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Preference: Administration and Health Services

2

Providing high quality care doesn’t pay

Current funding arrangements for general practice do not reward quality care and must be overhauled, the AMA National Conference has been told.

While not calling for the current fee-for-service model to be scrapped, speakers at the policy session Funding quality general practice – is it time for change?  said better patient outcomes could be achieved with changes to the way doctors are remunerated.

Former GP of the Year and Clinical Director of the Australian Primary Care Collaboratives Program Dr Tony Lembke told the Conference that although Australian practitioners provided high quality care, funding arrangements placed road blocks in their way.

Dr Lembke said there was a tension for general practitioners between their professional aspirations to provide quality care and the demands of running a business.

“The more I look after disadvantaged patients, those with chronic disease, or who are in aged care; the more time I spend training students, the less my income is,” he said. “That is a bizarre sort of system.”

Dr Tim Ross, National Medical Director for health insurer Bupa, said a shift was underway toward more team and community-based care, and the way GPs were remunerated needed to change to reflect and support a different model of providing care.

Bupa last year began trials of GP clinics where patients make a private payment for treatment which emphasises follow-up care and close co-ordination with specialists.

Dr Ross said he expected the Commonwealth to eventually adopt a capitation model of payment, where GPs are paid an annual fee to care for a patient, rather than be paid by service.

This would be part of a blended model including bundled payments from government, fees for services rendered and financial rewards for quality care, including outreach to patients.

He said a team-based approach to care would mean patients seeing a physiotherapist, psychologist or other allied health professional would not need to see their GP in order for funding to occur.

But AMA President Dr Tony Bartone said that providers carried the risk in a system of bundled payments, and the funding model encouraged cherry picking of patients.

Dr Bartone said the fee-for-service model often got a bad rap for issues that had more to do inadequate indexation of Medicare rebates and poorly designed Medicare Benefits Schedule items.

He said there was no evidence that any alternative funding models were superior to fee-for-service, a point admitted to by former AMA Presdient Dr Steve Hambleton, who has been appointed by Health Minister Sussan Ley to lead the Primary Health Care Advisory Group.

The Group has been established to make recommendations on how to provide better care for chronically ill patients and those with mental health conditions, as well ways to improve the co-ordination between hospitals and primary care, and to look at “innovative care and funding models”.

Dr Hambleton told the Conference the work of the Group, which is due to report in November, would be evidence-based.

Currently, he said, “there is no clear winner in terms of which [payment] system is better for outcomes, but we all know there are places where we can do better, [where] we can align the business and professional imperatives better”.

“It does not mean we throw out fee-for-service, but is there a way to say that, if you spend longer [with a patient], if you think about it longer and spend time planning a bit longer, how do you reward that?

“At the moment, the short you spend [with a patient], the less time you spend, the less you think and the less you talk, the more you get paid,” Dr Hambleton said.

A video of the policy session can be viewed at: media/ama-national-conference-29-may-2015-session-2

Adrian Rollins

 

AMA develops GP toolkit to help victims of family violence

AMA President Associate Professor Brian Owler has urged caution in any attempt to make the reporting of family violence mandatory amid an anticipated surge in victims coming forward and seeking help given heightened national awareness of the issue.

Speaking at the launch of a joint AMA/Law Council of Australia toolkit providing guidance and resources for GPs dealing with instances of family violence, A/Professor Owler said that while it was mandatory to report child abuse, governments should be careful about extending this to include adults.

“It’s a complex issue and what you don’t want to do…is set up a system where you might deter people from coming forward and having a conversation with their GP,” the AMA President said. “What you say to the doctor is something that should be kept in confidence, except in very extreme circumstances. We need people to have confidence in actually being able to disclose to their GP that there may be an issue at home and feel safe about doing that.”

The toolkit, prepared by the AMA in consultation with the Law Council of Australia, gives GPs vital information on how to detect and discuss family violence, assess risk, understand legal obligations and provide details of support services and resources for victims and their children.

A/Professor Owler said GPs were often the first port of call for victims of family violence, so it was important that they knew how to discuss the issue and where to access the resources and information needed to help victims and their families.

“There is likely to be more people coming forward…and so it’s important that our GPs are prepared when people do come forward that they have the right resources and the right information to allow and assist them to prescribe the right treatment,” he said.

The pervasiveness of family violence has been underlined by Australian Bureau of Statistics/Australian Institute of Criminology research showing one in six women suffer physical or sexual violence at the hands of their current or former partner, and a quarter suffer emotional abuse.

In a sign of the extent to which family violence is underreported, the study, conducted in 2012, found 58 per cent of women had not reported the attack to police and almost a quarter had never sought advice or support.

The AMA President said family violence could be “a very uncomfortable and difficult issue”, not only for victims but also for GPs, who might have both the victim and the perpetrator as patients.

A/Professor Owler said one of the important features of the toolkit was that it started from the very basics, describing what GPs needed to look for to identify potential victims, and providing crucial advice on how to broach the issue in a way that made people safe and comfortable about talking of what was happening in their home.

He said often patients would see their doctor with an unrelated complaint, and the toolkit helped GPs to ask the right questions as a way of initiating the discussion.

Importantly, he added, the toolkit also talked about what should not be asked when someone disclosed they were a victim of family violence, such as asking ‘what might you have done to avoid this?’, which could be taken as implying blame.

Law Council of Australia President Duncan McConnel said the toolkit was an important step in improving the co-ordination of services to help victims of family violence, which was “not just a law and order issue. It’s a broader issue, and in particular it’s a health issue”.

Mr McConnel said one of the big barriers encountered by victims seeking help was the fact that they had to go through a “sort of revolving door of seeking help from different service, after different service, after different service. It’s been identified as a critical issue”.

He said it was important that doctors helping a victim of family violence knew how to get help and who to contact, including being able to identify safe houses, specialist legal services and other supports.

The Supporting parents experiencing family violence – a resource for medical practitioners toolkit can be downloaded at:  article/ama-family-violence-resource

Adrian Rollins

 

Waste not, want not – ethics, stewardship and patient care

By Dr Michael Gannon

When it comes to managing health care resources, doctors must balance their primary ethical obligation to care for the patient with their secondary obligation to use health care resources wisely.

