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Preference: Administration and Health Services

2

Medibank putting profits before patients, says AMA

The nation’s largest health insurer has been accused of putting profits before patients amid revelations that it has refused to cover the medical expenses of a mother who dies in childbirth.

AMA President Professor Brian Owler told the National Press Club that maternal death in childbirth was one of the more than 150 ‘preventable’ clinical conditions Medibank Private was refusing to cover in hard-ball negotiations with private hospitals.

The AMA President said maternal death during childbirth, while rare, did happen, and Medibank’s position was “offensive” and betrayed a lack of understanding of medicine and the motivations of doctors and other health workers.

“I find it offensive that a private insurer would refuse to cover the costs of that patient and hospital in such a tragic event,” he said. “If someone thinks that a financial incentive will motivate doctors, nurses or anyone else in a hospital to prevent maternal death any more than they desire to do so now, then they have no understanding of medicine or the people in it.”

“They are putting shareholders before patients.”

The issue blew up last month after Medibank abandoned negotiations with the Calvary Health group on health cover.

Calvary was resisting Medibank demands that it pick up the tab for treating 165 medical conditions the insurer claimed would be caused by incompetence or neglect in the care patients received.

Medibank has argued that by insisting on a long list of exclusions, it is encouraging private hospitals to lift their standards of care. And it has received the backing of rival insurers Bupa and NIB, which argue it is time to hold hospitals to account for poor or inappropriate care.

Senior Bupa executive Dwayne Crombie told The Australian that insurers would take an increasingly hard line with private hospitals over costs: “I think you are going to see much blunter discussions. I totally support Medibank’s approach, and we would think similarly”.

NIB Chief Executive Mark Fitzgibbon told the same newspaper that “the trick here is to transfer the risk of poor quality to the person best placed to manage that risk, which is clearly the hospital. It’s right that the hospitals take that risk”.

But while the AMA accepted that hospitals should be held accountable for avoidable errors such as operations on the wrong limb or using the wrong blood type in a transfusion, Professor Owler said trying to avoid responsibility for complications like deep vein thrombosis that can and do arise despite the use of extensive preventive measures, was wrong.

The AMA President said the Australian Commission on Safety and Quality in Health Care already regulated the safety and quality of health care, and there was no evidence to support the items on Medibank’s list.

“What we should be doing is waiting for the evidence to come forward and then make recommendations. That is not what Medibank are doing,” he said.

A Medibank spokesman told News Corp the insurer rejected the criticism and said it would be rare for a hospital not to cover the cost when a mother died in childbirth, and if this did occur the insurer would “vigorously contest” the decision on behalf of its members.

“We understand it is a common industry practice not to pay for this event, because it is rarely charged,” the spokesman said.

The AMA President said the insurer’s decision to walk away from its talks with Calvary Group, which meant Medibank Private members would no longer be covered for treatment at the group’s hospitals, was in keeping with a shift in the health fund’s focus since being privatised from patient care to shareholder returns.

He said it was clear Medibank’s intention was to simply to shove costs off its books and instead dump them onto private hospitals, and would have the effect of forcing the most complex clinical cases onto the public hospital system.

Already, there is a well-established trend for private patients to be treated in public hospitals.

Figures released by the soon-to-be- abolished Private Health Insurance Administration Council show that public hospital admissions of privately insured patients surged from 20.9 per cent in 2003 to 28.8 per cent last year, and patient volume growth in public hospitals outstrips that in the private sector.

Professor Owler warned the Calvary hospital stoush was part of an aggressive and unwelcome push by Medibank to have a much greater say in the provision of care.

He said the nation had been well served by a private health insurance system which was open to all, regardless of health status. Under industry rules, patients can join the health fund of their choice even if they have a pre-existing condition, and they cannot be denied coverage (the principle known as community rating).

But the AMA President expressed concern that Medibank was trying to drag the system down a path toward US-style managed care, in which insurers were able to dictate what doctor a patient saw, and what sort of treatment they received.

“A US-managed care system is a system that places an enormous administrative burden on the patients and on the practices,” he said. “It actually increases costs and, at the end of the day, the only one that wins is the insurer. We don’t want to go down that system.”

“[But] I am concerned that as Medibank Private, given its float and new direction, that we are slowly heading towards that direction.”

While the private health insurance sector was not uniform, and mutual funds operated to benefit members, Professor Owler said Medibank’s relentless cost-cutting could create competitive pressures that would undermine the ability of other insurers to maintain their level of coverage and services.

Mr Crombie said that although Bupa did not have shareholders, it was facing cost pressures similar to those driving Medibank.

Adrian Rollins

 

 

Doctors ‘obliged’ to speak out on asylum seeker health

AMA President Professor Brian Owler has accused the Federal Government of trying to intimidate doctors and other health workers from speaking out about the treatment of asylum seekers being held in immigration detention centres.

The AMA President has mounted a strongly-worded attack on controversial provisions in the Government’s Border Force Act aimed at gagging whistleblowers amid mounting claims that many detainees – including children – have been sexually and physically abused while in custody.

Professor Owler said doctors were ethical and morally obliged to advocate for the welfare of their patients, and the new laws – which threaten up to two years imprisonment for unauthorised disclosures – placed them in an invidious position.

“As doctors, we have an ethical and moral obligation to speak out if we have concerns about the welfare of our patients, whether it be the treatment of an individual or whether it be at a system level,” he said.

Asked if the AMA was advising doctors to refuse to work in detention centres under these conditions, the President said that it “wouldn’t matter what I said, I suspect. I think doctors would vote with their feet and they would go and provide health care to asylum seekers, because that’s what they do”.

“Doctors will always go and look after the patient, and they will put their own interests second.”

The apparent attempt to gag critics has come against the background of ongoing reports of abuse and assault at detention centres.

The independent Moss review of allegations of abuse at the Nauru detention centre, released in March, found evidence of rape, the sexual assault of minors, and guards trading marijuana for sexual favours from female detainees.

Despite this, a separate Senate committee inquiry heard last month that no detention centre staff accused of abusing children have been charged.

Transfield, which has a $1.2 billion contract to operate the Nauru and Manus Island detention centres, said that of 67 allegations, just 12 had been referred to police.

In other testimony, a former senior doctor with Immigration Department contractor International Health and Medical Services, Dr Peter Young, told the Senate committee that medical staff were directed not to report mental health problems.

Dr Young, who was director of mental health for IHMS, said he was told several times not to report that asylum seeker mental health had been harmed by being detained at the Nauru detention centre.

Separately, the Government-appointed Council on Asylum Seekers and Detention has been told that detainees begin to suffer serious mental health problems within three months of incarceration.

Immigration Minister Peter Dutton has sought to provide assurances that health workers who spoke out would not be prosecuted under the Act, but Professor Owler said much more was needed.

