Health services administration

To the Editor: The motivating article by Bent and colleagues1 is a most welcome addition to the literature of what works in the movement for performance improvement. We can hardly overemphasise the need to share knowledge on innovations (ie, what works and what does not work) in the quest for best quality and safety practices. However, to aid efficient lesson-drawing, we are inclined to look for more contextual information and levers in any quality-of-care interventions. For a safety research discussion, the report by Bent and others has at least three important elements: the use of a technology (personal digital assistants [PDAs]), the clinical performance of healthcare professionals (here, anaesthetists), and the permissive culture (to want to learn and improve). Nevertheless, what such innovative pilot practices should also incorporate and report are the contextual factors responsible for successful acceptance,2 application and appraisal of quality interventions. Bearing continuity and sustainability in mind, one should be interested in the "characteristics" of anaesthetists who would voluntarily engage in personal monitoring and feedback. Initial technology use is seen among the "technologically proficient few" before becoming widespread.3 The introduction of PDAs for incident monitoring calls for the evaluation of the sociotechnical meta-system4 in which it will ultimately exist. Therefore, it is important for us to add a qualitative assessment to such a pilot study to identify personal motivating factors, climate for action, and the personal performance effects. Failure to evaluate technology "deployment" in healthcare results in lack of commitment, slow technology adoption, and perhaps decreased patient safety.5 The application of PDAs in reporting adverse events will increase within and across clinical disciplines and borders, but so must the rigorous appraisal to aid transference of knowledge. The global stage for international comparative research is widening, necessitating the need for integrated study designs, contextual analysis and robust reporting. It is often desirable to look for cost-effective means of improving patient care, with a dual learning carriage between institutions and nations. Patient safety and quality care studies will therefore continue to enjoy inputs from epidemiology, health services research, health economics, health policy, cognitive engineering, and information and communication technology. However, the main challenge remains: where is the patient in "patient safety"?.

Onyebuchi A Arah

In reply: I thank Arah for pointing out the importance of the "context" into which any quality and safety program will be deployed. Success or failure of innovative pilot programs will always depend upon the willingness of the end-user to embrace change. In the case of performance monitoring using electronic logbooks, this will first require an easily workable and reliable tool, not just for the technologically proficient few, but for all users. In addition, users must also be motivated to monitor their professional performance. In today's world, where medicolegal issues are increasingly significant, there is pressure to prove accountability and reduce one's risk exposure. In carrying out a pilot project only, we aimed to demonstrate the technological feasibility of such a tool. We believe that this has been successful, and that now is the time to embrace the use of such tools. Ultimately, cultural change will only occur when the "early adopters" and enthusiasts demonstrate the usefulness of a concept, leading the way and pulling the rest of the population behind them.

Paul D Bent

To the Editor: In concluding that health policy research in Australia is a virtual desert,1 Van Der Weyden failed to acknowledge several recent developments. The Health Services Research Association of Australia and New Zealand, formed in late 2001 (www.chere.uts.edu.au/hsraanz/), and its biennial conferences (the next to be held in Melbourne in November 2003), are evidence of good quality research across a range of topics. Particularly Australian contributions include economic evaluation as a basis for funding decisions in both pharmaceuticals and medical services; the Coordinated Care Trials; and the adaptation of casemix funding to Australian cost structures and payment mechanisms. Health policy development around the world borrows freely from other countries, but, unlike the generalisability of biomedical and clinical research, health services research can only be transferred after taking into account the characteristics of each country's unique system. Nonetheless, health services and policy research are underfunded and underdeveloped in Australia. Is the answer an internationally acclaimed Australian Institute for Health Policy? Not entirely. A well-funded institute would overcome some of the lack of security of tenure faced by health services researchers — and would certainly be a welcome advance over the usual Australian practice of spreading the available funds so that a paltry amount goes to each State or Territory. However, according to the Wills Review,2 Australia requires not one but several research centres with the necessary critical mass. We need a multifaceted strategy that goes beyond the organisational base. Funding is needed for investigator-initiated long term research to address underlying theory and methods, as well as contemporary policy issues. Researchers need to be able to build sustained inquiry into a specific area, instead of moving rapidly from topic to topic just to maintain their funding. Recognised avenues for training, education and further professional development are needed to build a critical mass of researchers. Only then will the success rate of National Health and Medical Research Council (NHMRC) project grants for health services research move from its current 5% or less to the success rate for public health of around 20%, or even the overall success rate of 25%–30%. Finally, the US-based Harkness Fellowships in Health Policy and Practice are important,3 but support only two Fellows each year. This program needs to be complemented by an Australian-based program of training and international exchange on a similar scale to the various public health training programs.

Jane P Hall

Objective: To examine doctors' perceptions and attitudes to prescribing within the Authority Prescribing System (APS).Design and setting: Questionnaire survey of Australian doctors' responses to a number of statements and factorial vignettes, conducted between 1 May and 30 June 2001.Participants: A national random sample of 1200 doctors, stratified according to specialist/generalist, rural/urban and high/low prescriber: 669 (56%) responded.Main outcome measures: Self-reported perceptions of the APS and attitudes to prescribing within the APS.Results: 72% of doctors agreed that the APS makes effective medications available to the socioeconomically disadvantaged members of the Australian public and 50% agreed that it compromises patient privacy. Fewer agreed that authority indicators were based on the highest quality of evidence quality (40%) or medication safety (12%). Doctors placed more emphasis on the doctor–patient relationship than on the criteria for authority prescribing in their decisions about prescribing APS medications. Doctors who used computers to prescribe were more likely to agree that computers can improve the authority prescribing process.Conclusions: This study suggests that authority-required prescribing is not achieving the stated aims of the National Medicines Policy in reducing variability in prescribing. Strategies to improve the quality of prescribing must consider the professional and ethical conundrum associated with prescribing outside of PBS/APS approved use for clinical and patient-centred reasons.

Siaw-Teng Liaw PhD, FRACGP · Christopher M Pearce FRACGP, FACRRM, MFM · Patty Chondros MSc · Leone Piggford MB BS, FRACGP · Kay Jones MSW, PhD · Barry P McGrath PhD, MB BS

In reply: We agree with Johnson and Lassere about the value of longitudinal studies, especially clinical trials, in assessing healthcare benefits and costs. They are critical to informing clinical practice and health policy. If it were possible to conduct these studies across a wide variety of settings, representing the range of "real life" practice, then there would be little need for epidemiological modelling. However, this is not possible. Clinical trials (with or without cost components) will only ever be conducted over relatively short durations, on circumscribed populations and under tightly controlled conditions. A key, but often overlooked, issue is whether the results of studies are externally valid (generalisable). Indeed, the evidence base that dictates clinical practice and health policy should comprise data that are both internally and externally valid. We do not suggest that epidemiological modelling replace longitudinal studies (in fact, modelling depends critically on robust prospective data); rather, it complements these studies by providing a means to assess their external validity. We are also mindful of the limitations of epidemiological modelling, as outlined in our article,1 and acknowledge the importance of ensuring rigour in the methods. Our article dealt with generating the data needed for sound economic evaluation, by taking into account the long-term benefits, risks and costs of treatment strategies, and "real-life" health service conditions. This is distinct from the issue of whether "conditional listing" on the Pharmaceutical Benefits Scheme should be implemented for drugs that are yet to be proven cost-effective.

