To the Editor: Debate regarding the prevention of peripheral intravenous catheter (PIVC)-associated bloodstream infection has been enriched by research and letters published in the Journal.1–3 Stuart and colleagues and Collignon and colleagues highlighted an association of long dwell times with PIVC-associated bloodstream infection.1,2 Rickard and colleagues refer to contrasting high-level evidence in a Cochrane review.3,4 We would suggest that important lessons can be learnt from both perspectives.

The Hawthorne effect and strict inclusion and exclusion criteria mean that, while largely free of bias, the outcomes of clinical trials are not generalisable. The retrospective data on PIVC-associated bloodstream infections reported by Stuart et al and Collignon et al, while methodologically limited, demonstrate the real-world experience of hundreds of patients.1,2

We believe that clinicians should consider all forms of evidence when designing processes to ensure safe stewardship of PIVCs. In health services with independent “line teams” and a comprehensive PIVC insertion bundle, a “replace as clinically indicated” approach may be appropriate. Other health care services may be better suited to a mandatory replacement policy.

Given evidence that half of PIVCs inserted in our tertiary emergency department (ED) were unused,5 along with the evidence of PIVC-associated infection,1 Monash Health introduced a comprehensive multimodal change process to reduce unused PIVCs and subsequent bloodstream infections. Clinicians in Monash Health EDs are asked to only insert a PIVC if they feel it is at least 80% likely it will be used in the following 4 hours. An accompanying education campaign provides guidance in cases where a precautionary PIVC may be required, such as for patients who present after a seizure. The aim of the intervention is to avoid insertion of unnecessary PIVCs, while ensuring appropriate insertion, and to improve insertion methods. Four months after the intervention began, we demonstrated a reduction in total monthly PIVCs from 1413 to 928 and an unused PIVC rate of 19.3% (unpublished data). This change process has been offered to EDs throughout Victoria by the Department of Health.6

We would support the establishment of a specific national standard regarding the stewardship of PIVCs, which should include the need to carefully evaluate whether insertion of the PIVC is necessary.

Providing the best care and containing costs depends on sharing and applying information

The rate of change in health care delivery and the need to provide more affordable health care continues to accelerate. Health is a major concern for Australians now and into the future, making the politics of health an important issue at both state and federal levels.

I joined the leadership team of the Australian Medical Association (AMA) just after one prime minister vowed to fix the nation’s public hospitals or take them over; and as I leave 5 years later, we have another prime minister vowing to fix primary health care with the proposed copayments for general practice and diagnostic imaging and pathology testing.

Both leaders clearly had laudable aims, with Tony Abbott intending to shift some of the costs and more of the responsibility for spending decisions onto the individual. History tells us that both may end up with compromises that don’t quite deliver on their original intent.

Australia’s problem is that health care costs are rising faster than the gross domestic product (GDP). This inevitably means a bigger spend in straight dollar terms and also as a proportion of GDP. The implication is that Australia will have less of its GDP to spend on education, roads and welfare.

At the same time, as the cost pressures on health spending are rising, the public’s access to and demand for information is exploding. Patients want to know that they are getting the best treatment, and soon they will want to know that it is being delivered by the best doctor or, at least, that their doctor is delivering best practice.

In the United Kingdom, the medical system has already focused on the quality of doctors with the introduction of revalidation in 2012. Licensed doctors are required to demonstrate on a regular basis that they are up to date and fit to practise. Revalidation aims to give extra confidence to patients that their doctor is being regularly checked by their employer and the General Medical Council (our Medical Board equivalent). The Australian Medical Board has started a conversation about the need for revalidation in the Australian context.

Lord Darzi, one of the leading international figures in health reform in recent years, gave us some clear guidance in his keynote speech at the 50th AMA conference in 2012, including his view that one of the simplest ways of improving care delivery — and therefore patient outcomes and managment of costs — is to close the gap between “what we know and what we do”.

We already know we must strengthen the primary health care system to enable it to provide high-quality, personal care and support to people when they are sick, to help people manage their chronic illnesses and to help the population stay healthy.

We also need to stop practices that have not been shown to benefit patients and do more of the things that are of benefit. We need to measure and minimise unwarranted clinical variation and to ensure that high-quality care is a consistent part of everyone’s experience of primary, community and hospital-based care, whether public or private.

We can only do this if we can measure what we are doing and share that information. This is where I think we will see the most change in the next few years. Already, the AMA and the Colleges are moving to more openness and more disclosure. Colleges are requiring more and more self-reflection as part of their continuing professional development programs; and we are beginning to see meaningful disclosure of outcomes in hospitals by way of the National Health Performance Authority’s MyHospitals website.

