Dear Minister, please save yourself from activity-based funding

Fragmented funding, governance and delivery remain major obstacles to health care reform for sustainability

Reforms undertaken by recent Australian governments have their origin in the 2007 federal election campaign. Then Prime Minister John Howard focused the campaign on hospital funding, as an example of poor state governance, by promising to directly fund the Mersey Hospital near Devonport in Tasmania. The newspapers captured the spirit of the move with the headline “PM goads states with hospital takeover”.1 Then opposition leader Kevin Rudd soon countered with his own plan, reported in the press as the “Health buck stops here”.2 As Prime Minister, Kevin Rudd tried valiantly to implement direct federal control of hospitals by linking it to significant funding increases. However, the states, at
the decisive April 2010 Council of Australian Governments meeting, won the political battle — they took the money, but rejected direct federal control.3 Not to be completely outmanoeuvred, the federal government did manage to implement a number of centralised control mechanisms, including the National Health Performance Authority and the Australian Commission on Safety and Quality in Health Care. The most intrusive, from the states’ perspective, is the Independent Hospital Pricing Authority (IHPA) whose “primary function is to calculate and deliver an annual National Efficient Price” for federal activity-based funding of state-run public hospital services
(http://www.ihpa.gov.au).

This is the public hospital arrangement the new coalition government has inherited. Notwithstanding the challenges of vertical fiscal imbalance, the states have insisted on retaining control of public hospitals, while the federal government has increased its control through these national structures. Moving forward, the federal government will need to decide what approach it will take to its relationship with the states on this matter — will it seek a policy of “dual federalism”, in which the federal government will have more power than the states, or will it encourage “new federalism”, with more power devolved to the states?

This choice will be tested by the government’s approach to activity-based funding. Activity-based funding is a piece of managerial rationalism that seeks to distil the vast and diverse range of hospital activities such as inpatient, outpatient, emergency and subacute care and some inpatient substitution into a single dollar value. This “national efficient price” (NEP), expressed as the “national weighted activity unit”, in the 2013–14 financial year is $4993.4 While acknowledging the rigour and transparency of IHPA’s work in developing the NEP, it is an artifice that can best be seen as a tool. The question is, how will the tool be used?

Using it as a funding mechanism, the federal government will be at risk of growth in demand for hospital services. It will also face a barrage of lobbying and political activity about the complex elements of the relative weighting of hospital and substitution activities, their costing and the pricing rules, and about which activities are in scope (and hence cost-shared with the federal government) and which are not. Each state will have its own story to tell as their health systems vary in structure and practice, including in the ratio of private to public beds, primary care systems, subacute care and the sophistication of hospital substitution. Innovation is stifled in such a funding model, and confusion is increased about the respective roles of the federal and state governments.

A lesson of the past 7 years is that the states want to continue to play the dominant role in providing public hospital services and have the clout to achieve this objective. To be effective, they need to transcend their focus on “controlling public hospitals” to becoming more sophisticated and nuanced purchasers, encouraging quality outcomes and innovations to enhance productivity. The federal government can help by moving away from its activity-based funding model for public hospitals to less intrusive population funding, adjusted for health care risks associated with age, sex, chronic disease, and socioeconomic determinants including remoteness and Aboriginality. This would reduce complexity, clarify the role of the federal government as a funder with a focus
on health outcomes rather than on the detailed cost of hospital processes, and leave the states to run the public hospital system with a clear incentive for efficiency. It might well pave the way for further transfer of federal health funding to the states, like in Canada, and provide the basis for the gradual evolution to a consumer-controlled, but tax-funded, health system5 that we
know as Medicare Select.6

The need for a chiropractic adverse events reporting system in Australia

To the Editor: Following media reports of a complaint to the Australian Health Practitioner Regulation Agency regarding a 4-month-old baby’s neck fracture following chiropractic treatment for apparent torticollis,1
the president of the Chiropractors’ Association of Australia stated that “not a single serious adverse event has been recorded in the literature (worldwide) involving a qualified chiropractor treating a child since 1992”.2 However, an examination of the medical literature on adverse events related to chiropractic reveals an interesting story. A PubMed search for “chiropractic adverse event(s)” identifies 18 primary research papers since 1992 that could be classified as examining adverse events, none of which were Australian.

Why are there no Australian reports of adverse events associated with chiropractic manipulation? The answer is strikingly simple — there is currently no adverse events reporting system for chiropractic in Australia. This lack of local data means we have to look internationally to gauge the likelihood of chiropractic adverse events. A 2002 Canadian study3 describes 23 cases of vertebral artery dissection associated with chiropractic manipulation over a 10-year period, suggesting a real risk associated with these techniques.

Adverse event reporting systems are crucial for maintaining quality and safety in health care. Such systems ensure that adverse events are reviewed, thus identifying root causes of error, minimising risk of recurrence, ensuring professional accountability and improving patient care.4 Recognition of adverse events is a fundamental principle of open disclosure, as highlighted by the Australian Commission on Safety and Quality in Health Care.5 Open recognition and analysis of adverse events fosters public trust in health organisations and individual health care providers. Mitigating risk through quality improvement has long been recognised by industries as distinct as aviation, construction and medicine. The chiropractic profession is no more immune to error than any other. A chiropractic adverse events reporting system would bring chiropractors in line with other Australian health professionals and fulfil public entitlement to safe, high-quality care.

Evaluation of the impact of National Breast Cancer Foundation-funded research

The role of charities in supporting health and medical research is substantial. In 2011, Australia’s total federal, state and non-government organisation spending on cancer research projects, programs and infrastructure was $300 million, of which $83 million was awarded by major national cancer research funding charities, including $9 million by the National Breast Cancer Foundation (NBCF).1 With growing competition for the charity dollar, it is becoming increasingly important for medical research charities to demonstrate the outcomes or benefits of the research that they fund and to identify research strategies that are most likely to produce future benefits.2–4

The NBCF was established in 1994, and by early 2012 had invested over $81 million in over 300 Australian-based research projects. The NBCF seeks to invest in breast cancer research that will have the greatest impact, aiming to reduce the burden of a breast cancer diagnosis for all those living with or at high risk of developing breast cancer, and their families. All funds are raised from and within the Australian community. The NBCF’s research investment strategy supports a commitment to funding across the research continuum from basic to applied research, and the translation of research into clinical settings.5,6 In early 2012, the NBCF’s board of directors sought an independent evaluation of its total investment in breast cancer research to identify and communicate the impacts of that research to the Australian community, and to use the findings as an evidence base to inform and guide the NBCF’s future funding strategies.

Traditional approaches to evaluating the benefits of health and medical research focus on impacts on knowledge production and the research system. However, research funders in Australia have increasingly sought to demonstrate the wider benefits of research, such as improved treatments and health gains.7,8 This has resulted in interest in developments such as the Payback Framework, which fuses traditional measures with broader categorisations of the benefits from health and medical research,9 and is internationally acknowledged as the most widely used comprehensive method for assessing returns from research.10–13

The NBCF commissioned the Health Economics Research Group (HERG) at Brunel University to conduct a Payback study to record the range of impacts across its research investment portfolio. It is the first study of its kind of a program of breast cancer research.

Methods

The Payback Framework9 was applied to the portfolio of NBCF-funded research from 1 January 1995 to 31 March 2012. Ethics approval was obtained from Brunel University’s Research Ethics Committee. Data were collected and analysed in 2012 from March onwards.

Data were collected to measure the impact of NBCF research in terms of:

scientific peer-reviewed publications as the central means of sharing knowledge with the research community;
dissemination of knowledge produced to academic and non-academic audiences;
interaction with the potential end users and beneficiaries of research, which increases the scientific and broader impacts of research;13,14
research training and career advancement;
capacity building and critical mass to undertake effective research;
translation of research into clinical practice, evident in changes to health service policy and decision making and best practice in diagnosis and treatment;
development of drugs, prognostic tools or diagnostic technologies;
actual health gain, which is often hard to show, but may be evidenced in changes in the behaviour or practice of health care staff, consumers or the public.

