e-Health, Telemedicine, and Elections

HP and Dreamworks' Halo Videoconferencing Solution.
Completely unnecessary for doctors, but it sure looks cool.

I love e-things. I am a gadgety sort of person – and yes, I do have a fancy super-duper iPaddy kind of thing. I consider myself to be techno-savvy, and run my private practice with an almost paperless electronic records system. I am an early adopter of many technologies, and will always try new things. But I am not so convinced on e-Health. Why?

e-Health is all the rage. The federal government even has a special taskforce called NEHTA (National e-Health Transition Agency) which is dedicated to wasting investing money in this area. It is all about "transforming and revolutionising" the way we practice medicine.

I don't want to transform and revolutionise anything. I just want to be able to treat my patients better and more easily. This does not require me to have access to every piece of medical documentation on a patient since they were born. It does not require me to be able to access a full medication list and prescribe remotely to a patient on the other side of the country. It also does not require me to videoconference with every patient or doctor in the country.

We have many, many technologies today which make things easier. Often they are the simplest things, and usually they are so pervasive and useful that we take them for granted, like the telephone.

Now, it would be remiss of me not to point out that we are in the latter half of a Federal Election campaign here in Australia. What prompts this post is not the lack of comprehensive health-care policy discussion from either major political party so far, nor the incessant, disproportionate focus on mental health whenever any health funding is mentioned. Julia Gillard's health policy is "Doctors are expensive so let's replace them with technology, physician assistants, nurse practitioners and allied health." Tony Abbott's health policy is "It's too hard let's just hand it to local communities."

But it does bug me that Julia Gillard can stand up and say that she will fund a revolutionary new "Online Consultation" service with a new Medicare Item Number. This is a government whose Health Minister, Nicola Roxon, has been trying very hard to slash item numbers such as those for Cataract Surgery, Obstetric Services, Coronary Angiography, Joint Injection, and Injection Sclerotherapy for Varicose Veins (MBS Website). There is no doubt that this is merely an "election sweetener" for rural GPs and rural voters, and those employed in the technology infrastructure sector.

Steady uptake in Telepsychiatry.

An item number already exists for Telepsychiatry consultations (Items 353-370), and uptake has been gradual - pushed primarily by a small number of psychiatry groups. One might think that psychiatric consults are ideal for videoconference but remember that a great deal of patient interaction is via non-verbal communication and behavioural cues, which even videoconferencing cannot replicate. The RANZCP has guidelines as to how they recommend Telepsychiatry be used.

But much as videoconferencing might be the poster-boy of this type of technology, it ignores the fact that there are many simpler and commoner means by which clinical information is communicated between patients, GPs and specialists, such as email and the telephone.

For example, this policy announcement outlines a scenario whereby a patient might conduct a combined GP visit with an online videoconference to an oncologist. Presumably this is encouraged by the GP and the Oncologist both being able to claim an item number for this consultation.

The key parts of this conference are that first of all, the patient knows that the oncologist exists and is not a figment of the GP's imagination (but there are other means of achieving this) and secondly, the GP is able to discuss the patient's individual treatment plan with a distant oncologist (which is best done in private away from the patient). Given that the private conference is the most important, why restrict any Medicare benefits to a combined patient-GP-specialist consultation?

Currently, patients who will not or cannot travel to see an oncologist can be cared for by a GP or local physician, with instructing care issued by a remote oncologist by much more prosaic technologies as mail, or telephone. Video-conferencing is sometimes used for multidisciplinary team meetings. Realistically, the video adds very little to such meetings or discussions, so it is silly to think that an item number must insist on the conference occurring via video-link. In that setting, should Medicare benefits be available for specialists who spend their time giving advice over the telephone, or reviewing patient files and sending a letter of advice?

If that is the case, then I should be paid Medicare benefits for all the GP queries that I get over the phone, and all the paperwork that I perform organising a patient's care in between physically seeing them. Instead of seeing review patients, I could just check their results, give them a phone call, and lodge the Medicare claim. Is that good or bad? It sure would make my job easier. I could see more patients. It would be significantly cheaper and more convenient for the patient. Even better, if the new Government were to fund practice nurses for specialists, then I could delegate the job to my nurse!

First patient to survive a stroke without side effects?
BULLSHIT! What a way to blow your own trumpet!

Why is it that when you slap a computer with the Internet on it, everything suddenly becomes "Telemedicine"? Since the telephone was introduced doctors have been giving instructions from remote. Is that "Telemedicine?" For years I have been reviewing photos of patients and their X-Rays via email from distant GPs. Am I on the cutting edge of Telemedicine? I have had remote PACS access to a number of hospitals and reviewed films from home. I have advised surgeons and GPs in other towns how to perform surgical procedures over the telephone. Should I be on the news because I am a frontier Tele-surgeon? I don't think so... this is just part of the pervasiveness of communications technology into common life, as well as medicine.

I don't know about you, but this thing
would scare the crap out of me.

My advice, Julia – scrap the "Online Consultations" rubbish and bring in an item number that pays doctors for all the organisational work involved in-between face-to-face patient visits, allow doctors to be paid for telephone consults, advice and services, and don't bother wasting money on teaching doctors to videoconference when they will use it perhaps once of twice a year just for fun. Spend the money on secure integrated email for all doctors and practices. Oh, and funding for specialist practice nurses please.

Reform for Reform's Sake?

It has been a big week in healthcare news. One cannot have missed all the talk about Kevin Rudd's bold new plan, to take health care where health care has never been before (except in Victoria). Much of these reforms derive from the previously published NHHRC report which I will not expand upon. I will, however, give some of my mind on efficiency in the medical sector.

Nicola Roxon loves banging on about efficiency, and funding the "efficient costs" of health care. Here she is on ABC's Lateline on the 27th of July last year:

NICOLA ROXON: Yes. Yeah, that's right. They - of the funding, what they recommend - and remember we're talking about their proposals to us - is 40 per cent of efficient funding, which is actually an interesting concept, which is the states should fund the extra 60 per cent and any inefficiencies that are in their system. And they even say if you even went up to 100 per cent in the future, you should only pay 100 per cent of an efficient system, which would sort of have a penalty there for -

TONY JONES: Just to clear up what that means. Effectively, that means that, centrally, you would set the actual cost that should be charged for individual operations. A hip replacement, for example, should cost X and that would be the efficient cost.

NICOLA ROXON: That's right. Yep. That's right.

TONY JONES: Inefficient costs would be anything above X, is that right?

NICOLA ROXON: That's right. And so you would have a activity-based and efficiency-based payment. So if hospitals were - in particular states were not good at particular procedures, they would bear the extra cost, or if you're in a booming state where you've got a higher population putting more demand on your hospital services, you get paid more because you're undertaking more activity. That's the key tool that they are recommending we use for funding, which is a big change from where
we are in block funding the states for their whole activities.

Nicola Roxon - ABC Lateline - July 27 2009

There is plenty in the media about the pros and cons of a central pricing authority, and either additional or streamlined bureaucracy (depending on your point of view), but I am more interested in the "efficiency" concept. Now, efficiency in health care can be measured in very different ways, but generally they do not directly relate to improved health care, quality of life, or prolonged life expectancy. Efficiency does not automatically lead to improved population health.

The usual argument is that if you treat more patients with the same amount of money, then you are benefiting more people and therefore improving the health of your population. That is great if you have lots of waste and slack in your system but that is a very managerial and administrative view of the world. There is, of course, a great deal of waste and slack in our health system nationwide partly because health events are by their nature episodic and unpredictable (just look at the recent swine flu pandemic) and health infrastructure is not something that can be ramped up and down as necessary.

An analogous situation would be that your would not want all fire stations to be working at full capacity all the time, because when a particularly nasty factory blaze occurred there would be nobody to fight it. There is therefore an inherent downside at encouraging hospitals to work at > 90% bed capacity.

Unfortunately the usual measure of efficiency is throughput, which features very highly in health-administration KPIs (also known as "Key Performance Indicators"). For example, a standard means of measuring emergency department efficiency is how many patients are treated in a day, or a month or a year. Similarly we often ask how many patients are seen in a clinic, how many patients are admitted or discharged from hospital, how many operations performed in a month, patients taken off a waiting list, etc.

