas. In 2001, a similar approach to recruitment identified eight potential applicants, but none came to interview. In 2002, three new strategies were therefore introduced: Flexible, joint rural–metropolitan positions were created; A rural physicians’ conference was organised;4,5 and A management consultant was employed to contact personally all 99 Victorian basic physician trainees expected to enter advanced training. The response to the new approach is shown in the Box. A third of contactable trainees indicated an interest in rural practice at the end of their basic training. Ten applications were received for the rural training positions, and seven trainees were appointed (three withdrew). We believe that our new strategies have merit, and that the personal touch has created goodwill which may improve the response for 2004. Recruiting for the 2003 Advanced Physician Training Programme for Rural Victoria

David Simmons · Amanda Fieldhouse · Leslie E Bolitho · Grant J Phelps · Rob Ziffer · Gary J Disher

Colleen T Bruce,* Margaret M Sanger,† Paul S Thomas,‡ Jonathon R Petkus,§ Deborah H Yates¶ * Research Assistant, ‡ Senior Lecturer, Faculty of Medicine, University of New South Wales, Randwick, NSW; † Deputy Medical Director, Concord Repatriation General Hospital, Concord, NSW; § Medical Student, ¶ Senior Lecturer, Faculty of Medicine, University of Sydney. Correspondence: Dr Deborah H Yates, Department of Respiratory Medicine, St Vincent’s Hospital, Darlinghurst, NSW 2010. deborahy88AThotmail.com To the Editor: The demands of practising medicine can have significant effects on general health, work satisfaction, professional and non-professional life.1 We conducted a survey among senior medical staff in a metropolitan teaching hospital. The survey explored the pressures of work, social and family demands on consultants, and whether there was a difference between sexes. Participants completed a self-reported questionnaire on quality of life, levels of stress and feelings of work satisfaction, using previously validated questions and scoring from the General Health Questionnaire (GHQ-28, a 28-question subset of the GHQ)2 and Specialist Doctors Stress Inventory (SDSI).3 (Questionnaire available from authors on request.) Respondents answered anonymously and gave informed consent. Fifty-seven per cent of consultants (54/94) returned surveys, of whom a third (18/54) were women. The response rates were comparable to those of other physician surveys.4 On average, consultants had been employed at the hospital for 10.8 (SD, 8.0) years, had been qualified for 22.2 (SD, 9.6) years, and were working 47.7 (SD, 14.0) hours per week. Eighty-one per cent (44/54) were married, 74% (40/54) had children and 54% (29/54) lived in a double-income household. Half (27/54) reported an unreasonable ratio between work hours and leisure time, and 50% (27/54) reported feeling stressed. Despite this, 65% (35/54) believed they had or would achieve their ideal medical career. Female consultants worked fewer professional hours, but more hours in unpaid domestic work, than male consultants. Furthermore, female doctors were more likely to have had their career modified by family or social factors; more likely to use paid support to cope with their domestic workload; and, if they had children, more likely than men to have modified their careers to look after dependants (see Box). Consultants who reported feeling stressed were more likely than other consultants to report an unreasonable ratio between work hours and leisure time (74.1% [20/27] v 48.1% [13/27]; P = 0.05). Forty-one per cent (22/54) scored above 4 on the GHQ-28, indicating that a high level of stress and psychiatric “caseness” (ie, clinically significant levels of psychiatric disturbance) is experienced by senior doctors. This result is similar to that of a UK study in which 46% (30/65) of senior doctors reported experiencing high levels of stress.5 From our data there appears to be a significant relationship between stress, psychiatric “caseness” and hours worked (P < 0.001). Our study and others have identified potential reasons why women work fewer hours in medical work and have a shorter working life. These include having and caring for children, stress, dual-career marriages, personality and social expectations.6 Our survey highlights the fact that female consultants in Australia face undue pressure in balancing their medical and domestic roles compared with male consultants. There is a continuing need for flexibility in workplace and training environments for women in medicine to ensure equal career choice, balance between work and domestic commitments, and professional satisfaction. Comparison of self-reported factors between female and male consultants (n = 54) Female consultants (n = 18) Male consultants (n = 36) P value Mean age in years (SD) 45.3 (10.5) 47.7 (8.1) 0.43 Mean hours in medical work per week (95% CI) 33.4 (28.5–38.4) 54.7 (51.5–58.0) < 0.001* Mean hours in unpaid domestic work per week (95% CI) 22.9 (8.0–37.8) 10.6 (7.6–13.5) 0.02* Uses paid domestic support 14/18 (78%) 18/36 (50%) 0.05* Has children 11/18 (61%) 29/36 (81%) 0.12 Expects to achieve future medical goals 12/18 (67%) 24/36 (67%) 0.78 Has had career expectations modified by: Workplace 8/18 (44%) 22/36 (61%) 0.25 College/training 4/18 (22%) 7/36 (19%) 0.81 Family/social factors 12/18 (67%) 14/36 (39%) 0.05* Illness 1/18 (6%) 4/36 (11%) 0.51 Has had career opportunities modified by care for dependants 9/11 (82%) 10/29 (34%) 0.02* Reports partner is inconvenienced by respondent’s career goals 10/18 (56%) 9/36 (25%) 0.03* Mean score on GHQ-28 (95% CI)† 2.24 (1.81–2.68) 2.10 (1.95–2.26) 0.45 Psychiatric “caseness”‡ 8/18 (44%) 14/36 (39%) 0.30 Median job satisfaction score§ 3 (range, 3–4) 3 (range, 1–4) 0.15 Median life stress score§ 2 (range, 1–2) 1 (range, 1–3) 0.13 GHQ-28 = 28-item General Health Questionnaire. * Difference between men and women significant. † Minimum score = 0; maximum score = 28. ‡ ie, Clinically significant psychiatric disturbance (GHQ-28 score > 4). § Minimum score = 1; maximum score = 4. Data were analysed by Pearson’s χ2 test, Student’s t-test or the Mann–Whitney test and stratified by sex.