At times, these obligations may conflict – but focussing on stewardship allows doctors to find an equitable and realistic balance between the needs of the patient and the need for the wider community to keep health care affordable.

The essence of stewardship is avoiding waste – it is not about denying care based on scarcity of resources, otherwise known as rationing.

How do we become effective stewards of health care and avoid waste without being seen to ration care?

How do we deal with health care administrators, third party payers and governments who place unreasonable constraints on our ability to make treatment recommendations based on our patients’ health care needs, rather than the cost of care?

How do we manage patients (and family members) who make unreasonable health care demands, requesting treatments that are simply ineffective or inappropriate for their health care needs?

And what about the ever present fear of litigation – isn’t ‘defensive medicine’ the best way to practice?

At this year’s AMA National Conference, I chaired a policy session on stewardship, Waste Not, Want Not: Ethics, Stewardship and Patient Care.

The purpose was to assist doctors to become better stewards of our health care resources through learning how to:

  • identify the medico-legal challenges to effective stewardship;
  • communicate with patients about resource use; and
  • participate in initiatives that identify and discourage ineffective care at the institutional level, as well as in the wider community.

The session’s presenters, Dr Ian Scott, Dr Sara Bird and Dr Lynn Weekes, were truly engaging.

Dr Scott, Director of the Department of Internal Medicine and Clinical Epidemiology at Princess Alexandra Hospital in Brisbane, outlined 10 clinician-led strategies to maximise value in Australian health care.

Dr Bird, Manager of the Medico-Legal and Advisory Services of MDA National, provided a medico-legal perspective on stewardship in relation to the practice of defensive medicine.

Dr Weekes, the CEO of NPSMedicineWise, presented the ChoosingWiselyAustralia campaign, whose goal is to enhance quality care by reducing unnecessary care.

We are truly indebted to our presenters and appreciate the time they took to engage with our delegates during a lively question and answer session following their presentations.

The AMA’s job now is to develop a policy on ethics and stewardship to assist our advocacy.

We want to ensure there is a culture of stewardship within the medical profession.

This clearly begins at medical school and continues throughout a doctor’s career with continuing professional development.

Doctors need to be informed of the cost of treatments and procedures, and be guided in making responsible treatment recommendations that balance efficiency with the primacy of patient care.

We also need to ensure that any system-level initiatives to reduce wastage involve the profession, and do not compromise our professional judgement and clinical independence to act in the best interests of individual patients and advocate for the wider public health. 

I strongly encourage all members to visit the AMA website and view the presentations, along with the question and answer session from the policy discussion session Waste Not, Want Not: Ethics, Stewardship and Patient Care. They can be viewed at media/ama-national-conference-30-may-2015-session-2.

 

Cross border hospital use: analysis using data linkage across four Australian states

The benefits of using linked administrative data in health-related research were recognised by the Australian Government through the National Collaborative Research Infrastructure Strategy Roadmap in 2006.1 This roadmap outlined a multimillion dollar investment strategy in national capability for data linkage, which led to the establishment of the Population Health Research Network (PHRN) to coordinate and champion this initiative.2 The purpose of the PHRN was to establish data-linkage units in all Australian states, support the implementation of secure data delivery and the provision of remote-access laboratories for researchers, and to develop the Centre for Data Linkage (CDL) for national and cross-jurisdictional linkage.

The CDL was established within the Centre for Population Health Research at Curtin University in Western Australia. It provides the data linkage infrastructure necessary for cross-jurisdictional linkage of health-related data in Australia, and uses a best-practice data “separation principle”. Under this principle, the process of data linkage is kept separate from the analysis of linked service data. Currently, projects requesting data linkage to Australian Government datasets, such as Medicare or Pharmaceutical Benefits Scheme data, must go through a risk-assessment process. If the risk to data security is found to be high, data linkage must be conducted through an Australian Government-accredited integrating authority.

Four “proof-of-concept” projects were selected to demonstrate the effectiveness of increased data linkage capacity in supporting nationally significant health research.3

Here, we present findings from the first of these projects that explored how cross-jurisdictional linkage can inform the nature and extent of cross-border hospital use and hospital-related deaths. A secondary aim was to evaluate the impact that cross-jurisdictional linkage had on estimating hospital standardised mortality ratios; these findings will be published separately.

Typically, single-jurisdiction studies investigating hospital use and hospital-related deaths have been unable to account for patients crossing state borders. This is problematic for densely populated border regions like northern New South Wales, for example, where patients are likely to attend specialist hospitals in Queensland.

This is the first Australian study to combine hospital and death data from multiple jurisdictions at the person level. A national data-linkage approach was used to bring together all of the hospital and death records of individuals, even when they crossed state borders. Linked hospital discharge and death registration data from NSW, WA, South Australia and Queensland were used in this study.

Methods

This was a retrospective cohort study of all people who separated from a hospital in NSW, WA, SA or Queensland from 1 July 2004 to 30 June 2009. Hospital separation records and death records were available for both public and private hospitals in NSW, WA and Queensland, but only public hospital records were available from SA.

Ethics approval was granted by human research ethics committees of the WA Department of Health, Curtin University, SA Department of Health and Ageing, NSW Population and Health Services, and Queensland Health. The extensive negotiation and approvals process required to conduct this study commenced in 2009. At that time, data from Victoria, the territories and Tasmania were unavailable for linkage. Datasets from NSW, Queensland, WA and SA containing the CDL-generated national linkage key were delivered to the analyst in late 2013.

Data sources

NSW: The NSW Health Department Admitted Patient Data Collection included inpatient records from all NSW private, public, psychiatric and repatriation hospitals and multipurpose services and day-procedure centres. NSW data were provided through the Centre for Health Record Linkage.

SA: Hospital separation data were provided through SA-NT DataLink. Data on SA public hospital inpatient separations from the Integrated South Australian Activity Collection included all SA inpatient records from public acute and psychiatric hospitals. Data from SA private hospitals were unavailable at the time of the study.