Danny Liew · John J McNeil · Anna Peeters · Stephen S Lim · Theo Vos

To the Editor: The articles by Reid1 and Paterson,2 former bureaucratic leaders of the New South Wales and Victorian health systems, respectively, on the process for developing the 2003–2008 Australian Health Care Agreements (ACHAs) are disappointing. They offer few original conceptual insights or clear proposals. Reid's dream is that the 2003–2008 ACHAs will see "a new expression of national health policy on which funding decisions can be based". However, he presents only old ideas, such as "ACHAs will need to extend beyond public hospital issues to incorporate primary care", and, on the perennial cost-shifting between the two levels of government, "clearer lines of financial management of care and appropriate incentives are needed". Reid laments that the focus of all previous agreements has been "narrowly limited to one aspect of healthcare . . . the maintenance of universally accessible public hospital care free of charge". Paterson does propose something radical, and the core of his proposals is that "the payer must stand behind the patient and not between the patient and the provider". The way to Paterson's "outcome-enabled health system" is to "relieve the constraints that bind inputs and distort the 'production' system". Does he mean we need more doctors and nurses, or does he mean substitutes should perform some of their current activities? Patterson proposes more investment in "information and communications technology" to facilitate a gradual move to "patient-based funding". Does this mean capitation, medical savings accounts, or is he proposing non-insurable copayments? Whatever it means, there will be "no outcome-driven healthcare until the system recognises the whole patient", and this will only be achieved with "electronic patient record systems in routine and ubiquitous daily use by providers". Given their experience as senior health system administrators, it is a pity neither Reid nor Paterson provides any explicit suggestions that recognise the key factor that will determine the outcome of the ACHAs. This is the policy gridlock that any federal system almost inevitably imposes. A recent issue of the Journal of Health Politics, Policy and Law was devoted to health politics and policy in a federal system. The editor, Petersen, concludes with a view relevant to Australia: "You can love it, you can hate it, but . . . federalism thwarts uniformity and universalism, frustrates responsiveness and policy analysis, limits large scale innovation while churning more localized mills of idea generation and promotion, and offers a permanent employment plan for health policy researchers".3 Parts of Australian health arrangements certainly need an overhaul. An example is general practice. This sector, differently organised and financed, could deliver much more to the community, the rest of the healthcare system, the Federal Government and to general practitioners themselves. Change in this sector would not depend on improbable cooperation between levels of government, and would be more manageable than the multifarious whole-of-system reforms about which Reid and Paterson speculate.

William Coote

Measurement of clinical performance. Practical approaches in acute myocardial infarction. Robert West, Robin Norris (editors). London: Royal College of Physicians, 2001 (viii + 128 pp). ISBN 1 86016 152 9. Evaluating the quality of clinical care is now the accepted, indeed mandatory, duty of all who practise medicine. Medical colleges have introduced programs for maintaining professional standards, and many of these feature clinical audit as a necessary activity. For the busy clinician, however, finding both the time and the means to perform accurate and consistent audits poses major challenges. This work, from the Royal College of Physicians (RCP), offers pragmatic strategies at both a national and a local level for conducting meaningful clinical audit. While focusing on the care of patients with myocardial infarction, the messages contained in this book can apply to any area of medicine. The first half deals with clinical governance (UK style): use of performance indicators and league tables; the choice between process or outcome measures; and an overview of national benchmarking projects in the UK dealing with coronary heart disease, asthma and stroke. The second half covers the practicalities of auditing the care of patients with myocardial infarction, as exemplified by the Myocardial Infarction National Audit Project. This ambitious project aims to recruit all hospitals in England and Wales, and uses a nationally funded, RCP-sponsored data collection, analysis and reporting system which is standardised, computer-based and centrally coordinated. Such a system relieves local clinicians of the need to develop their own audit system from the ground up. The authors of each chapter speak authoritatively from personal experience about the good and bad in conducting clinical audit, and offer advice on what to avoid. Finding a "how to" book in performance measurement that is short (128 pages), easy to read, inexpensive and rich in practical applications is a rare delight for this jaded healthcare researcher. My only regret — I would have liked a little more on how to use the results of audit to full effect in improving quality of care at the local level. Ian A ScottDirector of Internal Medicine Princess Alexandra Hospital, Brisbane, QLD

Ian A Scott

We need a coordinated approach to address the underlying problems in the health system The effects of access block on acute hospital services are most disturbingly reflected by patients on trolleys queued in emergency department (ED) corridors and ambulances circling hospitals, waiting to deliver acutely ill patients. The Australasian College for Emergency Medicine and the Australian Council on Healthcare Standards (ACHS) have defined access block for emergency patients as the percentage of all patients admitted, transferred or dying in the ED where their total ED time exceeds eight hours.1 For elective patients, access block is reflected in ballooning elective waiting list numbers and length of time spent waiting. Access block has been with us since the 1980s, but in recent years, in Australia, it appears to have become both endemic and critical across all our major cities.2,3 There is now evidence that access block causes poor patient outcomes and interferes with efficient hospital functioning.4,5 In this issue of the Journal (page 103) the impact of access block across Australia and potential solutions are outlined. Causes of access blockThe causes for this untoward development are not straightforward, but appear to correlate with major decreases in hospital bed numbers, community residential care facilities, and with changes in workforce and community attitudes. Bed numbers: In Australia, the total number of acute hospital beds has decreased over the past two decades, with a 15% decrease in public hospital beds occurring from 1995 to 2000.6 There have been concomitant decreases in inpatient length of stay, but the number of hospital admissions have also increased.7 There are now more day procedures and day admissions. Although some of these replace multiday stays, others represent new work or multiple admissions replacing a multiday, single admission.8 Concurrent with decreasing acute hospital bed numbers, access to residential care beds in the community has decreased, especially beds designated for high-dependency patients.9 This has increased demand on acute hospital services as elderly inpatients wait for long term placement or are inappropriately sent back to the community to avoid pressure on an already congested residential care system. Community-based treatments: Many patients with complex and chronic illnesses are now treated as hospital outpatients or in the community. However, when serious complications occur, patients frequently present to EDs, particularly if access to community healthcare services is not available. This lack of community support increases patient load on the acute care system. Workforce: No single person can master the high-technology solutions and complicated treatment regimens prevalent in acute care hospitals. At the same time, many elderly or infirm patients need basic nursing care, which at times is considered too mundane for highly trained hospital staff. Increasingly, the workforce model required in healthcare is team-based, with multidisciplinary input and multiple levels of expertise, even within disciplines.10,11 Training programs for doctors, nurses and allied health workers do not yet reflect this need. This imbalance between career aspirations, systemic needs and actual working environments results in dissatisfied workers or insufficient staff with necessary skills. These factors contribute to low morale, which further reduces workforce flexibility. Social changes: The demise of the extended family and changes in the demographics of marriage and childbearing have led to more elderly people living alone, and with greater feminisation of the workforce fewer people can be carers.7,12 Population projections indicate that the number of informal carers in the community (largely middle-aged women) will decline sharply as the baby boomers age and require care themselves. The default solution for many partially dependent people is referral to an acute hospital. Funding models: Payments to hospitals and healthcare providers are rigid and reward rapid treatment of uncomplicated conditions. In the community setting, payment is for episodes of care rather than continuity of care. Complicated emergencies, time-consuming conditions involving multiple medical specialties, and social issues stretch the time and financial resources required, and are dealt with piecemeal. Patients with complex or multiple problems frequently have no alternative but to attend a public hospital ED.11 Casemix payments in the acute care setting and fee-for-service models of payment in the community setting usually disadvantage patients who require longer stays and supported post-hospital care. Rigid rules around definitions such as "inpatient" versus "outpatient" treatment create financial risk for hospitals introducing innovative treatment strategies. Furthermore, public ED workloads increase as GP consultation rates in older age groups decline, along with a reduction in GP bulk billing and availability after hours.13 Increasing indemnity insurance premiums for procedural GPs and private specialists also lead to greater public ED demand. Potential solutionsSystematic management of access block is only just beginning to be discussed at a policy level. The extent of the issue is now such that a more strategic Australia-wide approach is necessary. The experiences described in this issue of the Journal show that hospitals can improve their individual performance with organisational changes. But, despite the impressive changes achieved with the outlined approaches to access block, it is apparent that our healthcare system has serious underlying problems that need to be publicly acknowledged by politicians and appropriately addressed. Workforce: Historically, the major solution to hospital access issues was to spend money and increase bed numbers by employing more staff. Recently, in Victoria, money was allocated for increased bed numbers and services, but there were insufficient staff to open more beds (see the Royal Melbourne Hospital report, page 109). Reasons for rigidity in work practice and roles within the healthcare workforce need to be explored, and, where there is no evidence to support limitations in practice, rules should be changed. Universities, clinical colleges and hospitals must work together to train healthcare professionals for the tasks required rather than for roles based on historical models. Funding: The innovative practices described in the hospital experiences were partly enabled by incentives from federal, State/Territory and hospital initiatives. The funding method can help direct healthcare services toward community needs. For example, funding hospitals for procedures, whether provided on an inpatient or outpatient basis, might allow a hospital to provide those services even when beds are not available. Casemix payments tend to favour hospitals that provide uncomplicated elective services — perhaps alternative models that encourage healthcare services to look after elderly, complicated, medical patients should be trialled. Funding that allows a hospital to experiment with new clinical pathways and not be financially penalised, such as the National Demonstration Hospitals Project14 (aimed at improved hospital service efficiency and utilisation) and the Hospital Admission Risk Program15 (aimed at decreasing hospital bed utilisation), should be encouraged. The next round of Australian Health Care Agreements should ensure balance in financial incentives between elective and emergency services. There should also be recognition of the need to better remunerate GPs for providing complex care, perhaps involving a trial of a capitated payment or managed competition model.16 Healthcare delivery systems: The central message conveyed by the experiences described in this issue of the Journal is that changing internal processes can improve access to inpatient resources. Initiatives such as medihotels, placing patients in a transit lounge before discharge, day-of-surgery admission for elective surgery, short-stay wards, and centralised bed control can all save bed-days. Encouraging clinicians to trial treating patients in different ways and objectively analysing outcomes requires leadership from clinicians and administrators. For high-volume conditions and procedures, there should be standardised treatment pathways to expedite inpatient stay. Efficient use of beds also requires accurate, transparent data collection with rapid feedback to clinicians. Many hospitals are unable to accurately account for every patient and the purpose of their continued inpatient stay. Similarly, many hospitals do not have an accurate bed census that identifies the variability in the number of beds that are open from shift to shift, nor do all have the ability to accurately count nursing sick leave rates by shift and day of the week. Residential care: It is important that use of residential care facilities is tightly controlled and residents are allocated to the appropriate level of care. However, the current problem is that patients are unable to access long term residential care facilities and are instead filling acute care beds. Reform within the subacute and residential/community care sector is necessary to improve efficiencies within the acute care sector and to provide appropriate long term care to patients. Attention to more appropriate locations to care for the small group of long-stay patients is likely to be the most efficient strategy to improve patient flow through the subacute sector. Service prioritisation: The public must become involved in the debate about which healthcare services are essential. The present rationing method is in essence a lottery — whether your ambulance is allowed to arrive at a certain hospital, or whether your elective surgery is on or off, depends on the capricious availability of beds. The healthcare system cannot provide every service, but basic emergency and elective services could easily be provided within present budgetary constraints. A more transparent and educated debate may allow healthcare providers to work in a more satisfying environment where expectations are matched with necessary resources. There remains considerable pessimism about the ability of the acute healthcare sector to deliver an effective service in the face of increasing demand and limited resources. There are solutions. However, political leadership and a coordinated national approach are necessary to resolve underlying structural issues surrounding workforce, work practice and funding.