Data sources

Data held by the NBCF

Archival material that was made available comprised a database with descriptive information about all NBCF grants, a database of publications linked to NBCF grants, and copies of grant proposals, annual reports and end-of-grant reports for the case studies.

Survey of chief investigators

A questionnaire was structured around the multidimensional categorisation of impacts in the Payback Framework. It also investigated factors influencing the dissemination and utilisation of research. A total of 242 surveys were sent to the chief investigators (CIs) involved in current and previously awarded grants. This excluded grants that had not yet started or had recently commenced and CIs who were unavailable for personal reasons.

Case studies

Sixteen case studies were conducted to provide validation of data collected from the survey and to supply richer information about the full extent of wider impacts of NBCF research. The HERG compiled a shortlist of potential case studies based on reported high impact in at least one of the Payback categories in the CI survey and high-impact project publications identified in Elsevier’s Scopus database. The case studies were selected using a purposive, stratified approach to ensure all Payback categories were represented across the range of grant types funded.

Each case study included document and archival review, citation analysis, searches for citations in clinical practice guidelines, and semi-structured telephone interviews with CIs. Each case study was described in a narrative account organised according to the stages of the Payback model, and sent to CIs for final validation. All CIs gave informed consent to participate in the study, and approved the narrative accounts.

Bibliometric analysis

Bibliometric analysis of the scientific impact of recent NBCF-linked publications was conducted. This used an existing database of publications from Elsevier’s Scopus citation index developed to analyse the impact of research conducted by the Victorian Comprehensive Cancer Centre (VCCC). Approval was obtained from Elsevier and VCCC for its use in this study. The publication window was the 5-year period 2006 to 2010. Two hundred and sixty-two NBCF publications were identified. The citation window was 1 January 2006 to 1 May 2011. Elsevier calculated world and Australian benchmarks for aggregate citation rates, and thresholds to identify highly cited journal articles.

Results

The response rate for the CI surveys was 63% (153/242). For numbers of not sent, not delivered and non-returned surveys, see Appendix 1 (pdf). The mean grant start date of non-returned surveys was in the range 2004–2005 and returned surveys reported on grants that started in the range 2006–2007. The mean individual value of grants related to returned surveys was $348 096, compared with $170 203 for those related to non-returned surveys. The grants covered by survey responses represented $53 million (66%) of NBCF expenditure.

In the survey data, the balance of funding mechanisms and of applied and basic research was representative of the NBCF’s investment portfolio, as was the focus according to Common Scientific Outline (CSO) classification, except for a slight underrepresentation of “Biology” and overrepresentation of “Cancer control, survivorship and outcomes research” (Box 1).

The mean end year of grants covered by the surveys was in the range 2008–2009, compared with 2007 for all NBCF grants awarded between 1995 and 2012. Of the grants evaluated, 111 (73%) ended from 2008 onwards, and 42 (27%) of all surveyed grants were still in progress when the survey was administered (Box 2).

Case study data provided illustrations of high impact for each Payback category (Box 3). Three case studies are outlined in more detail in Box 4.

Knowledge production

Publications

The bibliometric study found that between 2006 and 2010, the relative citation impact of the 262 NBCF-linked publications was 2.03, double the world benchmark (1.0) and exceeding the Australian average (1.40). The journals in which NBCF-linked publications were cited had an impact of double the world average. The analysis also found almost double the expected number of NBCF publications among the most cited articles (12 in the top 5%).

Dissemination

NBCF grant holders had made considerable efforts to disseminate the knowledge produced to academic and non-academic audiences (Appendix 2 (pdf)). Case studies showed that the findings of NBCF research were broadcast in Australia and internationally through a wide variety of platforms, thereby contributing to the pool of global scientific knowledge, supplying an evidence base for consumer groups, policymakers and clinical practice, and also raising community awareness of breast cancer and related concerns.

Interaction with research users

Data on interaction with research users can be found in Appendix 3 (pdf).

Research system

Research training and career development

As a direct consequence of the NBCF grant, 185 higher degrees were gained or expected, including 121 PhDs, and almost half of CI surveys (70 [46%]) reported career progression for at least one team member, such as promotion or gaining tenure.

Capacity building

The surveyed CIs reported that 101 grants (66%) generated tools for future research that would help to build capacity across the research system, such as new or significantly improved animal models, cell lines, physiological or biochemical markers, assays, models of disease, or validated patient questionnaires.

Targeting further research and attracting further income

The NBCF’s research investment of $53 million in the surveyed grants had generated significant opportunities to attract further funding totalling $74.5 million: for every dollar the NBCF invested, research teams leveraged an additional $1.40.

Informing policy development

The survey found that 15 applied grants had impacted on policy and 32 expected to do so, compared with one basic research grant impacting on policy and 13 expecting to do so. Data on actual and expected wider impacts can be found in Appendix 4 (pdf).

Informing product development

Ten basic grants and four applied grants had led to product development of drugs, prognostic tools or diagnostic technologies. Three applied research projects had informed a broader spectrum of product development; for example, development of a decision aid, a psychological treatment protocol and a sports bra.

Health gain and broader economic benefits

The survey results showed that applied research grants had made the largest contribution to changes in behaviour or practice, with 20 applied grants having realised impacts and 41 expecting to do so, compared with two and 18 basic grants, respectively.

Discussion

This assessment was based on information collected from 153 of 242 completed CI surveys (63%), a comparatively good response rate on which to base valid conclusions.15 The surveys were broadly representative of the whole NBCF portfolio in terms of grant mechanisms, balance of applied and basic research, and areas of focus (determined by CSO coding). Non-returned surveys tended to relate to grants that were older and smaller than those covered in the completed surveys, being on average 2 years older and half the value.

The relatively short time frame that had elapsed since many of the surveyed grants had been awarded or completed, with a demonstrable bias of returned surveys towards grants awarded in recent years, may have limited the assessment of impact, as most grants were yet to realise their promise. This was especially the case for basic research, for which downstream impacts take longer to accrue.14

The study also relied on subjective reporting of impacts in CI survey responses and case study interviews. However, multiple data collection approaches allowed comparisons to be made with objective measures such as citation data on the scientific impact of publications, or the impact of research on policy or practice in the form of citations in clinical practice guidelines. Interestingly, triangulation of data sources showed that in surveys, if anything, CIs tended to underreport the impact of their research, as has been noted in previous studies.4,15

While taking these potential limitations into account, this study, nonetheless, found a wide range of impacts across the Payback categories from citations through to informing policy — consistent with the NBCF’s investment in breast cancer research across the whole spectrum of the disease. It found that a mixed portfolio of research areas and mechanisms favoured a broad range of impacts. Because the NBCF is a community-funded organisation, a focus on generating health benefits to those impacted by breast cancer is particularly important. The evaluation found that applied research was effective in producing changes in policy and in the behaviour and practice of health care professionals, consumers and the public; thus generating wider health and health sector benefits, such as improvements in service delivery. The study found that basic research was more closely linked to impacts relating to knowledge production, and to product development in terms of developing drugs, prognostic tools or diagnostic technologies. It also highlighted that the funding of shared resources such as biobanks and other infrastructure was highly valuable to the research system for both basic and applied research.

The 16 case studies validated the survey data and provided rich illustrations of the full range of impacts.

The study builds on previous published examples of Australian research funding evaluations7,8 by adopting a more systematic, multidimensional and comprehensive approach. This is the first Payback study of a program of breast cancer research. Except for the separately commissioned bibliometric analysis, there are no benchmarking data for comparing the impacts with those of other breast cancer research organisations; however, this study creates a baseline for the future. Research supported by the NBCF attracted funds from other sources, such as state-based Cancer Councils, Cancer Australia and the National Health and Medical Research Council, and direct attribution of impacts to particular funders is complex.

This study is particularly timely as there is increasing pressure on both government and non-government research funders to provide evidence of the wider impacts of research. There is a renewed focus in the university sector on assessing the wider impacts of research, with trials of a proposed new initiative, Excellence in Innovation for Australia (EIA), having recently been completed. Many proponents hope to see EIA sitting alongside the existing Excellence in Research for Australia framework for assessing academic research performance.