Colleen T Bruce · Margaret M Sanger · Paul S Thomas · Jonathon R Petkus · Deborah H Yates

Jill S Butty Quality Facilitator, Werribee Mercy Hospital, 300 Princes Highway, Werribee, VIC 3030 jbuttyATmercy.com.au To the Editor: It was refreshing to see the report by South et al, describing a simple, inexpensive intervention which resulted in a positive effect on the appropriate prescribing of antibiotics and a cost saving for the organisation.1 In the current climate, it has been much more fashionable to suggest computerised prescribing as the cure-all for medication and prescribing errors. As demonstrated by Newby et al,2 computerised prescribing has inherent problems, including an increase in repeat ordering of antibiotics. The Australian Council for Safety and Quality in Healthcare suggests computerised prescribing as one of several strategies to reduce medication critical incidents.3 However, the costs of establishing such a system in smaller hospitals and community health centres can prove prohibitive. This can lead to an attitude of “too expensive” so do nothing. Other strategies and interventions can be introduced at minimal cost to the organisation and yet prove effective in reducing both inappropriate prescribing and the number of critical incidents or errors. The provision of easily accessible standardised protocols and guidelines, the review of medication charts and their ease of use, changing the times of daily medication administration to maximise access to clinicians, and empowering patients to be more aware and responsible for their medications are just a few. In summary, other strategies need to be developed and their success or failure reported. There should also be awareness that familiarity with procedures can lead to errors and reinforcement is required for all interventions. Computerised prescribing should not be viewed as the solution to all medication adverse events, but one of several strategies that healthcare organisations can use in their battle with medication errors.

Jill S Butty · Saji S Damodaran

Saji S Damodaran Associate Professor, Department of Psychological Medicine, Monash University, and Clinical Director, Monash Medical Centre, 246 Clayton Road, Clayton, VIC 3168 saji.damodaranATmed.monash.edu.au To the Editor: Australia has a high rate of antibiotic use. Increasing antibiotic resistance, spiralling pharmaceutical cost, need for evidence-based practice, public awareness, and widespread variation in prescribing practice, which may lead to quality and safety issues, are reported as the drivers for improving antibiotic use and prescribing. South et al are to be commended for the introduction of a laminated card for doctors as a simple intervention to improve prescribing practices.1 Despite the passive nature of the intervention, they found significant improvement in the appropriateness of prescribing. The authors acknowledge that they are not claiming that their intervention “is the cause or only cause” for change in practice. Areas like antibiotic prescribing and physician behaviour are highly complex and require a series of systematic approaches. Doctors are only one of the multiple stakeholders involved in this process. The level of experience, training background, and awareness of the public health and clinical implications of such interventions vary widely among doctors. Improvement of South et al’s methodology from a passive mailout to gathering systematic baseline information about the medical staff involved, clarifying the purpose of the initiative and finding the proportions of uptake among junior and senior staff would have made the intervention more robust. One of the fundamentals of any change process is to instil a sense of urgency and develop a coalition to drive and lead it. Development and evaluation of quality initiatives need more than just passive information provision. It has been suggested that any such quality and safety initiative should have set priorities, and these priorities should be developed using a systematic evaluation process with explicit criteria.2 Various systemic strategies that involved systematic methodology and evaluation processes, such as antibiotic decision support systems (both computer and manual) and drug utilisation reviews, reported sustainable changes in prescribing practices.3 The intervention by South et al is a welcome initiative, but it is important to realise that simplifying a complex problem like drug prescribing may lead to setting up wrong priorities for action and trivialise the problem and solution. Such initiatives will suffer the fate of the many quality programs that we hear about in hospital corridors but which fail to make a sustainable change.