The public want more granular information though, and I have no doubt that as we increase our use of information technology and see increased use of the nationally agreed standards like the Australian Medicines Terminology and SNOMED CT-AU, we will be able to provide the information required to demonstrate quality and allow comparisons within and between services.

Better data flows within the health system will improve efficiency and will improve outcomes and minimise misadventure at all levels, and we should be able to meet the information needs of the public, the needs of the regulators and the needs of governments while driving improved cost-effectiveness.

Dr Steve Hambleton, a Brisbane general practitioner, was Vice President of the AMA from May 2009 to May 2011 and President from May 2011 to May 2014.

Having a voice in complex policy decisions has never been more important

The Australian health care system is one of the best in the world. The foundations of our system are a well trained medical workforce, a commitment to quality and standards, and a delicate balance between public and private health systems.

Doctors and other providers working in our health system have a strong commitment to improvement. There is potential for improvement both in clinical outcomes and efficiencies. The past few years have been a period of clinical engagement, something not to be taken for granted.

While there is much to be learnt from overseas experience, our system is one that should be envied. Our system is unique, and caution should always be exercised when applying solutions developed overseas to the Australian health system. There are too many examples of solutions that have been imported enthusiastically only to be found to be not quite as good as initially thought. The latter realisation usually comes to light just as Australia implements the program.

The solutions and expertise reside with our clinicians here in Australia. Engaging with our doctors is key, not only to improving clinical results, but also to achieving financial efficiencies. This was illustrated so well by the recent failure of the personally controlled electronic health record in terms of its development and subsequent uptake. The advice of doctors wasn’t heeded and hundreds of millions of dollars were wasted.

Perhaps that is why it was so surprising that there was no consultation with the Australian Medical Association (AMA) or any other health group in relation to the copayment proposal and other health-related measures of the recent federal Budget.

While all AMA presidencies have their challenges, I suspect that there has never been a more important time to have strong professional representation.

The challenges are already here. While the so-called general practice copayment has occupied the headlines since the announcement of the federal Budget, there are many other budget issues that we need to grapple with.

For instance, the freeze on non-GP Medicare rebates has received almost no attention. Normally there would have been much said about this measure. Will all health funds still index their own schedules? If so, what is the implication for premiums? If not, will there be a reduction in use of no-gap or known-gap arrangements? Will patient out-of-pocket expenses increase?

With more than 3000 medical graduates expected to require internships this year, and with their predecessors requiring prevocational posts and training positions, the “training pipeline” remains a high priority and the central concern for our doctors-in-training. Three hundred extra general practice training positions, which the AMA welcomes, were announced in the federal Budget. However, apart from the loss of the Prevocational General Practice Placements Program, we are concerned that General Practice Education and Training has been subsumed by the federal Department of Health, with loss of its clinical leadership. The pending open tender for regional training providers must be watched with caution.

Indigenous health is a priority for the AMA, and always has been. Improvements are hard fought. This is not a time to cut Indigenous health funding. If inefficiencies are found, they need to be redressed, or the funding redirected. It should not be cut. The implementation of the new National Aboriginal and Torres Strait Islander Health Plan is an opportunity to ensure that successful programs are expanded.

The role of private health insurers (PHIs) in general practice is being examined closely by the federal government. While there may be a limited role, expansion of the role of PHIs in general practice should be viewed with scepticism and serious caution. Denials from PHIs that managed care is on the agenda ring hollow when we see some PHIs introducing preoperative assessment or approval processes for a range of procedures.

The AMA and the medical profession it represents are only too willing to engage with governments to get the right result for our health system and for patients. The health system is complex, and adjustments to policies in one area usually have consequences in many others. We may not necessarily always agree with proposals, but doctors have the knowledge and experience that can help avoid unintended and unwanted adverse consequences of various health policies.

Associate Professor Brian Owler, a Sydney adult and paediatric neurosurgeon, became President of the AMA in May 2014.

Neal Blewett and Michael Wooldridge were recent, memorable ministers for health, serving from 1983 to 1990 and 1996 to 2001, respectively. Bill Hayden understood both health and finance and blended these well in developing Medibank while minister for social security from 1972 to 1975. But the minister who appeared to me to have the greatest effect was Jim Forbes, who was health minister from 1966 to 1971. Forbes was an Adelaide patrician whose doctorate, like that of Neal Blewett, was non-medical. Unlike Blewett, Jim Forbes was a conservative of the most denim-blue hue.