Peter A Cameron · Donald A Campbell

Access block began to affect hospitals in the Australian Capital Territory during the winter of 2000. Practice was seriously affected first at the Canberra Hospital, a 500-bed mixed adult/paediatric tertiary hospital, in 2000, and then in 2002 at Calvary Hospital (220 beds), the other hospital in the ACT with an emergency department (ED). Access block in the Canberra Hospital averaged 9.1% (Australasian College for Emergency Medicine/Australian Council for Healthcare Standards [ACEM/ACHS] definition: proportion of admissions with total time in the ED longer than eight hours) during 1999. For 14 days between May and September the rate exceeded 20%. During 2000, it averaged 16.3%, with 56 days in excess of 20% between May and September (Box). This trend continued in 2001, when the figures were 22.9% and 79, respectively. The major underlying cause was a reduction in hospital bed capacity from a monthly average of 533 staffed beds in January–August 1999 to 491 in January–August 2000. As a corollary, a marked reduction in access block occurred when additional beds were made available by cancellation of elective surgery during the Sydney Olympics in September 2000. Although access block had a measurable effect on ED waiting time performance in 1999,1 it began to affect overall ED function in the second half of 2000,2 when a significantly lower proportion of presentations achieved their desired ACEM/ACHS waiting time performance. InterventionsThe onset of access block prompted review of ED work practice, leading to some improvement in ED performance in the face of access block during 2000, but little change since. The continued severity of the problem has stimulated ongoing review of all hospital work practice, aiming to reduce the demand on overnight beds through improving overall patient flow, and to improve ED function. The changes have proven to be of variable effectiveness. Interventions to improve patient flowRestructuring and expansion of the Bed Management Unit (May 2001); Revision of admission, discharge and bed management policies (July 2001 to March 2002); Expansion and increased use of hospital in the home and day surgery services (ongoing); Off-site transitional care arrangements for elderly patients (ongoing increase in transitional care beds); Activation of real-time estimated date of departure notification system and daily estimates of occupancy over next 24 hours (May 2001); Containment of elective surgery, particularly during winter (ongoing since 2001); and Opening of a discharge lounge (relatively little effect on time of discharge). Interventions to reduce ED demand for overnight bedsIncreased use of overnight discharge from the ED followed by day surgery for orthopaedic, plastic surgical, and gynaecological presentations; and Improved links with community services to facilitate discharge, particularly of geriatric patients. ED changes to mitigate effects of access blockRearranging medical staff rosters (2001 and 2002); Increasing by one the number of nursing staff on each shift (winter 2001 and ongoing); Drawing additional nursing staff from the hospital pool at times of excessive inpatient care in ED (2002 and ongoing); Establishing formal policies and procedures on prioritisation of ED activity (2001 and 2002); Revising hospital policies on ambulance diversion, although the effect has been limited, as the Canberra Hospital offers the only acute inpatient service in the region for paediatrics, orthopaedics, and most tertiary services; and Providing additional Hospital Assistant and Wardsman staff to assist in the ED (ongoing). Interventions planned for 2002–2003Renovation of the ED to make better use of the available space; Construction of a Clinical Decision Unit/Observation Unit in the ED to manage short-stay patients; and Opening of a short-stay surgical unit close to the operating theatre to better manage short-stay surgical patients. OutcomeAccess block is the major issue facing EDs in the ACT. Despite the above measures, hospitals in the ACT have experienced a continued increase in access block and significant decline in ED waiting time performance. Access block at the Canberra Hospital, January 1999 to September 2002

Drew B Richardson

The Queen Elizabeth Hospital (QEH) is a 340–361-bed acute tertiary referral hospital in the western suburbs of Adelaide. Since 1999, the hospital has had difficulties coping with emergency admissions demand, especially during winter. Over the previous years, there has been a reduction in acute bed numbers from 476 to 361. Also, within the past two years, there has been the loss of 250 residential care facility (RCF) nursing home beds from the western region of Adelaide. At the same time, the activity of the hospital as measured by casemix activity has remained constant. The inpatient occupancy in winter has resulted in the emergency department (ED) requesting to go on ambulance diversion (bypass) almost daily, usually in late afternoon; however, on most occasions, this has not been either approved or possible. Waiting times in the ED for patients to be transferred to a ward are sometimes up to several days and QEH's waiting times in the ED are the longest of South Australian hospitals. Cancellation of elective surgical and medical patients has sometimes been necessary. InterventionsIn a progressive response to reducing access block, the hospital has adopted a range of strategies. In 1996, an Interface Unit based within the Division of Medicine was developed to coordinate and facilitate early discharge from the wards and avoid unnecessary admissions from the ED by initiating treatment/management for patients with conditions that may be managed at home but require additional support. The nurses in this unit "broker" or organise external therapy or services (such as subcutaneous heparin for the treatment of deep venous thrombosis, or home supports for someone who is frail and would otherwise have been admitted to hospital) in association with the patient's general practitioner. With the loss of nursing home beds from the western Adelaide region, a step-down unit was created in the hospital with a lower registered/enrolled nursing skill mix. An active multidisciplinary team facilitates placing patients in RCFs or at home, with additional resources provided through brokered community services or State-based programs, such as the Adelaide Transition Alliance (which provides respite beds in RCFs) or with the Division of Surgery's "Hospital in the Home" program (which provides post-acute home nursing services from within the division's nursing resources). A transit bay of six beds for incoming (ED) and outgoing (discharge) patients has been created. In addition, overcapacity beds (ie, accepting an additional patient into a ward before a patient has been discharged) have been used, and day beds have been used for non-same-day inpatients. Emphasis has been placed on promoting appropriate admission and appropriate day stay, with audits conducted by senior nurses from the Interface Unit based on accepted clinical criteria. Early discharge remains a priority, and is reinforced at medical handover meetings held each morning to review new admissions, facilitate transfer of care, and provide clinical inservice. Home care specialist nurses have also helped prevent admissions (eg, heart failure nurses, home cancer therapy and respiratory care nurses). A "medical flying squad" was established to assess nursing home patients and was clinically effective in reducing transfers from the RCF to the ED, but was too costly to sustain. A GP service located within the ED was unsuccessful because of low numbers of triage category level 4 and 5 patients. A further issue was that it sometimes involved a GP referring to another GP. OutcomeThe impact of these interventions is difficult to measure, as ambulance diversion has sometimes not been allowed in SA. However, without the introduction of the above initiatives, a substantial further reduction in elective activity would have been necessary. One measure of the success of these programs is that in 2001 the hospital had 50 long-stay patients awaiting placement, and this is now down to an average of 25 patients. There have been strategies undertaken to increase the capacity of the ED, but medical and nursing staffing levels have remained an issue. Changes in chronic disease management are required to minimise acute inpatient demand, especially during winter. Strategically reducing elective surgical activity during winter and subsequently increasing it during summer is difficult. The Division of Surgery has trialled weekend surgery, but this has not been widely accepted by the community. The management of long-stay patients remains central to improving patient access. The appropriate allocation of nursing home and respite beds is needed on a regional basis. The failure of nursing home beds to become available through licensing is a major issue that must be addressed at a State and Commonwealth level.