1 All National Breast Cancer Foundation (NBCF) grants and grants reported in survey responses, by mode of funding and research type, 1995–2012, and by Common Scientific Outline (CSO) classification, 2000 onwards*

	All NBCF grants, no. (%)	Surveyed grants, no. (%)
Funding mode	n = 313	n = 153

Research projects	231 (74%)	111 (73%)
Fellowships	38† (12%)	21 (14%)
Doctoral scholarships	30‡ (10%)	16 (10%)
National resources	14 (4%)	5 (3%)
Research type
Applied	125 (40%)	66 (43%)
Basic	177 (57%)	84 (55%)
Equipment	11 (3%)	3 (2%)
CSO classification	n = 220	n = 122
Biology	54 (25%)	25 (20%)
Aetiology	22 (10%)	12 (10%)
Prevention	11 (5%)	7 (6%)
Early detection, diagnosis, prognosis	37 (17%)	18 (15%)
Treatment	26 (12%)	15 (12%)
Cancer control, survivorship and outcomes research	51 (23%)	37 (30%)
Scientific model systems	18 (8%)	9 (7%)

* Since 2000, NBCF has classified all grants awarded according to the International Cancer Research Partnership’s Common Scientific Outline. † Includes three top-up grants. ‡ Includes two top-up grants.

2 Distribution of the 153 grants covered by survey responses, by research type and end year of funding

3 Description of case studies and high impact Payback categories

Case study

Research type

Funding

Duration

Cost

Payback categories

A: Novel approaches towards targeting normoxic and hypoxic cancer tissue

Basic

Novel concept award

24 months (2011–13)

$185 200

Product development

B: Germline BRCA1 and BRCA2 mutations in the Australian Ovarian Cancer Study

Basic

Priority-driven collaborative cancer research scheme

35 months (2008–11)

$200 000

Practice/behaviour

C: The development and evaluation of a menopause information tool for young women after breast cancer

Applied

Novel concept award

36 months (2005–08)

$119 784

Policy/decision making

D: Compliance with breast cancer management guidelines and related health outcomes

Applied

Project grant

36 months (2000–03)

$137 045

Health/health service

E: A twin study of mammographic breast density and the risk of breast cancer

Applied

Project grant

24 months (1996–98)

$180 000

Knowledge production; research system

F: c-KIT: a novel target for the treatment of basal-like breast cancer

Basic

Novel concept award

24 months (2011–13)

$200 000

Product development

G: Investigation of the role of the prolactin receptor in mammary gland development and cancer using prolactin receptor knockout mice

Basic

Project grant

24 months (1997–99)

$183 101

Knowledge production

H: Nanoscaled biosensors: reading epigenetic signatures to improve breast cancer diagnosis and treatment

Basic

Priority-driven collaborative cancer research scheme

36 months (2008–11)

$400 000

Research system; product development

I: Novel strategies for prediction and control of advanced breast cancer via nanoscaled epigenetic-based biosensors

Basic

National collaborative breast cancer research grant program

60 months (2008–13)

$5 000 000

Knowledge production; research system; product development; health/health service

J: Multiple perspectives on sexuality and intimacy post-cancer, leading to the development and evaluation of supportive interventions

Applied

Australian research council linkage grant

48 months (2008–12)

$90 000

Research system; policy/decision making; practice/behaviour; health/health service

K: Identification of new therapeutic targets for metastatic breast cancer

Basic

Career fellowship

60 months (2009–2013)

$995 720

Knowledge production; research system; product development

L: Physical activity and breast cancer recovery: research to reality

Applied

Postdoctoral training fellowship

48 months (2005–09)

$260 000

Policy/decision making

M: Physical rehabilitation following breast cancer

Applied

Career fellowship

48 months (2009–13)

$1 000 000

Practice/behaviour; health/health service

N: Breast cancer and pregnancy: how does a concurrent or subsequent pregnancy affect breast cancer diagnosis, management and outcomes?

Applied

Doctoral research scholarship

24 months (2006–08)

$61 200

Policy/decision making; practice/behaviour; health/health service

O: The fertility and menopause-related information needs of younger women with a diagnosis of breast cancer

Applied

Doctoral research scholarship

36 months (2002–2004)

$76 800

Knowledge production; health/health service

P: Breast cancer biospecimen resource

Applied

Enabling grant

36 months (2005–08)

$380 000

Research system

4 Case studies

Case Study G

The aim of the grant was to define the role of prolactin in mammary gland development
15 journal articles 1997–1999 (808 citations)
The prolactin receptor knockout mouse developed is now a widely used model in endocrinology
Provided key preclinical model efficacy data supporting development of antiprolactin receptor antibody for treatment of breast cancer
Drug development by multinational pharmaceutical company now in Phase II clinical trials

Case Study L

The aim of the grant was to investigate the role of physical activity in enhancing functional capacity and quality of life among breast cancer survivors
16 journal articles (289 citations)
> 10 presentations to practitioners and consumer groups
Informed three different sets of clinical practice guidelines issued by professional associations in Australia
Findings adopted in clinical practice
Key public health gain is recognition that treatment-related concerns exist for breast cancer survivors and influence quality of life

Case Study P

The Australian Breast Cancer Tissue Bank (ABCTB) is a research-enabling infrastructure. The National Breast Cancer Foundation grant provided for collection of tissues, blood and clinical data from newly diagnosed patients with breast cancer; distribution of biospecimens and clinical data to Australian researchers; support of translational research
5200 donors, > 100 000 biospecimens collected, 7000 samples accessed by researchers
Around 30 organisations engaged with ABCTB
Instrumental in 20 research teams obtaining grants, ranging from Mayo Clinic (USA) to Canberra Hospital

Impact of the Rural Clinical School of Western Australia on work location of medical graduates

In the face of severe and ongoing medical workforce shortages in rural Australia, initiatives have been introduced to improve recruitment and retention in rural practice.1 These have included pathways for international medical graduates to enter the rural workforce, incentives for existing rural doctors, rural-bonded medical school places, quarantined rural student places in medical schools, scholarships for rural medical students, and undergraduate immersion in rural medicine through rural clinical schools (RCSs). The RCSs were intended to influence the future career choices of medical students and so contribute to a self-sustaining locally trained workforce.

It is clear in the international literature that multiple factors are associated with medical graduates’ career destinations. A prospective longitudinal study of medical graduates followed up 30 years after they graduated showed that selecting rural-origin undergraduates with a declared interest in primary care and providing rural-immersion programs each independently and linearly increased graduates’ likelihood of working rurally.2,3 Rural immersion has been favoured by some programs in the United States.4,5

Based on this collective evidence, the Australian Government initiated RCSs in 2002, with a mandate to produce rural doctors. Participating universities are financially supported to train 25% of medical graduates for at least 1 academic year in a rural setting.

Early Australian data showed that RCS exposure increases graduates’ stated intention to work rurally.6 RCS graduates are also more likely than their peers to work rurally as prevocational doctors,7,8 and studies of small numbers of RCS graduates have found they are more likely to work in rural areas and to have a preference for primary care.9,10 However, longer-term outcomes for large numbers of RCS graduates have yet to be reported.

Here, we report the impact of participation in the Rural Clinical School of Western Australia (RCSWA) on graduates’ rural work relative to their non-RCSWA peers. Our hypothesis was that RCSWA participation is associated with increased rural work.

Methods

The RCSWA commenced at the University of Western Australia (UWA) in 2002, and expanded in 2007 to include the University of Notre Dame Australia medical school at Fremantle. The RCSWA is based at 13 sites across rural and remote WA. Participation in the RCSWA is based on application and an interview that selects those students most informed about the RCSWA and living independently.

For this study, the cohort comprised medical graduates from UWA who completed their fifth year between 2002 and 2009 and graduated by 2010. This ensured graduates were in at least their third postgraduate year at the time of data collection in 2013. Medical students from the University of Notre Dame Australia were not included. RCSWA graduates were defined as those who undertook a fifth-year rural placement. The control group comprised graduates who had not participated in an RCSWA placement. The study was approved by the UWA Human Research Ethics Committee.