Obviously these are very simplistic views of the world and so token attempts are made to complicate things by "weighting", or "prioritising", or adding "descriptors" - all managerial jargon-speak for abstracting these figures from real life. The reason these KPIs predominate are:

1. They are readily reproducible (there is a defined common method for calculating these KPIs)
2. They are readily manipulated (there is no point monitoring a KPI unless you can improve it... ostensibly by improving performance, but in reality by a short term funding boost, or changing the way it is calculated)
3. They are readily manipulated in the short term (there is no point monitoring a KPI that takes 20 or 30 years to improve upon)

But back to the point I wanted to make. Kevin Rudd's whole health reform is said to be about eliminating State and Federal buckpassing, or the "blame game" as he likes to put it. This is mere political smoke and mirrors for what is the real purpose of these reforms. I am not saying that this is not worthwhile or important reform - but it should be seen for what it is.

The Blame Game
It has always been human nature to seek to blame someone else for your troubles. Currently our public hospital system is composed of infrastructure funding which comes from Federal and State Governments, recurrent operational funding which comes from State Governments (except when Federal Goverments seek short term headlines by giving away more money), and an Aged-Care system which comes from Federal Government funding.

All of these systems are interdependent, and the only thing that is really being changed is that the Federal Government is proposing to pay for recurrent operational funding through these new reforms. This pays for wages and consumables but who will pay for rebuilding a hospital or adding ICU beds? Who will decide whether a new hospital should be built or relocated against parochial or local interests? It is only natural that every resident wants to have every subspecialty service at their local and nearest hospital, even when this is a recipe for substandard care or unsustainable funding, and rural hospitals need to focus on core services and expanded primary care roles (PDF). Who will make the hard decision to remove maternity, or paediatric, or oncology services from some hospitals and centralise them at another? I'm no expert, but I don't see the Federal Government Reformists putting their hands out - and so the blame game continues.

Furthermore, Victorian Hospitals regularly find ways to manipulate the case-mix funding system to try to squeeze extra money out of the State Government. This is not unethical or immoral - it is just a fact of how the system is designed that a hospital cannot remain viable other than to make the most of the system under which it operates, and if that means improving your funding by meeting the targets in a innovative manner, then that is what the system encourages. Just like Darwinian evolution. Only now, hospitals (and State Governments) will be working hard to find ways to maximise the Federal Government's "Efficient Costs" payments. Get ready for some creative accounting, Kevin!

The Real Reform
The underlying purpose of this reform is no secret - it is merely obscured and obfuscated by the "Blame Game" argument. Kevin Rudd himself has said in his Australia Day Speech:

Treasury analysis which will be contained in the Government's upcoming Australia 2050 report points to the fact that over the next 40 years real health spending on those aged 65 and older is expected to increase around seven-fold. Real health spending on those aged 85 and over is expected to increase 12 fold.

This is a product of the increasing age of Australians overall and secondly the fact that within innovations in pharmaceuticals and medical technologies and the rest the cost of treating each individual aged Australian will rise as well. That is our first problem.

The second problem is, of course, the proportion of Australians in the workforce generating the tax revenue to support those services will become less.

So what does Australia, in response to this 2050 report that we will release soon, do about the challenges for the future when it comes to this ageing of our population.

One further thought we should bear in mind is the impact on our budgets.

Forty years ago, Australian Government spending on health equated to 1.2 per cent of Gross Domestic Product.

In 2010, Australian Government health spending equates to 4 per cent of GDP, and the Intergenerational Report projects that it will rise to 7.1 per cent in 2050.

In dollar terms, that's an increase of over $200 billion by 2050 - and equates to an increase in average Australian Government health spending per person in real terms from $2,290 today to $7,210 in 2050.

These are figures we should all reflect on.

Rising health and hospitals spending is already having an impact on state budgets.

States and territories have experienced growth in health spending of around 11 per cent per year over the past five years.

This contrasts with growth in state revenues of around 3 to 4 per cent a year.

Rapidly rising health costs create a real risk, absent major policy change, as state governments will be overwhelmed by their rising health spending obligations.

If current spending and revenue trends continue, Treasury projects that the total health spending of all states will exceed 100 per cent of their tax revenues, excluding the GST, by around 2045-46 - and possibly earlier in some states.

The NSW treasury has estimated that spending on health will almost double as a share of the NSW total Budget - from 30 per cent today to around 55 per cent in 2032-33.

These are challenging statistics, but it is important the nation becomes familiar with them, because we must do something about them.

Without reform - States ability to provide the services they currently provide will be significantly strained.

That is why 2010 must be and will be a year of major health reform.

Prime Minister Address to Australia Day reception, Sydney - 24 January 2010

The one success of Stephen Duckett's Victorian Case-Mix Funding model is that it has reduced the episodic cost of treating patients in public hospitals. Basically the way it works is that for patients being admitted to hospital with a specific condition (or similar groups of conditions, or similar operations) they receive a set payment which is predetermined. In order to allow for variations in the cost of treating those conditions throughout the state or between hospitals, or the State Government's desire for each hospital to provide various types of services, a complex series of calculations are applied to the actual amount that a hospital can receive. Effectively, hospitals are given a target of patients to treat or procedures to perform. If a hospital goes over that target either on a patient-by-patient basis or over a financial quarter then there is no further funding - they lose money.

In order to determine the appropriate payment, an audit is performed to estimate the costs involved with treating a standard patient in each hospital. This is compared to hospitals statewide and a statistical target is generated. Year upon year these figures are revised with more data, and hospitals try to make a little extra profit by beating their previous year's performance, until you get a "steady state efficient price" which is the price at which a hospital (the cheapest hospital) can treat a patient, most likely by cutting corners and taking risks - i.e. the price at which it starts to become unsafe to treat that patient.

As I intimated earlier - this is all about meeting budgetary targets, not about providing quality care. Doctors and nurses at the coalface are generally divorced from the cost of treating patients. Generally we like it that way as I don't feel guilty doing an ERCP on an 89 year old woman who will die in the next six months of a cholangiocarcinoma even if I save her life today. From a budgetary perspective the hospital would much prefer that I operated on a 20 year old man with early appendicitis than put the ERCP stent in, because it costs less to treat the appendix than the stent, but I have the luxury of not giving a shit, and therefore I am responsible for blowing out the health budget, as Kevin Rudd says.

There are perverse outcomes to this system (or "innovative solutions" depending which side of the fence you sit on). For example, the fewer days a patient is in hospital the more money a hospital gets for a certain condition. If you have shaved all the waste out of your hospital and are operating on maximum efficiency, the only way to get more money is to kick a patient out before they are ready. In order to combat this less money is paid if a patient "bounces", or is re-admitted for the same condition within 30 days. Therefore nobody comes in with the same condition within 30 days. They always have something unrelated to their last admission.

Furthermore, the more complications a patient experiences the more money a hospital gets. I remember my first day in a Victorian hospital included an orientation to "DRGs" or Diagnosis-related groups and "coding". I never realised that if a patient has an episode of dysuria and an equivocal dipstick they can be coded as having a postoperative UTI and therefore the casemix payment jumps 50%. Similarly, everyone has hyperkalaemia or hypernatraemia at some stage, or pulmonary atelectasis, or a wound infection (even if no antibiotics are required), or acute urinary retention (averted at the last minute by the threat of an urinary catheter).

And as Stephen Duckett also pointed out:

Mr Rudd's promise to provide 60 per cent of hospital funding also risked generating a rise in unnecessary hospital procedures.

The fixed cost of running a public hospital accounted for about 50 per cent, with the other half generated by surgery and treatment costs for individuals. "That will be an incentive to increase activity," he said.

The Age - March 5, 2010

Lastly, there is another downside to Case-Mix funding. In order for it to work, the funding body must define what procedures and conditions it will fund. If a patient suffers from something unusual that falls between the "coding cracks" or undergoes a procedure that is not listed in the manual, then they are unfunded, and the hospital must pay for that treatment out of general revenue at a complete loss. This discourages hospitals from treating patients with unclear illnesses (House would never survive in a Case-Mix funded hospital if it weren't for the fact that he does so many unnecessary procedures), and also discourages them from performing or rolling out new procedures or techniques which may have clear clinical benefits but are not in the list of funded procedures, unless a way can be found to "fudge the figures".

