Over the past two decades, the barriers to health care access for adolescents have been extensively researched. This research was sparked by worrying trends of adolescents’ worsening mortality and morbidity, such that their health status was worse than that of their parents, and the observation that their health services, compared with those for other age groups, had not improved.1,2 Based on this research, the US Society for Adolescent Medicine has been issuing position statements on effective health care access for adolescents since the early 1990s. In Australia, several national and state initiatives propelled an adolescent health movement, not least in primary care.3 Divisions of General Practice had the scope and financial resources to address local needs, and some chose to run youth-friendly health access projects. Training in adolescent health for clinicians and other professionals emphasised the biopsychosocial model of care and had evidence of effectiveness.4

In this issue of the Journal, the study by Kefford and colleagues (page 418) shows that, despite these major gains, uptake of the youth health access agenda has not been systematic, and barriers to effective health care for Australian adolescents still exist.5 Adolescents recently reported fears about lack of confidentiality, judgement from health professionals, cost and inconvenience of services, and inexperience recognising health needs and where to seek help.6 Kefford’s study gives voice to adolescents’ concerns and suggestions for maximising their access to health services and preventive health messages. Youth in this study suggest that health services be based on “being well” rather than on “diagnosis of illness”. Preventive health messages need to be delivered through a variety of settings, such as gymnasiums or pharmacies, or delivered by approachable youthful peers and reinforced by physicians during visits to health services.

The World Health Organization recently commissioned a global review of published and unpublished literature on means of improving adolescents’ access to health care,7 and a consortium of eight leading British health professional organisations published a report to guide service and professional development in adolescent health.8 Along with the latest US Society for Adolescent Medicine recommendations,9 these documents emphasise that accessible, “adolescent-friendly” health services should not be restricted to a particular setting or model of service delivery, but should address critical issues, such as confidentiality, cost, youth participation, competent staff, evidence-based treatments, efficient systems and collaboration across sectors.

With these themes echoing through the last decade, we now need to go beyond the idea of “breaking away from the medical model”.5 We need strong leadership to ensure that the principles of effective access are implemented and engrained into mainstream policy-making, clinical work, professional training and youth education, and have ongoing evaluation to ensure effectiveness. Several deficits in these areas provide directions for the future.

First, government policies on youth health access are currently non-existent or low profile, and many health services and general practice divisions still fail to target youth in their service planning. Implementation of the frameworks outlined by WHO could guide policy development and health service improvement, including involving adolescents as often as possible in the policy and planning initiatives that affect them.

Secondly, there is confusion about how to facilitate access in the Australian context, either within existing primary-care infrastructure or through alternative models. There is little peer-reviewed published evidence on improved access from different models of adolescent health care — most relates to school-based health centres. A review of retrospective cohort and cross-sectional studies of school-based health centres found that they facilitate access, particularly for those who are hard to reach, such as adolescent boys with mental health problems, and socioeconom-ically disadvantaged and rural adolescents.10 In contrast to the few well evaluated Australian projects addressing youth health care access,11 many initiatives lack evidence of effectiveness. A recent survey of 77 NSW youth health programs found that, despite many exciting and innovative programs, none were fully evaluated, mainly because of lack of resources and competing priorities.12 We need to define appropriate, measurable outcome indicators for adolescent services, to evaluate services against these, using sound methodology, including progression to large-scale trials when results of smaller projects are inconclusive or contradictory, and to publish results in both peer-reviewed journals and policy documents. Effective services need to be sustain-able and systematically accepted into practice. Notably, there is already sufficient evidence for policy on factors improving access, such as confidentiality,6-9 longer appointments, and multidisciplinary teams.11

Thirdly, Australia’s primary health care system is fragmented. Most primary health care occurs in general practice, but youth-specific health centres (which are much valued by adolescents) are more prominent in some states than others, and there is little communication between these important groups of providers.13 These services are needed in each region to cater for the more complex needs of adolescents and provide support and training for GPs and other primary health care providers.14 Professional colleges need to ensure training of undergraduates and postgraduates in adolescent health, and interdisciplinary training might help improve communication across sectors.15

Finally, as exemplified by the participants in Kefford et al’s study, an adolescent’s world crosses boundaries, and opportunities for promoting health care access and other health messages exist outside the health care sector. Yet health, education, recreational and community sectors do not often collaborate. Consistency of health messages to youth, reinforcement of help-seeking behaviours, and referral, if appropriate, is the minimum required. Two large Australian school-based mental health promotion programs involving pathways to accessing health care from school to general practice are currently being tested.16,17 Other promising programs involve school-based workshops on the knowledge and skills for seeking care and information from a variety of sources. Given the barriers reported by adolescents, school curricula could routinely incorporate such health access content.

Successfully meeting the primary health needs of adolescents involves recognising their unique developmental stage, delivering services in ways that overcome barriers to access, and supporting positive health and help-seeking behaviours. Australia needs a systematic, coordinated, policy-driven and evidence-based approach to improving access, which is one prerequisite to improving adolescents’ health. The rising problems of sexually transmitted infection, unwanted pregnancy, substance abuse, obesity, road accidents, depression and self-harm among adolescents demand that societies make adolescents’ access to health care a mainstream priority.