Critical care encompasses elements of emergency medicine, anaesthesia, intensive care, acute internal medicine, postsurgical care, trauma management, and retrieval. In metropolitan teaching hospitals these elements are often distinct, with individual specialists providing discrete services. This may not be possible in rural centres, where specialist numbers are smaller and recruitment and retention more difficult. Multidisciplinary integrated critical care, using existing resources, has developed in some rural centres as a more relevant approach in this setting. The concept of developing a specialty of integrated critical-care medicine is worthy of further exploration. In Australia, "rural" centres have been defined statistically as local areas where most of the population resides in centres of 10 000–99 999 people, and "remote" centres where the population is less than 10 000 people.1 It has been claimed that a two-tiered system of hospitals has developed, one tier composed of "centres of excellence", and the other of hospitals more limited in their range of expertise and technology.2 The first tier is predominantly hospitals in the heart of capital cities, while rural hospitals fall into the second tier. In this hierarchical system, metropolitan teaching hospitals are often perceived as setting the standards for practice, but this perception can be challenged. Standards are sometimes based as much on opinion as evidence and are not necessarily universally applicable.3 It has been questioned whether a resource-intensive intervention should become a standard of care if it produces a small benefit in clinical outcome in trials in large institutions, when a greater benefit may be gained by giving a greater number of patients a more basic minimum standard of care that is sustainable across the entire healthcare system.4 Metropolitan tertiary hospitals provide a super-specialised level of care that is essential for some patients, but not sustainable outside resource-concentrated centres. On the other hand, rural base hospitals and metropolitan district hospitals provide a broad spectrum of hospital and community medicine, and therefore training opportunities, that may no longer be available in major tertiary hospitals.5 With respect to hospital practice, then, it could be argued that it is the second-tier hospitals that currently deliver the generic standard of care. Part of the problem with rural healthcare systems is that models of care applied to super-specialised metropolitan practice are assumed to be relevant to rural practice. A different level of care does not necessarily equate with a lower standard of care. Indeed, structuring resources to match the specific rural milieu may well lead to more appropriate care for this setting and therefore better care. Wakerman and Humphreys6 suggest that a distinctive "rural health" approach is needed because rural Australia is sociologically, culturally, economically and spiritually different from metropolitan areas, and that a hallmark of rural and remote healthcare is innovation generated by local need and community action.6 This approach has been successfully applied in a number of rural centres to the problem of providing critical-care services in the face of limited numbers of medical specialists. Medical specialist involvement in rural intensive care in Australia — the status quoRecent reviews of intensive-care activity in Australia found that 37% of Australian public-sector intensive-care units7 and 34.5% of medical specialists working in public-sector intensive care8 were in rural and remote centres. The nature of the work in these units differs from that in metropolitan centres. Many are combined with high-dependency and coronary care, with over half the patients admitted being in these categories.7 The medical specialists involved also differ in their qualifications and background from specialists in major metropolitan hospitals, as training, recruitment and retention difficulties limit the number and type of specialists available in rural centres. Of the specialists currently involved in rural intensive care in Australia, only a small number have qualifications endorsed by the Joint Specialist Advisory Committee in Intensive Care (JSAC-IC).8 Instead, the majority have backgrounds in anaesthesia, emergency medicine, general medicine and/or general surgery and have acquired expertise in intensive-care medicine through specific training, clinical practice, or both. In addition to their base discipline, many specialists are also involved in other phases of critical care. Traditionally, this multiskilling has developed out of necessity. Increasingly, however, it is occurring by choice, as it can result in efficient use of skills and afford a unique and interesting casemix for specialist medical staff, while at the same time providing benefits to critically ill rural patients and rural communities. Models of integrated critical careTrunkey9 proposes that physicians and surgeons are evolving towards three types of practice: ambulatory care, hospital-based practice and intensive care. We suggest that the third branch is actually critical care. Critical-care medicine is the multidisciplinary healthcare specialty that incorporates the knowledge, skills, attitudes and problem-solving abilities required for the recognition and early management of patients with acute life-threatening illnesses and/or injuries.10,11 It encompasses elements of emergency medicine, anaesthesia, intensive care, acute internal medicine, postsurgical care, trauma management and retrieval medicine. Clearly, critical care is a continuum that begins at the onset of critical illness or injury, and continues through the transportation process and the acute hospital care process.12,13 The principles for managing critical illness and injury are similar, regardless of patient location or diagnosis. The aim is to keep alive those patients who have a reasonable chance of survival.14 In rural Australia, this may require organisation of resources in a fashion that is different from that undertaken in metropolitan centres. In metropolitan hospitals, subspecialists would be involved in each phase of the management process, but this may not be possible in rural centres, where specialist numbers are smaller. This is where a multidisciplinary critical-care physician becomes particularly valuable. This specialist has many of the characteristics that have recently been attributed to those of a "hospitalist".2,15 Through local innovation and necessity, models for effectively delivering critical care using existing resources have been developed in several sites in rural Australia, including Tamworth Base Hospital and Port Macquarie Base Hospital in New South Wales. These models of integrated critical care (see Box) involve a hospital-wide approach, acknowledging that care of critically ill patients is a collaborative endeavour, not the exclusive domain of an intensive-care unit. The critical-care facilities are located nearby and share specialist medical staff, resident medical staff, career medical officers and nursing staff. Integration has resulted in a more seamless interface between the various phases of critical care and between the respective disciplines. Although multidisciplinary and multiskilled, individuals are not required to perform multiple tasks at any given time — for example, when on duty in the critical-care unit, they are not given other responsibilities. Rather than being partisan about individual specialty groups, the focus has been on providing the most appropriate services to meet the needs of critically ill patients and their rural communities, using the most appropriate resources. Thus, these successful models are based on cooperation rather than competition or duplication. This was recognised in the 2001 NSW Government Action Plan for intensive-care services.16 The Plan recommended that, in rural hospitals, a formal working relationship be developed between staff of the intensive-care unit and anaesthetic or emergency-department consultants to provide appropriate senior medical cover for the unit.16 A collaborative approach for the future?Currently, there is no formal program for training specialists for multidisciplinary rural critical-care practice. Training in many of the relevant base specialties remains metropolitan-based with a metropolitan focus. For example, of the registrars working in Australian public-sector intensive-care units identified in a recent survey, only 3.7% were in rural and remote areas, and the majority of these were not JSAC-IC trainee registrars.7 To address this disparity, a fresh approach may be required. In rural and non-tertiary metropolitan centres, critical-care practice has characteristics that distinguish it from tertiary metropolitan practice. Integrated critical-care medicine could therefore be defined as "the practice of critical-care medicine that occurs in non-metropolitan Australia" and developed as a distinct specialty, with appropriate input from existing specialty Colleges and societies. Specialist training could be provided at appropriate rural sites rather than concentrated in tertiary metropolitan centres. Alternatively, strong subspecialty groups could be developed within existing Colleges, with a unifying cross-College standing committee and joint training. Approaches to critical care vary throughout the world,12,17-19 and a number of approaches tried elsewere may provide suitable models for integrated critical-care medicine in Australian rural areas. Whatever model is adopted, given the backgrounds of the majority of specialists currently involved in critical care in rural Australia, the specialties of emergency medicine, anaesthesia and intensive-care medicine will need to lead the process. Like anaesthesia, emergency medicine and intensive-care medicine have significant clinical links, and these need to be encouraged and strengthened.12,13,19 ConclusionTo ensure high standards of critical care for rural patients, it is vital that realistic solutions continue to be developed that match the existing realities of rural practice. The integrated critical-care model has successfully provided quality services in a number of hospitals and offers potential for wider implementation in rural areas. The concept of developing a specialty of integrated critical care is worthy of further exploration. This will require collaboration and cooperation between all stakeholders. Features of integrated critical care Multiskilled critical-care specialists trained and experienced in the various aspects of critical care in rural hospitals. Multidisciplinary critical-care teams that provide: a more seamless interface between the various phases of critical care and between its respective disciplines; a rapid response to, and a continuum of care for, critically ill and injured patients; clinical leadership in evaluating and managing critically ill and injured patients, both in the hospital (including the emergency department, critical-care unit and hospital wards) and in the community (including retrievals, and support for ambulance crews, peripheral hospitals and general practitioners); and training of medical students, medical staff, nursing staff and allied health professionals to recognise and provide a systematic approach to critical illness and injury. Team members who are empowered to work beyond perceived traditional boundaries, but within the realms of their clinical expertise and credentials, to enable the best use of available resources.