Ultimately, the real reason for this reform is to roll out the cost-capping measures of the Case-Mix funding system nationally. It provides a means to control and limit recurrent expenditure on health care in public hospitals over the long term. All the other claimed "advantages" are merely spin. This is the only valuable, long term and lasting outcome of these reforms. No doubt they are necessary, but it is disingenuous to hide this from the Australian public by overpromoting the other aspects of this reform.

The Underlying Problem
I have long held the opinion that the cause of ballooning costs of health care in this country is not the ageing population, or the costs of new drugs or devices (though these things do obviously contribute). It is that as a society we are completely incapable of drawing a line and saying that "This is as healthy as you need to be. If you want more, then you pay for it." Both the UK NHS and New Zealand health systems have had to overtly ration health care. South Australia has basically banned varicose veins surgery from public hospitals. Currently we prioritise but we don't limit what we offer in public hostels.

I do not speak from the moral high ground. I am no more likely to deny a patient varicose veins surgery or repair of a small hernia as a renal physician deny someone dialysis or a panelbeater recommend doing nothing to an insured smash-up. Generally as doctors we can tell when a treatment is futile, or unnecessary but ultimately we are people, and just like our patients - if a treatment is funded, the risk is low, and it works, then why not use it?

There is a precedent here which flies against the argument of those that say the Federal Government does not have the experience to roll out these reforms, and that precedent is Medicare. Medicare is effectively a case-mix system delivered on an outpatient basis. If you see a doctor, and you have a certain type of treatment (which correlates roughly to a certain condition) then the doctor receives a benchmark payment (75% of the Scheduled Fee). If the doctor's operating costs (+ profit) are greater than the reimbursement fee, then they charge you for the difference (the "Gap" fee). If the condition or treatment is not in the schedule, then the Federal Government does not pay and you get lumped with the whole cost.

Similar to the proposed efficient cost system, the Schedule fee is regularly revised (or some would say regularly ignored) to reflect the costs of providing each treatment. Sometimes the fee goes up, sometimes the fee goes down. Usually it goes down relative to CPI, and has (over the last 25 years) been a very effective way for successive Federal Governments to cap outpatient and primary care funding costs. Notice how the NHHRC said very little about primary care funding reform? It is because this reform is already in place, and the only thing that needs to happen is to turn the screws a little tighter as was recently attempted to cataract surgery.

I would predict that the nature of the Federal Government hospital reform funding rollout (Gee that is a mouthful) will closely reflect the way that private hospital cover is funded. Let us assume that the Medicare Schedule Fee for a Laparoscopic Cholecystectomy is the "efficient cost" of providing that service. The Federal Government currently agrees to pay doctors 80% of the "efficient cost" of that service. The remaining 20% comes from the patient's private health insurer. Any additional fees charged by the surgeon is paid for by the patient.

Similarly, private hospitals receive a payment for that patient's stay in hospital based on the patient's condition and their procedure, which is partly funded by state and federal governments but also by private health insurers. If those payments don't meet the hospitals costs then the patient is charged a further gap fee. All that Kevin Rudd and Nicola Roxon need to do is take that same system, insert "State Government" instead of "Private Health Insurer", apply it to public hospitals and voila - you have Public Hospital Medicare, with the added benefit that you can limit or reduce the "efficient cost" reimbursement as much as and whenever you like. If you don't want to pay for a procedure such as lap banding then you just refuse to add it to the list of funded procedures, and then it becomes the Local Board and the State Government's responsibility whether they want to pay for these unfunded procedures that the public is clamouring for access to… and the Blame Game continues.

We talk about a safety net but we are not brave enough to discuss how high or low the safety net should be positioned, or who we are really trying to catch. It is political suicide to say that some people need to suffer or die for the benefit of the rest of the community, even if that suffering is minor, or the death is inevitable. This reform is not about the "Blame Game", or restoring control to local or regional communities, or even improving the quality of our hospital system or population health.

It is about controlling the costs of health care in the long term, and it will work… for a little while, at least. But as I have pointed out before to my colleagues, Medicare (and these new Efficient Costs reforms) are basically the Australian version of public Managed Care, and I hope that we do not end up at the end of a Get Smart episode with Max lamenting: "If only Managed Care and Kevin Rudd's health reform had been used for good, not evil."

Links:

• Rudd to tour hospitals on reform opinions - ABC Lateline July 27, 2009. Watch: Win Lo | Win Hi
• Health reform proposal receives mixed reactions - ABC Lateline July 27, 2009. Watch: Win Lo | Win Hi
• Roxon discusses health reform proposal - Lateline July 27, 2009. Watch: Win Lo | Win Hi
• Taxpayers may have to dig deep for reform - ABC Lateline July 28, 2009. Watch: Win Lo | Win Hi
• Dutton discusses health reform plans - ABC Lateline July 28, 2009. Watch: Win Lo | Win Hi
• Much more than bravery required - The Australian July 28, 2009
• Healing a sick system - The Australian July 28, 2009
• Ageing population to add to pressure - The Australian July 28, 2009
• Federal government gets casemix wrong - The Australian September 19, 2009
• Rudd's magic cure: more process - The Australian March 04, 2010
• Hands off our hospitals, Victoria tells Rudd - The Age March 4, 2010
• Health deal a bitter pill for Victoria - The Age March 5, 2010
• Hospitals reform: Rudd says states running 'scare campaign' - Daily Telegraph March 04, 2010
• Top bureaucrat casts doubt on hospital overhaul - The Age March 5, 2010
• Fears for primary healthcare - The Age March 5, 2010
• Health FAQs for the confused - The Australian March 05, 2010
• Rudd's cosmetic surgery - The Australian March 06, 2010
• New hospital roof a huge waste of money, say doctors - SMH March 6, 2010
• Voters know I'm right' - SMH March 6, 2010
• Health reform plan has rationalist fingerprints - SMH March 8, 2010
• Voters warm to Rudd's health plan - SMH March 8, 2010
• Health reform causes local concern - Singleton Argus March 09, 2010
• Show us the money, Victoria tells Rudd - The Age March 9, 2010
• To improve rural health, we need to move beyond the hospital focus - Crikey.com.au March 9, 2010
• Issues and challenges facing rural hospitals - David Wilkinson, Australian Health Review 2002, 95-105,25(5)
• Managed care: Implications of managed care for health systems, clinicians, and patients - Fairfield et al., BMJ 1997;314:1895 (28 June)
• Casemix: moving forward Special Supplement - MJA 1998
• Casemix: moving forward. The surgeon and casemix - John A L Hart and David Wallace, MJA 1998; 169: S51-S52
• About Casemix - Victorian Department of Health Website

Waiting Lists? What Waiting Lists?

Waiting in Line at the Eiffel Tower - gadl @ Flickr

It is hard to ignore the news in Victoria about waiting list manipulation. Ho hum. This is old news. If you want to know how to manipulate a waiting list, refer to my previous blog entry. Every few months a politician rants on about how waiting lists are down and everything is just dandy. Shortly after the opposition carries on about how waiting lists are going up and the sky is falling down. Then an election happens, and sometimes they swap sides... and guess what, the newly-elected government politician says waiting lists are down and the newly-ousted opposition says waiting lists are up and the cycle goes on.

At the bottom of all of this political to-ing and fro-ing is an army of doctors, nurses, and paramedical staff who try their level best to treat as many patients as possible with the money that they have been allocated. It's not a lot of money, and there are an unending stream of patients, but we do what we can.

And then in between this sandwich is a layer of bureaucrats who fiddle the numbers. The Department of Healthiness, or Human Servicing, or Ageing Gracefully, or whatever (let's call them The Department) look after the politics, and dole out the money. The Hospital Administrators hold out their hands and grab as much cash as they can. The line between The Department and The Hospital Administrators can be very grey and muddy. Some people work both sides of the fence.

It is an area of pragmatism and compromise. The Department asks for good media release material - reduced waiting lists, greater throughput, briefer ED waits. The Hospitals deliver. No-one asks how they deliver... they just do. If you ask for Key Performance Indicators (KPIs) then you will get KPIs. If this means fiddling the books, then you fiddle the books. What does it matter as long as patients are still treated exactly the same as they were before? The media release is just meaningless drivel. At the end of the day youse goes to the hospital and youse gets your operation (after a variable waiting period which is dependent on so many factors that understanding it all would take a PhD or a Masters Degree).