“The AMA has been concerned about the provision of health care to asylum seekers, particularly those in the offshore processing centres of Nauru and Manus Island,” he said. “Legal advisers have confirmed that the Act provides penalties, including potential imprisonment for doctors, nurses and other health workers who speak out about abuse or the wellbeing of asylum seekers.”

Professor Owler said that if medical whistleblowers were not liable for prosecution, then “it should be clearly and directly spelt out in the legislation”.

“We call for this exemption because, for a doctor, an asylum seeker is no less a patient than any other patient. If we are willing to compromise the rights of doctors and patients for one group, how can we ensure that other groups will not be compromised in the future?” he said.

Adrian Rollins

 

Foreign aid cuts a health disaster for many

As a final-year medical student, I am the first person to admit that I’ve been very fortunate so far in life.

Most of these blessings are facets of our rich, first-world society – free, high-quality health care and cheap tertiary education, not to mention the basics that I take for granted every day like somewhere to live, food and clean water.

Sometimes, though, it can become easy to forget two things. Firstly, I did nothing to deserve these blessings. Secondly, billions of people around the world are less privileged than I am. For these reasons, I am thoroughly disappointed in the $1 billion cuts to foreign aid announced in the recent Federal Budget.

Under the previous Labor government, Australia had a bipartisan commitment to contribute 0.5 per cent of its Gross National Income (GNI) to foreign aid, though this was delayed several times.

Little did we know at the time that the 0.38 per cent of GNI level reached at the time Labor left office would be the peak.

Since then, a succession of major Budget cuts by the Coalition Government have driven to our foreign aid contribution down to the point where we are now only giving 0.22 per cent of our GNI.

These cuts fly in the face of the 0.7 per cent of GNI commitment Australia agreed to at the UN in 1970, and which has been repeatedly reaffirmed ever since.

Meanwhile, our counterparts in the UK have recently passed a Bill legally ensuring that they will continue to give at least 0.7 per cent of GNI as aid.

Doctors and medical students alike should be unequivocally outraged.

Our profession is one in which we are privileged to have the opportunity to help people each and every day.

In medical school, we are taught that it is essential to be an advocate for our patients, especially those who have no voice. We must apply this principle to the people of the developing world and fight for effective altruism.

The recipients of Australia’s development assistance have no real means by which to communicate their needs with our government, but doctors can take up this mantle. Of course, various advocacy groups are already doing this. However, it is clear that current efforts are inadequate.

We need to face the facts – these aid cuts will equate to lives lost. Real people with families will die. Australia’s foreign aid provides vital health services in developing countries, as well as emergency assistance to other countries when disasters strike, such as the recent earthquakes in Nepal.

If Australia, one of the most economically developed countries in the world, refuses to provide these funds to countries in our region, who will?

We tend to forget it, but giving aid also benefits us.

Along with the obvious advantages of diplomatic relations associated with generous aid, Australia should leverage its expertise as a leader in tropical diseases to fight the epidemic of tuberculosis in Papua New Guinea, or else the consequences might spread to our shores. Instead of diverting our aid money to offshore detention programmes for refugees, we should invest in developing countries to alleviate poverty and assist displaced people whose lives have been torn apart.

It is the responsibility of doctors to advocate for not only the health outcomes of Australian citizens, but those individuals without the good fortune to be born within our sunny borders. Foreign aid is an essential component of Australia’s contribution to global health and wellbeing, and must be consolidated rather than compromised.

Nicky Betts is a final year medical student at the University of Western Sydney, and Vice-Chair External of AMSA Global Health.[1] [2] [3] [4] [5] 

Can I jump puddles alone?

The young man was determined to walk at his graduation ceremony. The background to the television news report was that the young man had been severely disabled. The word paraplegic was not mentioned — only his determination to walk and, almost incidentally mentioned in the report, that he had a wife. When the picture came on the screen, he rose out of his wheelchair and, with his wife supporting him from in front as though he were a statue, he tottered a few steps across the stage. No, he had not walked — his carer had borne his weight and, even though she was half his size, she had held onto him while he made the small distance across the stage. Then the news item was over: no attention to the wife’s efforts, and no watching him struggle back to the wheelchair (the wheelchair had probably been moved into a position to avoid the need). He had said that he would walk to obtain his graduation certificate. It was the gritty devotion of his wife — his carer — that enabled him to do it. Good luck — hopefully he will improve; but what struck me was the essential importance of the carer and how little reference was made to her in the news item.

Likewise, had I not had my wife and others to care for me, I would not have been able to work full-time.

I hate being in a wheelchair. Not that I am in a wheelchair that much, but when I have to move more than 100 metres it becomes very difficult without one. What is wrong with the wheelchair? Nothing. I have been surprised by the comfort that a modern wheelchair affords. However, you become a different human being in a wheelchair. Until you make it clear that being in a wheelchair does not mean that your IQ is automatically halved, you tend to be ignored or treated as a child. I remember sitting in my wheelchair and being confronted by a small boy in a stroller. We were at a similar eye level and he, with the ingenuousness of a child, stared at me. To this I responded, “Son, see what awaits you.” His parents laughed, but I wondered whether they continue to deny the 5-year-old the use of his legs.

The other option is that you exist in a forest of legs belonging to the able-bodied. You become acutely aware of that facility to walk, which you considered to be an automatic right of homo sapiens. It is compelling to watch the easy facility of movement that you have lost. Watching the striding young man or woman clasping the iPhone to the ear brings home the sheer complexity of the evolutionary trail. There is plenty of time to observe when you are waiting in a wheelchair.

This waiting time is emphasised if you happen to be one of those people who has been both impatient and fidgety. In a wheelchair, impatience is not a wise strategy. Gesturing irritably — especially with a walking stick — is counterproductive!

Likewise, you cannot act on impulse — jump up and do something. Getting to your feet is a considered exercise. In other words, it is the carers who count in such an environment. Their understanding of the required level of background support is crucial.

This was brought home recently when I decided to walk along the Seattle waterfront from the ferry terminal to the hotel. The Seattle waterfront is undergoing massive reconstruction and therefore hailing a cab is difficult and, in any event, I misjudged both the distance and my capacity. The small boy had decided to get out of his stroller. For about 50 metres with two sticks, it was bearable. However, as I moved forward, the uneven asphalt became jolting potholes; improvised inclines, minor to the able-bodied, are challenging ski runs. I struggled, and my carer kept watch for an hour, hovering and supporting, without saying how stupid I was.

The occasional person, invariably a young woman, stopped to ask whether I needed help. For an hour, I moved along, away from the dusty, sulfurous fumes and clanging steel of the waterfront, onto quiet civilised pavement. The hotel was in sight and, as usual when walking with sticks, my eyes were mostly directed towards the terrain. What made this segment better was the line of copper beeches; I could count them as I passed each one. I remember when I ran those inaptly named “fun runs” and was getting tired, it was the next telegraph pole in the street or on the highway that was the marker of achievement.

