Health services administration

In response to difficulties meeting the demand for hospital services ("access block") at Royal Melbourne Hospital, a major metropolitan tertiary referral hospital, an audit of patient needs revealed a shortage of aged-care beds and a need for post-acute care. A multidisciplinary Care Coordination Team (CCT) was formed at the end of July 2000 to ensure that emergency department patients were provided with services that would facilitate their return to, or maintenance in, the community. The target population included the frail elderly, those living alone, the homeless, frequent emergency department attenders, and those with complex medical or drug and alcohol problems. As part of routine emergency department care, a risk screen was implemented to determine referral to the CCT. In the first 12 months, the CCT saw 2532 patients (5.8% of all emergency department attendances). Nearly half of these patients were discharged home with referrals to community service providers. The rate of hospital admission from the emergency department fell significantly compared with the 12-month period before implementation of the CCT (13 420 patients, 30.9% [95% CI, 30.5–31.3] v 14 217 patients, 32.6% [95% CI, 32.2–33.0]; P < 0.001). Surveys of staff, patients and carers, as well as community service providers, showed a high level of satisfaction with the CCT.

Joanne E Moss MNurs(Melb), BNurs · Liza M Houghton BAppSci(Nurs), GradDipNurseEd · Carolyn L Flower BOccThy, Occupational Therapist, Emergency Department Care Coordination Team · Danielle L Moss BA, BSW · David A Nielsen BAppSci(Nurs), GradDipGeronNurs · David McD Taylor MD, FACEM

To the Editor: I read with interest the MJA supplement The student and junior doctor in distress — "our duty of care".1 It is encouraging to see the time, effort and research currently being devoted to the health and mental wellbeing of our colleagues. One aspect of the medical workforce that was not discussed is that of locum doctors, who, in metropolitan and rural New South Wales, are increasingly called upon to staff public hospitals. Under this system, a doctor registers with a locum agency, hospitals advise the agency (often multiple agencies) of the shifts they need filled, and the agency then sends to all the doctors on their books a list of shifts available. Doctors then choose which shift(s) they would like to work and the agencies supply their names to the hospitals. They are paid by the hospital — the current rate for all doctors, Post Graduate Year (PGY) 1 and upwards, being a minimum of $70–$80 an hour — and the agency receives a 10%–15% commission. In contrast, the base hourly rate for a full-time PGY 1 doctor is $23.11, with a loading of 75% on Sundays and 100% for any hours worked beyond a 10-hour shift. The only barrier to locum work is that a doctor is unable to have two rates of pay within the one Area Health Service. There is thus a strong incentive for full-time employees to refuse extra overtime work at their own hospital and do locum work at other hospitals. The number of shifts needing to be filled by hospitals increases as Junior Medical Officers choose this option. The current restrictions on access to provider numbers, rather than serving as an incentive to remain in the hospital system, have encouraged many junior doctors to seek locum work. It is also relevant that, as more graduate students come through the system, more doctors are older and have financial obligations. Many have had good incomes prior to studying medicine and wish to maximise their earnings once they graduate. Wilhelm2 and Mouret3 both observe that financial concerns are a major stressor for Junior Medical Officers. There are significant disadvantages for the locum doctor (eg, lack of ongoing education from patient follow-up, feedback about mistakes, mentor and peer support; inadequate supervision of "safe working hours") and for the healthcare system (eg, lack of continuity of care; locums' unfamiliarity with the hospital and its procedures; variable skill levels of locums; resentment by regular staff of pay rate discrepancies; cost). While there is no doubt a role for locum doctors within the healthcare system, there is no overall control of the situation. Locum agencies are businesses that exist to make money for their owners. The hospitals see themselves as paying top dollar for locum doctors and therefore see no obligation to provide training and counselling. The doctors are in the middle. To protect the doctors and also the hospitals, changes must be considered. Representatives of the NSW Medical Board, Postgraduate Medical Council and Area Health Services need to discuss this issue.

Elizabeth Swinburn

In contrast to curative therapies, preventive therapies are administered to largely healthy individuals over long periods. The risk–benefit and cost–benefit ratios are more likely to be unfavourable, making treatment decisions difficult. Drug trials provide insufficient information for treatment decisions, as they are conducted on highly selected populations over short durations, estimate only relative benefits of treatment and offer little information on risks and costs. Epidemiological modelling is a method of combining evidence from observational epidemiology and clinical trials to assist in clinical and health policy decision-making. It can estimate absolute benefits, risks and costs of long-term preventive strategies, and thus allow their precise targeting to individuals for whom they are safest and most cost-effective. Epidemiological modelling also allows explicit information about risks and benefits of therapy to be presented to patients, facilitating informed decision-making.

Danny Liew BMedSc, MB BS · John J McNeil FRACP, PhD · Anna Peeters BSc, PhD · Stephen S Lim BA, BSc · Theo Vos MD, MSc

The United States will invest nearly US$70 billion (US$260 per capita) on medical research this year, more than half of which will be sponsored by the biopharmaceutical industry. This investment has been shown to provide major gains in basic, disease-oriented and patient-oriented research. It also provides a huge economic return on investment — whether measured in terms of jobs created, health costs saved, or the dollar value of lives saved. Australia, whose investment in medical research is less than 10% that of the United States, should increase its national commitment.

Leon E Rosenberg MD

To the Editor: The editorial by Steven and Shanahan on work-related stress1 indicated that claiming Medicare benefits for a workers compensation injury is specifically precluded. It also identified a need for guaranteed certainty of cost reimbursement for treatment. Medicare benefits are payable for professional services that are wholly covered by workers compensation, unless there is a reimbursment arrangement with the insurer.2 The patient may be bulk billed or given a private account. The recovery of any benefits paid once a settlement or judgement is made does not involve the practitioner. It is not claiming the benefit which is precluded, but keeping it if an outcome favourable to the plaintiff ensues. My understanding is that unsuccessful claims are rebatable under Medicare for clinically relevant medical services. The medicolegal expenses incurred, for example for reports, do not qualify, as they are not medically necessary. The fees are a private matter, as are any treatment charges in excess of the Medicare rebate. Herein lies the uncertainty.

Raymond L Carroll

In reply: What Carroll says is correct, but Section 3.6 of the general explanatory notes of the Medicare benefits schedule book also states that "The only exception to this is where a person has entered into a reimbursement arrangement with a compensation insurer. In such cases a Medicare benefit is not payable".1 While it may be arguable as to what actually constitutes a reimbursement arrangement, the situation is further clarified by Section 13.2.1 of the same schedule, which states: "Medicare benefits are not payable in respect of a professional service in the following circumstance: (b) where the medical expenses for the services are in relation to a compensable injury or illness for which the patient's insurer or compensation payer has accepted liability. However, if medical expenses relate to a compensable injury or illness and the insurer or compensation payer is disputing liability, Medicare benefits are payable until liability is accepted".