WA: The WA Hospital Morbidity Data System collects inpatient data from public and private acute and psychiatric hospitals and private day-surgeries.4 All data were obtained from the WA Department of Health.

Queensland: The Queensland Hospital Admitted Patient Data Collection includes all admitted patient separations from public hospitals, public psychiatric hospitals, licensed private hospitals and day-surgery units.

Death records were obtained from the four jurisdictional Registries of Births, Deaths and Marriages according to state-based data-access mechanisms. The linkage of over 44 million records was undertaken by the CDL; details are described elsewhere (manuscript submitted).

Data cleaning

After linkage, de-identified data were supplied to the research team. The data underwent extensive cleaning and manipulation. Variable names and variable coding were standardised across the datasets by using the lowest common denominator. For example, NSW hospital separations data included a hospital peer group variable with 23 categories whereas SA supplied eight categories, so NSW categories were collapsed to match the SA categories.

The data were standardised as much as possible to improve the validity of jurisdictional comparisons. Duplicate episodes of care that arose under contracted arrangements between hospitals where one hospital purchased hospital care from another were removed if this had not already been done by the data custodians. Episodes of care that were missing vital data such as age, sex, principal diagnosis or mode of separation were excluded, as were separations indicating that the health care facility was not a hospital or that a procedure had been cancelled. These types of jurisdictional differences were identified through systematic cross-checking and with reference to published metadata and local expertise. In some cases it was impossible to reduce this heterogeneity. In NSW, for example, deaths in hospital emergency departments were included as in-hospital deaths whereas this was not the case for the other three jurisdictions. There was no way to identify NSW deaths in emergency departments within the datasets used for this study. Overall, 1.44 million records were excluded during the standardisation process. Further details about the data cleaning and standardisation are available on request.

Variable definitions

Hospital transfer was defined as an episode of care with a separation mode value that indicated either transfer to another acute hospital or a statistical discharge within the same hospital. Up to 48 hours was allowed for a patient to transfer from one hospital to another. Transfer sets (sequences of transfer episodes of care that made up the completed hospital stay for an individual) where the first episode of care was not an acute care admission were excluded. Transfer sets involving a transfer from a hospital in one jurisdiction to a hospital in another jurisdiction were referred to as cross-border hospital transfers.

Hospital stays of interest were defined as having had:

  • an acute care type for single episodes of care and for the first episode of care of a hospital transfer set;
  • a hospital stay separation date in the period 1 July 2004 to 30 June 2009;
  • a total length of stay of less than 365.25 days;
  • an Australian postcode of residence (excluding island territories) for the patient involved;
  • complete demographic information for the patient involved; and
  • a principal diagnosis or principal procedure code and mode of separation recorded.

This definition of hospital stays was designed to match that typically used when estimating hospital standardised mortality ratios, a secondary aim of this project.

Hospital-related deaths were defined as deaths occurring between the day of hospital admission and 30 days after separation from hospital. If the jurisdiction where the death was registered was different from the jurisdiction of the last hospital stay, the death was considered a cross-border 30-day death.

Defining patient cross-border hospital flows

Travellers were defined as patients who crossed a jurisdictional border to attend the hospital. For example, a patient separating from a NSW hospital with a residential postcode of 6102 would be classified as a WA to NSW traveller.

Movers were defined as patients who had: (i) had at least two hospital stays in more than one jurisdiction with the postcode of residence matching the jurisdiction of the hospital (eg, a patient who had a NSW hospital stay recorded with a 2234 postcode of residence in 2004 followed by a WA hospital stay record with a 6102 postcode of residence in 2007); or (ii) had a previous hospital stay as a traveller in any jurisdiction followed by a hospital stay in the jurisdiction of residence, provided that the residential jurisdiction was not the same as the previous hospital stay as a traveller (eg, a patient who lived in the Northern Territory and travelled to Adelaide for a hospital stay whose next hospital stay was also in SA, but whose residential postcode indicated the patient had since moved to SA).

Mapping of cross-border patient flows

Spatial data were used to create choropleth maps to visually demonstrate cross-border patient flows.5 Residential postcodes of patients who had had hospital stays were assigned to a 2006 Statistical Local Area (SLA) and a weighting was applied such that the number of hospital stays within a postal area was multiplied by the relative proportion of the postcode that fell within an SLA boundary. All data manipulation and mapping was performed with Stata 13 (StataCorp).

Results

There were almost 19 million acute care hospital stays involving 7.7 million patients in NSW, WA, Queensland and SA hospitals over the 5 years from 1 July 2004 to 30 June 2009 that were brought together using a national linkage key. NSW and Queensland had the largest number of hospital stays and patients. There were relatively fewer hospital stays in SA because private hospital data were unavailable. NSW recorded the highest proportion (4.9%) and WA the lowest proportion (3.6%) of hospital transfers over the 5-year study period. The median number of hospital stays per patient over 5 years was one (interquartile range, 1–3 stays).

Travellers

There were 223 262 individuals (3.0%) who had 352 969 acute care hospital stays (1.9%) recorded as a traveller, although the proportion varied geographically. Of the four jurisdictions, NSW was the source of the largest number of hospital stays by travelling residents (140 246), with 93.5% (131 149) travelling to Queensland hospitals. Queensland and SA received the highest proportions of travelling patients (Box 1). Patients living in Victoria accounted for relatively high proportions of hospital stays in SA, Queensland and NSW.

WA received the lowest number of travelling patients. Geographical regions where travellers to NSW, Queensland, SA or WA hospitals lived were clustered in northern and western NSW, northern and western Victoria, central Australia, Arnhem Land in the NT and the major capital cities (Box 2A).

Movers

There were 48 575 individuals (0.6%) with hospital stays recorded as residents in two or more jurisdictions over the 5-year study period. This group moved 59 387 times over the 5 years. Queensland hospitals had the highest proportions of hospital stays by movers over the 5-year study period (0.45%), with most coming from NSW. Hospitals in NSW had the lowest proportion of hospital stays by movers, less than half that of Queensland hospitals (0.22%).