Richard E Ruffin MD, FRACP · Jan K Hooper RN, RM, BNursing

Royal North Shore Hospital (RNSH) is a 550-bed tertiary referral hospital serving a population of about 900 000 in the Northern Sydney Health Area. In 1999, the RNSH executive, to deal with ongoing restricted access (RA = ambulance bypass), decided to implement various changes to the structures, policies and practices of the hospital to alleviate the blockages to patients entering the emergency department (ED) by ambulance. The extent of RA at RNSH is shown in Box 1. As expected, RA was worse during winter, with more than 100 hours per month. InterventionsIn March 1999, the clinical heads of the hospital's divisions implemented a program aimed at improving utilisation of beds in the medical and surgical wards, in the belief that solutions to restricted access lay not within the ED, but within the rest of the hospital. The specific interventions were implemented by committed multidisciplinary teams, underpinned with significant senior medical staff involvement and executive support. Structural changesAdministrative responsibility for the ED was moved to the Division of Medicine so that the problems facing the ED were seen as belonging to the general ward areas. Clinical Supervisors, with responsibility for coordinating bed management, were appointed in the divisions of medicine and surgery, and a Clinical Bed Manager was appointed with responsibility for bed management across the entire hospital. Team-building initiativesDaily meetings with divisional nursing unit managers, the clinical supervisor and the bed manager. These meetings identified patients awaiting discharge, potential delays in treatment requiring attention, delays in consultation, inappropriate admissions, and patients suitable for treatment through ambulatory care or other outpatient services. Friday afternoon meetings with all medical registrars, divisional medical and nursing heads, the clinical supervisor, and the bed manager to ensure that all patients not requiring hospitalisation over weekends had appropriate discharge plans. Provision of data to medical staff regarding clinical practice variation (eg, variation in average length of stay for specific conditions). Clinical initiativesAmbulatory care ward open every day with extended after-hours service, with referrals from all medical teams and directly from the ED. This ward currently treats more than 1400 patients each month, and is available for patients who are well enough to be at home, but require in-hospital treatment as day patients. For example, patients who require blood transfusions, joint aspirations, lumbar punctures, chemotherapy or intravenous antibiotics were all moved from inpatient beds to the ambulatory care service. Similarly, rural patients referred for multiple specialist consultations or investigations are managed in this unit. Early-morning blood collection for patients awaiting results before discharge, with results available by 9: 00 am for discharge by 10: 00 am. Day-only angiography. Fax referral to rehabilitation beds to expedite transfer. Weekend discharge rounds by the divisional medical head and the clinical supervisor. Accommodation initiativesReconfiguration of beds to five-day short-stay to encourage management of elective activity from Monday to Friday. Use of off-site residential accommodation for patients not requiring inpatient beds for investigations. Provision of free transport (taxi vouchers, hospital transport) to patients to facilitate discharge. Nursing home liaison committee to improve communication with local residential care providers and facilitate appropriate transfer from the acute- to the residential-care sector. Leasing of 12 private hospital beds and attached clinical staff from Mater Misericordiae Hospital during winter. Policy initiativesRevision of the restricted access policy. Before activating RA, the ED Staff Specialist must contact inpatient managers to assess whether it is possible to avoid RA by hastening bed movements. Revision of the weekend leave policy. Ward leave greater than eight hours suggests the patient should be treated in the ambulatory centre. Development of an over-census bed policy. Wards to go one patient over census when the ED is considering RA and has no alternatives. This policy only needed implementation on two occasions between March 1999 and October 2000; on both occasions it prevented the hospital going onto RA. OutcomeThe effect of these interventions was dramatic. Within six months of commencing these initiatives, RNSH had effectively eliminated restricted access to the ED (Box 1, 2000), while maintaining elective surgical activity and significantly reducing the number of patients on the waiting list for admission (Box 2). These improvements occurred with bed occupancy rates in excess of 90%. The key contributors to the success of this program appear to be: significant medical leadership through visible operational roles for divisional heads and staff specialists/clinical supervisors in bed management processes; attention to discharge planning for ward patients; centralised bed management with a whole-hospital focus; team-building among senior nursing and medical staff; improved communication between ED and ward areas; engagement of junior medical staff in bed management processes; and a multifaceted implementation program that sought to correct process inefficiencies wherever they were identified. The outcomes of the program support the hypothesis that reducing ED ambulance bypass can be achieved by interventions that address upstream blockages in the hospital rather than specific ED interventions. Maintaining organisational focus on continually questioning the appropriateness of bed management practices is a challenge that must be met to ensure the sustainability of these sorts of improvements. 1: Restricted access (ambulance bypass) at Royal North Shore Hospital, 1997–2000 Interventions to reduce restricted access were implemented from March 1999, and had produced a dramatic decrease in restricted access by the end of 1999. 2: Proportion of patients experiencing a delay to treatment at Royal North Shore Hospital

Rohan J H Hammett MB BS, FRACP · Bruce G Robinson MSc, FRACP

In Queensland, access block was first observed in the peripheral urban hospitals in the Brisbane and Gold Coast area. As the absolute and relative bed capacity of public hospitals declined in the period 1999–2002, access block in Queensland's largest hospitals increased from a barely manageable average of less than 10% (Australasian College for Emergency Medicine/Australian Council on Healthcare Standards definition: proportion of admissions with total time in the emergency department longer than eight hours) to an average of about 14% in financial year 2001–02. Various administrative analyses have shown that the deleterious effects of access block start to become apparent at levels greater than 5%, and that these dysfunctional levels of access block occur when hospital occupancy consistently exceeds 95%. Other observations on Queensland data are that, generally speaking, access block is less of a problem in provincial centres than in metropolitan areas, and that hospitals with the best elective surgery performance tend to have the worst access block performance, and vice versa. The best-performing large hospital in Queensland in relation to access block is the Royal Brisbane Hospital (RBH), which had an average 6.2% in 2001–02. RBH is believed to be one of only two major hospitals in Australia that had no requests for ambulance bypass in 2001–02. This outcome has been achieved through considerable research and innovation and a management view that the RBH cannot go on ambulance bypass, as its emergency department (ED) is the sole department servicing a catchment area population of some 550 000, and because the other EDs in Brisbane do not have the capacity to absorb the additional workload if RBH ED closed its doors, even for a few hours. Over the past decade the hospital has implemented many strategies aimed at optimising the efficiency of the ED, the acute care process and discharge procedures. These are summarised in the Box. All of these strategies are believed to have had some benefit, but the most significant are the ED Short Stay Unit and the Medical Assessment and Planning Unit. It is known that small improvements in bed availability (ie, 5–10 beds) can cumulatively have a very substantial impact on access block, so RBH's current focus is on precision bed management through improved information systems and processes, including geographic information systems (which map the geography of the hospital against variables such as patient numbers, staff numbers, and nurse dependency). The objective is to maximise the identification of the relationships and correlations that exist in separate data sources within the hospital to precisely measure and predict demand and throughput in real time and to communicate that information throughout the organisation. Once this strategy has been exhausted, access block will only be able to be avoided through greater reductions in elective surgical throughput or an increase in system bed capacity, particularly during periods of peak demand. Strategies to improve bed management at Royal Brisbane Hospital, 1992–2002 Emergency department Increased consultants (from two to eight) Admission policy ED Short Stay Unit (18 beds: 24-hour stay for minor head injuries, overdoses, renal colic, etc.) ED Fast Track Zone (for Australasian Triage Scale Category 3 and 4 patients) ED Imaging Unit (computed tomography, ultrasound, picture archiving and communication system/radiology information system) ED Stat Lab Nurse-initiated X-rays (for peripheral skeletal X-rays, according to clinical pathways) Extended Hours Social Work (18 hours/day) ED Primary Care Unit Transit Lounge (a separate lounge for discharged patients awaiting transfer) Acute Mental Health Assessment Unit (6 beds) Inpatient departments Medical Assessment and Planning Unit Medical Day Procedure Unit Increased day-of-surgery admission Increased day-only procedural admission (no overnight stay) Interim Care Unit (inpatient facility for subacute and non-acute patients waiting for nursing home placement) Hospital-in-the-home program