My carer, who had been ever present, suddenly asked whether she could go and get the wheelchair from the hotel since the footpath was paved and the hotel was not more than 200 metres away. She had picked the right moment. I agreed and she disappeared as I slogged on with the vain hope that I would get there before she could bring back the wheelchair. The definition of bliss is being propelled in a wheelchair up to and through the hotel foyer and to the bar for a cold ale.

Caring, as I have found out, and the interaction with the person in care are things that you see; but, unless you are in the situation, you may not feel the importance of that interaction.

However, caring is not the exclusive preserve of some professional group or a financial benefit enshrouded in impenetrable regulation. It is a basic tenet of our society.

It is up to those who are disabled but articulate to advocate for a better deal, not only for the disabled, but also for the carers. Neither the carer nor the person being cared for live in parallel. However, a challenge remains: how best to translate that interaction between those who have the interpersonal skills intuitively and those who need to learn the skills to improve the interaction. The internet seems to be full of exhortation as to what is best for the disabled, but there does not seem to be much room for interactive comment.

Yet 300 000 carers are younger than 24 years.2 I have a 14-year-old grandson who, without prompting, brought me a chair when I needed to sit down. He knew without any words being exchanged what was wanted, because he was paying attention to his environment rather than a piece of technology. As against this was a young girl of similar age, head down and concentrating on her texting, who pushed past me into the lift. Suddenly there was a scream of anguish as the door closed on her. It was fortunate that it was not a railway crossing — or a puddle that turned into a fathom-deep pond.

Actual availability of general practice appointments for mildly ill children

There are concerns that there may be shortages in the Australian primary care workforce, especially in rural and regional areas. However, some have suggested that a shortage of general practitioners is also a problem in metropolitan areas.1 In some outer suburbs of Melbourne, residents have reported significant difficulty in acquiring a medical certificate for sick leave in a timely manner, and that waiting 2 weeks for a doctor’s appointment is common.2 Similarly, some GPs in Melbourne have reported having to close their books due to excessive demand, with one doctor stating he had to turn patients away for 2 years3. Even in some inner-city Melbourne practices, doctors have reported having to close their books, and hearing from patients that they have had to telephone four or five clinics just to obtain an appointment.4

An actual or perceived lack of availability of primary care appointments may contribute to the increased rates of attendances at hospital emergency departments (EDs), as patients seek alternative ways to reach health care providers. Attendances at EDs are increasing at a rate exceeding population growth, and there is a perception among hospital staff that a significant portion of attendances are for conditions that do not require the urgent or specialised services that such departments provide.5,6 While some ED visits are for serious acute conditions some of which result in hospitalisation, a large number could be treated in a primary care setting.6–8

Many hospital EDs are experiencing a severe strain on their limited resources, as evidenced by chronic overcrowding and long waiting periods.9,10 Thus, ensuring that primary care practitioners are sufficiently available and accessible in the community is essential for both individuals and the health system as a whole. This would help patients with urgent conditions receive more timely treatment in hospitals by reducing demand for ED services, while those who do not require emergency treatment would benefit from the continuity of care and preventive services available in the community.11

Understanding the true availability of the primary care workforce for the population is necessary to determine whether a shortage actually exists. Projected models of supply and demand for the primary care workforce do indicate a possible shortage of practitioners.12 However, beyond head counts of providers, there are few data that provide more than anecdotal reporting of primary care workforce supply and demand in Australia. For example, in 2009 the Australian Bureau of Statistics found that, in 1 year, about 937 800 people reported they had been unable to access health services when they needed them. Of the 82% who were attempting to access general practice services, 47% cited long waiting periods or a lack of available appointments as the main reason for lack of access.13 A study of an outer metropolitan region in Western Australia found that 59% of people had reported difficulty in obtaining GP appointments, citing lack of appointments, long waiting periods and inconvenient hours.14 Although indicative, such data are of limited use in assessing the actual availability and accessibility of services, given their focus on modelled data or on patient recall of health service access. No previous studies have provided a real-time assessment of GP availability or appointment charges from the patient’s perspective.

The lack of such data hinders adequate policy responses to ensure that the needs of the population are met. We undertook this study specifically to help fill this gap. We focused particularly on children because previous studies have shown a decrease in the proportion of GP visits specifically provided to children over the past 2 decades.15

Methods

We used “secret shopper” techniques, a well known and often-used method to determine the actual versus reported availability of physician appointments.16 This involved having research assistants pose as parents and telephoning general practice clinics seeking treatment for children with non-urgent, low-acuity conditions. The study was conducted between 1 August and 30 September 2014.

Sample

The sampling frame included all GPs working within the catchment areas of three Medicare Locals in the greater Melbourne metropolitan area. The Medicare Local catchments included urban, suburban and regional areas. Each Medicare Local provided contact details of all GPs within their catchment areas. A random sample of 225 practices were contacted, 75 from each Medicare Local list.

Data collection and analysis

Same-day appointments were sought for paediatric patients based on one of two clinical scenarios, each of which was designed to present non-urgent, low-severity conditions appropriate for general practice. The scenarios were developed with the help of two clerical staff from two general practice clinics and two GPs from other practices. The scenarios were:

  • a 3-year-old child with an earache and a mild fever; and

  • an 8-month-old with a slight cough, runny nose and mild fever.

Research assistants telephoned clinics between 9:00 am and 12:00 pm on weekdays to maximise the likelihood of same-day appointment availability.

Attempts were made to make an appointment with a specific, randomly selected GP in the practice. If a same-day appointment with that GP was not available, a request was made for a same-day appointment with any GP in the clinic. Same-day appointments offered with other GPs within the clinic were classified as an available appointment. Data were recorded on whether an appointment was unavailable, available with the requested practitioner, or available with another practitioner within the clinic. Where same-day appointments were available, the time between making the call and the next available appointment was recorded. Bulk-billing status of the clinic was a binary variable (yes/no). Where clinics did not bulk bill, both the upfront cost of an appointment and the final out-of-pocket cost (upfront cost minus the Medicare rebate amount) was recorded. Where the receptionist stated the cost of an appointment was likely to vary on length of appointment, a minimum and maximum cost provided by the practice were recorded.

Where an appointment was offered, the appointment itself was not accepted. Receptionists were told by the research assistant that they would call back if an appointment was actually needed and if the time offered was acceptable. No appointments were actually booked in any practice. The call process was developed and pilot-tested with medical reception staff from GP clinics to ensure that it did not have a significant impact on the administration of the clinics.

The study received ethics clearance from the University of Melbourne Human Research Ethics Committee. This committee required that, after the data were collected, letters be sent to clinics that had been selected within the catchment areas alerting them to the possibility of having been contacted by the research team and describing the nature of the study.

Statistical analysis

All data were analysed using Stata, version 13 (StataCorp). Analyses primarily involved the use of descriptive statistics, with the ?2 test used to investigate potential associations between appointment availability and the availability of bulk-billing in clinics.