The geographical distribution of movers differed to those of travellers (Box 2B). Patients who moved tended to live in regions typically associated with the mining industry, such as Mt Isa and the Bowen Basin in Queensland and the Pilbara, Gascoyne, Kimberley and Kalgoorlie regions of WA. Movers were also more prevalent from important tourist regions, such as the Coral Coast in WA, Tropical North Queensland, and the Whitsunday Islands and Capricorn Coast in Queensland. When population density was taken into account, rural and remote areas tended towards having higher proportions of movers compared with major metropolitan areas (map not shown).

Cross-border hospital transfers

Over 11 000 acute care hospital transfers across state borders of the four jurisdictions were identified (Box 3). NSW was the source of origin for most hospital transfers among these four jurisdictions (Box 4) and Queensland and SA received most of the NSW patients being transferred. WA received fewest cross-jurisdictional hospital transfers.

Cross-border hospital-related deaths

There were 206 721 in-hospital deaths observed in the 5-year study period and, of these, 2824 (1.4%) were in-hospital deaths of travellers who died in a jurisdiction different from that of their normal residence. Of the 66 324 deaths that occurred within 30 days of separating from hospital, 496 (0.7%) occurred in a different jurisdiction to that of the last separating hospital (Box 3).

Discussion

Cross-jurisdictional person-level linkage of hospital records and death registrations identified patterns of hospital use in Australia that have not been measured previously. From 1 July 2004 to 30 June 2009, 3% of all hospital patients had travelled across a state border before an acute care hospital stay. These finding have important implications for both health services planning and the ability to evaluate patient health outcomes in these border regions accurately. Longitudinal health studies that rely on administrative data from a single jurisdiction for hospital morbidity and mortality (in-hospital and within 30 days of leaving hospital) outcomes are at risk of follow-up biases for participants living in border regions, particularly in northern and western NSW, Victoria and the NT.

In this study, we followed hospital users who moved their place of residence between jurisdictions over the study period. Based on the residential location before the move, movers included a subpopulation of workers or residents of mining and tourism areas of Australia. This suggests that cross-jurisdictional linkage could be of great benefit to studies looking at occupational exposures and health outcomes that require long follow-up periods.

Only four jurisdictions were included in our study, but there was evidence that many Victorian patients travel to hospitals in other jurisdictions, particularly those living close to SA and NSW borders. Residents of the NT were also mobile when attending hospitals. A complete national approach to cross-jurisdictional linkage would markedly increase the ability to answer questions about the whole of Australia, and gain in-depth knowledge of the variation between all jurisdictions.

Currently cross-jurisdictional data are received in a variety of formats and coding schemes that required extensive cleaning and standardising. Some records and variables were not supplied by some jurisdictions at all (eg, private hospital data in SA). This heterogeneity in data arises for various reasons, including differences in jurisdictional legislation, operating environments and the coding practices of state-based custodians.

Future research would benefit from the development of national metadata and standard definitions that would enable data across jurisdictions to be more readily integrated and understood. A major advantage would be greater confidence by data custodians that their data were being used and interpreted correctly by researchers. In our study, for example, a direct comparison of hospital mortality rates across jurisdictions would be misleading without considering that deaths in emergency departments were included in NSW hospital data, but not in those of the other jurisdictions.

A more centralised approach to standardising data definitions would also provide long-term efficiency gains. While considerable resources and cooperation would be needed to establish such a standard, the time and savings in project-based research funding would be significant in the long term.

Access to person-level administrative data that have been linked across jurisdictions adds complexity and heterogeneity to the research process. The advantages include more complete follow-up, increased ability to study rare outcomes or disease, and to study geographically active populations. For policymakers, governments and health care providers, cross-jurisdictional linked data could provide a more accurate and cost-effective use of existing data collections for evaluating patient outcomes and health care service use, particularly where these are located near borders.

1 Number of acute care hospital stays per 10 000 hospital stays recorded for travellers by their state of residence and the jurisdiction of the receiving hospital and, for movers, by the state of residence before moving and the jurisdiction of the hospital stay after moving, 1 July 2004 to 30 June 2009

Original place
of residence

Hospital stays by travellers

Post-move hospital stays by movers

NSW

WA

QLD

SA

NSW

WA

QLD

SA

NSW

—

11.1

221.6

41.9

—

13.3

33.0

12.8

WA

4.1

—

4.3

8.8

3.3

—

6.7

8.2

QLD

75.1

9.3

—

11.2

14.7

11.2

—

10.6

SA

4.4

4.3

5.0

—

1.8

4.2

3.2

—

VIC*

68.7

9.7

20.5

67.2

1.1

0.8

1.0

2.0

TAS*

2.6

1.5

3.1

2.6

0.1

0.1

0.2

0.1

NT*

2.2

5.7

6.5

60.4

0.2

0.8

0.5

1.8

ACT*

23.9

0.7

1.9

1.6

0.8

0.1

0.2

0.1

Total

180.9

42.3

262.9

193.8

22.0

30.5

44.9

35.7

NSW = New South Wales. WA = Western Australia. QLD = Queensland. SA = South Australia. VIC = Victoria. TAS = Tasmania. NT = Northern Territory. ACT = Australian Capital Territory.

* Data pertaining to patients resident in the four non-participating jurisdictions were complete for travellers if they were admitted to a hospital in any of the four participating jurisdictions. The estimated number of hospital stays for movers from non-participating jurisdictions is an underestimation, as most hospital stays before they moved would likely have been based in the non-participating jurisdiction for which no data were available.

2 Number of acute care stays in hospitals in New South Wales, Western Australia, Queensland or South Australia by the statistical local area (SLA) of residence of travellers (A)* and movers (B)†

* Density of shading is attributed to the SLA of residence of the traveller. † Density of shading of post-move hospital stays is attributed to the SLA of the pre-move residence.