Ian D Steven · Michael Shanahan

Every five years over the past 15 years, the Commonwealth, States and Territories have negotiated healthcare agreements, and new agreements are about to be signed for the next five-year period (2003–2008). The Australian Health Care Agreements (AHCAs), which are negotiated bilaterally with each State, provide Commonwealth monies to the States in exchange for ensuring the States continue to provide free hospital care. Previous agreementsIf the negotiations of previous agreements are any guide, the States will stick together in arguing the overall size of the Commonwealth's contribution to the States, until the Commonwealth courts one State (usually a smaller one or one going into election mode) and offers a very good deal to break from the pack. That State accepts, and the "domino principle" then cuts in. If the content of previous agreements is any guide, the next agreement will be devoid of national health policy, contain perverse performance measures, be largely incomprehensible to all but its authors, and preserve the existing capacity and incentives to shift costs from State to Commonwealth funding sources and vice versa. Will this one be any different?Based on the April 2002 Joint Statement by the Commonwealth and State Health Ministers, it will be substantially different. In this statement the Ministers: 1 acknowledged that previous negotiations had focused more on health funding than on health outcomes; acknowledged the long history of "buck-passing" between States and the Commonwealth; agreed to a cooperative approach to the 2003–2008 agreement, focused on best care and health gain; and identified priority areas for commissioned work to inform the 2003–2008 agreement. The Joint Statement indicated that the 2003–2008 agreement would encapsulate national objectives for providing improved healthcare to all Australians.1 If these aims are only partially realised, they will substantially change the relationship between healthcare and healthcare financing in Australia. What are the problems with current AHCA arrangements?The focus of the existing agreements is narrowly limited to one aspect of healthcare. AHCAs provide money to the States on the basis that the States preserve the core feature of Medicare — the maintenance of universally accessible public hospital care free of charge. The call for the agreements to be used to articulate a national health policy for Australia highlights the fact that there is currently no such policy which is used actively by governments to guide the Australian health system. In the negotiations for the 1993 agreement, an ultimately unsuccessful attempt was made to use the agreements to commit States and the Commonwealth to developing and implementing a national health policy. To use the AHCAs to articulate national health policy objectives would constitute a major change. It is appropriate that such health policy objectives are incorporated in AHCAs, as the monies provided through the agreements are not specifically earmarked for hospital care. As there is no alternative broad health agreement between the Commonwealth and States, the AHCAs are currently, somewhat undeservedly, viewed as the major vehicle for Federal–State health debate. If, as Health Ministers have agreed, the "2003–2008 Agreement . . . [is to] encapsulate national objectives for the provision of improved care for all Australians",1 the AHCAs will need to extend beyond public hospital issues to incorporate primary care. There will need to be discussion in the agreements on primary care, chronic care, mental health, Indigenous health, aged care, rural health, public health, and, presumably, agreed quantifiable measures to assess achievement of these national objectives, while maintaining flexibility of resource allocation. The existing agreements have only one performance indicator for which funding is contingent — a commitment by States to provide public hospital inpatient services at an agreed level. For example, the current New South Wales agreement states: "New South Wales commits to provide services to public patients at an indicative public patient weighted separation rate [ie, public inpatient discharges from hospitals] of 261.21/1000 applicable weighted population."2 The Commonwealth can review its financial commitment to New South Wales if the level of inpatient separations falls below this figure. Other performance measures are reported under the agreement, although these do not affect funding provided to the States. At present, States are unlikely to significantly reduce hospital care unless other primary or community care programs can be substituted, presumably with Commonwealth approval, for hospital care. The commendable exploration by some States for ways to reduce hospital readmissions of people with chronic and complex conditions through improving community-based care depends on Commonwealth support, directly or indirectly, for care beyond the hospital. It would be good for this to be recognised in the new AHCAs. The agreements do not include the total value of Commonwealth contributions to the States for healthcare provision, much less the total value of health expenditure that is incurred by States, regardless of the source of funding. Other health monies which are expended in the State health sector are provided to States through their share of the goods and services tax (GST) revenue, and there remain a number of specific health programs and payments which are funded outside the AHCAs. These include payments for highly specialised drugs, Commonwealth subsidies to privately insured patients in public hospitals, payments for eligible veterans and their dependants, and payments for residents in State-owned residential-care facilities. Solving the cost-shifting problemCan the renegotiated agreement limit "the buck-passing between the States and the Commonwealth"?1 Clearer lines of financial management of care and appropriate incentives are needed if this problem is to be solved. Assuming the 2003–2008 agreement maintains the existing arrangements of the Commonwealth and States in co-financing the provision of healthcare, it is difficult to see how cost-shifting will be fully removed. Aged care provides a good example. The Commonwealth Government has responsibility for residential aged care. In the absence of what is generally taken to be an adequate residential capacity for infirm elderly people, some are inappropriately accommodated in public hospitals. In many cases, the care they receive in hospitals is inappropriate — better care could be more efficiently provided in purpose-built residential-care settings. Solving this problem will require a combined approach from the Commonwealth and the States, and a willingness by both to shake off an unhappy history. Several initiatives have led to a reduction of cost-shifting. The different funding streams for pharmaceuticals — whereby the States subsidise pharmaceuticals provided in hospitals, but generally under capped budget allocations, while the Commonwealth subsidises those provided through community pharmacies on an open-ended basis — has sometimes resulted in hospitals not providing adequate pharmaceuticals for patients at hospital discharge. So, the cost is shifted to the Commonwealth and also to the patients. Arrangements are now in place in some States for the Commonwealth to accept funding responsibility for pharmaceutical products dispensed in both hospitals and the community. How has the Ministers' April 2002 statement been carried forward?The strategy adopted by Ministers of tackling important health policy issues by involving the clinical workforce was initiated at the meeting of the Australian Health Ministers Council in April 2002 by the New South Wales Health Minister, Craig Knowles, and is based on a similar process introduced in New South Wales. Nine national reference groups have been formed to address the following policy issues: the continuum between preventive, primary, chronic and acute models of care; the interface between aged and acute care; collaboration on workforce, training and education; hospital funding and private health insurance; improving Indigenous health; improving mental health; improving rural health; quality and safety; and information technology, research and "e-health". Each reference group has about 12 members and is co-chaired by a clinician and senior bureaucrat. Each of the nine groups has clinicians as members, an endeavour designed to forge greater interaction between bureaucrats and clinicians. The terms of reference for the groups are ambitious given the short timeframe for reporting. The documentation guiding the reference groups3 states: "The reference groups will develop and implement a workplan, the outcomes of which will enable the next agreements to identify: national objectives for the provision of best care and health outcomes regardless of jurisdictional boundaries; opportunities to improve health service delivery; and linkages to other relevant health strategies. The reference groups will provide guidance to health ministers: on opportunities to improve the performance of service provision in relation to each group's designated segment of the health system; on how best to minimise the barriers which impede improved performance." The documentation then sets the scene for dampening overly high expectations from the process by stating: "The reference groups will consider: the primary focus of the AHCAs being an agreement between the Commonwealth and the States/Territories on funding for the provision of free public hospital services, and secondarily of services at the interface of hospitals and the greater community; the capacity of the AHCAs to generate significant health system reform in and of themselves; mechanisms outside the AHCAs through which to take forward the identified policy objectives; existing work by other bodies in the above areas, including subcommittees of the AHMC and AHMAC; and the requirement on all governments to be fiscally responsible".3 The Australian Health Ministers meeting in Darwin in July 2002 received progress reports from each of the nine national reference groups. There was then discussion by Ministers only, behind closed doors, as to whether they would allow the final reports to be collated and summarised by Commonwealth Health Department officials, or whether the Ministers themselves would meet again in September to personally receive the final reports from each group. They opted for the latter. Informal feedback to me from group members about the usefulness of the process to date is variable. Some report lively debate, while other groups are reportedly traipsing unproductively over old worn pathways. There is consensus that the time constraints for completing the documents will seriously limit the quality of the product. Most participants in the reference groups I spoke to supported the process, but many saw little prospect of the groups making any meaningful contribution to the 2003 AHCAs. One co-chairperson indicated that it would be more realistic to see the process as input to the 2008–2013 agreement! National health policy discussions involving key groups and individuals are both useful and overdue. That these discussions involve both clinicians and bureaucrats is valuable as well. These and other clinicians, and presumably the Australian Medical Association, will expect that this process is not merely window dressing. Whether the outcome of this process can achieve Health Ministers' objectives "that the 2003–2008 agreement would encapsulate national [health] objectives"1 is yet too early to judge. There is considerable danger, particularly to the Commonwealth, if, by the time the financial aspects of the new agreements are being negotiated (probably later this calendar year or early in 2003), there is little linkage between the "products" of the nine reference groups and the content of the agreements. The role of the Commonwealth and State Treasuries between now and 1 July 2003 will be critical. State Treasuries may be reluctant to accept increases in the numbers of performance measures with the agreements. The Commonwealth may cite such factors as the positive impact of the GST on State coffers and the increase in the proportion of the population holding private health insurance as reasons for not substantially increasing Commonwealth contributions to the States. Health Ministers have started down a pathway of significant involvement of Australia's clinical workforce in policy discussions, with a clear public focus on fundamentally reshaping the next AHCAs. The purpose is admirable. From it may come a new expression of national health policy on which funding decisions can be based. This would be good for everyone's health.