Students recruited into the UWA medical school through a quarantined rural pathway were identified as having a rural background. At the time, this was defined as having lived in a rural area of WA (towns > 75 km from the Perth central business district, all of which are classified as rural by the Australian Standard Geographical Classification — Remoteness Areas [ASGC-RA]11) for a minimum of 2 years and having completed Year 12 at a rural secondary school. All other students were classified as having an urban background. The few students who may have come from a rural background but did not enter through the rural pathway were included in the urban-background group.

Between March and June 2013, we accessed information in the Australian Health Practitioner Regulation Agency (AHPRA) database to identify graduates’ work locations. Graduates were designated as working rurally if their primary practice location was in an area defined by the ASGC-RA as RA2–5, and urban if RA1. Graduates with an urban practice address were conservatively considered to be working in an urban location, even though many will have spent part of their year working on rural rotation. A previous comparison of the more detailed RCSWA work location database with AHPRA information showed at least 89% agreement.12

Univariate comparisons were made using the χ2 test for categorical variables and the Kruskal–Wallis test for age, as this showed marked kurtosis and a tail towards the upper range. We used logistic regression to analyse predictors of the probability of working rurally by maximum likelihood estimation. Factors of current age, sex, rural background and RCSWA participation were considered. All interactions between covariates were included, but only interactions between rural background and RCSWA participation remained significant and were included in the final model. Further logistic regressions were run within the RCSWA cohort to identify the effect of covariates independently of RCSWA participation. Analyses were also run within the rural-background group, to identify any independent effect of RCSWA participation. All analyses were conducted using SAS version 9.3 (SAS Institute).

Results

We identified 1187 graduate doctors who had completed Year 5 between 2002 and 2009 (Box 1). After excluding those who had not been eligible for the RCSWA or were working overseas, 1116 graduates were eligible for inclusion in the study. Of these, 99 could not be traced (three RCSWA graduates and 96 controls), leaving 1017 graduates (91.1%) who were included in the study. The 96 control graduates not found on the AHPRA database were not statistically different from other controls by rural background, sex and age.

Of the 1017 graduates, 258 (25.4%) had participated in the RCSWA and 759 (74.6%) were controls. The RCSWA graduates differed from the control group in that more RCSWA graduates were from rural backgrounds, female and younger (Box 2).

Of the 258 RCSWA graduates, 42 (16.3%) were working as rural doctors, compared with 36 of the 759 controls (4.7%) (P = 0.001) (Box 3). Overall, there was no significant association between the proportion of graduates working rurally and the year in which they completed Year 5 of medical school. However, smaller proportions of graduates who had completed Year 5 in the 2 most recent years had a rural work address.

Univariate analyses found significant associations between rural work and RCSWA participation, rural background, sex and older age (≥ 40 years) (Box 4). Further analysis showed that 16.7% (15/90) of those who were aged over 35 years at enrolment in Year 5 were working rurally, compared with 6.8% (63/927) of their younger classmates (P = 0.003).

RCSWA graduates from an urban background were working as rural doctors at a similar rate as those from a rural background who did not participate in the RCSWA (Box 5). There may have been some additional benefit of the RCSWA program for graduates from a rural background, but this was based on small numbers and was not statistically significant (P = 0.28).

The RCSWA was oversubscribed from 2006 onwards by a total of 67 UWA graduates. Unsuccessful RCSWA applicants were not significantly different from successful applicants in terms of sex, age or rural background. However, only five unsuccessful applicants (7.5%) had a rural work address, significantly less than the RCSWA graduates for this period (P = 0.04).

In the final logistic regression model, the combination of having a rural background and participating in the RCSWA was the strongest predictor of being a rural doctor (odds ratio [OR], 7.5; 95% CI, 3.5–15.8), followed by RCSWA participation without a rural background (OR, 5.1; 95% CI, 2.9–9.1) (Box 6). A rural background without RCSWA participation (OR, 4.2; 95% CI, 1.8–9.2) was also significant, as was older age (30–39 years: OR, 2.2; 95% CI, 1.3–3.7 v ≥ 40 years: OR, 6.6; 95% CI, 2.8–15.0). Women remained more likely to work rurally (OR, 1.6; 95% CI, 0.9–2.6), but this was no longer statistically significant.

Further analyses within the group of RCSWA graduates showed that the major factors associated with rural work were age ≥ 40 years (OR, 17.0; 95% CI, 3.3–130.1) and being female (OR, 2.6; 95% CI, 1.2–6.3). Rural background was not independently significant (OR, 1.4; 95% CI, 0.6–2.9).

Within the smaller group of 131 rural-background doctors, no covariate was significantly associated with rural work. However, both older age (≥ 40 years, OR, 4.1; 95% CI, 0.9–17.3) and RCSWA participation (OR, 1.8; 95% CI, 0.7–4.9) may have important effects.

Discussion

While RCS programs are known to increase intention to practise rurally, we found that substantial proportions of RCSWA graduates actually do return to rural areas to practise. The clear increase in the number of graduates practising rurally in this study, if sustained across all RCS programs, will make a significant contribution to Australian rural medical workforce shortages.13

This finding corroborates results of previous smaller studies. Graduates of the Flinders University Parallel Rural Community Curriculum (PRCC) program were overwhelmingly more likely to be in rural work relative to non-PRCC graduates.9 In this small cohort of 29 doctors contacted 5 years after graduation, there was a strong preference for primary care, similar to findings in the North American literature.3 In a study with more detail but also with small numbers, University of Queensland RCS graduates have shown similar positive rural return and preference for primary care.10

We also found that medical graduates from urban backgrounds who undertook an RCSWA year were nearly four times more likely to be working rurally up to 10 years after graduation than those not exposed to the RCSWA. The observed outcome for urban-background RCSWA graduates was as strong as that for rural background alone. It is similar to the previously documented positive effect of rural background on medical graduates’ future rural practice.14 This result is significant, given the limited pool of rural-background students available to be recruited into medicine. Our study demonstrates that some of the substantially larger pool of future medical students from urban backgrounds can also, with appropriate experience, be convinced to pursue a rural career. Qualitative research could explore which aspects of the RCSWA experience are associated with future rural practice.

Our study methods were conservative and are likely to have underestimated rural work, especially for more recent graduates. The finding that fewer graduates from the 2 most recent years had a rural work address is likely related to the limited number of full-year positions available in rural WA for junior doctors. WA has relatively small rural population centres and most junior doctors who work rurally do so on rotation from urban centres. Our unpublished, detailed follow-up of RCSWA graduates documents that many are still in training programs undertaking brief placements in rural areas. These short rural placements are less likely to result in a change of primary practice address on the AHPRA database and hence will not be included as rural work in this analysis.12

Although all cross-sectional study designs have the potential weakness of sampling bias, overall sampling bias is unlikely in this study as we had data on 91% of graduates. Our finding that untraceable controls did not differ from other controls further decreases this likelihood. However, the small sample size of rural-background students who participated in the RCSWA and collinearity between rural background and RCSWA participation meant that statistically significant relationships could not be established. Larger numbers are required to better investigate the possible associations between rural background and rural practice. It would be worthwhile to increase the sampling of rural-background RCS students by including graduates from all RCSs and medical schools in Australia.

It can be argued that RCSWA graduates already had rural practice intentions as medical students and may have practised rurally anyway. However, it has been widely documented that urban-background graduates only become rural doctors in small numbers.2,3,15,16 In addition, our study shows that students who applied for but did not attend the RCSWA were not working rurally in significantly increased numbers. The size of the observed difference on urban-background graduates who participated in the RCSWA suggests an impact that is substantially greater than just initial intention or positivity towards rural practice.