Note that the number of movers is not directly comparable with the number of travellers because movers had to have had at least two hospital stays in 5 years, whereas travellers could have had only one hospital stay. SLAs of states that did not provide data for this study are shaded because residents living in these SLAs travelled to a hospital within the four participating states. Hospital stays for movers from non-participating jurisdictions will be underestimated as most pre-move hospital stays would have been based in the non-participating jurisdiction.

3 Number of hospital stays involving cross-border hospital transfers and cross-border registered deaths within 30 days of separation from the last hospital stay, 1 July 2004 to 30 June 2009

Jurisdiction
of sending/
last hospital stay

Cross-border hospital transfers
(jurisdiction of receiving hospital)

Cross-border 30-day deaths
(jurisdiction of death registration)

NSW

WA

QLD

SA

Total

NSW

WA

QLD

SA

Total

NSW

—

12

8114

1316

9442

—

7

196

25

228

WA

27

—

26

12

65

< 5

—

< 5

< 5

9

QLD

1258

8

—

12

1278

219

< 5

—

12

234

SA

299

8

24

—

331

< 20

< 5

< 5

—

25

Total

1584

28

8164

1340

11 116

239

12

205

40

496

NSW = New South Wales. WA = Western Australia. QLD = Queensland. SA = South Australia.

4 Source of cross-border hospital transfers recorded over 5 years between New South Wales (enlarged), Western Australia, Queensland and South Australia*

* Density of shading is attributed to the statistical local area (SLA) of residence of transferred patients.

Death due to intravenous use of α-pyrrolidinopentiophenone

To the Editor: Sellors and colleagues report a fatality where urine drug testing (UDT) failed to detect the drug of overdose detected on the coronial blood assay.1 This highlights how clinical care may be handicapped by older testing technology.

Historically, UDT was used for forensic and occupational safety testing. Medicare subsidises UDT that relies on an immunoassay and on standards designed for forensic and occupational safety purposes. The target substances and cut-off values are potentially inappropriate for contemporary use. When prescribing opioid analgesia for chronic pain,2 palliative care or emergency care, physicians need to know whether psychoactive substance use is complicating presentations or whether there may be drug diversion.3 Limitations of UDT include failure to detect buprenorphine, fentanyl, oxycodone (except at very high levels), anabolic steroids, synthetic cannabinoids and most designer and emerging drugs.1,2

Clinicians who wish to test for the presence of specific substances using refined and state-of-the-art technology such as mass spectrophotometry may find that laboratories are unwilling to assist because of the high cost of infrastructure, including highly trained personnel and expensive equipment. Where available, the effort and costs associated with the detection of novel substances is prohibitively expensive. Currently, these confirmatory tests are not subsidised by Medicare. Thus the costs of these tests may be passed on to consumers, who may be unwilling to pay for them.

The case described by Sellors et al presents a timely opportunity for a review of the UDT Medicare subsidy so that it can adequately support diagnosis and improve clinical outcomes.

Antenatal care for asylum seekers

To the Editor: We read with interest the recent perspective written by doctors from International Health and Medical Services (IHMS).1 They state that regular visits to Nauru by specialists, including paediatricians, deliver care “commensurate with that in Australian communities”. The IHMS doctors also state that “We encourage informed commentary and debate among the public and the medical profession”. As specialist paediatricians who recently visited Nauru for IHMS, we disagree with both these statements.

We agree with our fellow Australian general paediatricians2 and the Australian Medical Association:3 mandatory immigration detention of children is child abuse. This view is supported by the numerous specific instances of child abuse meticulously documented in the Australian Human Rights Commission’s report of the National Inquiry into Children in Immigration Detention4 and corroborated in the Australian Government Department of Immigration and Border Control’s own Moss Review.5 The Royal Australasian College of Physicians and 14 other colleges and health organisations have called for the immediate release of children from prolonged immigration detention.6

As long as asylum seekers are in detention on remote islands, IHMS cannot provide paediatric and obstetric care commensurate with that in Australian communities. However, IHMS doctors can claim that they are trying to provide the best health care possible by working within the system. Unlike the Red Cross, which eschews political involvement, IHMS, a private company, has a significant conflict of interest: its contractual obligation to the Department of Immigration and Border Control.

IHMS required us to sign a contract that included clauses forbidding media comment or “any public statement that concerns or is related to or which might reasonably be expected to affect the Department [of Immigration and Border Control] or IHMS”. IHMS cannot forbid transparency and then claim to encourage informed commentary and debate.

The value of clinical ethics support in Australian health care

Clinical ethics support may benefit professional practice, and we should evaluate it in Australian health care

Professional practice in health care inevitably involves difficult ethical considerations that are often embedded in universal events: birth, periods of ill health, and death. Clinicians may be unsure in these situations about what exactly they should do. In light of this circumstance, ethics should no longer be an implicit component of Australian health care, but instead be explicitly recognised and practised. Clinical ethics support (CES) would help to optimise the ethical delivery of patient care.

The aim of CES — whether it is provided by a clinical ethics committee, an ethics consultant (a trained ethicist who supports professionals or institutions), or a combination of both — is to assist ethical decision making in health care. CES is often invited when a specific need for ethics advice arises in the context, for example, of a difficult clinical case or problem, an educational need, or a gap in policy.

  “The development of [clinical ethics support]
   in Australia currently lags well behind that in
      other countries”

Ethics is included in Australian medical training curricula, such as the Royal Australasian College of Physicians’ Professional Qualities Curriculum, and is expected to inform individuals’ medical practice. Medical education, however, may not be sufficient, and professional clinical practice may not always allow detailed ethical deliberation. While the Australian Health Ethics Committee recently endorsed CES,1 there are currently few alternative dedicated mechanisms for considering ethical issues in Australian health care, and this limits individual and institutional development and professional practice in this area.

This does not mean that Australian clinicians are unethical, or that they are ignorant about ethics. In this issue of the Journal, Doran and colleagues explore ethical practices and decisions,2 and suggest that ethical practice in Australian health care is “mostly right”. However, their research also detected a phenomenon that can be termed silent “moral disquiet”. Australian health professionals appear to have persisting concerns about ethical aspects of their practices, but there are few appropriate forums for explicitly discussing them. This puts them at risk of “moral distress” — the stress that arises when a clinician feels unable to act ethically.3 CES has the potential to alleviate this situation.4

How does clinical ethics in Australia compare with overseas?