I admit that I have worked in Victorian Hospitals. At the request of Booking Office Managers I have signed off on forms making patients "Not Ready For Care". I have kept waiting list forms in my bag for two or three weeks before handing them in to the data-entry clerks. I have seen waiting list forms sit in a pile for several weeks waiting to be entered. Never has this process made any difference to how long a patient has physically waited for their operation - only the accounting. This is not isolated to a single hospital in Victoria - this happens in every hospital in Australia, and most likely around the world. The same thing happens in every large organisation or company world-wide. Don't be a hypocrite - if you are a manager you are probably doing exactly the same thing to your KPIs.

I once worked in a hospital where my manager would deliberately lose my overtime claim sheet for several pay periods in a row. After a few months she would find them all and pay my overtime, along with all of my colleagues in the same department. We thought she was incompetent until we realised that she got a monthly bonus if the salaries came in under budget. Once a quarter she would pay us out and forgo her bonus - but the other three months made up for it.

Where patients wait a long time for their operation there are generally only a limited number of reasons:

1. Rate-Limiting Steps. There are only so many resources to do a particular operation, and everyone has to wait. This may mean waiting for investigation results, theatre allocations, specialty staff availability for complex operations, ICU beds, or special equipment for a particular operation. Basically all operations need critical planning and preparation steps to be performed first. If one of these steps cannot proceed, then it becomes a rate-limiting step.


2. Administrative foot-dragging. This is where clinical or financial approval for a particular procedure takes a long time, or is difficult to organise. There is no excuse for this except lazy, procrastinating administrators who don't think anything needs to be done any earlier than the next committee meeting in 3 months time.


3. Patient indecision. Some patients just cannot make up their mind. They want to go on the waiting list but they don't want their operation when you ring them up. "It's not convenient." "I'd rather wait until school holidays." "Let me do it when I come back from New Zealand." "I can't get time off work." These patients inevitably get upset that they have been waiting 5 years despite ringing them 20 times and they complain interminably, often to their local MP.


4. Genuine stuff up. Sometimes forms get lost. Sometimes some poor data entry clerk spells a name wrong, or accidentally presses delete. Sometimes the doctor's handwriting is illegible. We don't like it when this happens, but it happens.

Waiting lists are a fact of life. Political maneuvering is a fact of life. Management data fiddling is a fact of life. Media beat-ups are a fact of life. Like Dr Simon Leslie of Shellharbour Hospital, I'd rather just get on with the job of fixing people.

We have an unhealthy obsession with statistics and numbers. Collecting data on every scrap of activity is the reason why hospitals have half the numbers of beds they had 20 years ago - they have all been converted to offices for data-collectors, administrators and managers. The administrators need administrators, and then they need auditors to oversee the administrators, and directors to supervise the auditors.

Why can't doctors and nurses just be given the money and the trust that they can go about their job treating as many patients as possible. So what if the waiting list is a bit longer this year, or a bit shorter? No amount of number juggling can hide a 5 or 10-year trend. Stop focusing on short term goals, stop using health statistics for political gain, and you will get accurate figures and more importantly the trust of your staff.

• Hospital data fiddling raises national concerns - ABC Radio PM (Click to See)
  
  

  Hospital data fiddling raises national concerns
  PM - Tuesday, 31 March , 2009 18:50:00
  Reporter: Simon Lauder
  
  LISA MILLAR: The revelation that a Victorian hospital has been faking waiting-list data for more than a decade has raised alarm bells about how Australia's hospitals are assessed and rewarded.
  
  The Victorian Government has responded by scrapping bonus payments for hospitals and ordering random audits.
  
  Simon Lauder reports.
  
  SIMON LAUDER: After months of allegations and headlines about the manipulation of figures at the Royal Women's Hospital, a Government-ordered audit confirmed it has been going on since 1998. The independent auditor found patient records were falsified to improve reported waiting times by as much as three months.
  
  Although the hospital says it's been years since it received any bonus payments for the falsified data, the Government's responded by shutting down a $40-million bonus fund, used to reward hospitals for meeting performance criteria. It's also ordered random audits of hospitals.
  
  The revelation's prompted others to suggest the Royal Women's Hospital is not the only place where performance data is fiddled with. This surgeon phoned in to ABC local radio:
  
  SURGEON: A number of my patients are regularly made not ready for care once they're placed on the waiting list and they look like they get their operation inside the month but their actual wait from the time the waiting list form is filled out is significantly longer than that.
  
  SIMON LAUDER: Allegations of similar behaviour have also been levelled at Mercy Hospital and Bendigo Hospital; both of which deny they fudge their figures.
  
  The Premier John Brumby says the Royal Women's Hospital case highlights the pitfalls of performance-based pay, which is being increasingly embraced in Australia.
  
  JOHN BRUMBY: More and more of the funding mechanisms that we are seeing across Government now are performance based. If you look at the agreements that come out of COAG, if you look at the hospital and reform commission report, they're all about performance-based funding.
  
  And I think what's occurred here means that we need to make sure that the reliability of the data, all of the measured outputs out of the system are as accurate as possible.
  
  SIMON LAUDER: Associate Professor of medicine at the University of Queensland, Dr Ian Scott, says if hospital data is to be relied on, the Federal Government needs to set the standard.
  
  IAN SCOTT: We're increasingly in an era where there's going to be constraint on health budgets, where expectations are going to have to be reconciled with the fact that we have a limited amount of money to spend on health care and I think that if we get distracted and use money in producing dodgy data, simply not to embarrass the health minister, then I think that's not an appropriate use of resources.
  
  SIMON LAUDER: So is there a warning in the Victorian example for other states and indeed the Commonwealth?
  
  IAN SCOTT: I think there is. I think quite definitely we need to ensure that if data is to be collected, it has to be standardised, it has to have agreed definitions around the data elements that are being collected.
  
  SIMON LAUDER: So if the Commonwealth is to judge the performance of the states and their hospitals on this data, does the Commonwealth need to take more of a leadership role in overseeing the collection of data?
  
  IAN SCOTT: I think that's probably true. I mean at the end of the day I think we do need to move more towards a national data set. I think we need to have some standardisation around the data that we're collecting across the country and to that extent the Australian Government then should play a greater role in helping to define that dataset and to help design and fund the processes by which that data is collected, it's collated centrally, analysed and reported.
  
  LISA MILLAR: Dr Ian Scott speaking with Simon Lauder.

  
  
  
• Nothing but the truth - AMA Vic President Doug Travis (Click to See)
  
  

  Nothing but the truth
  Doug Travis
  April 1, 2009
  
  
  Illustration: Spooner
  
  Patient treatment is being compromised as hospitals try to work the system.
  
  THE Victorian community has been dismayed to learn that a trusted institution, the Royal Women's Hospital, has been falsifying and manipulating reporting data. Yet, as the Victorian Government acts to stamp out the perverse incentives that have led to data manipulation, the Commonwealth is ready to impose reporting requirements across the health system that may reinvent those incentives.
  
  Federal Health Minister Nicola Roxon should therefore be watching this story unfold and considering the lessons learned.
  
  Good information is the lifeblood of good health care. For an individual patient, the more a doctor knows of his or her history and diagnostic profile, the more likely a good outcome. To protect the health of the community as a whole, we need accurate and complete reporting. Manipulated and falsified data means that Government cannot adequately plan for the future health needs of Victorians.
  
  Presenting a rosy picture hides the problems in our health system. For example, because of overstated successes, governments have held back on tackling bed shortages in Victorian hospitals. These shortages have become critical in recent years, meaning that bad data is compromising safe and effective patient care.
  
  Other hospitals may be found to have manipulated data. AMA members suggest that several hospitals have set up systems that appear designed to meet key performance indicators (KPIs) rather than good patient care, such as creating short-stay units attached to emergency departments. The definitions of "time to care" are tweaked in some hospitals to produce a more favourable KPI outcome.
  
  The community expects hospital boards and management to instil a culture that values integrity, long-term vision and whole of community service, not a culture that concentrates on the short term.
  
  A hospital under pressure puts staff under pressure. Nurses and doctors are working hard to ensure that the patients in the hospital are looked after to the best of their ability, despite a shortage of beds and a shortage of staff.
  