Craig T Hore MB BS, FACEM · William Lancashire FRACGP, CCFP · John B Roberts MB BS, FACEM · Rob Fassett MB BS, FRACP

Sociologists tell us that "Autonomy is the acid test of professional status ... all other characteristics of a profession flow from it".1 Poor Dr Zen* has no professional autonomy. Mr Unger's management is determined, not by her, but by an electronic decision system which then reduces her pay for taking too long and directs her continuing education. How did Dr Zen get into this thankless situation? Let me answer that with some more of her story. Dr Zen's dream is to become a Clinical Controller with Corporation Enterprise. Competition is intense as the status and salary are so much better than those of the general practitioners who labour in the corporation's clinics. To be considered she has to obtain an MBA from the Corporation Enterprise School of Business. One cold, wet night in 2020, Dr Zen is at a taxi rank waiting for a fare, correcting her first draft of an assignment for the subject HX101 "History of Corporation Enterprise". The assignment topic is a challenge: "Why did the GP leaders of 2003 call for policies to dramatically increase the number of general practitioners?" The course notes suggest that in 2003 the policies pursued by GP leaders undermined real opportunities for GPs. Dr Zen has undertaken extensive research. Her essay hypothesises that the key mistake in 2003 was not to pursue policy and structural changes so that general practice could adapt in a positive way to changing community expectations. GPs ignored opportunities flowing from technological developments and changes elsewhere in the health system. They concentrated on defending the status quo and, behind a smokescreen of rhetoric, lobbied government for higher pay for each consultation and for more doctors.2 This maintained short-term cash flow but further entrenched structural problems. The cash flow of most GPs depended on habits developed between 1984 and 2007 under a financing system called Medicare. Medicare rewarded "down-market" activities, not "up-market" skills. The highest incomes came from providing many short consultations and not providing services requiring the very skills that differentiated GPs from other "healthcare workers". The seriously ill and those requiring minor procedures or time-consuming care drained profits and, under Medicare, could be deflected to specialists or emergency departments. The network of corporate clinics already emerging across Australia before 2003 grew rapidly following the increase in GP numbers between 2003 and 2007. These clinics were based in the cities and absorbed most new GPs. In 2008, the government admitted that the policy of expanding numbers to get GPs into rural and outer urban areas had failed. A retired bureaucrat, Gletkin, was commissioned to review the situation. He concluded the government was simply underwriting the profits of a few large GP corporations: the GP workforce was less evenly distributed than in 2003; GPs were being paid for work that could be undertaken more cheaply by others; and the government's commitment of millions of dollars to educating GPs through six years of university and three years of vocational training was of doubtful value because GPs were not using the skills taught. The government of Mustapha Mond adopted radical measures recommended by Gletkin. Medicare was abolished and Corporation Enterprise established as a government-owned monopoly. This entity compulsorily acquired all GP clinics and rigorously implemented its charter of ensuring an even distribution of GPs across Australia and providing primary care at the lowest possible cost, using protocols designed to refer all serious cases to specialist polyclinics or hospitals. The company operated to a strict formula of one GP per 1750 people. With a population of 25 million, only 14 250 out of 30 000 GPs were contracted. Minimal incomes were offered. GPs had to agree to adhere strictly to the corporation's treatment protocols. The education of GPs was rationalised. School leavers, after five years administrative and assistant experience with the Corporation, could apply for entry to the GP course at the Corporation Enterprise School of Medicine, a three-year web-based course supported by "on-the-job" training. Dr Zen was in the first graduating class. Dr Zen now understands the sadness on the faces of the elderly couple in the next flat to hers in the Housing Commission complex. They commenced careers as GPs in the early 1980s, full of hope and expectation, but were bankrupted in 2007, when found personally liable for a medical indemnity claim. Since then they had been unemployed. Dr Zen hopes she can afford to buy them a hamper again next Christmas. Dr Zen is pleased it is a quiet night on the taxi rank. She can think about the conclusion of her essay. Students are asked to imagine a different scenario for general practice after 2003. She will argue that GPs, rather than squabbling with government over a few dollars, should have thought more deeply about what the community wanted from general practice and how GPs could "add value". They should have lobbied for policy and structural change so that simple tasks could be delegated to other staff, while the highly (and expensively) trained doctors used their skills managing acute medical conditions and common chronic conditions; coordinated the care of patients with complex conditions; enhanced the procedural aspects of their practices; and established arrangements of value to others, such as early hospital discharge. Such a role would have required fewer GPs, but those GPs would have had much more rewarding careers.

William Coote FRACGP, BEc

Those of us who wear spectacles consider "20/20 vision" utterly desirable. The "2020 vision" presented here,* however, is a nightmare that we must strive to avoid. The story of Dr Zen suggests that several important values have been lost to general practice. Having once been a positive career choice for many medical graduates, in 2020 the discipline is at the bottom of the heap — training in general practice is for "beggars" who miss out on other schemes. No longer valued by other members of the healthcare system, nor practising with any degree of independence, nor able to advocate for her patient, Dr Zen is just a binary drone, condemned to the restraints of protocol-driven diagnosis and algorithmic management. Such reductionism was rejected long before 2020 as a foundation for general practice1 and other branches of medicine.2 Can our elegant craft of hypothesis testing and revision survive alongside the brutishness of digital diagnosis? The primary focus of her attention is the third party paying for her time — what patient would appreciate that? Her clinical independence is severely compromised by the control the Ease manufacturer imposes on her therapeutic decision making. Dr Zen has no supportive collegiate contact, and her supervisors are the sort of managerial bureaucrats who thrive in environments from which general practitioners have been removed. What inspiration for medical students and vocational trainees would Dr Zen's role provide? Dr Zen's Fellowship of the Royal Australian College of General Practitioners still marks her as being competent to practise as an unsupervised GP anywhere in Australia, and she demonstrates this by moving easily between her outer urban push-button practice and the challenges of practice in an inner urban slum (presumably the future Toorak or Darling Point). At least her apparent comfort in working as part of a primary care team with a nurse practitioner makes it sound as though she has been trained in accord with the CanMEDS 2000 principles,3 which describe the GP as a collaborator among other things. The strength of GP training in Australia has long been its "enhanced apprenticeship" model, the only logical way to impart the values and skills of general practice. This combination of supervised training and needs-focused education allows registrars to practise in a real environment alongside carefully selected supervisors, while receiving relevant teaching from those supervisors and professional medical educators. Although vocational training for general practice has undergone major changes in the past two years, this model has continued. Our approach to training the doctors who will join us in general practice has a huge impact on the future of the profession. So where could we be in the year 2020, and how many of the positive values of the past will carry through to the future? Dr Zen's training, re-imaginedThe CanMEDS principles, updated, were incorporated by 2020 into a completely integrated curriculum for general practice that guides GP education from undergraduate study through to retirement. This curriculum has enough breadth to address all the disciplines that Dr Zen employs, ranging from population health, evidence-based practice and information management to business management, clinical governance and disaster medicine. Just as importantly, it has the depth to be relevant in any of the contexts in which GPs work, be that in Aboriginal health, a Muslim community, a rural area or the Antarctic. Information technology is a tool in the hands of the competent practitioner, but never a substitute for the practitioner's "presence". Nor does real time access to guidelines and algorithms substitute for the vast amount of knowledge about a patient that the GP acquires through careful communication. Dr Zen's Fellowship is not the endpoint of her formal learning. She will add a number of graduate certificates, a graduate diploma in preventive women's health, and a master's degree in cognitive behavioural therapy to her brass plate over the next decade. The Corporation values the role of the competent medical generalist, incrementally rewarding Dr Zen for the extra competencies she acquires, uses and maintains throughout her career. An exciting career path with the Corporation includes opportunities to contribute to its quality assurance, research and development program and to its education and training program. As part of its commitment to succession planning, continuing professional development activities form part of Dr Zen's paid contractual arrangements. Her work in the nurse-practitioner clinic is supported by a contract with the government. She enjoys this aspect of her life — different challenges, different demographics and a different team. But her commitment to quality patient care is just as strong. No taxi shifts for this alternative Dr Zen. Her income is sufficient, her work occupies four days each week by her choice and she has time for her children, friends and social activities.