Michael A Reid BEcon

In their Joint Statement of 5 April this year, the Federal and State Health Ministers acknowledged a widely recognised but rarely voiced truth — that past negotiations under the Australian Health Care Agreements (AHCAs) had focused more on health funding than health outcomes. The Ministers' candor took many completely by surprise. They laid a framework for work toward the 2003–2008 agreements, which emphasised a focus on provision of best care and health outcomes rather than jurisdictional boundaries, with jurisdictions working cooperatively to advance community health and well-being. To this end, they decided the agreements should contain a statement of principles, objectives and proposed outcomes. They also decided that work should be initially organised around a continuum across preventive, primary, chronic and acute care; improvement of the interface between aged and acute care; cross-jurisdictional collaboration on workforce, training and education; the interaction between hospital funding and private health insurance; improvements in Indigenous, mental, and rural health; quality and safety; information technology; research; and "e-health". This work is to precede and inform negotiations about funding within the AHCA. In that same week in April the Commonwealth Chief Medical Officer, Richard Smallwood, told a health conference in London that Australia's public hospitals are in "varying degrees of dilapidation", and that morale among doctors and nurses was fragile. He was quoted as saying: "The results of our care and patient experiences of the health care system are too often less than ideal, . . . Our public healthcare systems never seem to have enough resources . . . Access to care, while universal, is too often delayed. The medical workforce is undermanned, maldistributed, or both, and the shortage of nurses verges on the calamitous. In both professions, morale is fragile."1 Primary diagnosisThe indications noted by our Chief Medical Officer are uncontroversial, and could easily be extended. Do they reflect separate causes, capable of treatment seriatim, or are they symptoms of a deeper malaise? The work proposed in the Ministers' Statement has been allocated to nine separate working groups, implying at least some separability. An underlying ailment seems more likely — this is not the first time Health Ministers have committed themselves to "outcomes", yet the problems besetting the system have not diminished, or even changed much. There has to be more to this than meets the eye. Across countries in the Organisation for Economic Cooperation and Development (OECD) — that is, the rich world: many doctors are disgruntled, overworked and professionally unsatisfied; nurses are restless and in short supply; richer countries poach healthcare workers from wherever they can get them; popular demands for more health spending are universal; payers are widely unpopular, whether national governments or United States Health Maintenance Organisations (HMOs); many patients feel vulnerable and uncared for; and the politics of healthcare is ugly — governments retreat into obfuscation and the difficult issues are systematically avoided. The explanation can only lie in common and fundamental characteristics of system architecture. Structural questions are not explicitly on the Health Ministers' agenda. They need to be. Opinions as to cause will differ, but here are mine. RoboDoc and Nurse MechatronA burgeoning international literature on "unhappy" doctors and nurses offers all manner of causal explanations, and proposals for remediation. This literature usually presupposes that the causes lie in the specifics of healthcare.2-4 However, this seems unlikely. Commoditisation, which results from payment of a standard unit price for an implicitly standardised product or service, is a more probable cause. Commoditisation of the product of any industry leads to commoditisation of its labor force, and that always causes "unhappiness", and worse. When, as in healthcare, that labor force is bright, individualistic, highly educated, conscientious and oriented toward professional autonomy, reducing the fruits of their efforts to item numbers and "one price fits all" is clearly counter-indicated. Australian general practice represents commoditisation par excellence. The squirrel-wheel reimbursement system and narrow tasking imposed on GPs foster personal and professional isolation and disillusionment. GP work content has narrowed steadily over the years. Opinions differ as to whether the number of GPs is too many, as the Australian Medical Workforce Advisory Committee thought,5 or too few, as Access Economics thinks.6 Regardless of the findings of such studies, the elaborate system used to control doctor numbers in Australia means there are unquestionably too few GPs at prevailing "prices". The absence of unemployment among GPs, and the difficulties across the nation in filling the less desirable posts, puts the matter beyond doubt. Numbers are an important issue in other ways, but, regardless of numbers, general practice under Medicare is purpose-built to create discontent. A narrow majority of doctors and the substantial majority of nurses work in hospitals rather than in general practice and other forms of primary care.7,8 Public hospitals are kept alive on a lean diet of funding by governments, and are under intense pressure to maximise patient throughput. Governments are obsessively interested in hospital-throughput statistics, and in minimising indicators of excess demand, such as waiting lists and the frequency of ambulance bypass. These make headlines — quality of care and patient satisfaction does not. Facing an institutionalised payer, hospital managers respond by institutionalising working arrangements, and directing their efforts to the performance targets by which they are measured. Input controls and statistical output targets provide little defense against horrors such as those that emerged at the King Edward Memorial Hospital in Perth.9 However, these were no more than a minor departure from mainstream public hospital practice in professional deployment and quality management practice across Australia. Institutionalised and depersonalised working arrangements are the absolute enemies of professional satisfaction, high morale, and respectful, high quality care. It is not surprising that many doctors and nurses are unhappy. The surprising thing is that Australian healthcare, operating under such compromised arrangements, manages to be as good as it is. Good people can beat bad systems, at least for a time, but at enormous cost to themselves. Many are burned in the process. Institutionalised production systems destroy leadership talent and break the hearts of professionals of skill and integrity. Vital, customer-responsive organisations breed professional talent, active, committed leadership and display the high professional morale that, for most good people, is its own reward. Third-party payersA remote third-party payer is in itself a guarantee of alienation and quality problems. Australia did away with agricultural marketing boards in the 1980s, with good reason, and to impressive effect. The Western world largely abandoned nationalised industries in the 1980s and 1990s. The Union of Soviet Socialist Republics (USSR) never managed to produce decent consumer goods. Healthcare is the ultimate individualised product — no centrally planned and controlled production system ever succeeded at mass-customisation. Third-party payer systems are bad for the payer as well as the consumer. Western governments, other than that of the United States, meet 72% to 97% of all health expenditures, and this accounts for 12% to 18% of all public outlays.10 A blowout in health spending means a blowout in the Budget. Regardless of the feelings of Health Ministers, the overall interest of governments in healthcare centres on expenditure control, not health outcomes. The Health Minister's duty to the government is to protect the Budget and hose down the political consequences of doing so, not to open up difficult questions. Whenever the compact between the customer and the producer is nullified, there are dire consequences. Large, bureaucratised, third-party payers are a universal feature of modern healthcare the world over, and the consequential symptoms of malaise are also ubiquitous. None of this goes against the aims of universality and equality of access to healthcare, which all civilised nations embrace. However, the payer must stand behind the patient, and not between the patient and the provider. The starting point on the way back must lie in the realm of system design, not clinical reform — the professions will see to the clinical side if structures are right. System-based problems demand system-oriented remediesRemedies for the immediate roadblocks on the path to outcome-oriented healthcare lie not in the clinical realm, but in general properties of constrained optimisation. Instead of producing services in response to demand, the system is controlled by layer upon layer of regulatory constraints, operating both on aggregate-level inputs (dollars and doctor numbers) and product-level outputs (item numbers, descriptions and reimbursements) as follows: Budget caps constrain public hospital spending and most of the smaller healthcare and aged-care programs. Non-transparent restrictions on the supply of doctors, through limits on medical school intakes and doctor immigration, are used to control Medicare outlays. Pharmaceutical Benefits Scheme outlays are constrained by more complicated, though more rational and direct, measures. Capital investment is even more tightly rationed than "recurrent" inputs to force every possible dollar into statistically measured outputs rather than into investments in system improvement. New structures are not properly maintained — hence Smallwood's hospitals in "varying states of dilapidation". Governments may find the dollars for showy new equipment, often "opened" with elaborate political ritual, but the recurrent funding required for its operation and maintenance is another story. Investment in information and communications technology (ICT), being largely invisible, is even more restricted, with serious consequences for efficiency, quality and safety of care. The average age of the capital stock in Australian healthcare is 16 years, compared with 10–12 years in most of the private sector.11 According to Gartner Corporation, a major international ICT consultancy, spending on ICT is equivalent to about 3% of turnover in the centrally planned and controlled European and Australian healthcare systems.12 In the market-exposed United States health sector, ICT spending is equivalent to between 5% and 6% of turnover.12 The first objective en route to an outcome-enabled health system must be to relieve the constraints that bind inputs and distort the health services' "production" system. Ubiquitous input controls also distort the pattern of outputs, as, in the presence of input rationing, outputs reflect the supply of constrained inputs rather than the demand for health services. This is why the interminable academic debate about supplier-induced demand is just that — academic. If reform is to be possible, the system must be given some additional degrees of freedom. Eventually output must come to reflect demand rather than supply to make an outcome-oriented health system possible. Other measures will, of course, be needed, such as universal personal health records and other supports for quality and safety enhancement, before reform is complete, but the initial steps must centre on capacity building. The recent Wanless Review of the United Kingdom health system came to somewhat similar conclusions regarding input constraints.13 Wanless (Group Chief Executive of NatWest for seven years until he retired in 1999) carried out the Health Trends Review at the request of the Chancellor of the Exchequer in 2001–2002 as a key contribution to the Blair government's planning for a major increase in spending on the United Kingdom National Health Service. His report found that improving the use of information and communication technology in the Health Service is a key issue in improving quality and productivity. Wanless also concluded that there is scope for major changes in skill mix and the way professionals work in the healthcare service, although he was diplomatically silent as to how the existing distortions may have come about, and what might be done about ongoing causes. He stopped well short of questioning the structural features of the UK's monolithic National Health System. A modest proposalIf Ministers wish to entrench quality, safety and patient choice as the primary drivers of care, they must take measures to move the locus of control away from the input end of the production chain and toward the output end — that is, toward the consumer. This does not imply dismantling equitable and universal health insurance. It simply means that government must move towards a health financing system that insures the patient. It will take time, and must be done openly and carefully, if the effort is to endure. There is a growing consensus that Australia, like the UK, should be spending more on healthcare. However, if we were simply to increase spending the effect would be immediate inflation of healthcare costs. First we must feed out some slack in doctor numbers, settle the major nursing issues, and relieve the pinch points that stem from a history of capital rationing — a 5–10-year recovery program. While this may sound backward looking, there is no prospect that we can accurately see the system of the future while the system we already have does not match the demands of the present.14 Five to 10 years is also long enough to build a base for a universal longitudinal patient record, and to do so in the only way that can succeed — from the bottom up. The foundation of a national system must be electronic patient record systems in routine and ubiquitous daily use by providers. At present, only general practice makes widespread use of electronic records and orders. Practice grants brought about the revolution in GP computing. Tied grants must be offered to hospitals so that they can overcome their ICT investment backlog. Many of the elements of the wider program of reform require that hospitals begin the transition to enterprise-level electronic clinical support systems and electronic patient records as soon as possible. There will be no outcome-driven healthcare system until the system recognises the whole patient — a person with a past, a present, and a future. Ambitions for major gains in safety and quality of healthcare will come to very little until every patient encounter with any healthcare provider is supported by the patient's personal health record. Whether we stay with the present third-party payment system or move gradually to patient-based funding, as I believe we should, the injection of funds must not run ahead of real capacity or the whole project will end up in disrepute. Governments are right to dread healthcare cost inflation. ConclusionWe should look to Health Ministers neither for radicalism nor for a financial bonanza. Barriers to continuity of care and patient-based outcomes must be carefully dismantled. None of the conceptual, practical or financial requirements for fundamental reform is beyond us. The path will be long; there are 50 years of history invested in the existing Australian system and its counterparts elsewhere. The system has allowed people in all walks of life to achieve standards of health and longevity unimaginable 50 years ago. The next broad advance will take the form of healthcare which is precisely matched to the wishes of the individual. A mass-oriented public health system has taken us a long way, but it cannot do what is now required.