Results

Appointment availability

Overall, same-day appointments to see any doctor were offered by 78% of clinics (175/225). Appointment availability between the three Medicare Local catchment areas varied only slightly, from 72% to 81%. However, availability to see a specific doctor in the practice was more limited (Box 1).

Time until available appointments ranged from less than 1 hour in 15% of practices to over 8 hours in a single practice (Box 2). About half of the clinics contacted (111; 49%) were able to offer an appointment within 4 hours. A further 9% offered walk-in appointments, for which a waiting time could not accurately be determined (Box 2).

Appointment cost

About three-quarters of the clinics contacted (168; 75%) offered bulk-billing for paediatric patients. Actual proportions varied between 72% and 80% in the three Medicare Local catchment areas (Box 3).

Box 4 provides a comparison of appointment availability by clinic billing practices. Appointments were more likely to be available in clinics that provided bulk-billing for paediatric appointments, with 82% of those able to offer an appointment compared with 67% of private-billing clinics (P = 0.01). Mean out-of-pocket costs were lower at clinics in which appointments were available than at those in which no appointment was offered. In clinics that did not bulk bill, the minimum out-of-pocket costs cited by reception staff ranged from $2 to $75.65, with a mean of $32.18. Maximum out-of-pocket costs ranged from $12 to $94.30, with a mean of $34.67.

Discussion

Among the most important findings from this study is that there is significant same-day GP appointment availability for children with low urgency, low-acuity conditions in the areas we studied. Further, about three-quarters of clinics with same-day appointment availability offered bulk-billing for paediatric patients, suggesting that financial constraints are unlikely to be a significant barrier to accessibility of primary care appointments. With 78% of clinics able to offer a same-day appointment and with there being multiple GPs practising within the postcodes of our catchment areas, it seems likely that most people attempting to procure such an appointment would be able to do so, and with no out-of-pocket cost. In addition, a high proportion (almost 60%) of appointments were offered either within 4 hours of contacting the clinic or on a same-day walk-in basis.

Our results indicate that increasing attendances for children at EDs are unlikely to be driven primarily by a lack of availability of appointments in general practice. It is possible that a perceived lack of primary care appointment availability may be a contributing factor in some ED presentations. Parents and guardians may simply be assuming a lack of availability of GP appointments, and believe they are more likely to be provided with timely care in an ED. If this is the case, public information campaigns based on our findings may help to change the behaviour of patients in seeking acute care for low urgency conditions at their general practice clinic. Although not all GPs had same-day appointments available, there were multiple GPs able to see patients for non-urgent conditions in a timely manner. This is in contrast to the picture presented in some media reports.2–4

Our findings on the high proportion of clinics that bulk bill for paediatric care (75%), and the higher availability of appointments in these clinics compared with private-billing clinics is important. The perceived cost of appointments may be influencing the behaviour of parents seeking care for children with non-urgent conditions.17 A study of patients 15 years and older found that over a million Australians reported that they had not seen, or had delayed seeing, a doctor due to cost in a given year; another study found that 24.5% of those living in an outer metropolitan suburb cited financial matters as a barrier to visiting a GP.13,14 Publicising the availability and accessibility of same-day appointments for children in bulk-billing clinics may allay concerns over the cost of appointments.

A previous study has shown that if parents are unable to obtain appointments with a practitioner that they know and trust, they may instead seek treatment in an ED.18 Although parents may wish to see the same GP for all of their child’s health care needs, that appears to be an increasingly unrealistic goal. Trends in GP practices indicate that the number of GPs working in larger practices (of four or more partners) is increasing, while only about 11% work in solo practices.19–21 Frequently, patients are seen by several members of a practice.

A limitation of our study is that that the distribution of GPs may differ between metropolitan, regional and rural areas across the country, so our findings may not be generalisable to other parts of Australia. Further research would be required to assess the availability of same-day GP appointments in other areas. Further, we collected our data on weekday mornings — a time likely to maximise appointment availability. A similar audit conducted nearer closing time may produce different results.

This study provides an accurate and current real-time assessment of availability and accessibility of general practice appointments for children with non-urgent conditions from the patient’s perspective. We found high availability of appointments in GP practices, although not necessarily with a specific doctor in the practice. Additionally, the high availability of appointments in bulk-billing clinics indicates a lack of economic barriers to available care. We believe this information can aid in developing data-driven policy approaches for ensuring the availability of the primary care workforce and the use of paediatric ED services for non-urgent conditions. Further, the public should be made aware of the ready availability of GP appointments.

1 
Availability of same-day appointments for a mildly ill child in 225 general practices within three Medicare Local catchment areas

Medicare Local

Total phone calls

Appointments available

With requested general practitioner

With another general practitioner

Total

NMML

75

25 (33%)

36 (48%)

61 (81%)

MRNWMML

75

17 (23%)

43 (57%)

60 (80%)

INWMML

75

30 (40%)

24 (32%)

54 (72%)

NMML = Northern Melbourne Medicare Local (outer urban); MRNWMML = Macedon Ranges and North Western Melbourne Medicare Local (outer urban and regional); INWMML = Inner North West Melbourne Medicare Local (inner urban).

2 
Availability of appointments and time until appointment in 225 general practices

Time to appointment (hours)

Appointments

No.

Proportion

Cumulative proportion

Within 1

34

15%

15%

Within 2

38

17%

32%

Within 3

26

12%

44%

Within 4

13

6%

49%

Within 5

20

9%

58%

Within 6

13

6%

64%

Within 7

6

3%

67%

Within 8

4

2%

68%

8 or more

1

0%

69%

Walk-in (time unknown)

20

9%

78%

No appointments available

50

22%

100%

3 
Availability of bulk-billing for paediatric appointments in 225 general practices within three Medicare Local catchment areas

Medicare Local

No. of practices

Bulk-billing practices

Within 2

38

17%

Within 3

26

12%

Within 4

13

6%

Within 5

20

9%

Within 6

13

6%

Within 7

6

3%

Within 8

4

2%

8 or more

1

0%

Walk-in (time unknown)

20

9%

No appointments available

50

22%

NMML = Northern Melbourne Medicare Local (outer urban); MRNWMML = Macedon Ranges and North Western Melbourne Medicare Local (outer urban and regional); INWML = Inner North West Melbourne Medicare Local (inner urban).