The proportion of RCSWA graduates who returned to rural practice in this study compares well with results from a 30-year-old program in the US, which has a threefold higher return for its selective rural program relative to standard-intake graduates.17 It also compares well with results from several retrospective studies for rural general practitioners having had rural undergraduate experiences (OR range, 2.0–3.7).15,16,18,19

We add to the literature with our finding that women and older graduates are more likely to enter rural work after RCS exposure. Women were initially recruited into the RCSWA in higher numbers and, contrary to findings about mature male practitioners already in rural practice,19 female RCSWA graduates were more likely to enter rural practice, although this did not quite reach statistical significance in our multivariate model. In a field that has been male-dominated, this is a very positive result. Our finding that older entrants were more likely to work rurally is in line with results from the Flinders University PRCC program.9 The increasing numbers of graduate medical programs in Australia may well be good for future rural workforce.

This study is an important addition to the evidence for RCS success in contributing to the Australian rural medical workforce. It provides strong support for the Australian Government to maintain the program and to increase RCS funding to expand the number of places. This would allow increased rural recruitment from the large pool of urban-background medical students. Given the expense of using locums and fly-in fly-out workers to overcome rural workforce shortages, state and territory governments should add to RCS capacity by investing targeted additional funding to increase RCS-based training in sites of greatest workforce shortage. Our finding that the RCS program is producing a new rural workforce indicates this would be well placed.

1 Description of University of Western Australia medical graduates

	Year completed Year 5
	2002	2003	2004	2005	2006	2007	2008	2009	Total

Graduates	131	121	121	109	140	163	193	209	1187
Ineligible for inclusion in study
Ineligible for RCSWA*	4	1	2	2	4	10	13	27	63
Working overseas†	3	0	4	1	0	0	0	0	8
Unable to be traced†	23	13	19	12	7	13	7	5	99
Included in study	101	107	96	94	129	140	173	177	1017
Completed RCSWA year	7	21	28	32	36‡	42	43‡	49	258

RCSWA = Rural Clinical School of Western Australia. * Temporary residents and those with student visas. † From information in the Australian Health Practitioner Regulation Agency (AHPRA) database, accessed March–June 2013. ‡ Excludes two RCSWA graduates in 2006 and one in 2008 who were unable to be located in the AHPRA database.

2 Demographic characteristics of RCSWA and control University of Western Australia graduates

	RCSWA graduates (n = 258)	Control graduates (n = 759)	Total (n = 1017)	P

Working rurally*	42 (16.3%)	36 (4.7%)	78 (7.7%)	0.001
Female	162 (62.8%)	380 (50.1%)	542 (53.3%)	0.004
Rural background	63 (24.4%)	68 (9.0%)	131 (12.9%)	0.001
Median age in 2012 (IQR)	29.0 (27.7–31.2)	30.0 (27.6–32.1)	29.7 (27.6–31.9)	0.007†
Age group				0.006
< 30 years	157 (60.9%)	381 (50.2%)	538 (52.9%)
30–39 years	94 (36.4%)	336 (44.3%)	430 (42.3%)
≥ 40 years	7 (2.7%)	42 (5.5%)	49 (4.8%)

RCSWA = Rural Clinical School of Western Australia. IQR = interquartile range. * Defined as RA2–5 in the Australian Standard Geographical Classification — Remoteness Areas.11 † Based on a Kruskal–Wallis test because the age distribution showed marked kurtosis and a tail towards the upper range. Age was recoded into 10-year groups for further analysis.

3 Work location* of RCSWA and control University of Western Australia graduates

	RCSWA graduates (n = 258)		Control graduates (n = 759)
Year completed Year 5	Rural work location†	Urban work location‡	Rural work location†	Urban work location‡

2002	2 (28.6%)	5 (71.4%)	7 (7.4%)	87 (92.6%)
2003	4 (19.0%)	17 (81.0%)	5 (5.8%)	81 (94.2%)
2004	4 (14.3%)	24 (85.7%)	6 (8.8%)	62 (91.2%)
2005	4 (12.5%)	28 (87.5%)	1 (1.6%)	61 (98.4%)
2006	8 (22.2%)	28 (77.8%)	4 (4.3%)	89 (95.7%)
2007	12 (28.6%)	30 (71.4%)	3 (3.1%)	95 (96.9%)
2008	5 (11.6%)	38 (88.4%)	6 (4.6%)	124 (95.4%)
2009	3 (6.1%)	46 (93.9%)	4 (3.1%)	124 (96.9%)
Total	42 (16.3%)	216 (83.7%)	36 (4.7%)	723 (95.3%)

RCSWA = Rural Clinical School of Western Australia. * From information in the Australian Health Practitioner Regulation Agency database, accessed March–June 2013. † Defined as RA2–5 in the Australian Standard Geographical Classification — Remoteness Areas (ASGC-RA).11 ‡ Defined as RA1 in the ASGC-RA.11

4 Univariate associations for working in a rural location

Number (%)

Odds ratio (95% CI)

RCSWA

Yes

42/258 (16.3%)

3.91 (2.44–6.25)

0.001

36/759 (4.7%)

1.0

Rural background

Yes

23/131 (17.6%)

3.22 (1.87–5.39)

0.001

55/886 (6.2%)

1.0

Sex

Female

51/542 (9.4%)

1.72 (1.07–2.83)

0.03

Male

27/475 (5.7%)

1.0

Age group

< 30 years

30/538 (5.6%)

1.0

0.002

30–39 years

37/430 (8.6%)

1.59 (0.97–2.64)

≥ 40 years

11/49 (22.5%)

4.90 (2.20–10.3)

RCSWA = Rural Clinical School of Western Australia.

5 University of Western Australia graduates participating in the RCSWA and/or having a rural background

RCSWA
participation

Rural
background*

Total

Working
rurally

691

26 (3.8%)

Yes

10 (14.7%)

Yes

195

29 (14.9%)

Yes

13 (20.6%)

RCSWA = Rural Clinical School of Western Australia. * Defined as living in a rural area of WA for at least 2 years and having completed Year 12 at a rural secondary school.

6 Final logistic regression model for working in a rural location*

RCSWA = Rural Clinical School of Western Australia. * Log scale. Bars represent 95% confidence intervals.

Double standards in clinical practice ethics

Is the researcher held to a higher standard than the clinician?

H uman research ethics committees (HRECs) are now firmly entrenched in the research environment. Clinical research, including quality improvement activities, can only be performed and published with HREC approval. Clinical practice, however, is not subject to such approval, yet the risk of harm (to the individual and to society) from clinical practice may be considerable.1 Are researchers being held to a higher standard than clinicians? Has our concentration on ethical standards for clinical research led to an ethical blind spot for clinical practice?

Instances of research-related harm led to the development of ethics committees.2 Rightly, such committees have considerable control over research. However, this control does not extend to clinical practice ethics at their institutions.

Systematic follow-up of treated patients (research) needs ethics approval, yet clinicians can use new techniques and new prostheses (practice) without such approval, provided they do not wish to publish their results. Researchers cannot seek informed consent from a non-English- speaking patient without an interpreter or appropriately translated documents, but clinicians often obtain consent for surgery from the same individuals without these provisos.3 The ethical standards for independent assessment of the effectiveness of a procedure, therefore, are higher than those required for performing the procedure.

Clinical governance over clinical practice exists, but it may not prevent harm or ensure optimal outcomes. Governance in the form of morbidity and mortality meetings and incident reporting occurs after the event, and is largely dependent on voluntary reporting. Although present, guidelines for introducing innovations rely on self-regulation and are subject to individual interpretation.4 When does the modification of an instrument, device, surgical approach or any diagnostic or therapeutic technique become innovative, and therefore subject to formal analysis by research, rather than fall within the realm of professional judgement? For example, several minimally invasive approaches for hip replacement surgery currently exist, but surgeons do not usually request oversight when introducing these techniques. Nor is it usually asked of them, despite evidence of increased complications.5

Even the prospective governance provided by regulatory bodies for device and drug approval may not ensure effectiveness. Approval does not imply effectiveness — it implies only that a drug or device is safe and at least equivalent to current treatments. Mistakes are still made and bias in the assessment and approval of new drugs is well documented.6 In this context, placebo trials are not deemed necessary and neither are large-scale equivalence trials. Mostly, devices only require theoretical and laboratory support to show that they perform as intended in order to be approved. For some procedures, like autologous stem cell injections, testing of effectiveness is not required as stem cells fall outside the regulatory framework reserved for implants and devices.