What did Jim Forbes do? In 1968, he appointed a Committee of Enquiry into Health Insurance headed by Justice John Nimmo. Nimmo had cut his teeth in the Depression years as a young criminal lawyer and possessed an excellent insight gained from years at the Bar and on the Bench. He was assisted by an economist who had shifted from engineering into actuarial work as a young man, and for whom Lord Keynes had much admiration, Sir Leslie Melville, as well as Norman McIntosh, a distinguished chartered accountant. Among the many who presented to the Committee, the most influential were two young University of Melbourne academics, John Deeble and Dick Scotton.

The Nimmo Enquiry was limited to work within a voluntary framework. For Deeble and Scotton, its report provided the platform to prosecute the case for a universal medical insurance scheme, with Bill Hayden as their ally.

Nimmo recognised the importance of universality. He also recommended that standard ward accommodation be made available to every person, regardless of means. In differentiating private ward accommodation as a matter of choice, he confirmed retention of the mixed public and private hospital system, with the states having continuing responsibility for public hospitals.1 However, what Nimmo did not enshrine was the endless bickering, gaming and cost shifting that have coloured hospital funding ever since.

The initial voluntary element in Nimmo’s proposed arrangements sucked in the medical profession, who participated in the establishment of the first list of fees for medical benefit. Doctors contributed “fair and reasonable” fee relativities — in effect defining each item’s “common fee for medical benefit”. Apart from several notable exceptions, relativities in fees for medical benefit hardly shifted for 30 years.

Australian doctors have always bridled against any suggestion of compulsion, bolstered by the constitutional provision preventing “civil conscription” of medical doctors by the national government. This stance had led to an earlier successful High Court challenge by the British Medical Association, the forerunner of the Australian Medical Association (AMA), of a federal government requirement for signing prescribing paperwork. Conflict between doctors under the AMA banner and supporters of Deeble and Scotton’s proposed compulsory scheme was never fully resolved.

First came Medibank, which required a double dissolution of Parliament for its introduction in 1974, and then Medicare in 1983. It soon became so obvious that the Medicare scheme was better than anything else that the conservatives eventually gave up the ideological diatribe around “free markets”. Health care does not conform to the rules of the unfettered marketplace. Try the efficiency argument out when a new drug or technique that promises varying degrees of immortality comes onto — or even near — the market. The price tag is exorbitant when considered against the benefit. However, the tide of emotion washes away reality. Clinging to the 100-to-one chance for cure will make the health system as broke as if you tried to use that system on the racecourse.

It is that same emotional tide that can be exploited when there is any suggestion that improvement in the technology should result in reduction in the service price.

Modern living abounds in examples of improvement in technology accompanied by reduction in price. However, using medical equipment is apparently different from the smartphone or the DVD. Medical care is all about “complexity”, and it is the dexterity in pressing the switch that is important — and that switch often means “life” or “death” or “good life” quality against “poor life” quality.

When Nimmo produced his report, community expectations of the health care system were considerably lower. Shimmering immortality was not an option. It is not age per se that drives cost, but — as has been summarised elsewhere2 — as chronic disease progresses, the amount of high-tech health care delivered and the cost associated with this care increase dramatically. Patients with chronic illness in their last 2 years of life account for about 32% of total Medicare spending in the United States.

Nimmo, Melville and McIntosh, and Deeble and Scotton were remarkable in designing our health financing system by which the government sets a price, and fees and charges can be aligned with this price (or not). Despite all the criticisms, the system has survived. However, fuelled by having medical bulk-billing and the right to a public hospital bed, the community often mistakenly expects “universal” to mean “free”. Community rating remains an article of faith. Australia thus possesses a universal health scheme whereby the government is the ultimate paymaster — and hence the “fount of all funding” — and the pressures for continued expenditure increasingly displace concerns with cost-effectiveness.

Thomas Hobbes in 1651 published his treatise entitled Leviathan: or the matter, forme and power of a common–wealth ecclesiasticall and civil. Written during the English Civil War, it concerns society and how it might be managed by a strong and united government (the Leviathan), averting war and avoiding anarchy. The treatise is riddled with allusions to the functioning of the human body — and if Leviathan becomes ill, beware! Hobbes wrote of a disease of a Treasury out of control that resembles what he called pleurisy — “too much abundance” concentrated in too few hands, in the way that Hobbes thought blood to be concentrated in pleurisy with its consequent inflammation and pain.3

Australia is now subject to a rampant health Leviathan, where order is missing and anarchy prevails, destroying virtue. Our Leviathan threatens to devour our national wealth. While the “military-industrial complex” has had in the past a Leviathan-like quality in the United States, defence now accounts for but 4% of the gross domestic product (GDP), while health approaches 18%. When Nimmo wrote his report, health represented about 4% of Australia’s GDP; it now approaches 10%.

The first Nimmo Report came at the right time, but Leviathan had yet to emerge; the next Nimmo will have to face the Leviathan, asking “What price immortality?”