  Until Monday, Victorian public hospitals had perverse incentives that paid extra funds to hospitals that reported they met their KPIs. More funding went to hospitals that did well, and less money to hospitals that were struggling with extra demand.
  
  Imagine you are in a highly pressured environment with too many patients and not enough resources. A manager comes in and tells the staff that if they don't meet the KPIs, the hospital loses funding. Staff get a clear message. Meet the KPIs or patient care will suffer.
  
  The suggestion that hospital boards and management are not aware of data manipulation is puzzling — hospital officers must be accountable for the culture in their organisations. Yet as state Health Minister Daniel Andrews professes fury, he elects to hold no one accountable.
  
  If the minister's actions are part of a plan to draw a line under the past and move forward, then his failure to punish can be understood. If the minister is serious about changing the culture and replacing the trust in our hospital system, he needs to back up his words with action.
  
  First, the minister should be congratulated for removing the bonus payments system that has contributed to the problems of data manipulation. This is an important and valuable first step.
  
  The next step the minister must take is to direct all hospital chief executives to report truthfully from now on, or face dismissal. As a representative of the Victorian people, the minister cannot be seen to condone actions that betray the community's trust. The minister must also make public all the data that shows the demand pressures on the health system, including previously secret information on outpatient waiting lists. We need all the data to have a sensible debate about resources for our health system.
  
  However, as the Victorian Government removes some of the barriers to accurate reporting, the Commonwealth Government is considering a host of incentives across the health system that could create more problems than they solve.
  
  Again, hospitals (and states) will have incentives to report success against benchmarks, rather than concentrating on quality care. Roxon has also floated new benchmarks for general practice to improve a range of health indicators for their patients, such as weight, insulin dependence and smoking.
  
  Under these proposals, GPs who help some of the most disadvantaged in our community may be penalised. The incentives mooted appear to encourage doctors not to see sick people.
  
  I hope Roxon is watching the Victorian health system closely to see what perverse incentives can do to resources, planning and quality care. We must report accurately and truthfully to be accountable to the community.
  
  The bottom line problem is that the truth can be embarrassing. Let's address the problem, not by spinning the statistics to avoid embarrassment, but by treating enough patients, so that the truth does not embarrass us.
  
  Doug Travis is president of AMA Victoria.

  
  
  
• Minister orders hospital audits after dud figures - The Age (Click to See)
  
  

  Minister orders hospital audits after dud figures
  April 1, 2009 - 2:40PM
  
  Elective surgery waiting lists will be audited at every Victorian public hospital in response to a widening scandal over manipulated figures.
  
  Victorian Health Minister Daniel Andrews announced on Wednesday a director of data integrity would be appointed to oversee system-wide audits of hospital waiting lists.
  
  The announcement follows revelations the Royal Women's Hospital in Melbourne manipulated figures to make waiting lists appear shorter.
  
  A damning report by the auditor-general has exposed fundamental flaws in hospital data keeping, saying the problem is widespread and figures cannot be relied on for accuracy.
  
  It has also identified figure fudging in the emergency department at the Latrobe Regional Hospital in Gippsland.
  
  Mr Andrews said independent auditors would immediately start checking the books at Latrobe.
  
  Former Victorian public advocate Julian Gardner has been appointed to the Royal Women's and Latrobe Hospital boards to stamp out improper practices, he said.
  
  "I take responsibility for these matters, I am determined to fix these issues, I am determined to stamp these practices out, and I think the measures that I have announced today, along with the reforms I announced on Monday, are a big step forward in terms of fixing these issues," Mr Andrews said.
  
  AAP

  
  
  
• Audit slams phantom wards scam - The Age (Click to See)
  
  

  Audit slams phantom wards scam
  Julia Medew and David Rood
  April 2, 2009
  
  
  Audit slams phantom wards scam
  Julia Medew and David Rood
  April 2, 2009
  
  The Royal Melbourne Hospital. Photo: Marcus Ferraro
  A SCATHING audit of four Victorian hospitals has confirmed staff are creating "ghost wards" and manipulating surgery waiting lists to secure bonus funding and avoid critical scrutiny.
  
  Auditor-General Des Pearson's report on hospital data, tabled in Parliament yesterday, cast serious doubt on the accuracy of Government health system performance reports.
  
  It also shifted the spotlight back on beleaguered Health Minister Daniel Andrews and the Department of Human Services for not providing "effective quality control regimes" and validating data reported to them for funding.
  
  "These conditions have opened the way for inappropriate practices such as data manipulation, which undermine the integrity of hospital performance monitoring," the report said.
  
  Mr Pearson's audit found three hospitals had been inappropriately listing elective surgery patients as "not ready for care" and that one hospital had recorded "admitting" patients to wards when they were still languishing in emergency departments. These practices could be more widespread, the report said.
  
  The report did not name the hospitals involved, but Mr Andrews confirmed Latrobe Regional Hospital had been manipulating its emergency department data and that the three remaining hospitals were the Royal Children's, the Royal Melbourne and Dandenong hospitals. It is unclear which were inappropriately altering surgery waiting lists.
  
  Until this week, public hospitals received bonuses for reaching Government benchmarks, including some that related to emergency department performance and elective surgery waiting lists. But after the discovery of fraudulent data reporting at the Royal Women's Hospital, Mr Andrews has decided to abolish the system.
  
  Mr Pearson's report said in some cases, nurses were retrospectively altering patient data records so the hospital met Government benchmarks. It also found hospitals were inconsistently measuring waiting times for care.
  
  While no hospitals had received funding that would need to be withdrawn, the report recommended sweeping changes to the system, including the implementation of new checks and balances.
  
  The finding comes after The Age revealed allegations in May that hospitals were creating "virtual wards" and fudging waiting times to attract funding. At the time, Mr Andrews said he would investigate the issue but since August, he has repeatedly denied there was any evidence of data manipulation to investigate.
  
  Yesterday, Mr Andrews said although responsibility for the health system rested with him, he did not think he had mishandled the scandal. He said that when allegations of data manipulation were raised with him last year, there was no hard evidence to prove it, and the Department of Human Services had "processes in place".
  
  He is resisting growing calls from the Opposition to resign and said his priority was to fix the problem. "I'm sorry if any patient has been adversely affected by these inappropriate practices; there is clearly a need to improve," he said.
  
  As the crisis gathered pace yesterday, Mr Andrews announced a system-wide audit of elective surgery waiting lists to match an audit already assessing emergency department data. He also announced the creation of a "Director of Data Integrity" role within DHS and appointed former public advocate Julian Gardner as a delegate to the boards of the Latrobe Regional Hospital and the Royal Women's Hospital to ensure their problems would be fixed.
  
  In response to comments from Federal Health Minister Nicola Roxon yesterday that deliberate data manipulation would have serious implications on future funding, Mr Andrews said: "I don't expect that there will be any impact on commonwealth health funding."
  
  In a fiery question time that saw shadow treasurer Kim Wells ejected from Parliament, the Opposition repeatedly called on Premier John Brumby to sack Mr Andrews.
  
  But Mr Brumby defended his Minister, saying he had taken decisive action to ensure tight standards across the hospital system.

  
  
  
• Bullying, bottlenecks and death by a thousand paper cuts - SMH (Click to See)
  
  
  
  

  Bullying, bottlenecks and death by a thousand paper cuts
  March 28, 2009
  
  'At heart, I'm a doctor who likes to look after patients' . . . Simon Leslie's case forms part of the Garling review into the culture of NSW hospitals. Photo: Jacky Ghossein
  
  The story of Shellharbour Hospital's Dr Simon Leslie is a microcosm of the malaise Peter Garling observed on a statewide tour of 61 public hospitals, writes Julie Robotham.
  
  ON APRIL 28, 2006, Shellharbour Hospital boss, Michael Brodnik, distributed an email. A decision had been made, he wrote, to set up a new unit within the emergency department.
  
  "The unit will be … four beds, conceptually down the right hand wall of ED but using the concept of 'virtual beds'," he told colleagues. Patients who arrived at emergency and needed admission would be assigned a virtual bed if no official in-patient bed was available, remaining physically in emergency. Brodnik said he had no control over the change, reassuring staff: "It really is a paper exercise."
  