Stephen C Trumble MD, FRACGP · Nicholas J Glasgow MD, FRACGP

Recent attempts by several corporate entities to secure more of Australia's primary medical care profits have so far been unsuccessful, but it is probably not the last we will hear from them. The 2020 scenario,* far fetched though it may seem, depicts general practice succumbing to the dollar lures of the Corporates. It is a primary healthcare model characterised by heavy regulation, structural division, detachment and constant change. An interventionist government bureaucracy and a ruthless commercial administration have effectively removed all autonomy and personalised attention from the individual's practice. Adherence to strict administrative protocols protects the commercial interests of the company, and both take priority over providing quality primary care. "Practice management" has become "policy management", and the general practitioner's needs are second to those of business managers who have become slaves to legislative conformity. GPs no longer have support staff to help them provide quality care; rather, the tables have turned and the doctors assist the administration in toeing the company line. As a result, Dr Zen has been forced to compromise on almost every value and ethic crucial to best care. Today, the profession is witnessing unprecedented bureaucratic proliferation. Multiple regulatory bodies, including federal and state governments, make demands of increasing quantity and complexity. The cost of practice administration, insurance and government regulatory compliance is escalating at an alarming rate.1 The financial pressure presently being brought to bear on general practice may ultimately precipitate the collapse of bulk billing and "universally accessible healthcare for all Australians". To prop up a dying primary healthcare system, the federal government may continue to add legislative "patches" that succeed only in transforming a once simple primary healthcare model into one that will ultimately be too complex and financially unsustainable for the medical profession.2 At that point, frustrated, overworked and underpaid doctors, no longer able to cope with the administrative convolution and burdensome regulatory demands being forced upon them, will finally abandon their practices in search of an easier way. The attraction of the Corporates lies partly in the promise of inexpensive, efficient, centralised administration.3 Yet, as a profession, we should recognise that a corporation's loyalty necessarily lies with its shareholders and that there are inherent dangers in "selling our souls" to these groups. Dr Zen's passing self reminder to raise the issue of quality care again at the next managers' meeting is illustrative of the gap that has opened up between our future practitioners and administrators. An increased administrative complexity demands attention from managers and diverts valuable human resources away from the patient's comfort, confidentiality and care, and from work relationships. A centralised administration is, by its very nature, one that operates remotely and, in this case, one that uses technology to monitor and control the performance of its human resources. The digital revolution will continue to influence virtually every aspect of our professional lives, but only time will tell if that influence will be for the betterment of general practice. Given the sheer volume of information in which we presently trade, it is inevitable that clinical records will ultimately pass between practitioners exclusively in a digital format. In the nightmare scenario, patient records have become an "online resource", with potential compromise of privacy. Therefore, as we develop systems in which confidential information is exchanged, "secure" communication channels must be among the highest priorities for software developers, the profession and law makers. At Corporation Enterprise, technology primarily serves the administration by monitoring the activities of practitioners inside the consulting room. Time has become the single most valuable commodity. Quality care comes a distant second to the commercial interests of the firm. Can we imagine a better future? 2020: extract from television newsThe Federal Government and general practice representatives emerged from their latest series of goodwill talks on regulatory reform today to confirm that the future of independent private practice was guaranteed. The restructuring of general practice under the "Red Tape" reform package has seen the elimination of inefficiency over the last three years by removing administrative complexity in general practice structures and payment systems. Outmoded bureaucratic systems were scrapped virtually overnight, and new payments systems, linked to better patient outcomes, were introduced. Dr I M Spock, National President of the AMA, said that "simplified administrative systems combined with a better use of technology" meant that the costs associated with practice would be halved by 2022 and that "the funding crisis could be averted after all". It looks like government-funded universal healthcare is back, and community groups around the country have applauded the initiative. A union representative from the Australian Medical Borg, an army of half-human, half-microprocessor humanoids, said today that "assimilation into this new system is inevitable and resistance is futile".

Mark V Lipscombe

Objective: To investigate the effect of incontinence on clinical outcomes and costs for patients in subacute care.Design: Retrospective analysis of data collected over a 3-month period in 1996.Setting: 54 medical facilities in Australia and New Zealand providing subacute care in an inpatient setting.Patients: 6773 episodes of care provided to 6455 rehabilitation and geriatric evaluation and management patients.Main ...

Janette P Green MStat · Irenie Smoker MEc · Maria Theresa Ho MD, MRACMA · Kate H Moore MD, FRANZCOG, CU

Clinical record At 11: 30 on 8 April 2003, a 64-year-old man presented to the National University Hospital emergency department (ED) complaining of light headedness for 3 days, and dry cough and body aches for 2 days. His general practitioner had recorded a temperature of 37.7°C. On further enquiry in the ED, he described mild dyspnoea and palpitations. For over 40 years, he had smoked 25 cigarettes a day, ...