For research, however, the standards are different. The rationale of the research is subject to scrutiny and research protocols should be beyond reproach. The researcher must seek approval to measure outcomes involving any patient contact and where publication is expected. We suggest that rather than researchers requesting ethics approval for patient follow-up, those charged with clinical governance should demand that clinical outcomes be measured. We feel that not measuring the outcomes of interventions is unethical.

There is a difference between the ethics of research (for the potential benefit of society and future patients) and the ethics of clinical practice (for an individual’s benefit),7 but this does not explain the double standard. Ethical standards for clinical practice are arguably stricter than those for research, yet they are not overseen by ethics committees. The guiding principle covering new or untested techniques in clinical practice is to “do no harm”; if there is uncertainty about a treatment, it should not be performed. Research ethics are such that if uncertainty exists, scientific enquiry should evaluate effectiveness, balancing the (largely individual) harms against any (largely societal) benefits.8

Increased oversight and regulation of clinical practice might delay the introduction of potentially beneficial treatments.9 But surely this is better than inadequately tested treatments becoming so entrenched that it is deemed “unethical” to test them against a control? Ironically, the delay occurs when these interventions are being withdrawn from standard practice because of ineffectiveness or harm.1,10

The ethical standards required for research are indeed higher than for clinical practice. We need to lower the ethical oversight required for some clinical research (particularly for low-risk, quality improvement activities), and raise the ethical oversight of clinical practice. Otherwise the ethical blind spot for clinical practice will persist, while the ethical oversight of its evaluation will remain restrictive.

Nutrition in schools — outdated guidelines need updating

To the Editor: The National Healthy School Canteens (NHSC) project commenced in 2008 to help provide guidelines for healthier food and drink choices in Australian schools. At their core, the guidelines seek to restrict the availability of poor food choices by encouraging the preferential availability of healthy options. These guidelines should ensure the translation of health research and national health curriculum into practice. However,
the current NHSC guidelines are inadequate and fall short of their aims as they rate foods only on energy, fat and sodium, and disregard the sugar content of commercially available foods.

The initial decision to disregard sugar as a criterion for rating foods available in school canteens was intentional. The New South Wales government website states that sugar content was not included “To keep the criteria as simple as possible and to ensure that foods containing naturally occurring sugars . . . were not disadvantaged”.1 Surprisingly, sugar content is not even a criterion for assessing “sugar-sweetened drinks”.2

Excess sugar consumption is associated with type 2 diabetes and obesity. This has been reported in both human and non-human studies and is evidenced by outcomes including fatty liver, impaired glucose tolerance and increased site-specific adiposity. It is of little surprise then, that the most recent update to the Australian dietary guidelines in February of this year included a revision of the recommendation about foods and drinks containing added sugars (Guideline 3).3

Before February 2013, national dietary advice was to consume only moderate amounts of food and drinks with added sugar. This has since
been revised to advise their intake be limited. This shifts foods and drinks containing added sugar into the same category as foods high in fat, salt or alcohol. There is now an immediate need to review policies borne from the outdated national guidelines (such as the NHSC) to include “added sugar” as criteria for assessing the suitability of foods, just as fat and sodium currently are. Until then, the healthy development of our children and hence future health of our nation is at risk.

Notifying a doctor of a first hypoglycaemic episode is associated with a lower rate of recurrence among inpatients with diabetes

To the Editor: Hypoglycaemia is a common problem in inpatients with diabetes and is associated with morbidity and mortality.1,2 We conducted a retrospective single-centre cohort study to evaluate the management (notifying a doctor and taking appropriate preventive actions, defined as altering the hypoglycaemic agent that led to the event or commencing dextrose in appropriate cases by the doctor) of the first hypoglycaemic episode and its impact on recurrence and length of stay.

We evaluated the first hypoglycaemic episode (capillary glucose level < 3.5 mmol/L) of all 915 patients with diabetes admitted to our inpatient ward over 3 months, from January to March 2012. One hundred patients experienced one or more hypoglycaemic episodes and, of these, 57 experienced recurrences. For 19 patients, a doctor was notified of the first episode. Recurrence was seen in six of these patients, compared with 51 of the 81 patients for whom
a doctor was not notified of the
first episode (P = 0.013). Severe hypoglycaemia (< 2.5 mmol/L) was seen in 11/19 patients during the
first episode in the doctor-notified group and in 18/81 patients in the doctor-not-notified group. Age, hypoglycaemic agents, symptoms and after-hours occurrence were similar between groups.

Twelve patients were admitted twice during this time. For 10 of the readmitted patients, a doctor was not notified during the first admission and, for 11 patients, a doctor was not notified during the second admission. Of the doctor-not-notified patients, five and seven in the first and second admissions, respectively, experienced a recurrence. However, none of the doctor-notified patients experienced a recurrence.

Appropriate preventive action was taken for 14/19 patients in the doctor-notified group, compared with 28/81 patients in the doctor-not-notified group (P = 0.002). Recurrence occurred in 21 of the 42 patients for whom appropriate action was taken, compared with 36 of the 58 patients for whom it was not taken (P = 0.31).

Recurrent hypoglycaemia was associated with longer length of stay: 13.5 days v 7.5 days for a single occurrence (P = 0.035).

In our study, 10% of patients hospitalised with diabetes had a hypoglycaemic episode, which is similar to previously documented rates.3 The association between notifying a doctor of the first hypoglycaemic event and a lower recurrence rate highlights the importance of notification and appropriate management of the
first episode. The association with longer length of stay is similar to that previously observed.4 A causal effect is difficult to infer due to many confounding factors and the retrospective nature of the study. As expected, there was an association between appropriate action and doctor notification. The lack of association between appropriate action and recurrences may be due
to small sample size or other factors that were not classified as appropriate action.

A pilot study of an influenza vaccination or mask mandate in an Australian tertiary health service

To the Editor: Health care workers (HCWs) play an important role in influenza prevention. They are at risk of exposure and subsequent illness which can lead to transmission to close contacts and patients.1 Conversely, high HCW influenza vaccination rates can reduce nosocomial influenza, decrease sickness absenteeism and are cost-effective.2,3 Despite this and the increasingly visible voluntary vaccination programs, the rates of influenza vaccination among HCWs in Australia vary between 16.3% and 58.7%.4 The Victorian Department of Health has recently stated that HCW vaccination must be > 75% in 2014.

Monash Health is a tertiary referral service in Melbourne, Australia, with 2200 beds and 13 389 HCWs. The service provides for 1.3 million residents. The Department of Nephrology (DN) provides dialysis and transplant services and employs 208 HCWs. Annual HCW influenza vaccination is undertaken through the Infection Control and Epidemiology Unit, with vaccinations recorded in a secure database. The program is free and incorporates mobile rounds, extended hours and promotion via newsletters and announcements.

To increase influenza vaccination rates in the DN, we undertook a pilot study to understand the feasibility and acceptance of a program requiring HCWs to receive vaccination or wear a mask during influenza season. The study was approved by the Monash Health Ethics Committee as a quality study.

In December 2012, the DN was informed that to increase influenza vaccination rates, unvaccinated HCWs would be asked to wear a surgical mask during patient care throughout the influenza season. Staff were given the opportunity to ask questions about the program and raise any concerns. In February 2013, a follow-up letter confirmed that the program would be enforced, and vaccination commenced in April 2013 (when the vaccine became available).

Overall, 193/208 HCWs (92.8%) in the DN received the vaccine in 2013. This compared with 6873/13 181 (52.1%) for the remainder of Monash Health in 2013 (P < 0.001) and a vaccine uptake of 47% in the DN in 2012 (P < 0.001).

We found that a program that enforced vaccination or the wearing
of a mask had a major impact on vaccination rates. This is the first Australian report of such an initiative. The reasoning behind the use of face masks is twofold. First, it is an incentive, since not being vaccinated equates to a few months of mask-wearing. Second, mask-wearing can be seen as a means of decreasing transmission of influenza in the hospital setting.