Richard H Ashby

Royal Perth Hospital (RPH) is the largest hospital in Western Australia. The Wellington Street campus has about 600 beds and is located on the edge of the inner city. The emergency department (ED) has an annual census of around 55 000, with an admission rate of 44%. Forty-two per cent of all attendances arrive by ambulance, and data from the ambulance service indicate that RPH receives more priority one ambulances than the other major teaching hospitals combined. From 1996 to 2001, attendances increased by 14% and admissions by 16%. In the same time, inpatient bed numbers have been reduced by about a third. Before 1999, ambulance bypass was extremely rare. In October 2000, four WorkSafe orders were issued because the ED was contravening regulations of the Occupational Safety and Health Act 1984 (WA): employees were not able to move safely within the ED corridors because of obstruction from too many patient trolleys; patient trolleys and other equipment were blocking egress through corridors for evacuation in event of fire or other emergency; employees were exposed to violence hazards; and employees were suffering work-related stress because of excessive work demands. On 12 December 2000, all three major teaching hospitals in Perth were on simultaneous ambulance bypass. As a result, the then Health Minister appointed an Ambulance Bypass Coordinator to prevent this event recurring. On 17 November 2001, the cover story of the West Australian detailed the poor conditions for patients and staff in the ED. As a result, the Department of Health formed an Emergency Services Task Force, with broad representation from the emergency medicine and nursing community. The Box shows the extent of ambulance bypass at RPH from July 1999 to June 2002. Analysis of the first two years indicates that the most common reason for initiating ambulance bypass was entry block (30.4%). Entry block is a result of overwhelming numbers of patients attending the ED in a short period, resulting in a functional block to the entry of the ED and ED overcrowding. This necessitates ambulance bypass, even if there are sufficient inpatient beds available. InterventionsA transit lounge was established in July 1999, allowing ward patients who are being discharged to await discharge medications and collection, thus freeing up their beds earlier. In July 2000, an eight-bed holding bay was opened next to the ED. This is designed for patients who are ready for admission, but for whom the inpatient bed is unavailable, and to relieve the stacking of patients in the ED corridor. Nevertheless, stacking of patients in the corridor still occurs. Within the ED, a transfer coordinator has been appointed since July 2001. This is a senior nurse who readies patients for inpatient admission and organises transfer to the ward. This frees nurses for clinical duties. The transfer coordinator also identifies and coordinates admission of patients to other sites (eg, private hospitals), and can arrange direct admission to the ward, bypassing ED. Bed management within the hospital was changed from a divisional system to a centralised bed management mechanism, allowing for effective crisis management. The hospital now has well-defined criteria for initiating ambulance bypass (involving factors such as excess patient load, environmental, staff or resource issues, excessive number of high-acuity patients, or declared disaster situation). Other options to reduce ED overcrowding include sending trolley patients awaiting admission to wait in the ward corridor. ED medical staffing was increased to address the large patient volume. The ambulance communications room now has a computerised ED patient tracking system (EDIS) installed. EDIS is present in all EDs in Perth. This allows the ambulance service to distribute its workload between sites. Other recommendations of the Emergency Services Task Force that have been implemented are to: increase bed capacity by permanently opening some closed beds if nursing staff can be found (about 40 beds); increase aged care and rehabilitation beds at a regional secondary hospital to allow transfer of inpatients from RPH; increase the availability of care awaiting placement beds; and increase the bed and investigatory capacity of another secondary hospital in the region to allow for greater retention of patients, thus easing the burden on RPH. ED staffing was significantly increased. The above measures have had significant clinical input and are designed to increase the capacity of the system, but the most important outcome has been the recognition at all levels of government that the problem exists and needs to be addressed. The situation is under constant review. Episodes of ambulance bypass at Royal Perth Hospital, July 1999 to June 2002

Daniel M Fatovich MB BS, FACEM

Royal Melbourne Hospital (RMH), a 360–390-bed acute tertiary referral hospital in inner Melbourne, began to experience an acute increase in access block from early 2000. Over the previous few years, there had been a gradual reduction in acute bed numbers and a marked reduction in subacute and nursing home beds in the area serviced by the hospital. At the same time, patient throughput, as measured in weighted inlier equivalent separations (WEIS), had not decreased. The access block was manifest by ambulance bypass of up to 150 hours per month in 2001, worsening access of emergency patients to inpatient beds, and increasing and chaotic theatre cancellations for elective patients. InterventionsDuring 2001, in response to a Victorian government initiative, RMH formed a clinician-led taskforce that developed 51 interventions. These aimed to maximise efficient use of inpatient beds and improve access for elective and emergency patients, and were generally adapted from programs tried at other institutions. The interventions were developed over three months from April to June 2001, and were implemented over the following three months. The more important initiatives were: centralising bed management, introducing a 48-hour short-stay ward, employing care coordinators in the emergency department to improve discharge and avoid inpatient admission,1 monitoring inpatient length of stay, with alerts for patients staying longer than 14 days, and improving access and referral to subacute care. OutcomeFollowing the implementation of the taskforce recommendations, there was a significant improvement in access block indicators, even though hospital bed numbers actually decreased in acute and subacute sectors. The hospital's WEIS remained the same and emergency WEIS increased during the six months from implementation. Ambulance bypass was reduced to fewer than 10 episodes per month, emergency patients waiting more than 12 hours for inpatient beds were reduced by 40%, and same- or prior-day theatre cancellations were reduced to fewer than 10 per month. The elective waiting list remained static during the first six months of implementation. Although the hospital was funded to increase bed numbers, this was not possible because of nursing shortages and rigid workforce rules. Significant components of the success of the interventions appeared to be that clinicians were empowered to drive the changes and the focus was on maximising bed use rather than saving money. Individual interventions that had substantial effects on access block were the 48-hour short-stay ward, care coordination in the emergency department, centralised bed management, day-of-surgery admissions, and monitoring of patients staying as inpatients for more than 14 days. Using a similar strategy, hospitals similar to RMH could function with fewer beds or treat more patients with the same number of beds. It is not possible to determine from our experience whether this would result in cost savings.

Peter A Cameron · Donald A Campbell

The Alfred Hospital, in Melbourne, is a 350–390-bed tertiary referral hospital with acute medical, surgical and psychiatric services. It is one of three hospitals in Bayside Health, a major metropolitan health service, and is one of the two major adult trauma centres in Victoria. The hospital also provides a number of statewide services, including those for heart–lung transplantation, cystic fibrosis and major burns. In 2000 and early 2001, there was a considerable increase in the occasions that the Alfred's emergency department (ED) had to implement ambulance bypass, and there were difficulties in timely access for high priority elective admissions. Several initiatives had already improved access in the hospital, such as hospital-in-the-home, pre-admission and day-of-surgery admission strategies. In addition, an integrated approach to bed management was in place. This involved daily review of priorities for emergency and elective admission, through a centrally coordinated bed assignment process, overseen by senior medical and nursing managers. InterventionsIn financial year 2001–02, the Victorian Department of Human Services funded a number of initiatives under the Hospital Demand Management Strategy, which aimed to improve access for emergency and elective patients. The funded initiatives in the Alfred ED include increased senior medical staff cover after hours and the development of fast-track, an area of the ED where a doctor and a nurse work in partnership to fast-track the patients' care. Other hospital initiatives included a targeted length-of-stay strategy, involving strategies such as additional care coordination for patients admitted to specific clinical units, and the introduction of a weekly ward round by senior medical and nursing staff to facilitate early discharge planning. A third project focused on strategies to avoid patients' presenting to the ED, such as multidisciplinary mobile teams working in concert with nursing homes and general practitioners. Among the more successful strategies were the Medical Ambulatory Day Unit and the Medihotel. These were designed to meet the needs of patients who required inpatient interventions, but who did not need overnight stay in an inpatient bed. These might be rural patients, patients receiving treatment over a series of days, or patients for clinical review or investigation. Previously, there was no alternative but to admit these patients to multiday inpatient beds. The Medical Ambulatory Day Unit (MADU) and Medihotel are next to each other within the main part of the hospital's ward area. The MADU was designed to provide a range of medical interventions and consultation facilities, and patients may attend on consecutive days for their treatment or investigation. The Medihotel provides accommodation to patients of the Alfred who are ambulatory and independent who do not require clinical intervention overnight, but who need to be close to professional expertise if required. OutcomeA review of the outcomes in late 2001 and early 2002 showed a significant reduction in ambulance bypass, from 291 episodes in 2000–01 to 158 episodes in 2001–02. However, similar improvement was not achieved in the number of ED patients waiting for more than 12 hours for an inpatient bed. Hospital-in-the-home substitution rates, which estimate the resulting inpatient capacity, were around 11%, which compared well with similar hospitals. Up to June 2002, there had been more than 3500 occasions of service for patients of the MADU, and more than 1900 patient-nights in the Medihotel. Nearly all clinical units at the Alfred have used the MADU/Medihotel at least once. The ability to plan for elective medical admissions without the risk of cancellation has been well received by staff. The centralised bed allocation and coordination process is extremely effective in maximising access to multiday beds, although this requires a considerable senior medical, nursing and management commitment. Some of the improvements to bed management flows did not require extra resources, as they related to changes in process. An example was the decision to allocate the first five multiday beds that became available each morning to patients awaiting admission in the ED — this had a considerable impact on the ED, without a flow-on disadvantage elsewhere. Other initiatives with high impact on access were increasing the number of senior staff in the ED, care coordination and ED disposition nurses, and weekly ward rounds by clinical bed management staff to identify opportunities for redesign of the processes of discharge and bed management.