Dale A Fisher MB BS, FRACP, DTMH · Madeleine H L Chew MB BS · Yean-Teng Lim MRCP, FRCP · Paul A Tambyah MB BS

Objectives: To conduct a systematic review of how short-stay observation units (SOUs) affect the efficiency of healthcare delivery and the quality of services provided.Data sources: MEDLINE, CINAHL, Best Evidence and The Cochrane Library were searched for the period 1 January 1960 to 31 July 2000.Study selection: Studies were eligible if published in English and rated at National Health and Medical ...

Sue Daly RN, MN, FRCNA · Donald A Campbell MD, FRACP · Peter A Cameron MB BS, FACEM

How to heal the festering sore of Indigenous health? In Australia, Indigenous health remains a blot on the nation's collective consciousness. There has been little, if any, improvement in the last quarter of a century.1 Although an association between health and socioeconomic status has been described in many different societies, in Australia we seem to avoid taking this connection into account when considering Indigenous health. The First Nation's people of Australia still do not have the same access to housing, education and employment as those who are relative newcomers; thus, it should not be surprising that their health status is worse. Senator Aden Ridgeway, in his address to the United Nations Human Rights Commission,2 summarised the root of this problem as: Non-Indigenous Australians are keen to embrace the rhetoric of reconciliation, so long as it doesn't require them to take effective action to share the country's abundant resources and political power. Most are not prepared to make any significant adjustments in how they live their lives or how they see their future. Few are prepared to really look within themselves to challenge their beliefs and values, for fear of what they might find and for fear of what they think they might lose. So, what might it be that non-Indigenous Australians are so fearful of finding? Possibly, that the entire basis of land ownership in Australia, and therefore our economy, is based on the lie of Terra Nullius — that is, that no one owned the land claimed by others.3 And, what might non-Indigenous Australians be so fearful of losing? All their benefits, including health benefits, that they may have derived from this lie. At a recent National Health Summit in Sydney (held at Merchant Court Hotel, Sydney, 18–19 February 2003; hosted by Terrapinn), speakers outlined Australia's achievements in health, most notably that we can boast the second highest longevity among OECD countries. But little of what was said had any bearing on Indigenous health — it was almost as though Indigenous health had to be annexed so that the mood could remain positive. However, it is neither moral nor ethical for Australia to continue to ignore the deplorable state of Indigenous health. For too long, too many of the issues have been relegated to the too-hard basket. The festering sore of Indigenous health will not go away by ignoring it, but rather needs direct action — the active promotion of opportunities for Indigenous Australians in mainstream professions and services, health or otherwise. The medical profession has long recognised its social contract to Indigenous Australians, and we can easily start to fulfil this contract by attending to our own backyard. For proportionate racial representation in the medical profession in Australia, we should have about 1260 Indigenous doctors; however, there are no more than 55. All have graduated since 1983 and more than half from the one medical school. Had the other nine medical schools made the same effort to recruit and train Indigenous doctors, we would now be much closer to the racial equity goal of 1260 doctors. The presence of Indigenous Australians within the student body of our medical schools does more than just help to meet a target. It enriches the profession and enables other medical students to access something of the Indigenous experience — many Indigenous medical students and doctors have been the first Indigenous Australians that our non-Indigenous colleagues have met. The presence of Indigenous Australians in our medical schools also keeps the focus on Indigenous health active and honest. And it can provide a shining example and model for other professions who should recruit, support and graduate Indigenous students. In fact, it is important for our Indigenous students in primary and secondary school to see that all professions are accessible and supportive, so they can confidently consider tertiary education as a reality rather than a fanciful dream. Many of our medical postgraduate clinical colleges are already seeking to actively recruit Indigenous doctors into their training programs; we will also need to see the introduction of compulsory Indigenous health curricula into each of the postgraduate training programs. Beyond incorporating Indigenous health and health workers into our ranks, we need to actively encourage appropriate access to health services. For example, as a profession we need to call for the introduction of a Medicare safety net that will make a discernible improvement to the health status of Indigenous Australians. Real gains in Indigenous health are attainable by incorporating Indigenous health provision (albeit with additional benefit or consideration) into our mainstream delivery of health services, rather than, or at least in addition to, setting up more and more services specifically for Indigenous Australians. Beyond healthcare delivery, more of our profession should consider taking leadership in issues related to sovereignty and treaty, and ensure that satisfactory access to housing, education and employment is pursued. What benefit can Australia expect to receive from such a radical change in approach? As Senator Ridgeway said, much of Australia may avoid self-examination for fear of what will be found and what will be lost. This apparent milieu of fear is a poor legacy to leave to future generations of Australians. In confronting these issues, we can offer a better future for our nation and bring healing to the festering sore that is Australia's Black history (and health). The medical fraternity can play a leading role in this process — after all, healing is the prime concern of our profession.

Louis G Peachey BMed, FACRRM

To the Editor: The editorial by Cameron and Campbell on access block is an excellent summary of the causes and potential solutions to access block.1 The effects of overcrowding in the emergency department (ED) have been previously reported, including risks to patient safety, prolonged pain and suffering, and decreased clinical productivity and effectiveness.2 Access to emergency care is impaired. The fundamental problem is that while demand has increased, the capacity of the system has decreased.3 This is best exemplified by the significant reduction in hospital bed numbers. Healthcare in Western societies has been through a period of severe economic rationalisation, resulting in closure of thousands of beds in the acute hospital system. For example, in the United States, the number of medical and surgical beds declined by 18% in the period 1994–1999. From 1990 to 1999, attendances at EDs increased 15%. There have also been many aged care beds closed or changed to community-based facilities.4 It has been suggested that the problem is "a badly flawed approach to financing health care that values profits over patients."5 Spare bed capacity is essential for the effective management of emergency admissions. At least one study has found that if hospital bed occupancy rates exceed 85%, then bed crises occur.6 In fact, the Guinness Book of World Records now has a category for longest wait on a hospital trolley!7 The official record currently stands at 77 hours 30 minutes, although anecdotes report longer times. It is paradoxical that other departments within a hospital cannot exceed 100% occupancy, and yet the ED, which may contain some of the most seriously ill or injured, is allowed to exceed the safe level of 100% occupancy. The ED has always been available to help if all else fails in the healthcare system. That basic tenet is now being challenged, and the general public may no longer be able to rely on EDs for quality and timely emergency care, placing the safety of people at risk.8 In addition, Derlet has stated that should there be a major infectious disease epidemic or national catastrophe, EDs and hospitals could not accommodate the demand, undoubtedly leading to increased suffering and excess mortality.3 For all patients, increasing the capacity of the hospitals across the system (viz beds) would really make a difference.