The right of an individual to choose vaccination is longstanding and
one that is used by antivaccine campaigners. Poland argued that mandated HCW influenza vaccination is ethically, morally, legally and financially well founded,5 and many health associations support HCW influenza vaccination mandates in the United States. Of note, HCWs in the DN are mandated to have hepatitis B vaccination to protect themselves and patients, and this
is not controversial.

Limitations of our pilot study include the small number of HCWs involved and the fact that unit leadership was strong within the DN, such that our results may not be generalisable. Nevertheless, the program contributed to a vaccination rate far exceeding our expectations. Further studies on the use of influenza vaccination mandates for HCWs in the Australian health care setting are required.

The cost of teaching an intern in New South Wales

In Australia, the first year after medical graduation is called the intern year, a transition between formal medical school education and subsequent vocational training. Its successful completion is a requirement for medical registration.

In New South Wales, the Health Education and Training Institute (HETI), a statutory health corporation, is responsible for setting and monitoring standards for internship and postgraduate training. HETI allocates interns to one of 15 prevocational training networks. Each network provides a mixture of rotations at metropolitan, rural, and regional hospitals to ensure wide clinical experience. Intern training is supervised by Directors of Prevocational Education and Training (DPETs).

Teaching received by interns can be regarded as formal or informal. Formal teaching is organised by the DPET in each hospital, who is assisted by Junior Medical Officer (JMO) managers in each network. It consists of timetabled teaching sessions in protected time, delivered as lectures, tutorials or practical sessions. This requires infrastructure and financial support. Some of this is provided at HETI, such as training grants and the committees and staff required for statewide governance of intern teaching. Some is provided where the interns work, such as JMO managers, education support officers, DPETs, teaching facilities and skills-training facilities.

We defined informal teaching as being spontaneous, non-timetabled and sporadic. It may occur during a ward round, a walk along a corridor or at the end of a consultation. It can be initiated by the intern or the intern’s supervisor as well as registrars, staff specialists and other health care professionals.

Intern education also includes department meetings and grand rounds, which interns may be encouraged to attend but which are not aimed specifically at them. A further mode of education involves the acquisition of skills and knowledge by observation and practical experience. These forms of education were not included in this study.

The aims of this study were to determine: the salary-related and infrastructure costs of timetabled, formal teaching provided specifically for interns; the amount of non-timetabled informal teaching received by interns and its salary-related cost; the total cost per intern of providing teaching, by combining these estimates; and how much of an intern’s time is committed to formal and informal teaching.

Methods

Formal teaching

The cost of formal intern teaching for 2012 was estimated by HETI after wide consultation with administrators, educators and clinicians within HETI and the prevocational training networks. It included costs of medical and administrative staff responsible for the organisation and local delivery of formal, timetabled intern teaching, infrastructure costs and governance costs. In NSW, the prevocational training program manages teaching for resident medical officers (RMOs) as well as interns, but costs were allocated on a pro-rata basis depending on what proportion of the program was allocated to intern teaching. Time involved in preparing teaching sessions was not included.

A telephone survey of JMO managers in the sampled networks (see below) was conducted to determine the number of hours of formal, structured teaching provided each week for interns in their networks.

Informal teaching

The salary-related cost of non-timetabled teaching was estimated from a self-completed internet cluster sample survey of interns in May 2012. The clusters were the 15 prevocational training networks. These were numbered sequentially and a sample of five was drawn by random numbers. During 2012, the total number of interns in the 15 networks was 870. Every intern within each of the five sampled networks was invited by email to participate in the survey. Those who agreed were sent an online survey form that asked for separate estimates of the amount of non-timetabled teaching received in a typical week during their current rotation from five categories of teacher:

RMO, registrar or Fellow;
general practitioner;
visiting medical officer (VMO), staff specialist or university academic;
nurse;
allied health or other professional.

Respondents could report an estimate of teaching time received in steps of 5 minutes, ranging from zero to 60 minutes, then in categories of 1.5 hours, 2 hours and 3 or more hours. Those who had agreed to participate but who did not complete the survey initially were reminded on two occasions.

The times reported for each category of teacher were summed across all respondents and the total multiplied by an appropriate hourly dollar rate to give an estimated weekly total dollar value for each teacher category. These were then summed over all teacher categories to give an overall estimated weekly total cost for the whole sample. The various hourly rates were determined as follows. As the senior staff specialist rate1 with all on-costs is about midway between the VMO (specialist) rate2 and the senior academic rate3 with on-costs, the senior staff specialist hourly rate ($160.06) was used for calculating the value of teaching by these three groups. The GP rate ($167.35) was based on the NSW Health Award 2012 rate for a GP with at least 5 years’ experience.2 Junior hospital staff teaching costs were based on the second-year registrar rate plus on-costs ($58.31).4 Because of the variation between different awards for nursing, allied health and junior hospital staff, the junior hospital rate was used as an approximation for these three groups.

Results were expressed as total time or dollar values, means and standard deviations or medians as appropriate. Confidence intervals were at the 95% level.

The study was approved by the University of Sydney Human Research Ethics Committee.

Results

Formal teaching

For 2012, HETI estimated the expenditure provided by the NSW Ministry of Health for the teaching of 870 interns to be $10 345 829 (Box 1), equivalent to $11 892 for each intern.

The telephone survey of JMO managers showed that an intern received an average of 2 hours of formal, structured teaching. This figure validated the 0.25 days per week (2 hours) provided by HETI for formal teaching sessions.

Informal teaching

Of the 243 interns in the five sampled networks, 154 responded, giving a response rate of 63%. The response rate differed significantly among the networks (P = 0.001; χ2 test), ranging from 45% to 79%. In all networks the distributions of estimated total weekly teaching time were distinctly positively skewed with maxima ranging from 75 to 255 minutes but medians ranging from only 20 to 30 minutes (Box 2). The overall weekly median was 28 minutes, with no significant difference among the five networks (P = 0.21; Kruskal–Wallis test).

The 154 respondents received a total of 101 hours of teaching per week. Slightly over half (51.4%) of the total teaching time was from RMOs, registrars or fellows, and slightly over a third (34.5%) was from VMOs, staff specialists or academics. Slightly less than 10% (9.3%) was from nurses, and less than 1% (0.7%) was from GPs. Allied health and other professionals contributed slightly less than 5% (4.3%). At the relevant hourly salary rates for the various categories of teacher, the total cost of informal teaching to the 154 sampled interns in a typical week was $9513 (Box 3). Assuming 48 working weeks per year, the annual cost of providing informal teaching for the 154 interns sampled was $456 624, or $2965 per intern.

The combined cost of formal ($11 892) and informal ($2965) teaching was $14 857 per intern per year.

The time allocated to formal intern teaching (2 hours per week) and the median for informal teaching (28 minutes per week, Box 2) show that in the networks sampled, 2 hours and 28 minutes of teaching was received by interns each week. Assuming a 40-hour working week, this amounts to 6.2% of their time.

Box 4 shows how the total cost would increase if a proportion of an intern’s salary was considered to be a teaching cost. For example, assuming that an average 20% of an intern’s time was spent receiving teaching would add an additional $15 303 to the cost, totalling $30 160.

Discussion

Most of the $14 847 overall cost of teaching an intern was for formal teaching ($11 892), and most of this was provided by professionals (staff specialists, VMOs, nurses and clinical academics) whose payment came from NSW Health. Relatively little was provided by university-paid staff.

The cost is based on an assumption that none of an intern’s salary is related to teaching and that the intern performs a service role only.

Alternatively, it could be argued that part of the intern salary is a teaching expense, with intern work being part of their education rather than for service provision. For example, in the emergency department, interns are effectively supernumerary: their work provides them with invaluable educational experience, but adds little to patient throughput. In contrast, in surgical wards, interns free residents and registrars from clerical and ward duties and increase total work capacity. The real contribution of interns to work productivity in health services would require a different study.

There is much more involved in intern education than the formal and informal teaching considered in this study. The intern’s experiential learning includes observation, self-learning practical experience, self-reflection and the influence of role models. The importance of these experiences should not be underestimated.