John P Paterson BComm, PhD, AO

Publicly available reports of "surgical waiting times" are, at face value, of interest to patients and referring doctors wishing to access surgical care. Such information might be expected to provide a reasonable indication of the absolute time to surgical intervention for an individual patient, and allow reasonable conclusions to be drawn on the relative performance (in terms of waiting times) of surgical services. Definition Healthcare performance indicators: statistics or other units of information which reflect, directly or indirectly, the performance of the healthcare system in maintaining or increasing the well-being of its target population. Surgical waiting times are a specific example of "healthcare performance indicators" (see Definition). In addition to providing information for users, such indicators are likely to inform the opinions of politicians, journalists, hospital managers and state and federal health departments on the adequacy of our healthcare system and relative hospital or regional performances. They may be used to construct "league tables" of the relative performance of surgical units — individual hospitals, surgical units or surgeons may be deemed to have "good" or even "substandard" performance. Public outcries and political pointscoring are likely to ensue. Good indicators should be easy to understand and use by the intended audience. Depending on how these data are collected, processed and presented, reported waiting time data might or might not provide useful information to people seeking guidance on time to treatment. Reports of surgical waiting times that use different definitions of "waiting time", or simply report on past performance, are of limited value. Waiting time data presented as the frequency with which a certain proportion of patients receive treatment within a stated time (eg, 75% treated within 4 weeks) may also fail to adequately inform patients or general practitioners as to likely delays. Few existing systems are capable of adjusting for delays before initial surgical consultation (ie, waiting time to get onto the surgical waiting list), let alone factors such as primary illness severity, comorbidity or health insurance status — all of which influence actual waiting times. In this issue of the Journal (page 253), Cromwell et al report an assessment of the utility of information regarding surgical waiting times available on the World Wide Web.1 Their findings indicate that current Web-derived information has significant shortcomings in data quality. They conclude that waiting time data currently published on the Web are, by and large, unsuitable for informing either clinician referral or patient decision-making.1 This critique should not be misinterpreted as an example of the well-recognised "dot.com" data reliability phenomenon. It is not just Web-based sources of such data that are open to criticism. Analysis of healthcare performance indicator data derived from any existing sources would generate similar critiques, with similar caveats required on interpretation and use.2,3 The appropriate desire to develop performance indicators in healthcare has often seen a race to deliver indicators overwhelm the need for methodological rigour in development and implementation. All too often, too little emphasis is placed on initial identification of who will use the indicator and how and why they will apply the data. The absence of such ab initio clarity of purpose leads to performance indicators that do not meet the needs and expectations of consumers, providers or purchasers of healthcare services.2-5 Surgical waiting times, and many other indicators, generate a natural curiosity to compare or rank relative performance. For comparisons to be made, common indicator definitions must exist and be systematically applied in data generation, with common data collection methodologies and results that are risk-adjusted. As Cromwell et al found, requirements for clear, consistent definitions are frequently not met, rendering comparisons invalid.2-8 It is crucial that people intending to use indicator data for judging comparative performance, or in any potentially punitive fashion, fully understand the strengths and weaknesses of the primary data. Perhaps the greatest error by those who use indicator data is that of assuming the indicator is an objective measure of relative performance based solely upon its apparent face validity. Reported surgical waiting times would then be assumed to be a direct linear measure of access to care. This ignores evidence that clinician decision-making processes and administrative practices have major impacts on reported waiting times. Without adjustment for relative urgency or disease severity (at a minimum), reports of waiting times are of limited utility. Significant progress has been made in developing and refining healthcare performance measurement locally (by the Australian Council on Healthcare Standards among others) and internationally (by groups such as the Joint Commission on Accreditation of Healthcare Organisations and the Health Care Financing Administration in North America). There is, however, still considerable scope for improving the methodological rigour of both indicator development and application in the field. At present, the reliability and utility of indicator data cannot be assumed. Most current indicators of healthcare performance should be viewed as tools that prompt additional inquiry, rather than allowing definitive judgements on quality and safety of care. Over time, robust, credible indicators will increasingly become available to reliably inform consumers and allow accountability to purchasers of healthcare services. Nevertheless, given the complexity of healthcare, the predominant enduring benefit from attempts to measure performance in healthcare is likely to be the use of data generated by providers of care to provoke reflection on existing practice and to plan efforts at improving care.