Kim N Hill MB BS, MHP, FRACMA

Objective: To describe the changes in bulk-billing and out-of-pocket costs for Australian general practice consultations over the period 1995–2001.Design: Retrospective analysis of 1996–2001 survey data from the Australian Longitudinal Study on Women's Health (ALSWH), linked with Medicare and Department of Veterans' Affairs (DVA) data on general practice consultations from 1995 to 2001.Participants: 22 633 women who gave consent to linkage of their ALSWH data with Medicare/DVA records. In 1996, women in the "young" cohort (n = 6219) were aged 18–23 years, those in the "mid-age" cohort (n = 8883) were aged 45–50 years, and those in the "older" cohort (n = 7531) were aged 70–75 years.Outcome measures: Out-of-pocket costs paid by patients for general practice consultations, by calendar year, urban/rural area of residence, age, frequency of attendance, self-rated health, and education level.Results: For each age group and year studied, the use of bulk-billing was lower in rural areas than in urban areas. For example, in 2000, the percentage of women in rural and urban areas, respectively, who had all their general practice consultations bulk-billed was 31% v 52% (young women), 24% v 45% (mid-age women) and 58% v 79% (older women). There has been a steady decline in bulk-billing for general practice consultations in rural areas since 1995. The average out-of-pocket cost per consultation for women in rural areas was higher than the cost for women living in urban areas. After adjusting for age, health and socioeconomic factors, women living in urban areas were more than twice as likely to have all their consultations bulk-billed as women living in rural areas: odds ratio (OR), 2.4 (95% CI, 2.1–2.7) (young women); OR, 2.5 (95% CI, 2.3–2.8) (mid-age women); OR, 2.6 (95% CI, 2.3–2.9) (older women).Conclusions: In Australia, the geographic differential in the cost of general practice consultations is widening. Policy changes are required to enable women in rural and remote areas to have access to affordable healthcare services.

Anne F Young BMath(Hons), DipMedStat, PhD · Annette J Dobson BSc, MSc, PhD

Australia must consider carefully the implications of developing a specialty of hospital medicine A hospitalist is a clinician who safely manages a patient's acute hospital course and who specialises in hospital medicine, free of any compelling priorities of ambulatory care.1,2 Hospitalists work only with inpatients, taking over care from primary care physicians after admission to hospital. They are site-defined specialists with skills in general internal medicine,3 who care for patients with a wide range of organ derangements, illnesses (and ages) within the specific location of an acute hospital. The hospitalist movement is most active in the United States, with adherents soon to be comparable in numbers to cardiologists.4 Many leading US hospitals now have active hospitalist programs,5 and, in this setting, the hospitalist is usually a specialist physician. About half are general physicians rather than single-system specialists; the others are often specialists in intensive care.6 The US movement is establishing its own credentials as well as its own areas of research and teaching.5 The major "driver" for this trend in the US was initially related to funding. Hospitalists represent a rationalisation of the medical workforce within an acute hospital, appealing to a cost-oriented, managed-care model. The evidence for the impact of hospitalists is so far unconvincing, although there is some evidence that patient length of stay is decreased when hospitalists manage care.5 The evidence for improved quality of care and patient satisfaction is equivocal.5 What possible advantages would the hospitalist bring for Australian medicine in the new century? Those in favour of the concept suggest that a physician with specific training in acute hospital medicine would be more appropriate than the existing system in Australia, whereby the patient's admitting physician is usually trained as a single-system specialist. This is because a hospitalist has skills and training in general medicine, particularly acute medicine on a background of chronic complex conditions. Not only do they consequently have a more holistic approach to patients with complex, chronic problems, but they are also specifically trained in caring for the seriously ill and resuscitation. This set of skills may be especially relevant in Australian hospitals, where there is evidence of an alarming incidence of potentially preventable deaths and serious complications.7,8 Hospitalists may bring extra skills and expertise in acute medicine and resuscitation as a way of addressing this problem. In the US model, hospitalists also have skills in the organisational aspects of the hospital stay, including communication with all other inpatient services required by the patient, as well as in discharge planning and end-of-life care. Hospitalists in the US are also involved in the acute medical aspects of surgical and obstetric inpatient management. How does the US hospitalist concept "fit in" with current Australian hospital medicine? From an Australian perspective, considering the concept of a hospitalist may assist us in focusing on the changing patient population in our hospitals and re-examining what the role of an acute hospital is exactly. The US concept of the hospitalist suggests that hospital medicine can now essentially be viewed as a general specialty, with system specialists consulted as required. This would seem to require a radical departure from the current Australian model. However, in Australia, it is already common for single-system specialists to hand over care to more general acute-care physicians in the emergency department and intensive care unit. The complexities of acute medicine now demand its own specialists with general training and experience, such as those who practise emergency and intensive care medicine. This is because understanding not only how each organ is affected in acute insults, but also how the affected organs interact with each other, is crucial to the practice of acute medicine. A similar generalist approach is now being demanded in specialties such as geriatrics and rehabilitation. Further, with the increasing comorbid complexity of patients in acute hospitals, management by multiple referral is often required, especially in large teaching hospitals, with a potential danger of there being no generalist to pull it all together. Australian rural hospitals and smaller metropolitan hospitals resisted the move that occurred in the latter part of the last century to increased physician specialisation, often more by default than choice. The US hospitalist model represents a trend back to this "general physicians" concept and using single-system specialists as they once used to be — referring a patient only when the generalist requires an opinion. Perhaps geriatricians in Australia would consider that this concept is already incorporated into their own model of care. Single-system specialists in America seemed willing to forgo control of hospital care because it was interfering more and more with their professional life.4 Increasingly, specialist physicians are practising ambulatory medicine in outpatient settings or performing specialised procedural skills, often in non-hospital settings. With this change in practice arose the very practical issue of the amount of time left to manage increasingly ill and complex patients in an acute hospital setting. Similarly, surgeons spend much of their day either in an operating theatre or an outpatient setting. However, in the US, just as important in allowing professionally non-threatening expansion of the hospitalist model were the relatively low fees that non-procedural hospital inpatient care attracted. Do we need to develop site-specific acute hospital specialists in Australia? Is there a call for a hospitalist in Australia, similar to the US model: one whose training and skill covers acute medicine and resuscitation medicine, chronic and multisystem problems, as well as aged care and end-of-life care — a coordinator of admission and discharge planning, a clinical governance coordinator and a communicator between all the service providers involved in patient care? The current system of clinician responsibility in Australian hospitals has evolved over many years. This evolutionary process has been influenced by many factors, including accountability of the individual clinician, the patient–doctor relationship and continuity of care. Changing this system by replacing existing hospital specialists with hospitalists would radically change the way we deliver healthcare and, at this stage, the advantage of the hospitalist, even in the US setting, is speculative. Potential benefits to patients and the cost of this change would need to be carefully evaluated in the Australian setting — in the same way we would evaluate the relative cost–benefit of a new drug or procedure. Just as importantly, a well-informed debate is needed about important issues raised by the hospitalist concept. These include the future role of acute hospitals, the population of patients who may be managed in such hospitals and their expected needs, and how to set the balance between ambulatory and hospital-based care. In addition, if single-system specialists continue to play a central role in this environment, we need to think about how they will maintain their skills across a broad range of ambulatory and acute hospital care.