The development of CES in Australia currently lags well behind that in other countries. CES has been available for more than three decades in the United States5 and for more than two decades in the United Kingdom.6 CES has also been established in other countries, including New Zealand.7 In contrast, there are no current surveys of Australian CES services, and earlier analyses had methodological problems.8 Only a few Australian CES services have been described in the literature.9,10

In the US, almost all hospitals have a clinical ethics committee and many also have clinical ethics consultants. CES services are well integrated into the clinical setting, and can often, for example, be contacted through the hospital bleep service. In addition to individual case consultations, many CES services also offer “ethics rounds” conducted by an ethics consultant in a specific ward, such as an intensive care unit or a geriatric patient ward, to discuss pertinent ethical issues. Ethics consultants are also permitted to write in patient notes (personal observation). A professional code of ethics for clinical ethics consultants has recently been introduced in the US.11

In the UK, there are more than 70 clinical ethics committees in a variety of health care settings, including primary care, mental health and tertiary hospitals, many of them providing case consultation. An emerging national network links clinical ethics committees and individual consultants across the country. The UK also benefits from access to a network of clinical ethics practitioners in the European Union, allowing ready comparison of practice and policy between countries (personal observation).

CES services in countries such as the US and UK may help with cases or broader discussions in areas such as end-of-life care, confidentiality and its limits, pandemic planning, termination of pregnancy and refusal of treatment by minors. Some have excluded certain questions from their remit, such as resource allocation decisions (personal observation).

Australia, in contrast, has fewer CES services9,10, with no professional organisation or standards, and “implicit ethics” are more typical for medical practice here. Clinicians need to be able to justify decisions on ethical as well as other grounds, but support for ethical decision making should not just be left to individuals. Opportunities to discuss ethics with colleagues can be helpful. If CES is not introduced more widely in this country, we risk increasing the levels of silent moral disquiet and moral distress in our medical staff, together with the disruption and disaffection that this may cause. We should look to examples of successful CES overseas and assess their suitability for adoption into Australian clinical practice.

Challenges for clinical ethics support

Successful CES is subject to several challenges. Overseas CES processes may not be immediately translatable to Australian health care contexts and further practical challenges are also likely to arise. For example, not every hospital in Australia may have the means or demand to sustain local CES services, particularly those in rural and remote areas. Other factors relevant to how CES would be organised and implemented include the organisation and funding of health care in Australia, the cultural mix of Australian society and the role of CES in hospitals with particular religious affiliations. These, however, are not impediments to the implementation of CES, but simply highlight that Australian CES will need to be tailored to the population it serves.

An institution that introduces CES will also need to endorse and promote it; otherwise it will eventually struggle or even flounder entirely. To prevent this, an institution must commit itself to financial and practical support of its CES over a sustained period of time. Endorsement and oversight of clinical ethics at state and national levels would be even more preferable.

CES can struggle to generate conditions or a culture in which referrals for case consultation, educational provision or policy work are more likely.6 How such conditions can be achieved remains an open question. The concept of specific CES itself is also subject to critiques of the “place” of clinical ethics in decision making,12 and the appropriate role of patients in CES processes.13

Is there a place for clinical ethics support in Australia?

One aim of CES is to support professionals and families. This should not be misunderstood as “telling health professionals what to do”, hunting for “poor practice” or “taking sides.” Using CES should not be compulsory, nor should it replace “everyday ethics” in clinical decision making. CES offers a mechanism that facilitates sound and reasoned decision making in ethically contested situations, supported by ethical experience, training and research into what facilitates appropriate ethics support. Clinical ethics can also assist clinical professionals to help themselves and each other, proactively encouraging a reflective culture of health practice.

Australian health professionals may be sceptical about CES, as I recently found after presenting my overseas experience of CES to such a group. Many were perplexed and unsure of its potential benefits. If they were competent clinicians, should they not be able to do this kind of reasoning as part of their everyday work? This exemplifies the “settled morality” discussed by Doran and colleagues2 in which ethics becomes “part of the fabric” of clinical work, leading to its invisibility. This works when there is no silent moral disquiet, but, as Doran et al claimed, we should be wary of “overlooking rather than tackling difficult but important ethical issues”.

The sceptical view also misses the point of CES. When implemented well, CES optimises decision making in difficult circumstances, and enhances a culture of sound ethical practice at the institutional and system levels (through, for example, regular ethics grand rounds). A clinical ethics service can also help avoid having to resort to legal means to solve problems — although this point needs more investigation.

A separate teaching session with the same group of health professionals I mentioned earlier helped resolve some of the uncertainty many of the clinicians felt about CES. Acting as a mock clinical ethics committee, and using a trained chair, a difficult published case was explored to simulate how CES might work in practice. We discussed the complexities of the case and possibilities for its resolution from a variety of perspectives, questioning our assumptions after hearing from colleagues with other viewpoints. The session ended with the group enthusiastic about and appreciative of the process, having developed a proposed course of action that was both based on ethical reasoning and practicable within a health service.

Conclusion

Australian CES is still in its infancy. It will be subject to practical, political and professional challenges. International experience with CES across a range of jurisdictions and health care systems suggests, however, that, when appropriately implemented, CES benefits clinical practice, health professionals, patients and their families. Ethics is already integral to clinical practice in Australia, but it is often not overtly discussed. It is assumed, but not critiqued, practised, but not reflected on. CES should be introduced and evaluated to determine if and how it strengthens the delivery of ethical health care.