Neil W Boyce FRACP, PhD, MRACMA

Objectives: To assess Web-based waiting time information services to identify how they aimed to meet the information needs of patients and general practitioners, and to evaluate how well waiting time information was presented.Design: A cross-sectional survey of six government websites in English-speaking countries with publicly funded hospitals. Sites were evaluated on the clarity of instructions about how their information should be used, and the accuracy of the statistics they contained was assessed indirectly using methodological criteria.Results: The services were judged to encourage GPs and patients to use the statistics to avoid surgical units with long waiting times, but overall advice was poor. Services did not state whether the statistics predicted expected waiting times, and just one stated that the statistics were only intended as a guide. Statistics were based on different types of data, and derived at different levels of aggregation, raising questions of accuracy. Most sites explained waiting list terms, but provided inadequate advice on the uncertainty associated with making statistical inferences.Conclusions: GPs and patients should use Web-based waiting time information services cautiously because of a lack of guidance on how to appropriately interpret the presented information.

David A Cromwell BSc, MSc · David A Griffiths BSc, PhD · Irene A Kreis MD, PhD

To our readers: For most of us, the word "professional" conjures up an image of an individual with expertise in a discrete area of knowledge and a commitment to use this expertise judiciously. The word "doctor" has similar connotations, but also suggests the altruism of service to patients and society. Of late, however, medical professionalism has been buffeted by the tumultuous changes affecting the industrialised world. These include the explosion of information technology, the increasing dominance of corporatism and of government management of social services, and the ascendancy of individualism. These changes, and their attendant uncertainty, have been accompanied by a questioning of the purpose and values of the medical profession. At the same time, these very stressors have also awakened an interest in medical professionalism, particularly in North America and the United Kingdom. This interest has yet to reach Australia. In view of this, the Medical Journal of Australia is pleased to introduce the Charter on Medical Professionalism to its readers. The charter first appeared in the Annals of Internal Medicine and the Lancet earlier this year, and is the outcome of the Medical Professionalism Project, which involved the American Board of Internal Medicine, the American College of Physicians–American Society of Internal Medicine and the European Federation of Internal Medicine. The charter should be read by all in our profession, and individual doctors will have to decide whether they will subscribe and adhere to its precepts. These include the principles of social justice, improving the quality of care and sustaining and strengthening the research base of medicine. The Charter on Medical Professionalism should not only be advocated by our medical schools, learned colleges or politico-professional bodies, but by all in our profession As noted by Harold Sox, editor of the Annals of Internal Medicine, in his prologue to the charter, ". . . the challenge will be to live by the precepts and to resist efforts to impose corporate (or government [my words]) mentality on a profession of service to others . . . The responsibility for acting on these principles and commitments lies squarely on our shoulders." Martin B Van Der Weyden Editor Medical Journal of Australia Physicians today are experiencing frustration as changes in the healthcare delivery systems in virtually all industrialised countries threaten the very nature and values of medical professionalism. Meetings among the European Federation of Internal Medicine, the American College of Physicians and American Society of Internal Medicine (ACP-ASIM), and the American Board of Internal Medicine (ABIM) have confirmed that physicians' views on professionalism are similar in quite diverse systems of healthcare delivery. We share the view that medicine's commitment to the patient is being challenged by external forces of change within our societies. Recently, voices from many countries have begun calling for a renewed sense of professionalism, one that is activist in reforming healthcare systems. Responding to this challenge, the European Federation of Internal Medicine, the ACP-ASIM Foundation, and the ABIM Foundation combined efforts to launch the Medical Professionalism Project (<www.professionalism.org>) in late 1999. These three organisations designated members to develop a "charter" to encompass a set of principles to which all medical professionals can and should aspire. The charter supports physicians' efforts to ensure that the healthcare systems and the physicians working within them remain committed both to patients' welfare and to the basic tenets of social justice. Moreover, the charter is intended to be applicable to different cultures and political systems. PreambleProfessionalism is the basis of medicine's contract with society. It demands placing the interests of patients above those of the physician, setting and maintaining standards of competence and integrity, and providing expert advice to society on matters of health. The principles and responsibilities of medical professionalism must be clearly understood by both the profession and society. Essential to this contract is public trust in physicians, which depends on the integrity of both individual physicians and the whole profession. At present, the medical profession is confronted by an explosion of technology, changing market forces, problems in healthcare delivery, bioterrorism, and globalisation. As a result, physicians find it increasingly difficult to meet their responsibilities to patients and society. In these circumstances, reaffirming the fundamental and universal principles and values of medical professionalism, which remain ideals to be pursued by all physicians, becomes all the more important. The medical profession everywhere is embedded in diverse cultures and national traditions, but its members share the role of healer, which has roots extending back to Hippocrates. Indeed, the medical profession must contend with complicated political, legal, and market forces. Moreover, there are wide variations in medical delivery and practice through which any general principles may be expressed in both complex and subtle ways. Despite these differences, common themes emerge and form the basis of this charter in the form of three fundamental principles and as a set of definitive professional responsibilities. Fundamental principlesPrinciple of primacy of patients' welfareThis principle is based on a dedication to serving the interest of the patient. Altruism contributes to the trust that is central to the physician–patient relationship. Market forces, societal pressures, and administrative exigencies must not compromise this principle. Principle of patients' autonomyPhysicians must have respect for patients' autonomy. Physicians must be honest with their patients and empower them to make informed decisions about their treatment. Patients' decisions about their care must be paramount, as long as those decisions are in keeping with ethical practice and do not lead to demands for inappropriate care. Principle of social justiceThe medical profession must promote justice in the healthcare system, including the fair distribution of healthcare resources. Physicians should work actively to eliminate discrimination in healthcare, whether based on race, gender, socioeconomic status, ethnicity, religion, or any other social category. A set of professional responsibilitiesCommitment to professional competencePhysicians must be committed to lifelong learning and be responsible for maintaining the medical knowledge and clinical and team skills necessary for the provision of quality care. More broadly, the profession as a whole must strive to see that all of its members are competent and must ensure that appropriate mechanisms are available for physicians to accomplish this goal. Commitment to honesty with patientsPhysicians must ensure that patients are completely and honestly informed before the patient has consented to treatment and after treatment has occurred. This expectation does not mean that patients should be involved in every minute decision about medical care; rather, they must be empowered to decide on the course of therapy. Physicians should also acknowledge that, in healthcare, medical errors that injure patients do sometimes occur. Whenever patients are injured as a consequence of medical care, patients should be informed promptly because failure to do so seriously compromises patients' and societal trust. Reporting and analysing medical mistakes provides the basis for appropriate prevention and improvement strategies and for appropriate compensation to injured parties. Commitment to patients' confidentialityEarning the trust and confidence of patients requires that appropriate confidentiality safeguards be applied to disclosure of patients' information. This