4 
Availability of and billing practices for paediatric appointments in 225 general practices

Appointment available

No. of practices

Bulk-billing

Private-billing

No

50

31 (62%)

19 (38%)

Yes

175

137 (78%)

38 (22%)

All practices

225

168

57

Revalidation is not to be feared and can be achieved by continuous objective assessment

Medical professionalism in the United Kingdom has been a contentious issue for over a decade.1,2 Lack of competence may contribute to patient harm and is, therefore, part of the debate involved in defining and assessing professional competence.3,4

The International Association of Medical Regulatory Authorities defines revalidation as “the process by which doctors have to regularly show that they are up to date, and fit to practice medicine”.5 On 3 December 2012, the UK General Medical Council (GMC) introduced revalidation procedures that require doctors to collect evidence of professional competence and fitness to practice in their current role. This evidence is presented by a “responsible officer”, who is usually the medical director of the hospital or primary care provider, directly to the GMC for appraisal; but more may be required.6 The time taken to collect and analyse the portfolio and sources available are all contentious issues, along with the cost of the revalidation process. To understand this bureaucratic drive to demonstrable competence and to identify mechanisms to achieve this laudable goal, it is necessary to understand the context in which these proposals were developed.

An unforeseen consequence of health care’s increasing complexity is the identification of systemic health care error as a cause of patient harm and unnecessary cost.7 Safety experts calculate the cost of error in Australia is “over $1 billion — possibly $2 billion — annually” with 50% of errors potentially preventable.8 Australian health care expenditure was $130.3 billion in the 2010–11 financial year.9

Emerging evidence indicates that the rate of systemic health care error has not declined significantly since it was initially identified, although some limited trials have shown promise in improving outcomes presumed to result from failures of coordinated health care delivery.10–12 The medical profession should accept some responsibility for systemic health care error, particularly those errors which harm patients. We believe that the profession should be committed to rectifying current deficiencies and minimising future errors for ethical reasons, as well as the obvious reason of financial rectitude. The importance of an ethical component to the approach to patient safety is that it imposes an overarching imperative to guide professional behaviour.

Professional ethics are the rules or guidelines that dictate professional behaviour. They are related to, but not inseparable from, the morality of the society in which the profession practices. In 1999, the Tavistock Group of medical ethicists proposed that minimising errors, minimising unnecessary and inappropriate variation in practice and a continuing responsibility to help improve quality were important professional ethical principles.13 These principles were further endorsed by Peter Singer (professor of bioethics) in his review of medical ethics in 2000 and they remain applicable today.14

In this article, we examine how an ethical and professional commitment to reducing errors, adhering to best practice and improving quality of care should be reflected in the training and practice of competent doctors. One obvious mechanism to embed such competent, professional practice is through the process of revalidation once doctors have completed training.4,13,15 There is little doubt that patients would request and respect such a revalidation process if it provided them with less harmful, less costly, more available and higher-quality health care. This expectation is recognised by experienced medical educators and is implicit in the definition of professional competence published in 2002 by Ronald Epstein (professor of family medicine, psychiatry, oncology and nursing) and Edward Hundert (dean for medical education and professor of global health, social medicine and medical education): “the habitual and judicious use of communication, knowledge, technical skills, clinical reasoning, emotions, values, and reflection in daily practice for the benefit of the individual and community being served”.16 This thoughtful and inclusive definition from the United States exceeds current definitions from Europe. The essential facets of competence (FOC) proposed by Dutch and German medical educators in 2013 identifies six more limited professional competencies,17 shown in Box 1. These FOC overlap the GMC’s four domains of expected standards of practice,18 shown in Box 2.

The potential for broad, societal input into the processes defining medical competence is highlighted by the different emphases of the various definitions: the science, empiricism and professional development of the Dutch and German medical educators’ FOC; the reflection on daily practice and consideration of community benefit in the US definition; and the inclusion of the patient and the public in the GMC’s domains. Including the views of patients and the lay public in the revalidation process enables professionals to acknowledge community considerations of competence and revalidation in the society in which they are practising. It is possible to incorporate such broad definitions of professional competence into valid assessments of individual and organisational professional practice that will contribute to improved outcomes, systematic safety, reduced health costs and higher-quality care. The principles of these assessments were developed in the 1980s and are supported by good evidence. They fall into three broad groups, linked by the need for measurement or assessment of performance in all specialties.

First, collecting, analysing and providing feedback on outcome data at a unit level and an individual level will improve patient outcomes.19–21 Although in New York State the performance monitoring exercise commencing in the late 1980s was originally labelled “report cards” and viewed with suspicion, the feedback of risk-adjusted performance data in surgical specialties is now an accepted means of ensuring the delivery of high-quality clinical services in many countries, including Australia.20,22,23 Such data collections must be physician led and conducted in a non-threatening manner to ensure successful adoption.19,20,22,23

Second, specialist registries, which serve a similar function, have proved valuable as voluntary data collections that can be used to review practice, act as centre report cards and generate hypotheses for randomised trials.24 Medical practitioners who self- report their performance are already reflecting on their practice and are therefore more closely aligned with modern principles of medical education and revalidation.4,16 Such voluntary examinations of practice take the profession beyond the New York State performance monitoring exercise for providers of cardiac services that started in 1988 as a compulsory data collection. Contributing data to the state database was a licencing requirement for providers of cardiac services in New York State. However, these registries also represent evidence of “the habitual and judicious use of communication, knowledge, technical skills, clinical reasoning, emotions, values, and reflection in daily practice for the benefit of the individual and community being served”.16 This can be seen as competence at the coalface, which should contribute to revalidation in a very practical way.16,25–28 This routine collection of personal and unit performance data would render unnecessary retrospective examinations of performance at the time of perceived, or actual, problems with patient safety, or questions pertaining to a practitioner’s competence.29,30 Although the Bristol heart scandal and the Harold Shipman murders relate to the National Health Service in the UK, the effect on the Australian public of the Jayant Patel case in Bundaberg should not be underestimated and any mechanism for preventing recurrence should be carefully examined.2,29

Third, the application of a combination of technology and statistical analysis to monitoring individual performance facilitates high-quality, objective performance monitoring and is easily achieved for practical procedures.25 These advances represent an enormous opportunity for the objective measurement of competence and quality in health care.4 This level of professionalism has been advocated by some European medical educators as a new standard for “entrustable professional activities” as a means of addressing medical professional competence.31 This component of objective analysis of professional performance has proved valuable when coupled with the use of statistical methods to define and confirm competence. These methods were pioneered in paediatric cardiac surgery and subsequently applied in other specialities.4,21,25,32 We are convinced that the routine collection of these data during training and subsequent specialist practice makes revalidation easier and even irrelevant.4 The reason for suggesting that revalidation may become irrelevant is not to be controversial but to emphasise the value of routine performance monitoring. The collection of appropriate data in routine practice supports the revalidation process more accurately and objectively than the current processes suggested.4 In fact, only those practitioners not collecting performance data may need to undergo a formal revalidation process because objective evidence of good practice would not be available for them.4,6

Revalidation based on the UK model may not fulfil all the requirements of the medical profession in Australia. However, the broader definition of competence — including reflection on practice, consideration of community benefit, or protecting the health of the patient and the public — arising from the US and the UK indicates that the process of performance monitoring is a much better tool for effectively identifying and supporting contributors to poor health care performance. The evidence that the collection of performance data and feedback of results improves unit and individual clinician performance, thereby reducing patient mortality and morbidity, represents examples of a tangible commitment to reflective practice and patient and public health.19,20,33 Such professional activity provides a clear example of determination to achieve demonstrable competence. Participation in such data collections may be more valuable to patients, the medical profession and the bottom line than the more formulaic aspects of existing or proposed revalidation processes.