Listen, hear, act: challenging medicine’s culture of bad behaviour

There is no place for humiliation, discrimination or any kind of harassment in medical education

A perfect storm occurs when a situation is exacerbated by a rare combination of events. In recent media reports, there has been a perfect storm of accusations of every kind of abuse levelled against the medical profession by some of its own. Abuse is not new. Few who have experienced medical training can honestly say we have never seen nor been victims of any form of bullying or humiliation throughout that process. But the rare exacerbation early this year was the separate deaths of four junior trainees, apparently by suicide, followed soon after by Dr Gabrielle McMullin’s comments about the sexual harassment of female surgical trainees.1

The tragic deaths of the young doctors triggered my recent article in Croakey;2 but before that there was a long-brewing frustration fuelled by endless stories from students and doctors — of sexual harassment, bullying, teaching by humiliation, discrimination and the trauma of medical education — and by my own experiences of being a woman in medicine.

One reader’s comment in Croakey was particularly confronting.

The saddest part of this story is … deja vu. This has been happening intermittently for decades. A lot of noise is made about it, promises are made, and then after a few “death free” years everyone moves on — until tragedy strikes again.3

Looking back over nearly four decades since I entered medical school, I know my reader is right: much is said, but little changes. Well intentioned programs, policies and services are in place, but, as the reader continued,

one of the biggest impediments to seeking help is that the young doctors would be seeking help within their own system and are too ashamed to do so.

The services, supports and reporting pathways are there, so why don’t doctors use them? Perhaps the strongest example of why not was revealed by McMullin’s suggestion that female surgical trainees who are asked for sexual favours by senior colleagues should oblige rather than risk their careers. The ensuing uproar suggests McMullin is an astute media tactician. Despite the vocal insistence of medical organisations to the contrary, McMullin stood firm that current systems are not solving the problem.

This is not a problem only for women or surgeons. My inbox was flooded with stories from women and men experiencing harm at the hands of colleagues and the system. One male intern wrote:

If I had known back then what I know now there is no way I would have chosen to do Medicine. In fact, the choice to do Medicine is the single biggest regret of my life … there are some real a**holes still out there; and I am at a loss as to how they can still be employed, given how completely unacceptable and out-of-line their behavior is.

A male senior student wrote,

I suffered terrible and sustained abuse and humiliation at the hands of a [specialist] physician culminating in my attempted suicide … The mental scars inflicted by him, and others … are, however, still painfully present … I strongly considered abandoning medicine altogether … because of the culture of abuse that is still inherent.

The Royal Australasian College of Surgeons,4 the Australian Medical Association5 and the Victorian Health Minister6 have now all weighed in with a range of proposed reviews and taskforces. Frank and fearless examination of current processes is welcome, but it must genuinely aim to remove the significant barriers to doctors using them without personal peril. Negative impacts on the right to practise and on career progress are among the most common reasons doctors cite for not seeking treatment or support for mental health conditions.7

What needs to change most is a medical culture that condones and even encourages bad behaviour. That will not happen through advisory panels and external forces. Medicine is a complex, multicultural affair: a loose coalition of high-achieving, competitive individuals belonging to numerous workplaces and associations, each with its own internal hierarchies and cultures. No single person in medicine has the power that the former Chief of Army, Lieutenant General David Morrison, displayed in his unequivocal response to sexual harassment in the army.8 Also unlike soldiers, doctors are trained to work autonomously: to give, rather than take, orders.

For most of the past two centuries, doctors stood atop the health care pyramid and enjoyed enormous autonomy and deference. But as society began to change after World War II, so too did medicine.

More women entered medicine, and gender parity among students occurred around the mid 1970s. And yet, that gender balance is still not reflected in most specialist training schemes or in the medical workforce where the ratio of women to men is 2 : 5.9 More worryingly, selection criteria seem once more to be favouring male students.10

Consumers began to demand more say in their care and increasingly held doctors to account; legislation and external regulatory bodies became more prominent in governing doctors’ actions; non-medics took over hospitals; and interdisciplinary teams became the new work paradigm. However, the training and expectations of doctors to be on top of the pyramid remain largely unchanged. I wonder if some of the bad behaviour we see is symptomatic of a profession struggling to adapt to lost status. Cultural change is difficult, and resistance is common.

Whatever the cause of medicine’s discontent, for change to start, we must first accept that we have allowed a workplace culture in which incivility and frank bullying are commonplace. There are too many deniers and too much victim shaming in the current commentary. “It didn’t happen to me, therefore it didn’t happen”, is not evidence. Simply suggesting junior doctors develop “resilience strategies” and “stand up to bullies” is further victim blaming.11

Bad behaviour is often unconscious. Like evil, it is banal and takes hold when the unthinkable becomes normalised as the way things are and people fail, for fear or favour, to challenge the status quo.12 The belief that, to succeed, it is necessary to acculturate to, accommodate and perpetrate this negative culture is, sadly, all too common. It’s time to stop talking and harness one of medicine’s most powerful and underused diagnostic skills: listening. All the taskforces and policies in the world will not make an iota of difference if the victims’ voices are silenced by fear or shame.

Change is most successful if it’s modelled from the top. As medicine has no single chain of command, leaders committed to genuine change must be championed and supported to implement a zero-tolerance approach. Training in respectful communication could be made mandatory for all teachers and supervisors. Feedback and appraisal mechanisms can be built into performance reviews and accreditation processes. Providing an independent regulatory authority such as a health workplace ombudsman13 deserves serious consideration as a safe pathway for raising concerns and getting support, and for removing those in power who refuse to change.

It is possible to learn skills to improve your ability to communicate and to model positive behaviour. At the University of Sydney, for example, we are developing workshops to train health professionals in acting skills. Actors are able to be fully engaged within a role while also observing their own performance and adapting it to the situation. By practising these skills, doctors can start to recognise the impact of their actions on others and to safely challenge the normalisation and perpetuation of bad behaviour.

But real change also requires each of us to listen to our conscience and ask, “Am I part of the problem?”. It requires individuals to challenge “the way things are” so that reporting bad behaviour becomes everyone’s responsibility, not just the victims’. The consequences of bullying and harassment are reduced concentration, anxiety, compromised communication and poor team work. Shooting the messenger does great harm. It is killing both doctors and patients. What we cannot allow to happen is for the prediction of my reader to come true:

when this all “blows over” I’m sure the next crop of young doctors will be in the same boat.