Ken Hillman FRCA, FJFICM

Re: "The effectiveness of coordinated care for people with chronic respiratory disease", by Smith BJ, McElroy HJ, Ruffin RE, Frith PA, Heard AR, Battersby MW, Esterman AJ, Del Fante P and McDonald PJ, published in the 4 November issue of the Journal (Med J Aust 2002; 177: 481–485). The correct credentials and title for Peter A Frith are MB BS, FRACP, Director, Respiratory Medicine, Repatriation General Hospital, Daw Park, SA 5041. The web version of the article was corrected on 18 December 2002.

Brian J Smith MB BS, PhD · Heather J McElroy BSc(Hons) · Richard E Ruffin MD, FRACP · Adrian R Heard MPH, BSocAdmin · Peter A Frith MB BS FRACP · Malcolm W Battersby MB BS, PhD · Adrian J Esterman BSc(Hons), MSc · Peter Del Fante MB BS(Hons), MSc(Public Health) · Peter J McDonald MB BS, FRACP

Health is one of our major industries, employing more than half a million people — 7.1% of the national work force.1 In the 1999–00 financial year its funding reached $55.7 billion, equivalent to 8.8% of Australia's GDP. The major costs are incurred by the hospital sector ($19.1 billion), medical services ($9.7 billion) and pharmaceuticals ($6.5 billion).2 Conventional wisdom would have it that such an extensive and expensive enterprise as ours is underpinned by a lively culture of research and development informing health policy. But is it? In October this year, the National Health and Medical Research Council (NHMRC) announced that, commencing in 2003, it would support 406 new research projects to the tune of $150 million.3 This welcome announcement was quickly followed by press releases from universities and research institutes proclaiming their success in attracting funds. However, not one of the 406 projects directly involves health policy research and development (R&D).3 Furthermore, of the 16 new NHMRC program grants — larger and longer-term multidisciplinary grants funded with an additional $118 million — only one (with funding of $6.8 million) specifically addresses health policy.4 In short, from 2003, less than three cents of every dollar the NHMRC is investing in new research has been earmarked for policy R&D in an industry that costs the nation nearly $56 billion. So, is health policy R&D in Australia a virtual desert? Before dismissing such a judgement as being too harsh, it might be helpful to revisit health policies that have had a major impact on our health system in the final quarter of the 20th century. Most will acknowledge that these include Medibank (1975) and its progeny, Medicare (1984);5 casemix funding (1993) that accelerated the drive for efficiency and effectiveness in the hospital sector;6,7 the evidence-based medicine movement (early 1990s)8 that, among other things, augmented the growth of evidence-based guidelines;9 and finally the development of an organisational structure for general practice — the Divisions (early 1990s).10 While not wishing to downplay the contributions of many Australians to these health policies, is it not significant that all but one were imported ideas? Medibank came from Canada,11 casemix funding from the United States,12 and evidence-based medicine from North America and the United Kingdom.8,13 Is it not intriguing that during this period of change, our own health bureaucracy apparently remained devoid of productive policy ideas? Why has Australian health policy been a net importer of ideas? Could it be that its culture has not fostered an environment for "think tanks", such as the Institute of Medicine and the Commonwealth Fund in the US, the King's Fund and the Nuffield Trust in the UK, or the Canadian Health Research Foundation, all of which regard health services research and policy as their primary concern? There can be no doubt that coping with the clinical dividends of biomedical and biotechnology research, along with changes in society's expectations, will require innovative approaches to the health system through R&D. This can best be fostered in an environment free of political patronage, that is permeable and receptive to ideas from academia, the health professions and bureaucracies, and the community itself. It will require capacity building, as recently recognised by the belated development of the Joint Health Services Research Program, a cooperative initiative of the NHMRC, the Commonwealth Department of Health and Ageing and the States.14 But, most importantly, it requires a flagship — an independent institute — for vision and leadership. Australia's health policy community recently published a collection of essays, Daring to dream: the future of Australian health care,15 which paid tribute to the many contributions of John Deeble to healthcare in this country. His legacy is wide-ranging, from Medibank and the Australian Health Institute (the progenitor of the Australian Institute of Health and Welfare) to his work in Indigenous health. The essays clearly show that the R&D desert of Australian health policy is dotted with oases. The dream, surely, is to consolidate this enterprise and other ventures, such as the Health Leaders' Network (www.hln.com.au), into a policy flagship. Is it dreaming too much to envisage a John Deeble Institute of Australian Health Policy? Australia is currently blessed with an array of internationally acclaimed medical research institutes. In light of this, the stark absence of an internationally recognised Australian institute for health policy is a damning national disgrace.

Martin B Van Der Weyden MD, FRACP, FRCPA

On changing careers midstream An identical plea for help marked both the beginning and the end of my career as a general practitioner, and I think that the particulars of these two events reflect the great changes that took place during my decade or so spent as a GP. In 1959, I returned to Australia from England and began working as an assistant in a general practice in the eastern suburbs of Sydney. In the middle of the night, in the middle of winter, I received a phone call from a man who politely identified his mother as a patient of my boss. He asked me to come to the house, and said, "Mother can't breathe, doctor"; he surmised that mother might have a bad cold. I took down the name and address, and got dressed, cursing myself for agreeing, without closer inquiry, to see someone who might have nothing worse than coryza at that hour. The patient's home was not far away, but it was a bitterly cold night, with a howling westerly wind blowing; in those days, cars did not come with a heater as standard equipment! When I reached the house, the son (much older than me) took me to his mother, a very elderly woman who was, at once, seen to be in extremis as a result of acute left ventricular failure. A quick history was taken from the son, the standard remedies of the day given — intravenous theophylline, morphine, and digoxin, as I recall — and an explanation of the condition and its bleak prognosis given to the son. The patient died soon after. The son thanked me for attending promptly and for doing what I could. I felt ashamed for my unspoken resentment at the time of agreeing to make this house call, but I also felt a sense of great relief that I had attended. The old aphorism "to cure sometimes, to relieve often, to comfort always" came to mind. I left the practice at the end of that year to join a group practice — still in the eastern suburbs — where I remained for the next 11 years. During that time, my initial indifference to the psychiatric aspects of illness was gradually replaced by a growing realisation of the importance of emotional factors in medical practice. Eventually, I decided to undertake specialist training in psychiatry, and it was agreed that I would leave the practice at the end of 1970. I was on call for the practice on a weekend late in 1970 —perhaps my last weekend on call. The Sunday evening was warm and still. Towards midnight, there was a phone call, and a woman asked me to make an urgent house call, saying, "Mother can't breathe, doctor!". My mind went back to the incident of years before, and I simply took the address without getting any medical details and got there as soon as I could. I found that, this time, Mother was a middle-aged woman with a head cold, who could not breathe through her nose. Respiration through the mouth was unimpeded and examination of the respiratory and cardiovascular systems was otherwise normal. I wrote a prescription for ephedrine nose drops. Both mother and daughter protested that the chemist shops would not be open until the next morning. I suggested that the medical "urgency" of the situation would justify waiting until then. A pensioner medical service voucher was signed, and I left with gritted teeth and, no doubt, seriously high blood pressure. When the red mist settled, I was able to reflect that this might have been a suitable valediction to general practice, an appropriate omega to the alpha of the earlier incident. The two incidents encapsulated some of the reasons for my ever-increasing dissatisfaction with general practice. I had seen the role of the GP move from that of front-line treating doctor — as my training, experience and inclination had taught me to be — towards that of gatekeeper or signpost-man. I had given some thousands of general anaesthetics as a GP, but could see that the days of the GP-anaesthetist were limited, and, in any case, I had decided that I preferred to be dealing with patients who were conscious and inclined to talk. "Blood tests" and medical imaging were insidiously displacing clinical skills as the primary methods of diagnosis. It took a long time, 20 or 30 years, but ultimately I came to be almost glad that I had experienced that second house call. Changing horses in midstream is something to avoid, so it is said, but these two episodes seemed to me to help justify changing my career when in darker moments I had doubted the wisdom of doing so.