  The rationale was to get patients off the emergency department's books within eight hours of arrival - a watershed imposed by government as a so-called "key performance indicator" or KPI, amid political pressure over backed-up hospitals and ambulances unable to offload patients.
  
  At Shellharbour Hospital, an outpost serving the cookie-cutter sprawl that straggles down the coast from Wollongong, that target was hard to achieve, because some patients had to be transferred for diagnostic tests.
  
  By May, Shellharbour was still processing emergency patients too slowly, and emails were flying. The head of the hospital's emergency department, Dr Simon Leslie, sent a measured one to Sue Browbank, Brodnik's boss: "We are being asked to run our health service on the basis of the need to treat one statistic," he wrote. "Doctors have not been ignorant or uncaring of the need to manage our resources appropriately … but are driven firstly by patient care and community needs."
  
  For a while, Leslie continued a vocal opposition to the imaginary beds. The directive to reclassify patients "according to any objective look at it was fraudulent", he told the Herald last week. "It required staff in my emergency department to write down records that were incorrect."
  
  Later he tired of battling the fait accompli and settled back to running front-line health care in the hard-to-staff hospital.
  
  That could have been the end of it, but then Peter Garling, SC, came to town. On April 14 last year, at one of the inquiry's 34 public hearings, "Dr Leslie told me the 'virtual ward' was a fiction to compensate for the fact that Shellharbour Hospital does not have a short stay unit," Garling recounted in his report. Leslie's evidence resulted - finally - in the ward's abrupt termination, though this, as he had previously observed to Browbank, was, "easy because it doesn't actually exist".
  
  Three weeks later, Browbank informed Leslie of the appointment of a Southern Hospitals Network Director of Emergency Medicine - which, according to Garling's later deconstruction, "both technically and in reality … effected the abolition of Dr Leslie's position".
  
  Leslie was ordered to stop calling himself director of the emergency department and told he could instead apply for a part-time position. "How is it possible," he asked a human resources manager, "to remove me from the role for which I have a contract and in which I have been acknowledged and satisfactorily functioning for over two years?"
  
  The vaporisation of his job and claim it had never really existed were normal practice during "amalgamations and clinical reviews," the manager soothingly responded. "In many cases roles and responsibilities have changed, staff displaced and new position descriptions written."
  
  Leslie's was a story Garling could not resist. A microcosm of the poisonous malaise he had observed on a statewide road-trip to 61 public hospitals, it comprised four elements the senior counsel had noticed repeatedly: a bottleneck between emergency and in-patient beds; inflexible performance criteria imposed from on high, then middle-management sleights-of-hand to meet those demands; and a yawning gulf of alienation between clinicians and administrators.
  
  So when Leslie updated the inquiry on the personal fallout from his testimony, Garling in late September 2008 ordered five people as well as Leslie to four gruelling days of extra hearings, devoted to the doctor's treatment. They included Debora Picone - in 2006, chief executive of the South Eastern Sydney Illawarra Area Health Service, but elevated in 2007 to director general of NSW Health.
  
  That won Leslie no respite. On the contrary, shortly after Garling's summonses landed on managers' desks, Leslie was cut out of meetings and told to hand back his pager and vacate his office - though ultimately he did not do so, successfully arguing both were essential to his work.
  
  In her sworn evidence, Browbank acknowledged Leslie's job description was signed by a doctor expressly delegated to work out his role and title. Yet she maintained the position could not exist, because the doctor had no authority to create it.
  
  Garling rejected the semantic contortion. Browbank's stance "flies in the face of the obvious facts revealed by the evidence and is wholly untenable," he concluded.
  
  Because Leslie's treatment was "unreasonable, repeated, unwelcome, unsolicited, offensive, intimidating, humiliating and threatening," Garling wrote, "I find it amounted to bullying and harassment in accordance with NSW Health's own guidelines."
  
  Leslie is an unlikely poster boy for victimhood. Affable and easygoing, it is hard to imagine him having the sleep disruptions and obsessive thoughts he says beset him at the time. He simply carried on going in to work. "At heart," said the 52-year-old, "I'm a doctor who likes to look after patients."
  
  Doctors who like to look after patients are the backbone of the health system, but are massively disenfranchised.
  
  Re-engaging them would be the most critical step in reforming NSW Health, Garling said, proposing a Clinical Innovation and Enhancement Agency - under which clinicians would determine protocols for patient care. As well, he proposes an independent Bureau of Health Information to monitor hospital performance, freeing doctors like Leslie from political pressure to fudge the loathed KPIs.
  
  The toughest challenge is how to make hospitals gentler. "The workplace culture in NSW public hospitals is characterised by lack of respect and trust, absence of empathy and compassion, inability to celebrate the success of others, failure to communicate, and a lack of collaboration," was Garling's damning verdict after his journey to the heart of the health system. Its anti-bullying policy had failed, dissent was quashed and persecution was rife.
  
  Garling recommends making individual employees - all 118,000 of them - more directly responsible for their behaviour, reorienting the system away from blame towards constructive criticism and strengthening complaints procedures.
  
  Last July, Leslie lodged a formal complaint about his treatment. Eight months later he has not been told how it will be resolved. Terry Clout, the area health service's chief executive, told the Herald he was seeking more information and would consider "any actions that may be required". He declined to comment further, citing, "procedural fairness" in the "personnel matter".
  
  Leslie said the delay was "a process to wear me down". He understands deliberations will not privilege Garling's account of events - despite the evidence the commissioner collected under unmatched statutory powers.
  
  Perhaps that is unsurprising. Garling said Leslie's situation went unresolved because Shellharbour managers "did not demonstrate … the slightest knowledge of what constituted bullying and unacceptable behaviour".
  
  When is a bed not a bed? Leslie has paid a price for trying to reconcile the internal logic of NSW Health's storytelling with empirical reality, and no one has ever apologised. He will now take his case to the NSW Industrial Relations Commission. If Leslie - with the inquiry's weight behind him - cannot bring NSW Health managers to account, possibly nobody can. "Mr Garling's put a fairly heavy burden on me," he said. "I feel an obligation not to let that go to waste."

Walking backwards, slowly.

I have been following, on and off, a thread on Paging Dr about how to "Survive First Year". After three pages of posts it is a bit muddled about the first year of what, but all the talk about work-life balance has raised the hairs on the back of my neck.

Now don't get me wrong, I am not against doctors having a social life and being able to wind down away from work. Heaven forbid, my family would be very unhappy if I completely ignored them to work all day and all night.

But this concept that doctors (and medical students) are entitled to a fun and enjoyable experience during their work or study irks me. Medical school is meant to get you trained up as a decent doctor... but it just so happens that all the students want it to be fun and enjoyable. Being a doctor is about treating patients as best as you can, and drawing appropriate reward (personal satisfaction is a form of reward) from doing so.

There are many previous generations of doctors who chose to let (or failed to stop) work taking over their lives. 50 years ago it was normal to eat, breathe and sleep medicine all day every day while you were a RMO or Registrar. Even as a GP in a solo practice it was normal. And your patients appreciated it. Doctoring was not a job, it was a lifestyle.

These days, nobody (in any profession) wants to make any personal sacrifices for the sake of work. We all want to clock off at the end of our shift, turn off our pagers and forget about work. And by that I don't mean just doctors, but everyone in the wider community. No longer is the community expectation "8 hours work, 8 hours rest, 8 hours sleep" (care of the trade union movement) but so is the 2 week overseas holiday, investment property, beach-house, private school education, 4WD, and token sustainable garden. Are we becoming a society of spoilt brats?

I increasingly see it in the surgical trainees (and I must confess that I am and was no exception). They don't want to move out of town for rural rotations, let alone interstate or overseas, for fear of disrupting their personal or family arrangements (neither did I, at that stage). They want to claim every single dollar of their award entitlements (as do I), though obviously this eats into the budget for treating patients. There is a cost and a benefit to each of these decisions - though self-interest increasingly outweighs that of community-interest.

But back to the point - if you want to give up your social life you will make significant professional and educational advances. If you want to prioritise your social life you will suffer some impediment to your career or study (in comparison to those geeks who don't sleep and talk med all day long). You may well live longer as well. BUT IT IS YOUR CHOICE.