With respect to the unnecessary and inappropriate variation of practice and its impact on patient safety, there is now very good evidence that treatment which follows the guidelines of professional bodies ensures better outcomes than treatment that omits important components of care.34 The high-quality data for this study was taken from a randomised controlled trial of the management of acute coronary syndromes (ACS), including acute myocardial infarction (AMI), in the US (the CRUSADE study). It confirmed that a 10% increase in process compliance with American College of Cardiology guidelines conferred a 10% decrease in mortality for patients with ACS and AMI. Collection of this process adherence data alongside personal performance data would improve the quality of revalidation assessments at multiple levels in health care — for example, at organisational (hospital), unit (team) and individual (doctor) levels. Coupling the collection of unit and individual performance data with supervised feedback of results should optimise assessments of individuals in their workplace. This will advance the goal of objective, measured competence confirming “the habitual and judicious use of communication, knowledge, technical skills, clinical reasoning, emotions, values, and reflection in daily practice for the benefit of the individual and community being served”.16

Through these processes, we believe that the medical profession can lead other health care professions to achieve a level of training and maintained competence that exceeds the current formulae for revalidation. Such processes of personal professional monitoring in medicine, through self-reporting, can confirm objectively and routinely the value of the health interventions of the medical profession in maintaining the health of the individual patient and the public. If the profession can take that lead, it will be well placed to ensure that the health interventions of the future will continue to be of higher quality, deliver optimal benefit and become more affordable to the populations in which they practice and the communities that they serve.

1 
Essential facets of competence*

  • Scientific and empirical grounded method of working
  • Knowing and maintaining own personal bounds and possibilities
  • Active professional development
  • Teamwork and collegiality
  • Active listening to patients
  • Verbal communication with colleagues and supervisors

2 
General Medical Council’s four domains of expected standards of practice*

1. Knowledge, skills and performance

  • Make the care of your patient your first concern
  • Provide a good standard of practice and care
    • Keep your professional knowledge and skills up to date
    • Recognise and work within the limits of your competence

2. Safety and quality

  • Take prompt action if you think that patient safety, dignity or comfort is being compromised
  • Protect and promote the health of patients and the public

3. Communication, partnership and teamwork

  • Treat patients as individuals and respect their dignity
    • Treat patients politely and considerately
    • Respect patients’ right to confidentiality
  • Work in partnership with patients
    • Listen to, and respond to, their concerns and preferences
    • Give patients the information they want or need in a way they can understand
    • Respect patients’ right to reach decisions with you about their treatment and care
    • Support patients in caring for themselves to improve and maintain their health
  • Work with colleagues in the ways that best serve patients’ interests

4. Maintaining trust

  • Be honest and open and act with integrity
  • Never discriminate unfairly against patients or colleagues
  • Never abuse your patients’ trust in you or the public’s trust in the profession

Partnering with consumers: national standards and lessons from other countries

Effective partnership requires professionals and consumers to redefine their roles and responsibilities

Partnering with consumers is a national priority and central driver of global health care reform.1,2 The National Safety and Quality Health Service Standards stipulate that partnering with consumers is a central component of safe, high-quality care, and a performance indicator against which health care organisations will be assessed and accredited.2

Consumer participation is a complex and dynamic concept.3 Australian health services are currently undergoing the challenging task of understanding what consumer participation means and how it can be used to improve health and health care. Opportunities for consumer participation are diverse: education and training,4 research,5 accreditation,6 service design and evaluation, policy, patient care and treatment.7 Empirical evidence describing the best methods to involve consumers and the effects of that involvement is limited,1,5,7 leaving health services to rely on practical experience and common sense.7 Although the importance of partnering is widely recognised, in the absence of proven approaches, it is not surprising that efforts to partner with consumers can be tokenistic and ineffective,7 leaving the goals of consumer participation unrealised, and health providers and consumers disappointed or cynical.The National Standards have stimulated widespread interest in consumer participation. Australian examples of community participation are often from rural and Indigenous communities,8 and published studies with high levels of community participation and long-term evaluation are relatively small in number.9 Australian health services seeking to discover the characteristics of effective consumer participation can find examples of success from other parts of the world. The examples suggest that effective consumer participation requires a fundamental shift in how both consumers and health care providers define their roles and responsibilities. Successful projects and services go beyond asking select individuals for feedback and advice, but approach and engage entire communities to understand current challenges, design and prioritise services, and implement solutions. Involved, egalitarian relationships based on trust, mutual respect and careful listening appear fundamental to successful engagement and partnership. Professionals must relinquish control as consumers accept greater responsibility. Partnerships are multisectoral and move beyond biomedical models to recognise the social determinants of health.

Lessons from other countries

The Nuka System of Care provides health services for 60 000 Alaska Native and American Indian people and is a leading example of successful health care redesign, receiving a Malcolm Baldrige National Quality Award in 2011.10 Since 1996, the health service has experienced a 36% reduction in hospital days, a 42% reduction in emergency department and urgent care usage, and a 58% reduction in specialty clinic visits; results have been sustained for at least 10 years.10 The key to the Nuka system’s success is the radical way in which professional–consumer relationships have been redefined, and how roles and responsibilities have changed.10 Before the Nuka system, Alaska Native people were beneficiaries who received services from a centrally controlled government system. Now, Alaska Native people are customer-owners who share responsibility and ownership with service providers. The new role comes with increased control and responsibility, not just regarding personal health choices, but over the entire health system that is managed and owned by the people — a process supported by federal law. Understanding the community’s current priorities requires careful listening “with an open mind”.10 The Nuka system goes to great lengths to harness the community’s views through opportunities such as comment cards, surveys, a telephone hotline and online form, focus groups and advisory committees. Because reform is based on the needs and values of Alaska Natives, results indicate that it is better positioned to meet the needs and preferences of Alaska Natives.

Beyond Alaska, initiatives in developing nations provide examples of how appropriate and effective consumer partnership can be the difference between successful or failed projects. Many development initiatives have not created sustainable change;11 between 1973 and 1985 the World Bank lent $19 billion for 498 projects but few succeeded.12 Failure to engage with communities has been suggested as a major reason for lack of sustainable and scalable change in many poor countries.11,12

The Comprehensive Rural Health Project in Jamkhed, India (the Jamkhed project) and the Kakamega Orphan Project in Kenya (the Kakamega project) are examples of successful community-based health care programs that realised great improvements in infant mortality, infectious diseases, malnutrition and sanitation.11,13,14 The projects demonstrate how partnering with communities can drive successful change and, conversely, how abandoning community participation can lead to project failure. The projects show that partnering with consumers is first about developing trusting, respectful and involved relationships, which takes time, effort and proximity. Project workers went beyond their institutional walls and immersed themselves in the community, avoiding a common mistake made by development projects where workers are geographically and socially distant from the communities they are trying to help. In the Jamkhed project, partnership started with volleyball matches that engaged diverse sections of the community.14 Project workers subsequently assisted community representatives to identify their own problems, collect their own data and implement their own solutions.