commitment extends to discussions with people acting on a patient's behalf when obtaining the patient's own consent is not feasible. Fulfilling the commitment to confidentiality is more pressing now than ever before, given the widespread use of electronic information systems for compiling data on patients and an increasing availability of genetic information. Physicians recognise, however, that their commitment to confidentiality must occasionally yield to over-riding considerations in the public interest (for example, when patients endanger others). Commitment to maintaining appropriate relationships with patientsGiven the inherent vulnerability and dependency of patients, certain relationships between physicians and patients must be avoided. In particular, physicians should never exploit patients for any sexual advantage, personal financial gain, or other private purpose. Commitment to improving quality of carePhysicians must be dedicated to continuous improvement in the quality of healthcare. This commitment entails not only maintaining clinical competence but also working collaboratively with other professionals to reduce medical error, increase patients' safety, minimise overuse of healthcare resources, and optimise the outcomes of care. Physicians must actively participate in the development of better measures of quality of care and the application of quality measures to assess routinely the performance of all individuals, institutions, and systems responsible for healthcare delivery. Physicians, both individually and through their professional associations, must take responsibility for assisting in the creation and implementation of mechanisms designed to encourage continuous improvement in the quality of care. Commitment to improving access to careMedical professionalism demands that the objective of all healthcare systems be the availability of a uniform and adequate standard of care. Physicians must individually and collectively strive to reduce barriers to equitable healthcare. Within each system, the physician should work to eliminate barriers to access based on education, laws, finances, geography, and social discrimination. A commitment to equity entails the promotion of public health and preventive medicine, as well as public advocacy on the part of each physician, without concern for the self-interest of the physician or the profession. Commitment to a just distribution of finite resourcesWhile meeting the needs of individual patients, physicians are required to provide healthcare that is based on the wise and cost-effective management of limited clinical resources. They should be committed to working with other physicians, hospitals, and payers to develop guidelines for cost-effective care. The physician's professional responsibility for appropriate allocation of resources requires scrupulous avoidance of superfluous tests and procedures. The provision of unnecessary services not only exposes patients to avoidable harm and expense but also diminishes the resources available for others. Commitment to scientific knowledgeMuch of medicine's contract with society is based on the integrity and appropriate use of scientific knowledge and technology. Physicians have a duty to uphold scientific standards, to promote research, and to create new knowledge and ensure its appropriate use. The profession is responsible for the integrity of this knowledge, which is based on scientific evidence and physicians' experience. Commitment to maintaining trust by managing conflicts of interestMedical professionals and their organisations have many opportunities to compromise their professional responsibilities by pursuing private gain or personal advantage. Such compromises are especially threatening in the pursuit of personal or organisational interactions with for-profit industries, including medical equipment manufacturers, insurance companies, and pharmaceutical firms. Physicians have an obligation to recognise, disclose to the general public, and deal with conflicts of interest that arise in the course of their professional duties and activities. Relationships between industry and opinion leaders should be disclosed, especially when the latter determine the criteria for conducting and reporting clinical trials, writing editorials or therapeutic guidelines, or serving as editors of scientific journals. Commitment to professional responsibilitiesAs members of a profession, physicians are expected to work collaboratively to maximise patients' care, be respectful of one another, and participate in the processes of self-regulation, including remediation and discipline of members who have failed to meet professional standards. The profession should also define and organise the educational and standard-setting process for current and future members. Physicians have both individual and collective obligations to participate in these processes. These obligations include engaging in internal assessment and accepting external scrutiny of all aspects of their professional performance. SummaryThe practice of medicine in the modern era is beset with unprecedented challenges in virtually all cultures and societies. These challenges centre on increasing disparities among the legitimate needs of patients, the available resources to meet those needs, the increasing dependence on market forces to transform healthcare systems, and the temptation for physicians to forsake their traditional commitment to the primacy of patients' interests. To maintain the fidelity of medicine's social contract during this turbulent time, we believe that physicians must reaffirm their active dedication to the principles of professionalism, which entails not only their personal commitment to the welfare of their patients but also collective efforts to improve the healthcare system for the welfare of society. This Charter on Medical Professionalism is intended to encourage such dedication and to promote an action agenda for the profession of medicine that is universal in scope and purpose. Members of the Medical Professionalism Project ABIM Foundation Troy Brennan (Project Chair), Brigham and Women's Hospital, Boston, MA, USA; Linda Blank (Project Staff), ABIM Foundation, Philadelphia, PA, USA; Jordan Cohen, Association of American Medical Colleges, Washington, DC, USA; Harry Kimball, American Board of Internal Medicine, Philadelphia, PA, USA; and Neil Smelser, University of California, Berkeley, CA, USA. ACP-ASIM Foundation Robert Copeland, Southern Cardiopulmonary Associates, LaGrange, GA, USA; Risa Lavizzo-Mourey, Robert Wood Johnson Foundation, Princeton, NJ, USA; and Walter McDonald, American College of Physicians-American Society of Internal Medicine, Philadelphia, PA, USA. European Federation of Internal Medicine Gunilla Brenning, University Hospital, Uppsala, Sweden; Christopher Davidson, Royal Sussex County Hospital, Brighton, UK; Philippe Jaeger, Centre Hospitalier Universitaire Vaudois, Lausanne, Switzerland; Alberto Malliani, Università di Milano, Milan, Italy; Hein Muller, Ziekenhuis Gooi-Noord, Rijksstraatweg, Netherlands; Daniel Sereni, Hôpital Saint-Louis, Paris, France; and Eugene Sutorius, Faculteit der Rechts Geleerdheid, Amsterdam, Netherlands. Special consultants Richard Cruess and Sylvia Cruess, McGill University, Montreal, Canada; and Jaime Merino, Universidad Miguel Hernández, San Juan de Alicante, Spain.

Medical Professionalism Project

To the Editor: The article by Bellomo et al,1 with its alarmist conclusions, received a lot of media attention. However, the authors' methodology is flawed and their conclusions are unsupported by their data. They describe postoperative adverse events in a group of largely elderly patients (median age, 65.5 years) who stayed in hospital more than 48 hours after inpatient surgery. These selective criteria were used "to exclude patients having day surgery or minor procedures". Stratifying the severity of operations according to duration of stay is fundamentally flawed. This would have excluded many major, short-stay operations if the patient had had an uneventful postoperative course (eg, laparoscopic cholecystectomy and complex endoscopic procedures), and included others simply because a complication prolonged the patient's stay. The result is a selective bias towards a high complication rate. A more valid approach would have been to stratify all inpatient operations by severity and to include all major operations in the denominator for the study. This strategy would undoubtedly have shown significantly lower complication and mortality rates than those reported by Bellomo et al. The "silent epidemic" referred to in the study is neither silent nor an epidemic. An epidemic refers to a disease normally absent but liable to outbreaks. What the authors describe is an endemic situation (habitually present, of common occurrence); it is quite obvious and already extensively documented. Elderly patients undergoing major operations (especially in an emergency — "unscheduled surgery" in the authors' pejorative lexicon) are likely to have complications, and, when they do, need to stay in hospital longer. The authors did not analyse whether the adverse events were preventable, and therefore they cannot justify their conclusion that "there is much scope for improving postoperative care".