Some people like to blame "the system" for making medicine stressful and demanding. Blame it all you like. "The System" is the way it is, and if you want to go into medical politics and change it for everyone else, it will have community-wide ramifications (not necessarily all for the better). A plethora of large and small organisations from the AMA to the DRS push their views on how to improve the health system and also working conditions for doctors.

Sometimes I don't know whether reform of the medical profession or medical employment is for the better or worse. I find it a rather ego-centric view that we have to demarcate roles, engage professional industrial representatives, or wage public campaigns in order to maintain wages and conditions for doctors.

It feels like we are stooping to a lower level, and that it demeans us as a profession that we have to engage in underhand tactics, or play hardball in order to maintain conditions. Every "victory" over some measly little payment or benefit seems to degrade my professional self-respect even more. Perhaps it says more about our government, our industrial landscape, or our lawyers. Most of all, it sickens me that the time spent on this detracts from what I want to do - treat my patients well.

I'd like to see someone stand up and say "Good Job, Doctors. Here's a pat on the back, a few days off, and a pay rise because you deserve it." But I know I'm just dreaming.

Haneef's Christmas Present

This is really just a followup post to mention that Dr Mohammed Haneef has finally jumped all the hurdles to retain his working visa and return to work in Australia as a doctor.

Perhaps his trip to Mecca has made all the difference, perhaps it is the Federal Court giving him a Christmas Present. It doesn't matter - common sense has prevailed.

And as for the rest of you, may you all make the most of the holiday season! I will be spending my holidays on call yet again!

Haneef keen to return to Gold Coast - The SMH
(Click to Expand)

Haneef keen to return to Gold Coast
December 22, 2007 - 7:15PM

Former terrorism suspect Mohamed Haneef is keen to reapply for his position at the Gold Coast Hospital after the federal government yesterday paved the way for his return.

New Labor Immigration Minister Chris Evans said the Indian national was entitled to return to work after the full bench of the Federal Court upheld a judge's earlier decision to reinstate his work visa.

The doctor's visa was withdrawn by the former Howard government on character grounds despite terrorism charges against him being dropped.

Dr Haneef's Brisbane-based lawyer Peter Russo today informed the devout Muslim, who is currently in Mecca with his wife and mother, of Mr Evans' decision not to appeal the court's ruling.

Mr Russo said Dr Haneef was pleased with the news but had been hard to contact because he was in prayer at the annual religious pilgrimage.

"When I spoke to him yesterday it was prior to the minister making the announcement," Mr Russo told AAP.

"He is very, very happy and keen to talk to his family to resolve any outstanding issues with them and then try and get organised to come back."

The doctor has agreed to speak to Australian media from Mecca on Monday afternoon.

Mr Russo said Dr Haneef was due to return to his Indian home in Bangalore in early January when he would investigate options to return as a medico to Australia.

"He's got to get his medical registration first and if there is a position available there, I understand (the Gold Coast Hospital) is going to be his preference," Mr Russo said.

A Queensland Health spokeswoman said Dr Haneef was considered a competent young doctor by colleagues at the Gold Coast Hospital.

"If he is in a position to seek employment, Queensland Health would be happy to consider his application," the spokeswoman said.

She said he would first have to obtain a work visa from the Commonwealth and appropriate registration from the Medical Board of Queensland.

Mr Russo said his client would also try to organise a visa for his young baby daughter and wife Firdous, who continued to harbour concerns about their return following their treatment at the hands of Australian authorities.

Australian Federal Police arrested Dr Haneef at Brisbane International Airport on July 2 as he attempted to board a one-way flight to India, just days after failed UK terrorist attacks.

He was held for 12 days before finally being charged with providing support to a terrorist organisation for giving his mobile phone SIM card to his cousin Sabeel Ahmed, one of the men accused of the attempted UK bomb attacks.

The charge was dropped a fortnight later after Commonwealth Director of Public Prosecutions Damien Bugg found there was no reasonable prospect of securing a conviction against the 27-year-old.

But former immigration minister Kevin Andrews had already cancelled his visa on character grounds, meaning Dr Haneef was unable to return to work.

A full judicial inquiry will now investigate the saga.

AAP

Triumph for Haneef in terror farce - The SMH
(Click to Expand)

Triumph for Haneef in terror farce
Cosima Marriner, Tom Allard, and Amrit Dhillon in New Delhi
December 22, 2007

THE former terrorism suspect Mohamed Haneef is free to return to Australia after a court victory for the doctor yesterday, but the new Labor Government may pass laws to ensure it can reject foreigners with questionable links.

The full bench of the Federal Court dismissed the former immigration minister Kevin Andrews's appeal against a decision to reinstate the Indian doctor's visa.

The court found the law did not allow the government to revoke a visa on character grounds simply because a person had an "association", no matter how innocent, with an unsavoury individual.

But the new Immigration Minister, Chris Evans, has reserved the right to change the Migration Act if the verdict sets the bar too high to revoke a visa on character grounds. Senator Evans is also not ruling out a High Court challenge to yesterday's ruling, although he said this was unlikely.

Dr Haneef's brother, Shuaib, said that he told his brother about the verdict on the telephone from Bangalore. "He said that it was what he had been expecting all along but he was relieved that it had turned out the way he expected," Shuaib said.

Dr Haneef is on the Muslim pilgrimage to Mecca with his wife and mother-in-law. The Queensland Premier, Anna Bligh, said he would be welcome back in the state's hospital system.

Dr Haneef was working at Gold Coast Hospital before he was arrested on July 2 while trying to leave Australia on a one-way ticket to India. Mr Andrews cancelled his visa on the grounds that he failed the character test because two of his second cousins were allegedly involved in British car bomb plots, and he had been communicating with one of them, Sabeel Ahmed, just days before he tried to leave Australia.

Dr Haneef was charged with "intentionally providing [a mobile phone SIM card] to a terrorist organisation". This was dropped on July 27 after it was revealed the SIM card was in Liverpool, nowhere near Glasgow Airport, where Sabeel's brother, Kafeel, rammed a burning Jeep into a terminal.

The Federal Court's Justices Black, French and Weinberg agreed with the August finding of Justice Spender that Mr Andrews had applied "too wide" a definition of Dr Haneef's association with the Ahmed brothers. They rejected the minister's argument that it "did not require any suspicion that Dr Haneef was sympathetic to, or supportive of, or in any way involved in the criminal conduct of which the Ahmeds were suspected".

A spokesman for the Haneef family in India, Imran Siddiqui, said they had hoped for an apology from the Government.

"We were hoping that it would say it regretted what had happened to Haneef and that it would welcome him back and give him a helping hand to see what can be worked out for him in Australia," Mr Siddiqui said. He indicated the family could seek compensation. Dr Haneef has not worked since leaving Australia.

Queensland Health said Dr Haneef was considered "a competent young doctor". Ms Bligh said: "If Dr Haneef satisfied the visa requirements and the registration requirements, I would be very pleased to have him … We have a lot of pressure on our hospitals. We want to see qualified doctors working in them as soon as possible."

After reviewing the latest federal police material on Dr Haneef, Senator Evans said: "There are no grounds to take further action in relation to [his] visa." But he said: "Should any further relevant information come to light in relation to Dr Haneef, I will re-examine the situation at that time."

Senator Evans's lawyers sought to stay yesterday's ruling pending a possible High Court challenge. The court rejected the application.

Medical Students are not GPs!

Will they never learn? Kevin Rudd announced a commitment to build Family Healthcare Clinics for Defence Force members and their families. That doesn't bother me one little bit. Go for it, Kev.

This statement, however, left me frustrated that both major parties continue to fail to appreciate how the medical workforce works, and illustrates the simplistic concepts that seem to underpin major decision making amongst politicians and high-level government.

He denied it would be difficult to attract staff to the new medical centres, saying Labor would also invest in more medical places at universities to boost medical workforce numbers.

Labor in health bid to retain personnel - The Australian, 13 Nov 2007

Every time the lack of doctors to staff new facilities is raised, the same response is trotted out: recruit more medical students. It sounds good. It doesn't make sense.

John Howard is not innocent of this. I have previously pointed out the problems with the Howard Government's approach to the training of doctors, but this was typical of statements at the time in February 2006:

Prime Minister John Howard's February 10 announcement of a new health package at the Council of Australian Governments (COAG) meeting has drawn both criticism and praise in its addressing of the ongoing shortage of qualified doctors.