The Jamkhed and Kakamega projects highlight that one of the most important yet difficult activities in partnering with consumers is the attitudinal and behavioural change required to shift control away from professionals and give it to communities.12 Reflecting on 60 years of development work, Taylor-Ide and Taylor indicated that professionals can be the greatest barrier to change because they can be more interested in protecting their positions and priorities, see balanced partnership as unnecessary, and consider themselves in the senior position.12 Professionals relinquishing control is vital for successful partnership; it creates a more egalitarian relationship that shares power and responsibility, and sees the community as a partner and colleague rather than employee or subordinate.

The Jamkhed and Kakamega projects underscore the importance of taking a broad view of partnership and the determinants of health. Partnership involves multiple stakeholders including those outside the health sector.12 In the Kakamega project, women in obstructed labour were unable to access hospitals due to inadequate roads and bridges.13 The district road engineer became a third partner and, by building bridges and improving roads, was pivotal in improving maternal and obstetric health outcomes. Three-way partnerships created potential for top-down, bottom-up and outside-in perspectives.12

Partnership must also recognise that the community’s priorities might not be the same as those of health services and that non-health-related priorities might initially take precedence. In the Jamkhed project, community members were more interested in the health of their farm animals than in their own health. Once the animals’ needs were met, people became interested in their own health. If health services had prioritised human health at the outset, then locals would have resisted interventions, perhaps passively, and health workers would have been frustrated that the community was not responding to their efforts to help.

Eight years after commencing, the Kakamega project disbanded.13 Two years before that, following international acclaim for its successes, the Kenyan Ministry of Health took direct control and international donor agencies contributed large amounts of money. As a result, the intimacy of locally built projects was lost in the distance between the community and displaced officials. According to the Kakamega project’s founder, bureaucratic rules and top-down directives replaced local ownership and joint decision making, which “killed” the project.13 Performance targets and less inclusive time frames replaced the unhurried process necessary for community engagement. The Kakamega project exemplifies the difficulty of taking local successes, packaging them and transplanting or upscaling them to other settings.

Consumer participation in Australia

More than 35 years ago, the Declaration of Alma-Ata affirmed that people have the right and duty to participate not only in receiving health care but also in planning, organising and implementing health care.15 In Australia, the National Standards have stimulated resurgent interest in consumer participation which creates a unique opportunity to accelerate our understanding of successful consumer participation. Health service accreditation enables collection and collation of consumer participation activities from across the country. Disseminating national data would enable health services to efficiently learn about successful and unsuccessful consumer participation methods; the Australian Commission on Safety and Quality in Health Care could oversee collecting, collating and disseminating consumer participation activities from around Australia. Concurrently, health services can look to other industries, such as retail, for methods to successfully engage consumers in a way that develops products and services that meet consumers’ needs and preferences.16 When replicating or expanding successful initiatives, the process and context of the initiative must be recognised, understanding what worked and why. Bureaucratic processes in the form of rules, regulations and one-size-fits-all programs are likely to suffer the same fate as many development initiates.

Successful partnership requires health services and consumers to redefine their roles and responsibilities. The National Standards have captured health services’ attention. Now, the broader community must be engaged, so that consumers understand and participate in health care not just as an individual right but as a shared, corporate responsibility.

Beyond the belief that consumer participation is good (Arnstein famously noted 46 years ago that community participation is like eating spinach — it’s obviously good for you),17 rigorous evaluation of consumer participation is required to identify and fill current knowledge gaps. Research is required to determine if and how consumers and professionals want to partner. Evaluation methods must be incorporated into consumer participation initiatives to demonstrate the effects of partnership on service- and consumer-related outcomes. Concurrently, the potential downsides of partnering with consumers — such as tokenism, slower progress, increased costs and conflict between consumers and professionals — should be evaluated.7 Research requires time, skill and effort. Unless health services support staff with time, funding and research expertise, high-quality consumer participation research is unlikely to happen.

News briefs

Inhaled Ebola vaccine stops virus in monkeys

The New York Times reports that a single dose of a new, inhalable Ebola vaccine has neutralised the virus in monkeys. The study, conducted by University of Texas researchers, was published first in the Journal of Clinical Investigation. Four rhesus macaques were given one aerosol dose, four were given two aerosol doses and two were given the vaccine in liquid form. Two were not vaccinated, serving as controls. Four weeks after treatment, all the monkeys were given a dose of Ebola, 1000 times the fatal dose. A week later, the two unvaccinated monkeys died but the vaccinated animals remained healthy. The survivors were euthanised and their blood and tissues showed no sign of Ebola. The next step is for the National Institutes of Health to perform clinical trials on humans.

http://www.nytimes.com/2015/07/14/health/inhaled-ebola-vaccine-stops-virus-in-monkeys-study-finds.html

New CEO for Medical Deans is Carmel Tebbutt

Former New South Wales cabinet minister Carmel Tebbutt has been announced as the new chief executive officer of the Medical Deans Australia and New Zealand. She will replace incumbent Professor Judy Searle, who is retiring from the role after 2.5 years. Ms Tebbutt starts in the position on 19 October. She spent 11 years as a minister and senior member of the Cabinet in the NSW Parliament, with portfolio responsibilities across a number of areas including education and training, health, community services and the environment. “There are many challenges confronting medical education and research. I am looking forward to using my skills to forward the objectives of the Medical Deans”, Ms Tebbutt said. “One of my first tasks will be to meet with members and stakeholders to hear first-hand about the key issues for the sector.”