Daniel M Fatovich

To the Editor: The series of articles concerning access block1 indicates that access block is a major health issue in this country. It is remarkable that, despite all these efforts to avoid admissions and reduce inpatient length of stay, only a few occasions of brief success at reducing ambulance diversions were described, and only one case of reducing access block (Royal Melbourne Hospital). We contend that it is now time to increase available beds. In several cases, the association between worsening access block and closure of beds was noted (Australian Capital Territory, Queen Elizabeth Hospital, Royal Perth Hospital). Available data show a steady reduction in hospital beds per thousand population in Australia, from 3.3 in 1995–96 to 2.8 in 1999–2000,2 a decrease of more than 11%. Keeping inpatient occupancy below a threshold percentage is important to controlling access block.3,4 Reducing occupancy by increasing available beds is the logical recommendation.

Peter A Roberts · Paul A Cunningham

To the Editor: I was interested in the letter by Marks et al,1 indicating that the efforts of over-worked medical staff in emergency departments to introduce patients to local general practitioners had been largely unsuccessful. A few years ago I noted the success with which this problem was handled by the emergency department management at Huddinge University Hospital in Stockholm. All patients were charged 60 krone at triage. Those who sat in the waiting room were confronted by two large electronic signs. The first listed the waiting time for the 10 most common GP-type ailments. The second listed 10 local GPs, where the consultation fee was then 50 krone, with the offer to refund their initial payment if they chose to take their business elsewhere. I was told that this was the very successful first of eight "barriers" between the emergency department door and the intensive care unit. Since the middle of last century, Sweden has been held up as a model provider of an egalitarian and "free" healthcare service. Perhaps our country could benefit from the revisions and improvements that the Swedes have made over recent decades.

Peter J Burke

The Better Medication Management System (BMMS) is an Australian project to provide electronic access to patient medication records. It aims to improve access to patient medication information and to reduce adverse drug events and hospital admissions. Evidence supporting the achievability of the BMMS aims is limited. Voluntary participation of patients in the BMMS may limit its ability to achieve its aims and capitalise on its potential benefits.

Jeremy P Wrobel LLB, BCom, MB BS(Hons), Hospital Medical Officer, Barwon Health

Rationing, the equitable allocation of medical resources, is both an economic and moral challenge — economic, because the various components of healthcare must be budgeted; moral, because the prioritisation of these resources is a value-laden decision. The moral debate about rationing pits individual choice against communal interests. The advocacy of equitable distribution of healthcare resources originates in arguments for distributive justice and a revised version of individual autonomy. If autonomy is defined strictly in terms of atomistic individuality, then the social obligations and duties of persons are subordinated to their individual rights. Alternatively, when people are defined by their relationships, "relational autonomy" balances responsibilities against the claims of individual rights to maximise distributive justice. The concept of relational autonomy provides medicine with a philosophical basis for communal rationing of healthcare resources.

Alfred I Tauber MD

To the Editor: The most recent newsletter of the New South Wales Medical Board1 opens with a plea by the president for better understanding of the Board's initiatives, inspired by the "public interest". We hope that the board recognises the gulf between legitimate public interest and unrealistic, illegitimate public expectation. The newsletter goes on to justify the Board's policy against doctors self-prescribing, with six examples (hardly significant from a register of 25 000). The first, Dr A, aged 70 (the only one whose age was given) was referred to the Board by colleagues for mental impairment, and was not self-prescribing. He was prescribed warfarin by his cardiologist, but also took aspirin. The other five were all involved with drugs of addiction, earning whatever sanctions the Board applied. The newsletter then states that these were "ordinary doctors providing ordinary services in the community" (p. 3).1 They were certainly not, and it is this patronising assessment of the behaviour of ordinary doctors that is objectionable. We are next told that "these dramatic examples represent the tip of an alarming iceberg" (p. 3).1 The Board has enough to do without plumbing the depths for imagined "icebergs", and should reconsider their policy on the alleged dangers of self-prescribing, a policy both unwarranted and unwanted. The mocking adage that "doctors who treat themselves have a fool for a physician" is not made correct by repetitive quotation. There are not many fools in our profession, and sanctions applied to them should not affect the Board's assessment of the whole profession. Although not mentioned in this newsletter, similar motives are apparent in the Board's disapproval of self-referral, where we are not credited with sufficient wit to discover for ourselves appropriate specialists for clinical referral. All medical boards are currently seized with similar agenda. The Victorian Medical Board ponders the "problem" of retired doctors, with the comment in their newsletter on doctors affected by "increasing age and commensurate reduction in cognitive ability", another gratuitous observation without supporting evidence. They could as correctly, and more kindly, have referred to the accretion of clinical wisdom commensurate with age, but respect for seniors seems to have declining value in current professional ethics.

G Douglas Tracy

In reply: Tracy's letter seems to focus on age. The Board's policy about treating family members is not about age, but about the wisdom or otherwise of this practice for medical practitioners at any stage of their career. The policy is not mandatory, but reflects what the Board considers to be prudent practice. The policy does not prohibit writing referrals or repeat prescriptions, but emphasises the importance of having an independent treating practitioner responsible for initiation of treatment and ongoing management. The New South Wales Medical Board is not alone in having such a policy, with similar views being expressed by UK's General Medical Council, the Medical Council of New Zealand, and Canadian, American and other Australian medical boards. The Australian Medical Association position statement on the "Health of medical practitioners" emphasises the importance of medical practitioners and their families having their own general practitioners. The case studies were published following a request from members of the profession for the Board to provide examples of problems arising through treating themselves or family members. Sadly, there are many more instances than the five referred to in the article. The doctors were certainly not ordinary once their attempts to treat family members went astray, but the point is that they had been ordinary doctors who got into difficulties because they crossed the professional–personal boundary.