NSW Health makes a significant contribution to medical student teaching as well as intern teaching. At Sydney Medical School, we recently showed that the cost of medical education was $90 576 per student per year. The cost to the university was $56 250 and the cost of non-university-paid staff (mainly from the NSW Health Department) was $34 326 per student per year.5,6

Considerable concern has been expressed in Australia and overseas that relatively little time is spent on education during the intern year,7–16 and it has been suggested that the intern year should have a greater educational emphasis than service emphasis.15 There are few estimates in the literature of the proportion of interns’ time devoted to education. It has been reported that, on average, junior doctors in the Netherlands spent about 5% of their time per week receiving organised formal education.7 In the United Kingdom, junior doctors’ spent most of their time on routine work and most considered that training constituted less than 10% of their working time.11 A survey of Australian junior doctors found that half spent 1–2 hours per week receiving education, and 10% reported spending no time receiving education, including bedside teaching, tutorials or grand rounds.9

Regarding a 2009 survey of junior doctors conducted by the Australian Medical Association (AMA), the chair of the AMA Council of Doctors in Training concluded,

We are concerned that the survey shows that the obligation of hospitals to teach and train junior doctors is being outweighed by the demand for service delivery, and this trend is worsening.17

Workload issues are regarded as a major factor in reducing the emphasis on education.7,10,12,15,16 This is not helped by the fact that the Medical Board of Australia currently has no minimum attendance or participation requirements to qualify interns for progression to general registration.18 However, the Australian Medical Council is currently completing work for the Medical Board of Australia aimed at providing a standard framework for intern training in the national registration and accreditation scheme which came into effect in July 2010.19

Our finding that 6% of an intern’s paid time is spent in formal and informal teaching is consistent with these findings. It is in stark contrast with the recommendation of the Special Commission of Inquiry in its final report on acute care services in NSW public hospitals that prevocational clinical staff in Year One should spend a minimum of 20% of their ordinary rostered time participating in training programs.20 This recommendation recognises that better education will enhance patient care.

Considerable public benefit could result from intern positions being restructured so that 20% of interns’ time was spent receiving formal and informal teaching: doctors would be better trained and more competent; medical errors would be fewer; and the care of patients managed by interns would improve.21 However, this raises the question of who would pay for this additional teaching, as well as the problem of finding the required extra number of interns to provide a service role if 20% of their time were devoted to education rather than direct service.

Quarantining 20% of intern time for education would require hospitals to increase their intern numbers. This would help to resolve the current imbalance between new graduates and available intern posts.

However, there would be a cost. The first step in determining this increased cost would be to unravel the current cost of intern training. Understanding the true cost of intern training is complex, as some of it is hidden within the cost of providing clinical services. While we have looked specifically at formal and informal teaching costs, the current work of the Independent Hospital Pricing Authority may be able to “unbundle” some of the hidden education on-costs, resulting in a suitable mechanism to provide activity-based funding for education and training.

A component of activity-based funding for intern education and training would defray some of the cost of increased intern positions. This would be a federal government contribution, similar to the federally funded direct and indirect graduate medical education payments provided to hospitals in the United States.22

It could be argued that universities could also contribute to better intern education if universities saw their medical degree courses as just one step in the medical education process.

Finally, private hospitals could fund some intern positions. Interns are now taking up positions in private hospitals, some supported by federal funds. Private hospitals would benefit from the service interns could provide and be expected to contribute to their training costs.

Whatever funding mechanism is determined, it should be recognised that adequate funding of intern teaching is an investment in the future, as many of these interns will continue to provide services to patients in hospitals in NSW and other states throughout their professional careers.

1 New South Wales Ministry of Health costs for intern teaching*

Item	Proportion towards intern teaching	Amount ($)	Basis for calculation

Expenses at HETI
HETI Medical Director	20%	$86 564	Senior staff specialist with 30% on-cost plus private practice allowance
Accreditation program and surveys	66%	$901 825	Salaries, expenses and overheads
Clinical Chair, accreditation	66%	$43 948	Senior staff specialist plus all costs, 0.2 weeks
Prevocational training program	66%	$316 680	Salaries, expenses and overheads
Clinical Chair, training council	66%	$54 935	Senior staff specialist plus all costs, 0.25 weeks
Prevocational training grants	66%	$548 055	Subsidy from HETI for prevocational training costs
Intern assessment process	100%	$11 597	Printing, distribution and collection of forms
Prevocational committees	66%	$50 708	Secretariat and committee members’ time
Expenses at workplace
JMO managers and support officers	66%	$1 853 280	2 days/week at 60 sites at $90 000 per annum
Term supervisors for interns	100%	$1 976 279	Average of 1 day of work/term
Directors prevocational education and training	66%	$1 948 878	0.8 days/week at 60 sites, senior staff specialist plus all costs
Intern training committees	100%	$48 447	Committee members’ time
Formal education sessions specifically for interns	100%	$998 810	0.25 days/week at 60 sites, senior staff specialist plus all costs
Orientation, venepuncture, cannulation and plastering training	100%	$875 163	Staff time plus disposables
Teaching facilities	100%	$870 000	Infrastructure, maintenance and depreciation, estimated at $1000 per intern
Total		$10 345 829

HETI = Health Education and Training Institute. JMO = junior medical officer. * Workforce-related costs, such as intern allocation, intern accommodation while on rotation, and human resources management of interns are not included in these calculations.

2 Distribution of total teaching time (min) over the five categories of teacher among the five sampled networks

Network	Minimum	Maximum	Median	Skewness

A	0	200	20	2.5
B	0	165	25	2.0
C	0	75	30	0.5
D	0	255	23	2.7
E	0	180	30	2.1
Median	–	–	28	2.5

3 Estimates, by 154 interns who responded to the survey, of non-timetabled one-to-one or small-group teaching received in a typical week of their current rotation

Provider of teaching	Received teaching, no. (%)	Did not receive teaching, no. (%)	Total hours/week (% of overall total of 101 hours)	Hourly rate	Total cost/week

Resident medical officer, registrar or fellow	129 (83.8%)	25 (16.2%)	51.9 (51.4%)	$58.31	$3026
General practitioner	3 (2.0%)	151 (98.0%)	0.7 (0.7%)	$167.35	$117
Visiting medical officer, staff specialist, or academic	115 (74.7%)	39 (25.3%)	34.8 (34.5%)	$160.08	$5571
Nurse	61 (39.6%)	93 (60.4%)	9.4 (9.3%)	$58.31	$548
Allied health professional or other professional	23 (14.9%)	131 (85.1%)	4.3 (4.3%)	$58.31	$251
Total	–	–	101.1	–	$9513

4 Cost of intern education, by proportion of an intern’s salary considered to be teaching cost

Proportion of intern salary* considered as teaching cost	Formal teaching costs (HETI and health services)	Informal teaching provided during work hours	Total cost of intern teaching

0	$11 892	$2 965	$14 857
10% ($7 651)	$11 892	$2 965	$22 508
20% ($15 303)	$11 892	$2 965	$30 160
30% ($22 954)	$11 892	$2 965	$37 811
50% ($38 257)	$11 892	$2 965	$53 114

* $76 515 per annum including on-costs. HETI = Health Education and Training Institute.

Australia is continuing to make progress against cancer, but the regional and remote disadvantage remains

Correction

Incorrect footnote: In “Australia is continuing to make progress against cancer, but the regional and remote disadvantage remains” in the 4 November 2013 issue of the Journal (Med J Aust 2013; 199: 605-608), there was an error in Box 2 (page 607). There should be two separate footnotes for Box 2A and Box 2B: the footnote to Box 2A should state “Based on age- and sex-specific rates for metropolitan areas”, and the footnote to Box 2B should state “Based on age- and sex-specific rates for Australia for 1997–2000”.

There was also an error in the year groupings described in the Methods (page 605). This should read: “The expected number of deaths was obtained by applying the 5-year age- and sex-specific mortality rates for 1997–2000 to the corresponding age- and sex-specific populations for each subsequent year through to 2010.”