Tax on soft drinks: it’s working in Mexico

Health economists at the University of North Carolina in the US have studied Mexico’s 18-month-old “soda tax” and found that it is reducing consumption of sugar-heavy drinks in the country where annual consumption tops out at 163 litres per person, Wired reports. The one-peso-per-litre tax has caused a drop in consumption of an average of 6%, according to the researchers. “The decline accelerated as the year went on, reaching 12 percent by December [2014].” With plans to increase the tax to two pesos per litre, the results show that it was the poorest Mexicans who cut back on soda the most, averaging a 9% decline and peaking at 17%. Consumption of bottled water increased by 4% in the same time period. “A soda tax alone is not going to solve the entire obesity and diabetes epidemic”, the researchers concluded. Still, it might help “shift people’s mindset about these beverages. They’re not innocent”.

http://www.wired.com/2015/07/mexicos-soda-tax-working-us-learn

Non-invasive device could end finger pricking for people with diabetes

Science Daily reports on a new low-powered laser sensor that monitors blood glucose levels without penetrating the skin. Developed by a team at the University of Leeds in the UK, the device “has continuous monitoring capabilities making it ideal for development as a wearable device”. It could also be a simpler and cheaper alternative to the two current methods — finger pricking, using disposable sample strips, or invasive continuous monitors using implanted sensors that need regular replacement. “This technology opens up the potential for people with diabetes to receive continuous readings, meaning they are instantly alerted when intervention is needed. This will allow people to self-regulate and minimise emergency hospital treatment,” the researchers said.

http://www.sciencedaily.com/releases/2015/07/150714200110.htm

Retracted papers cited years after withdrawal

Retraction Watch reports that disgraced American anaesthetist Scott Reuben’s retracted papers are still being cited 5 years after retraction, and only 25% of those citations correctly acknowledge the retraction, according to a new study, published in Science and Engineering Ethics. Reuben, who fabricated data, spent 6 months in prison in 2009, and has now accumulated 25 retractions. In the new paper, the authors counted 274 citations of 20 of Reuben’s papers between 2009 and 2014, 45% of them more than once. “Our paper shows that perpetuation of retracted publications is still an ongoing problem in our scientific community… In addition, we could demonstrate that, despite the overall number of citations of retracted publications decreasing over the years, the percentage of correctly labeled citations dropped even more.”

http://retractionwatch.com/2015/07/14/half-of-anesthesiology-fraudsters-papers-continue-to-be-cited-years-after-retractions

[Correspondence] Legal preparedness and Ebola vaccines

On Dec 9, 2014, US Secretary of Health and Human Services Sylvia Burwell issued a declaration1 under the US Public Readiness and Emergency Preparedness Act to provide immunity from legal claims in the USA related to manufacturing, testing, development, distribution, and administration of three candidate Ebola vaccines except in instances of wilful misconduct. Although progress in combating Ebola in west Africa has shifted public attention away from vaccine development and deployment, we should not forget that the management of legal liabilities related to vaccines has been an important subject of discussion between national governments, international organisations, vaccine manufacturers, and other parties who have been engaged in the worldwide response to the Ebola outbreak during the past year.

Appropriate use of oxygen in acute medicine

Oxygen use in acute medicine requires regular monitoring to maintain saturation levels within the prescribed range

It may seem intuitive that oxygen is “good”, so, for the ill or even just distressed, more must be better! However, the evidence for this common clinical approach is at best anecdotal and mainly cultural.1 In fact, both (very) low and high oxygen levels are bad and, indeed, inappropriate use of oxygen in acute medical treatment may be harmful.2–4 Hyperoxia leads to vasoconstriction, and oxygen uptake actually falls.5 Overly vigorous prehospital use of oxygen may well be a significant contributor to death in common acute medical conditions.6

When is a human truly hypoxaemic?

Technically, hypoxaemia occurs when tissues begin to produce lactic acid because of anaerobic metabolism. In the 1960s, a study showed that heart muscle in healthy people did not produce lactic acid until the circulating blood oxygen saturation level was in the region of 50% (equivalent to a partial pressure of less than 30 mmHg), but in people with ischaemic heart disease, oxygen saturation levels were usually in the range of 70%–79%, occasionally as high as 85%, (around 55 mmHg) when cardiac lactate was produced.5 In practice, hypoxaemia has been arbitrarily and conservatively assumed at a saturation level of 88%–90%, although humans can cope quite well at lower levels than this, for example, during sleep, on mountains and when flying. This threshold for hypoxia is also above the point at which central cyanosis is likely (ie, less than 85%). Thus, in clinical situations the target of 88%–90% in arterial oxygen saturation should provide a very adequate buffer. Of course, supply of oxygen to the tissues also depends vitally on haemoglobin concentration and cardiac output, and elevating the central oxygen saturation will not compensate for tissue hypoxia if that is due to abnormalities in oxygen carrying capacity.

Thoracic Society of Australia and New Zealand guidelines

In an attempt to provide evidence-based interpretation in this currently confusing clinical area, the Thoracic Society of Australia and New Zealand (TSANZ) has developed new guidelines for oxygen use in the acute medical setting. These guidelines used the evidence base of the 2008 British Thoracic Society guidelines7 and the draft of an update to these guidelines due to be published in 2015. However, the TSANZ guidelines differ in some practical ways, aiming to avoid the worst “compromises” made to achieve professional consensus in the United Kingdom. The TSANZ guidelines will shortly be published in the journal, Respirology, but have already been endorsed by the Board of the TSANZ and a wide range of other professional medical, nursing and allied health bodies.

A core and firm principle of the TSANZ guidelines is to formalise the use of oxygen as a drug that is rationally and precisely prescribed — that is, with a specified mode of delivery (our practical preference is by nasal cannulae), flow rate (or FiO2) and rational target range of oxygen saturation. The latter would be 88%–92% in patients with chronic obstructive pulmonary disease or other chronic respiratory conditions in which carbon dioxide retention is a possibility, and 92%–96% for most other medical conditions requiring oxygen supplementation. For the reasons discussed, 92%–96% is probably unnecessarily high, but it is the Australian guidelines’ compromise so as not to cause controversy. This range does allow both deterioration and improvement in the patient’s condition to be detected easily and in a timely way, rather than being masked by overoxygenation. Regular and iterative monitoring is necessary to determine if saturation levels are remaining within the prescribed range. If the patient’s need for oxygen decreases, then oxygen flow rates are adjusted down to stay within the prescribed range of oxygen saturation. Conversely, if a patient’s oxygen needs increase and flow rates need to be increased to keep saturation levels within the prescribed range, then medical review is needed and the patient may need to be moved to a high dependency unit. The emphasis is on heeding changes in the levels of oxygen saturation, not for their own sake, but as a reflection of the underlying condition.

The TSANZ guidelines support initial arterial blood gas measurements to define the true oxygen and carbon dioxide status of the patient. They discuss the usefulness of currently overpopular venous blood gas assessments (which cannot assess oxygenation and have problems with assessing carbon dioxide levels)8 and underutilised arterialised capillary blood gas assessments.

The most practical way to monitor oxygenation is with a pulse oximeter. Most manufacturers of oximeters quote an accuracy of ± 2%, although older published data quote higher variability.9 A new study with modern equipment is urgently needed, but the TSANZ guidelines include sufficient safety margins to make the variability of oximeters relatively unimportant.

It needs to be stressed that oxygen is not indicated for breathlessness without hypoxia. Further, acute hypoxaemia is commonly caused by hypoventilation and carbon dioxide retention, which must be recognised (by measuring arterial blood gases), and may mean that the patient requires assisted ventilation in an appropriate setting.10