Thomas B Hugh · G Douglas Tracy · Rinaldo Bellomo · Donna Goldsmith · Sarah Russell · Shigehiko Uchino

To the Editor: The information in the article by Bellomo et al,1 which documents postoperative serious adverse events in a teaching hospital, contains no surprises; nor does it support some of the authors' conclusions. In 1995, the findings of the Quality in Australian Health Care Study2 were immediately sensationalised by the press with the headline "Hospital errors kill 18 000 a year".3 The article by Bellomo and colleagues provoked similar predictable media sensation. As acknowledged by the authors, the study addressed neither the causes of the serious adverse events, nor whether they were "preventable". Furthermore, the authors fail to show how their findings "suggest that there is much scope for improving perioperative care in our tertiary hospitals", or why "this is a 'silent' epidemic which requires urgent and systematic attention". However, in televised interviews, they made no effort to reduce the alarm aexpressed at the prevalence of errors. They have invented a new designation of "unscheduled surgery" (which presumably refers to acute, urgent or emergency admissions), preferring a title that suggests an avoidable lack of scheduling. It is hardly surprising that this group of patients required most of the admissions to the intensive care unit for which no prior booking had been made. It is unclear why the authors mention that "six of nine patients over 92 years of age having hip surgery died". Again, one presumes that these operations were for hip fracture, a condition with 100% mortality if untreated. And why leave out patients aged between 90 and 92 years? No amount of statistical manipulation conceals the bias that is obvious in their article. It might provide a media story, but it has minimal value for the critical reader.

Thomas B Hugh FRCS, FRACS · G Douglas Tracy · Rinaldo Bellomo MD, FRACP · Donna Goldsmith RN · Sarah Russell RN, PhD · Shigehiko Uchino MD

In reply: We thank Tracy and Hugh for the issues they raise. The goal of our study was to establish baseline information on the incidence of serious adverse events (SAEs) for use in subsequent intervention studies.1 The data were needed for statistical power calculations. Our inclusion criteria were predefined, as is scientifically orthodox for any study. We chose to study a population of clinical relevance to inpatient medicine. Most simple procedures at our hospital require day admission with no overnight inpatient stay, so these were not relevant to our goals. Others may wish to study different patient populations and are free to do so. In our opinion, there was no particular bias in our study, just accurate, prospective documentation of events. We used the term "unscheduled surgery" because it is verifiable and objective. An operational definition is necessary; otherwise, judgements about what is a true emergency (like judgements about what is preventable) are very dependent on observer bias. Nonetheless, according to our judgement, only 48 of 426 "unscheduled" operations were true emergencies. We wanted to identify groups that were at particular risk of death, hence the mention of patients over 92 years of age who had had hip surgery. Up to what level of expected postoperative mortality does it remain acceptable to perform major surgery in very elderly patients? We stand by our opinion that we are dealing with a silent epidemic. It is silent because we could find no previous prospective studies of SAEs for all major operations published (in English) in the medical literature, and there was no systematic plan to tackle them. We use the term epidemic because (in the absence of objective documentation of rates of SAEs in the past) our impression is that this is a growing phenomenon, related to the increased use of major surgery in the elderly. We also consider that only the absence of SAEs would offer no scope for improvement. A rate of SAEs of 16.9% should, logically, offer much scope for improvement. Whether such improvement can be realised remains a matter for future interventional investigations.

Thomas B Hugh

Objective: To evaluate an intervention developed to improve test-ordering practice.Setting: Public hospital emergency department with an annual census of 42 500. The study comprised a six-month pre-intervention stage (November 1998 to April 1999), which was compared with a similar post-intervention period (November 1999 to April 2000), and trends were examined over an 18-month post-intervention period (May 1999 to October 2000).Intervention: The intervention comprised three integrated components: implementation of a protocol for test ordering; education program for medical staff; and audit/feedback process.Main outcome measure: Test utilisation (assessed as cost per patient).Results: There was a 40% decrease in the ordering of investigations in the emergency department (95% CI, 29%–50%), with test utilisation falling from a mean of $39.32/patient to $23.72/patient. The decrease was similar for both laboratory and imaging tests and was sustained for the duration of the 18-month follow-up.Conclusions: Our intervention appears to have produced long term modification of test ordering in the emergency department of a public teaching hospital.