At what Prime Minister Howard described as "an unbelievably successful COAG meeting", a package of health reforms were agreed upon by state, territory and federal leaders.

In addressing the shortage of trained doctors COAG announced that there would be 25 per cent more university places made available to train new doctors but that they would be full-fee paying university places. As a part of this, incentives are to be made to increase the number of qualified doctors which includes raising the loans cap for full-fee paying medical students from $50,000 to $80,000.

More Doctors but not via HECS - Epoch Times, Feb 14 2006

Putting aside the qualifications that are always involved in these pronouncements ("money is being provided - but it's up to universities to implement them", "money will be invested into innovative new training schemes", "private sector training will be explored") keep in mind that many of these places will be full-fee paying (i.e. only minimally subsidised by the Government) and that they could well be occupied by overseas candidates (i.e. ones that do not contribute to the Australian Workforce).

The lag time between recruiting a medical student and producing an independently practising doctor is significant: a minimum of 4-6 years before an intern is produced. Such an intern cannot staff a GP clinic. It takes another 4-6 years to do that, assuming that there are enough accredited training positions.

Depending on the specialty, such positions are limited by State Government funding of public hospitals (such as for surgery, medicine, and all of those hospital-based specialties), or by the Federal Government (via Vocationally Registered Provider Numbers for GP Trainees).

Furthermore, Provider Number and Medicare limitations means that unless a doctor completes a training program and achieves specialist recognition (including completion of GP training), they are effectively unable to service patients in the public sector. The 1996 Howard Federal Government hobbled its own ability to fill the need for GPs in its overexuberant attempt to reign in Medicare expenditure (Link 1, Link 2).

Of course, the traditional response is that training numbers are limited by Specialty College intakes, lining the pockets of specialists along the way. In reality, the Colleges go out of their way to accredit as many viable training positions as possible, but such positions can only be worthwhile if there is enough funding to treat patients and maintain throughput.

This is and will continue to be the bottleneck limiting the production of independent medical practitioners. Long-serving readers may recall that I have written about this before and while the terminology is being superceded by SET and PreSET, the basic principles remain the same.



There is a lot of talk about the impending "medical student tsunami". There is no doubt that we are turning out record numbers of medical students. Hospitals are also absorbing record numbers of Interns and RMOs, due to the enforcement of safe working hours, and the desire of these new generations of doctors to have a life outside work. These doctors are typically employed, however, in non-training positions.

Despite the best efforts of specialty colleges to approve more training positions, they are stymied by hospital and Medicare's Vocational Registration infrastructure. New graduates (and governments) are developing an expectation that they will come out of medical school and go straight into a training program, emerging as a specialist in the minimum amount of time possible.

Unless the incoming government realises that they will not be able to adequately staff these GP clinics without stealing GPs from other parts of the medical workforce, or they address all the rate-limiting steps in medical training, then we will continue to see short-sighted, short-term, sound-bite based health policy and workforce planning in Australia. We don't need politicians and political parties that make knee-jerk decisions and can't see beyond the next press conference. Unfortunately, that is all that we have to choose from.

Labor in health bid to retain personnel - The Australian
(Click to Expand)

Labor in health bid to retain personnel
Patricia Karvelas, Political correspondent | November 13, 2007

THE spouses and children of defence force personnel living in remote areas of Australia will have their medical and dental bills paid under a Labor plan to help retain troops.

Unveiling Labor's defence policy at the Lavarack Barracks in Townsville yesterday, Kevin Rudd committed $33.1 million for 12,000 ADF spouses and children to access free health and dental care at 12 Defence Family Healthcare Clinics.

The first two clinics will be at the Lavarack Barracks, in the marginal Liberal-held seat of Herbert, providing services for about 4000 spouses and children, and the Robertson Barracks in Darwin, which will cover 3650 spouses and children.

"This is the first time free medical and dental services are being extended to the spouses and kids of defence force personnel," Mr Rudd said.

He denied it would be difficult to attract staff to the new medical centres, saying Labor would also invest in more medical places at universities to boost medical workforce numbers.

"This policy ... is an important step forward in providing a better standard of living, a better quality of life to continue to attract people to join the defence force and to stay in the defence force," Mr Rudd said.

In 10 of the clinics, the GP will work half a day, five days a week, with a full-time nurse five days a week. A dentist and dental nurse will work five days a week.

Labor defence spokesman Joel Fitzgibbon said the health plan could be rolled out more broadly if it was successful.

"This is very much a retention initiative designed to put something on the kitchen table as defence families are considering whether to take an offer outside the ADF or stay within the ADF," he said.

Mr Rudd said that in recent years the structure of the defence force had been "torn in multiple directions".

"There had been an absence of clarity of strategic purpose, including asking our force structure to be able to maintain simultaneously hot operations in the theatres far from Australia as well as other operations near to Australia in our own immediate sphere of strategic importance here in the Southwest Pacific and Southeast Asia."

Mr Rudd said the ADF needed direction on what was expected of it in the future.

Labor was committed to all current defence projects but would ensure a new defence white paper returned discipline and strategic coherence to the Defence Capability Plan.

He said federal Labor would ensure defence was adequately funded through a commitment to at least 3 per cent real growth in spending each year.

Labor would also commission the defence white paper if it won government, with Mr Rudd asserting that defence procurement under the Howard Government had become a "rolling scandal".

"We are determined in Government to ensure that we've got the processes in place to make sure there is rational long-term planning for our equipment requirements ... which is in turn consistent with a strategic doctrine laid down in the white paper," he said.

"When you look at the long-term force structure, quite apart from immediate operations here in our own region and war-fighting operations currently occurring in various parts of the Middle East, it's very important that clarity is achieved in a new defence white paper, and that the full structure evolves from that."

More Doctors but not via HECS - Epoch Times
(Click to Expand)

More Doctors but not via HECS
By Sandra Keaton, Epoch Times, Australia Staff | February 14, 2006

Prime Minister John Howard's February 10 announcement of a new health package at the Council of Australian Governments (COAG) meeting has drawn both criticism and praise in its addressing of the ongoing shortage of qualified doctors.

At what Prime Minister Howard described as "an unbelievably successful COAG meeting", a package of health reforms were agreed upon by state, territory and federal leaders.

In addressing the shortage of trained doctors COAG announced that there would be 25 per cent more university places made available to train new doctors but that they would be full-fee paying university places. As a part of this, incentives are to be made to increase the number of qualified doctors which includes raising the loans cap for full-fee paying medical students from $50,000 to $80,000.

The Australian Industry Group (Ai Group) has said that it is confident these reforms will help assist the skills shortage currently facing the nation.

"COAG has taken important steps in helping the alleviation of skill shortages by agreeing to this raft of reforms," Ai Group chief Heather Ridout said.

Queensland Premier Peter Beattie is "delighted", as he says his state's health system will benefit – he has been lobbying for more than 300 new doctor training positions in his state.

Meanwhile Australian Medical Association President Dr Mukesh Haikerwal told the ABC that the increase in university positions will help the current shortage of Doctors. He said that it is important that enough doctors are trained but he said for that to be on a fee-paying basis is against the principles of university training and the principles of equality of access in education.

Dr Haikerwal foresees medical degrees costing students as much as $250,000.

"You know, you could have an awful lot of well-qualified people that could do medicine and do it well, having to give those places up because they can't afford this sort of money. If government is serious about getting doctors into the system and is serious about training doctors, then they need to pay for those places under the HECS system as they currently do," said Dr Haikerwal.

Doctors Reform Society President Tim Woodruff was also critical of the proposals. He said the full fee-paying medical student places were offered "to produce doctors who aren't good enough to qualify for HECS funded places".

Australian Vice Chancellors Committee CEO John Mullarvey, says he would have preferred the places to have been fully-funded by the Government.

Opposition spokeswoman Jenny Macklin saying that only government-funded university places would have helped.

"At the University of New South Wales, a medical degree costs $216,000. That leaves a huge gap for students to have to find," she said.

"We want to make sure that our doctors get there on merit not on how much their parents have got in the bank."

The Opposition also claims that Australia's university sector is being "Americanised".

The commonwealth will contribute $666 million to the health plan while another $479 million will come from the states and territories.

With AAP