Andrew R Robertson MB BS, FRANZCP

To the Editor: Several studies have documented the high incidence of adverse events arising during hospital admission. The potential for discontinuity of care and poor communication is significant when patients are admitted to and discharged from hospitals, hence the Australian Pharmaceutical Advisory Council (APAC) has established guidelines to ensure continuity in the quality use of medicines.1 A study reported in 2001 by Mant et al found very low compliance with a minimum dataset based on the APAC guidelines.2 These authors subsequently held workshops to identify problems, develop action plans and refine these strategies. However, the follow-up report, published recently in the Journal, reported little change in adherence to the minimum dataset.3 Why are providers failing to follow the APAC guidelines? Certainly, one cannot assume that the formulation and dissemination of guidelines will necessarily lead to their implementation.4 To be effective, users must be aware of guidelines and convinced that they will add value to the way in which they work. Guidelines need to be credible and should make sense in the "real world". Given the attitudinal barriers of some groups to the uptake of guidelines, multiple strategies are required to ensure their effective implementation. Among these is the involvement of key stakeholders in guideline development. Who are the key stakeholders for ensuring continuity of care regarding therapeutics between hospital and the community? While Mant and colleagues report workshops involving general practitioners and hospital staff, their reports do not identify which hospital staff were involved.2,3 Were clerical, pharmacy and junior medical staff included? These staff could make a critical difference in adherence to the minimum dataset. Furthermore, are these staff even aware of the APAC guidelines? The APAC guidelines use the definition of discharge planning established by the Council on the Ageing (Victoria). This describes people, hospitals and community-based services working together — but the guidelines and associated minimum dataset place little importance on the patient. Patients' knowledge of their medications is discounted. Despite being mentioned in principles 4 and 6 of the APAC guidelines, patient knowledge of medication changes and satisfaction with the communication regarding medications is not considered in the minimum dataset.1 Strategies involving consumers should be explored as a mechanism for improving information exchange between hospitals and GPs. Similarly, an enhanced role for pharmacists warrants further consideration.5 Certainly, further critique of the APAC guidelines and exploration of reasons for their poor uptake is important to ensure optimal patient outcomes.

Michael Jefford · Joanne L Clancy · Sharon M Butler

To the Editor: It is refreshing to see quality initiatives like that of Mant et al,1 which examine issues of continuity across different territories. Use of a simple audit tool (minimum dataset) and methodology has worked well to illuminate what misleadingly appears to be a simple problem (ie, the two-way exchange of information between the hospital and general practitioner in relation to medication). Unfortunately, like many problems that appear straightforward and easily fixable, the reality is that this issue is far more complex to address. A lack of clinical governance has been made apparent in both the public hospitals and the Divisions of General Practice that participated. Clinical governance demands that organisations be accountable for standards and performance in relation to clinical care,2 and this is integral to addressing problems both internally and across the continuum of care. Mant et al demonstrated that many hospitals had policies and strategies to accomplish the exchange of medication information,1 indicating that these procedures were thought to be achievable with current resources. Before this study, knowledge among staff of implementation was scant and confused, and there was no system of review to reveal existing problems. When problems were exposed and changes made, staff were not upskilled to incorporate the change into their practice (eg, junior doctors not completing the new discharge referral form). Similarly, the Divisions of General Practice did not resolve issues surrounding the production and distribution of business cards that they had agreed to undertake. This study has determined a means to measure performance and has intervened to analyse problems and yield some improvements. However, if the organisations involved do not commit to develop clinical governance, the path towards continued improvement will be extremely slow (if at all) and the findings of this project made irrelevant.

Catherine L Wilson

To the Editor: Mant et al1 explore an important aspect of the quality use of medicines in their study on the continuity of medicines from hospital to community. Their study on compliance with an agreed minimum dataset for patient medication information exchange between hospitals and general practitioners provides a useful perspective of an approach to systems change. I wish to point out a number of limitations that may have affected their results and make some suggestions to improve the quality use of medicines. GPs were audited on whether they provided medication information to hospitals. Many GPs work part-time. There is the possibility that the medical practice was contacted by a hospital employee, who obtained the information from a doctor other than the patient's usual GP. The audit covered discharge summaries received by the GP by fax. Although faxing discharge summaries is convenient, there are potential problems with this method. There are the possibilities of dialling a wrong number, and faxed discharge summaries (particularly handwritten ones) may be difficult to read, which could also result in medication errors. In addition, a discharge summary may have been posted to the practice instead of faxed, which would under-report the true percentage of GPs who received the information. It is not uncommon for patients to have multiple GPs.2 However, it is my experience that only one GP is documented in the patient's medical file. This issue could have influenced the results of the GP audit and would be a further factor complicating the continuity of medicines from hospital to the community. The authors mention the introduction of GP liaison officers to facilitate the notification of GPs about patient admissions and the rationale for medication changes. They do not report any other measures that they plan to introduce to improve their results. Given that systems problems have multifaceted answers, further expansion on what other steps could be taken would have been a useful addition to their article. I suggest that it would have been appropriate to include a broader range of key stakeholders in the workshops, such as community pharmacists and patients. In addition, a computerised hospital prescribing system could be integrated with an on-line evidence-based clinical guide to prescribing to assist in optimal medication selection. This could also be used to generate a discharge medication list that was automatically sent to the patients' GPs. Such an approach would reduce errors and improve outcomes.3,4

Peter W New

In reply: We were pleased at the number of letters received exploring issues raised by our recent article.1 Jefford and colleagues question whether staff are aware of the Australian Pharmaceutical Advisory Council guidelines.2 We expect to answer this question during the consultancy that the NSW Therapeutic Assessment Group is conducting for the Commonwealth Department of Health and Ageing. In this consultancy, we are evaluating the implementation and effectiveness of these guidelines. After its completion in October this year, we will have an implementation map of activities being undertaken relevant to the guidelines in Australia. Recommendations formalised at a national workshop will be made to the Department of Health and Ageing regarding future implementation, including alternative models and workable solutions. All three letters raise questions about the key stakeholders for continuity of care. We invited a range of clinical and administrative staff, including senior and junior medical staff, nurse clinicians, clinical pharmacists and general practitioners from the relevant Divisions. However, participation of junior medical staff was limited. As Jefford et al comment, consumers and community pharmacists warrant further consideration in strategies for improving information exchange between hospitals and GPs. We also agree that patients' knowledge of their medications is often deficient: with limited resources, we were only able to address this through the GPs who interviewed their patients following discharge. Wilson rightly observes that continued improvement is dependent on organisations' developing clinical governance — accountability is a key driver for change. Change in practice is usually incremental, however, as we found in our study. Sustained change requires ongoing effort and support. New comments on practical problems with faxing discharge summaries. In our study, GPs identified faxing as preferable because of problems experienced with summaries posted or delivered by patients. New also refers to the problem of patients having multiple GPs. It is up to the patient to advise the hospital appropriately, and this is a matter for consumer education. His suggestion of computerised hospital prescribing is an ideal we all hope will come to fruition sooner rather than later. In the meantime, we believe we have demonstrated the quality improvement process and its limitations and the value of GP audit in prompting that process.

Andrea Mant · Karen I Kaye · Linda Kehoe · Wendy C Rotem

Objectives: To evaluate the effectiveness of coordinated care for chronic respiratory disease.Design and setting: Community-based geographical control study, in western (intervention) and northern (comparison) metropolitan Adelaide (SA).Participants: 377 adults (223 intervention; 154 comparison) with chronic obstructive pulmonary disease, asthma or other chronic respiratory condition, July 1997 to December 1999.Intervention: Coordinated care (includes care coordinator, care guidelines, service coordinator and care mentor).Main outcome measures: Hospital admissions (any, unplanned and respiratory), functionality (activities of daily living) and quality of life (SF-36 and Dartmouth COOP).Results: At entry to the study, intervention and comparison subjects were dissimilar. The intervention group was 10 years older (P < 0.001), less likely to smoke (P = 0.014), had higher rates of hospitalisation in the previous 12 months (P < 0.001) and had worse self-reported quality of life (SF-36 physical component summary score [P < 0.001] and four of nine COOP domains [P = 0.002–0.013]). After adjustment for relevant baseline characteristics, coordinated care was not associated with any difference in hospitalisation, but was associated with some improvements in quality of life (SF-36 mental component summary score [P = 0.023] and three of nine COOP domains [P = 0.008–0.031]) compared with the comparison group.Conclusions: Coordinated care given to patients with chronic respiratory disease did not affect hospitalisation, but it was associated with an improvement in some quality-of-life measures.

Brian J Smith MB BS, PhD · Heather J McElroy BSc(Hons) · Richard E Ruffin MD, FRACP · Adrian R Heard MPH, BSocAdmin · Peter A Frith MD, FRACP · Malcolm W Battersby MB BS, PhD · Adrian J Esterman BSc(Hons), MSc · Peter Del Fante MB BS(Hons), MSc(Public Health) · Peter J McDonald MB BS, FRACP