Peter J Stuart MB BS, FACEM · Shelley Crooks BA(Hons.Psych) · Mark Porton BAppSc

Since 1998, listed public corporations have actively sought to capture a significant proportion of the Australian general practice market. They have paid generously for the "goodwill" of existing practices, entered limited contracts with the doctors in those practices, and relocated some of these doctors to large centres where general practice is linked directly with other diagnostic, imaging and treatment services owned by the corporation. The benefits of these changes for the corporations include assuring referrals to their diagnostic and imaging services (in a competition for market share for these high-cost services), access to private insurance rebates through licensed day-procedure centres, and possible economies of scale. General practice corporatisation and the issues involved have been described elsewhere.1-3 However, the process of general practice corporatisation is maturing, and I would like to discuss some emerging trends and their implications. Emerging trendsThe initial enthusiasm for shares in general practice corporations is waning. Shareholders, institutions and analysts now focus on earnings rather than projections. A collapse in the price of shares in listed general practice corporations in August 2001, followed by a partial recovery, led to a more realistic focus on earnings as a determinant of share price. In addition, the collapse contributed to decisions to terminate practice purchases and to delay public listing by at least one corporation.4 General practice corporations have not shown the same earnings performance as other sectors of the health market, such as private hospital operators. Those owning their own pathology, imaging and specialist services are more profitable than those without vertical integration of referrals. These changes, coupled with recent amendments to the Privacy Act — Privacy Amendment (Private Sector) Act 2000 (Cwlth) — which now require a patient's consent for the transfer of medical records, have caused most general practice corporations to limit new practice purchases, making their initial targets of 50% of the general practice market overly optimistic. Although corporations have a large share of the Perth market (around 40%), it is unlikely they will achieve more than 20% of other metropolitan markets, such as Sydney or Melbourne. Future trends include corporatised practices moving away from bulk-billing of all GPs' services (this has already commenced in some areas of Sydney). Mergers between general practice corporations should further concentrate the market. Other models of general practice integration are emerging, such as general practice market-based cooperatives, where GPs share ownership of diagnostic and therapeutic services and benefit from the profits of those services; Division-based cooperatives;5 and serviced-office arrangements, where GPs collocate, but retain ownership of their own practice (for example, Health Connectiv Pty Ltd). General practice corporatisation and medical ethicsIn the past, some Australian doctors have been induced to act as agents of corporations, not of their patients.6,7 I have previously argued that an informed health consumer relies on the advice and assistance of his or her GP. For the health system to operate as a free market, GPs must act as their patients' agent, not as agents of third parties.3 As there is considerable information asymmetry between health consumers and providers, access to an informed agent or broker, who is free to act solely as a patient's agent in the health system, is a consumer protection issue, not just an issue of professional freedom. This is also the primary principle of medical ethics, which for over 3000 years has required doctors to put their patient's health needs before all other considerations.8 On the other hand, directors of corporations are required to put the needs of shareholders first.9 Meeting the needs of shareholders through customer service is good business practice, but the needs of patients and shareholders will not always coincide. In such a situation, if GPs are not able to put their patient's needs before the needs of the corporation their patients lose. Governments, health consumer representatives, health professionals and managers of health corporations must clearly understand that GPs have a role as honest brokers for their patients in the healthcare system, and must ensure GPs are free to stand up to third parties such as insurers or corporations in the event of competing interests. Governments and general practice corporatisationThe New South Wales Government was the first in Australia to respond to the potential for doctors to experience competing interests. After ministerial inquiries into the provision of male impotency services and the cosmetic surgery industry,6,7 the NSW Government introduced amendments to the Medical Practice Act 1987 (Medical Practice Amendment Act 2000). The Act can now exclude an employer, manager or director from involvement in any company providing medical services if he or she is found to have incited doctors to unsatisfactory professional conduct, or is party to either payment of pecuniary benefits for unnecessary services or directing referrals. Although some States are prepared to act to the extent of their powers to ensure corporations do not influence clinical practice, the Commonwealth Government has encouraged corporatisation of medical practice through its own inertia. It is responsible, through the payment of Medicare rebates by the Health Insurance Commission, for most of the expenditure in this market, where listed corporations are making shareholder profits largely from the public purse. As an example, the Commonwealth Government permits vertically integrated corporations to share profits from internal referrals while continuing to enforce regulations that prohibit the sharing of profits from referrals between traditional practices. The Australian Medical Association and some corporations, with the later involvement of the Royal Australian College of General Practitioners (RACGP) and the federal Minister for Health, developed a Code of Conduct, which was released in October 2001.10 The code was criticised as ineffective at that time.11,12 At 3 June 2002, the code had three signatories. Corporatised practice and health policyThe balance of powerThe prime policy problem is imbalance in the relationship between GPs and their contracting corporation, and the subsequent vulnerability of their patients to exploitation by third parties. As a result of the Australian Competition and Consumer Commission's (ACCC) interpretation of the Trade Practices Act 1974 (Cwlth), the AMA is able to provide professional and legal advice about contract issues to its members, but is prevented from representing individuals or groups of GPs in a contract dispute with a corporation. Leaving aside the possibility that corporate doctors could be deemed to be employees by the Australian Taxation Office, and so become eligible for group representation through a union, GPs under contract are currently sole agents in their relationship with a corporation. Regardless of the details of the contract or the merits of their position, all remedies involve possible civil action. It is unlikely that many individual GPs would take action against a corporation able to defend its position with hundreds of millions of dollars. It would also be difficult for a GP to win a contested case in a civil court against a well funded opponent. An additional inhibiting factor for corporatised GPs is the need to renegotiate a contract with the corporation every four to five years. It is a simple matter for the corporation to refuse to renew a contract, or to make a contract so onerous that a GP would not renew. The doctor is then without a practice or an income source, facing ongoing geographic exclusions from the area of the previous contract, as well as the costs and difficulties of establishing a new practice in another area. Far more subtle, however, is the use of recontracting by corporations to reward profitable or compliant doctors. As more contracts come up for renewal, this is likely to be the most pervasive form of influence corporations exert on GPs. There is an overwhelming argument that it is in the public interest to support organised representation for GPs in contracts with general practice corporations. If the Commonwealth Government, the ACCC and the AMA are unable to provide this, GPs' class actions in civil courts could provide some relief and alter the balance between individual GPs and large corporations. GPs of the future: agents or honest brokers?A policy initiative within the medical profession's grasp is ensuring that GPs clearly understand their ethical responsibilities to their patients, and remain alert to the ways corporations, governments, drug companies and insurers seek to influence them, and so influence the decisions they make on behalf of their patients. This is not a simple matter. The medical profession must also recognise that its actions as a group determine the services and resources available at a population level, while at the same time encouraging doctors to deliver the best possible care for each individual patient. As Australia moves further along the path to "for profit" healthcare, there is a need for greater emphasis on teaching professional ethics in undergraduate, postgraduate and continuing education for general practice. The economics of medical practiceEconomists and governments, under the mistaken belief that primary medical care is not delivered in a competitive market, attempt to apply free-market principles without understanding their effects on the operation of the market and the vulnerability of uninformed consumers in the market. The response to corporatisation of general practice is only one example of government confusion about the components of competition in healthcare, and their need to ensure public protection.3 Other examples include advertising of medical services, the application of the Trade Practices Act to rostering arrangements by medical practitioners, and recent attempts by the Commonwealth Government and insurers to influence the way GPs prescribe or refer their patients. A better-informed economic analysis of the operation of the Australian health system, which includes the opinions of consumers and providers, could assist policymakers to design a health system which follows function, rather than the current design which promotes dysfunction. LegislationFinally, legislation to cover competing interests when doctors refer should not be seen as a remedy for this problem. Attempts in the United States to codify relationships between referring doctors and third parties (the Stark Laws)13 have, for little benefit, increased the clinical and legal complexity of medical practice. These laws were passed in response to widespread public and legislative dissatisfaction about the perceived divided loyalties of US doctors, and the consequent effects on patient care, resulting from longstanding interference by insurers, governments and corporations in the relationship of trust between doctors and their patients. Enforcing the existing prohibition of commercial arrangements between referring doctors, and between doctors and third parties, is preferable to legislating to ensure propriety in arrangements which result from corruption of normal ethical practices. Australians are still in a position to prevent a similar outcome, but the market is operating and time is short.

Paul D Fitzgerald FRACGP, FAFPHM, FAIM

There is compelling evidence that doctors are an at-risk group. Their high rates of mental illness and stress-related illness are of particular concern, and are reflected in tragically high suicide rates, high levels of drug abuse, and decreased job satisfaction and "burnout".1,2 All of these are powerful indicators of poor self-care. Junior medical officers, in particular, are at risk. The New South Wales Medical Board has ...

Narelle E Shadbolt MB BS, FRACGP, MFM

The training of junior doctors requires a delicate balance between "on the job" experience and quality training. . . . The preregistration year is a time in which training, skills and working role are consolidated under supervision, and it has been suggested that it may be the most stressful period in medical practice.1 In South Australian teaching hospitals, the education and training of doctors in their ...

Anne A Martin BSc(Hons), PhD

Despite our best efforts to create systems and organisational supports to facilitate optimal development for all junior medical officers (JMOs), some will continue to perform suboptimally and experience distress. It then becomes necessary to take an individualised approach to these JMOs. It must be emphasised that there is a clear distinction between distress and impairment. Distress does not imply impairment, although prolonged and unalleviated distress ...

Karen Grace BA, MSSc(Counselling)

At the 3rd and 4th National Forums on Prevocational Medical Education, held in 1998 and 1999, it was realised that the issues surrounding students and junior doctors who are distressed warranted further attention. As a consequence, this Conference, The student and junior doctor in distress — "our duty of care", was arranged with the aim of formulating recommendations to educational bodies, health departments and medical ...

Geoffrey W Dahlenburg MD, FRACP

All medical boards have as their primary objectives protection of the public; and maintenance of the highest possible standards of medical care. The Boards are state-based and constituted under Acts of Parliament. However, they are independent, operating at arm's length from government, and are self-funded through medical registration fees. While it is often stated that the medical profession is self-regulated, the reality is that the profession, community groups, ...

Alison M Reid MB BS, MHA, FAFPHM

A recent article noting that "unhappy doctors are a worldwide phenomenon" imputes this to ongoing changes in relationships with patients and society.1 Despite this phenomenon, many young people, for a variety of reasons, still wish to study medicine. The reasons include: parental pressure — "you've got the marks" . . . "it's a secure income" . . . "doctors are well respected" . . . ...

Kay A Wilhelm MD, FRANZCP

[The comments made in this article and given at the conference were appropriate at the time. Since then, the South Australian Parliament was prorogued and an election held. The proposed new Medical Practitioners Act had not passed both Houses of the Parliament and has therefore lapsed. At this time, I am not aware of what the new Government may include in a Bill it ...

David H Wilde BA(Hons), JP

It has been long recognised that the practice of medicine is stressful and that doctors are prone to anxiety, depression, drug and alcohol problems, and even suicide.1,2 Similarly, the process of medical education is stressful and medical students, too, are at risk of psychological problems.3 In New South Wales, in 1997, after a report on doctors' mental health, the NSW Medical Board convened an independent Doctors' ...

Chris C Tennant MD, MPH, MRCPsych, FRANZCP

The Medical Board of Queensland, through its Health Assessment and Monitoring Program, provides active support to the medical profession, particularly to doctors recovering from impairment (ie, illness which has been serious enough to affect their capacity to practise). There are about 50 new referrals to the program each year — 37% have a psychiatric illness, 45% involve drug misuse (other than alcohol), and 7% alcohol ...

Jillann F Farmer MB BS, FRACGP