Call for Australia’s ratification of the Optional Protocol to the Convention against Torture

Let’s not wait another 10 years

The forgotten children, the Australian Human Rights Commission’s 2014 national inquiry into children in immigration detention, has come and gone. Its findings are clear and damning and should be a surprise to no one.1

A decade earlier, the Human Rights and Equal Opportunity Commission released its national inquiry, A last resort?.2 It is unacceptable that we might wait another 10 years before such gross abuses cease and people are restored to both health and justice.

Further, the United Nations has named Australia for its breach of the Convention against Torture and Other Cruel, Inhuman or Degrading Treatment or Punishment.3 The medical community has been made aware of our ongoing human rights violations over the past decade.1,4–7 Ignorance is not an excuse that we can cling to for being part of this national embarrassment.

What more could be done to make us pay attention to the need to move beyond the multiple peak body position statements? They are only useful in as much as they highlight the chasm between acceptable standards of medical care and what we know is being practised in immigration detention.1,4–7

One option to increase genuine accountability would be to ratify the Optional Protocol to the Convention against Torture and Other Cruel, Inhuman or Degrading Treatment or Punishment (OPCAT). The OPCAT is a bipartisan-supported UN protocol signed by Australia in 2009. It is as yet unratified.6,8–10 At the time of publication, the OPCAT has been ratified by 78 countries (Box). It was established recognising the need to take measures beyond the simple agreement not to engage in the inhumane treatment of people in detention.8

Ratifying the OPCAT would ensure adequate oversight of the conditions of detention within Australia through the establishment of a national preventive mechanism (NPM) and through international scrutiny.8–10

Such a need for monitoring and independent oversight in immigration detention was not addressed through the establishment of the Detention Health Advisory Group in 2006, later remodelled as the Immigration Health Advisory Group, which was abandoned in 2013.11

An NPM would include a system of regular visits and reporting undertaken by independent national and international bodies. NPM assessments should inform legislation and intervention, as well as act as deterrents in their own right.8–10

An NPM would extend protections well beyond immigration detention centres. Monitoring would apply to people in all forms of detention where the protection of human rights is more challenging. This includes involuntary psychiatric admissions, aged care placements such as secure dementia wards, mental health facilities, forensic disability units, police lockups, juvenile detention centres and correctional environments.8–10

There is already considerable support for Australia’s ratification of the OPCAT. This was demonstrated in September 2014 when 64 organisations wrote to the Attorney-General calling for its endorsement.6,12 Significant work has been completed on the requirements for implementation.9 Tasmania, the Australian Capital Territory and the Northern Territory have released draft bills.6

We have the benefit of seeing different ways the OPCAT has been implemented and ratified internationally in comparable countries such as New Zealand and the United Kingdom (Box),9,10,12,13 where this process has led to strong review mechanisms with legal force that regulate places of detention of all kinds. These mechanisms also find expression in legislative changes to procedures in situations where human rights might otherwise be threatened.9,10,13

Such a mechanism would also assist in alleviating dual loyalty conflict experienced by the health workforce, whereby a lack of appropriate transparency and accountability leads to conflict between fulfilling duties to patients and the demands of employers. Many doctors and other health care providers have stated that such conflicts are commonplace in the detention of asylum seekers, as is a lack of ethical guidance when faced with decision making in the absence of a system grounded in human rights.4,5,14

For doctors, preserving and protecting the right to health falls squarely within our duty of care. As the World Medical Association makes clear:

As health professionals, physicians have a key role to play in providing high quality care to all patients without discrimination and preventing and reporting acts of torture and ill treatment that constitute gross human rights violations.15

Further, as all human rights are intimately connected, the preservation of the right to health serves to protect justice and dignity for asylum seekers. It is our obligation to ensure appropriate safeguards are put in place to regulate a clear separation between the management of health care and immigration policy. This is imperative when, despite the best intentions of the health care workforce and the bodies that represent them, we have thus far failed so badly.

1 Ratification of the Optional Protocol to the Convention against Torture and Other Cruel, Inhuman or Degrading Treatment or Punishment*

Country status: dark blue = state party (78 countries); light blue = signatory (18 countries); orange = no action (101 countries). * Reproduced with permission from United Nations Human Rights, Office of the High Commissioner for Human Rights. Optional Protocol to the Convention against Torture Subcommittee on Prevention of Torture. http://www.ohchr.org/EN/HRBodies/OPCAT/Pages/OPCATIndex.aspx (accessed May 2015).

NHMRC initiatives to improve access to research outputs and findings

The National Health and Medical Research Council (NHMRC) funds about $850 million of Australia’s best medical research each year. To continuously deliver tangible health benefits to the Australian community, NHMRC has implemented a suite of initiatives to maximise the returns from this investment.

In April 2015, NHMRC released a statement encouraging its funded researchers to improve their data sharing practices (http://www.nhmrc.gov.au/grants-funding/policy/nhmrc-statement-data-sharing). The statement says:

NHMRC encourages data sharing and providing access to data and other research outputs (metadata, analysis code, study protocols, study materials and other collected data) arising from NHMRC supported research.

This is an ethos consistent with the 2007 Australian Code for the Responsible Conduct of Research (http://www.nhmrc.gov.au/guidelines-publications/r39) and a practice that stands to benefit all Australian researchers and those who fund Australian research.

NHMRC’s statement on data sharing follows the NHMRC Open Access Policy (http://www.nhmrc.gov.au/grants-funding/policy/nhmrc-open-access-policy), which was implemented in July 2012 and requires that:

any publication arising from NHMRC supported research must be deposited into an open access institutional repository and/or made available in another open access format within a twelve month period from the date of publication.

NHMRC also requires all clinical trials it funds to be registered with a clinical trials registry.

These initiatives are aligned with the strong global movement for open access to research information. Greater transparency of research and better use and reuse of data will ensure that waste in research is minimised, while improving the reproducibility and value derived from research.

NHMRC will continue to ensure that its assessment processes are rigorous, that only the most significant research ideas are funded, and that access to research results remains as open as possible.