Brian C McCaughan

Infarct angioplasty has the potential to increase the disparity in outcomes between rural and urban patients with myocardial infarction The need for rapid treatment of coronary syndromes has been recognised for many years. Despite recent emphasis on the benefits of rapid thrombolysis, the main advantage of early presentation remains resuscitation from ventricular fibrillation. Defibrillation has been estimated to save about six times as many lives as thrombolytic treatment,1 but patients must reach medical assistance in time for it to be effective. On average, patients delay more than an hour before seeking help for symptoms of acute myocardial infarction, and about another hour elapses before they arrive at hospital.2-4 Attempts to shorten patient delay by education campaigns have been generally ineffective5 and, in recent years, efforts have been mainly directed towards expediting transport and hospital treatment of patients with myocardial infarction.2,3,6 In Australia, these efforts include fast-track pathways and delivering thrombolysis in emergency departments, before cardiological review.2,7 Significant improvements in call-to-needle times have been achieved,6 but, as Kelly and colleagues document in this issue of the Journal (page 381),2 not all patients are treated as rapidly as is desirable. The study by Kelly et al is particularly useful because it includes many of the patients treated with thrombolysis in Victoria over their study period of 30 months, and includes patients from rural and urban regions. Their data show that patients from rural areas delay longer before seeking attention and are slower to receive treatment than patients from large urban areas. While the association between delay in treatment and increased mortality in this study is likely to be partly confounded by unmeasured variables, few would dispute that these delays increase infarct size and the likelihood of dying during and after hospitalisation. Delayed treatment of myocardial infarction is one more manifestation of the geographic gradient in healthcare and outcomes in Australia.8 Controlled trials have shown that prehospital thrombo-lysis reduces mortality by about 20%.9 Prehospital thrombolysis is particularly suitable for remote regions with long ambulance transport times, and has been successfully implemented overseas without the use of mobile intensive care units.10 Even in urban areas, significant reductions in treatment delay have been achieved (between 30 and 60 minutes9), perhaps partly because a diagnosis is established before patients arrive at hospital and the hospital assessment process is circumvented. Yet, in Australia, prehospital thrombolysis has not been implemented in a systematic way. Kelly et al identify many of the barriers to the use of prehospital thrombolysis, including lack of appropriate ambulance equipment and failure to train and empower paramedics and nurses to give thrombolysis.2 They argue for a "bottom up" approach where individual healthcare ser-vices develop and own their strategies. Unfortunately, by itself, this is unlikely to effect change because of the complex funding mix of healthcare services in Australia and the parlous financial state of many rural health services. While rural and regional centres struggle to treat patients expeditiously with limited resources, metropolitan hospitals with cardiac catheterisation laboratories are moving steadily towards infarct angioplasty instead of thrombolysis.11 Whether this proceeds on a 24-hour basis depends mainly on the ability of individual cardiology departments to corral the necessary resources from their hospitals and the willingness of their staff to work nights and weekends. There is a strong body of evidence showing that infarct angioplasty is a better treatment than thrombolysis,12 but it is certainly more expensive to institute upfront. Proponents argue that it is cost effective compared with thrombolysis as it reduces hospital stay, but experience has taught hospital administrators to be wary of these claims as they rarely result in real cost savings. However, there is little doubt that infarct angioplasty is here to stay and that it will improve outcomes from myocardial infarction in patients fortunate enough to have access to it. If current trends continue, it has the potential to further increase the disparity in outcomes between rural and urban patients with myocardial infarction. How then should we respond to the data provided by Kelly and colleagues? Time delays in administering thrombolysis need to be seen in the context of the emergence of widespread use of infarct angioplasty and the particular geographic difficulties imposed by the Australian setting. In areas with transport times of more than 20 minutes, systematic use of prehospital thrombolysis could substantially improve outcomes at a modest cost. In urban areas, rapid transit to a facility with the ability to perform percutaneous transluminal coronary angioplasty (PTCA) is likely to become the standard. A combination of the two strategies could also be trialed in patients from areas without rapid access to PTCA (so called facilitated infarct angioplasty). Finally, in the debate about how best to achieve early revascularisation, it should not be forgotten that most of the delay occurs before the patient contacts the ambulance service and that, in this period, death is usually the result of ventricular fibrillation. As no strategy has been identified that encourages patients to present earlier, research should be directed towards improving the treatment of cardiac arrest with interventions such as prehospital thrombolysis13 and public access defibrillators.14

James W Leitch MB BS, FRACP

Objective: To achieve sustained improvement in use of cefotaxime and ceftriaxone (CEFX) in a major teaching hospital, as measured against national antibiotic guidelines.Design and setting: Pre- and post-intervention survey of CEFX use in the Royal Melbourne Hospital, a tertiary hospital in Melbourne, Victoria.Intervention: Web-based antimicrobial approval system linked to national antibiotic guidelines was developed by a multidisciplinary team and implemented in March 2001.Main outcome measures: Change in rate of CEFX use (defined daily doses [DDDs] per 1000 acute occupied bed days) over 8 months pre- and 15 months post-intervention; concordance of indication for CEFX with national antibiotic guidelines pre- and post-intervention.Results: CEFX use decreased from a mean of 38.3 DDDs/1000 bed days pre-intervention to 15.9, 18.7 and 21.2 DDDs/1000 bed days at 1, 4 and 15 months post-intervention. Concordance with national antibiotic guidelines rose from 25% of courses pre-intervention to 51% within 5 months post-intervention (P < 0.002). Gentamicin use also increased, from a mean of 30.0 to 48.3 DDDs/1000 bed days (P = 0.0001).Conclusion: The web-based antimicrobial approval system achieved a sustained reduction in CEFX use over 15 months as well as increased prescribing concordance with antibiotic guidelines. It has potential for linking to electronic prescribing and for wider use for other drugs, as well as for research into the epidemiology of antibiotic use.

Michael J Richards FRACP · Lyn-Li Lim MB BS · Marion B Robertson BPharm, MSc · Nicholas R Jones BPharm, Grad Dip Clinical Pharmacy · Simone E Taylor PharmD, Grad Cert CRM · Margarida M Duarte BA (CompSci), BEng (partial) · Dale A Kerr BBus (Information Systems) · Graham J Stanton · Peter D Ritchie MPubHlth, FACEM · Jonathan G A Dartnell BPharm, PhD