In this issue of the Journal, Scott and Coote provide an important contribution to a better understanding of one of the more significant Australian health policy changes of the past 20 years: the Divisions of General Practice (→ Wither Divisions of General Practice? An empirical and policy analysis of the impact of Divisions within the Australian health care system).1 Why this article is so significant in policy impact terms is that, according to the Australian Government:

This makes the Divisions the third component of the Australian national organised health care system, the other two being the public health/hospital and private insurance sectors. It is therefore a national disgrace how little is known about the impact of the Divisions of General Practice after 15 years of operation. It is in this context that the article by Scott and Coote is so critical.

A unique and key feature of the Divisions is that they are GP member owned and operated, regional health care organisations. This private ownership by a medical professional grouping is a unique approach to a national health structure, and is unlikely to be emulated by any other medical or allied health specialty group in the future. The Divisions have been allocated further core funding, as noted in the recent Australian Government budget papers:

Additional funding from various state governments and other sources is now growing more rapidly than the core Australian Government funding.

My Division, the Hunter Urban, is a typical Division with more than 10% of local GPs having participated in a leadership role at board level over the 15 years. The Division serves a population of more than 400 000, with over 420 GP members; more than 90% of GPs participate in any divisional service or clinical activity and 80% of GPs were involved in more than five service or clinical activities in 2006. The range of activity is very broad, and encompasses funding from over 10 different sources (both public and private), a budget of more than $10 million (of which Australian Government core funding is about $1.5 million), and services across a significant spectrum of GP activity, including practice infrastructure support.4

However, the burning question for 15 years has been, and continues to be, what do Divisions do and, more importantly, what impact do they have? Are taxpayers receiving value for their investment? What should that value look like and how might it be quantified?

The study by Scott and Coote involved “Regression analysis using longitudinal data across Australia”,1 and the first question it raises is why was such a complex tool necessary? A more conventional organisational analysis using targets and benchmarks set by the main funder (the Australian Government) should have been possible, particularly where a cumulative total of $2 billion or more of taxpayer funds have been expended over 15 years. Unfortunately, as the authors have noted, these data simply do not appear to exist — certainly not in readily analysable form.

Despite a major review of the Divisions undertaken in 2002–2003,5,6 which made recommendations related to the need for clarity in measuring performance and for a rigorous evaluation process, in 2006–07, the Divisions’ goals for core funding from the Australian Government remain couched in vague terms. In 2006–07, the agreement between the Australian Government and the Divisions, known as the Multi Program Funding Agreement, has a set of overall goals (Australian Government, Agreement plan for the funding period annual plan 07/08). These include:

• Governance: organisational capability, financial accountability, and governance;

• Prevention and early intervention: focus on prevention and early intervention;

• Access: improve access;

• Integration: encourage integration and multidisciplinary care;

• Chronic disease: better manage chronic conditions;

• General practice support: support GPs and general practices within a changing primary care environment;

• Quality support: support quality and evidence base;

• Consumer focus: ensure a growing consumer focus; and

• Workforce: support the recruitment and retention of an appropriate primary care workforce.

The only clearly specified funding-dependent target is organisational (organisational accreditation), with few other clearly targeted benchmarks for health or service outcomes. This lack of specificity in targeted outcomes is not unique to Divisions as, for example, an examination of the private health insurance sector (with an annual government subsidy expenditure in 1 year greater than Divisions over 15 years) also demonstrates how widespread the absence of service and health outcome data is.

So what does the article by Scott and Coote reveal and, particularly, what does it not reveal?

They report that Divisions have a positive effect at the infrastructure and organisational level and, in the absence of any other equivalently rigorous research, this now represents the best evidence we have for some aspects of the utility of Divisions of General Practice in 2002–2004. In an environment where workforce shortage and lack of patient access is a key issue, with improvements in infrastructure being seen as one of the main solutions, then the inference from the article is that Divisions should be increasingly funded to tackle the infrastructure and organisational deficits within general practice.

Critical to the analysis of the Divisions, and acknowledged by Scott and Coote, is that “Only a relatively narrow range of Divisions’ outputs and primary care performance was examined, because of a lack of data”.1 This lack of outcome measures clearly is an indictment of the lack of responsibility the government and its agency, the Department of Health and Ageing (DHA), take in monitoring their own performance as administrators of community resources. It represents an accountability deficit at government level. What is puzzling is that, in other DHA-administered program areas, there are clear, simple and effective measures of performance. This does not seem to extend to the Divisions program.

Service delivery forms a major part of the activity of many Divisions, particularly in rural areas. For example, under the More Allied Health Services program, rural Divisions are often the major or only suppliers of these services to their rural communities. As another example, in my region, the Hunter Urban Division is the default provider of ambulatory after-hours GP services, with more than 100 000 patient interactions each year delivered by more than 250 GPs and 60 nurses. Service delivery, as acknowledged by Scott and Coote, is the most rapidly growing part of divisional activity, and the relationship between Divisions and service provision needs something better than a “lack of data”, which implies a lack of performance indicators and targeted benchmarks to define its worth. My experience has been that individual Divisions and their peak bodies have been ready, willing and able to set and meet specific targets and it is the Australian Government and its bureaucracy that apparently is struggling with this facet of accountability.

So, where to from here? The first step is not more studies using regression analysis or research involving experimental and control groups. Australia has had far too much policy by trials (a phenomenon internationally unique to Australian health policymakers and their bureaucracies).

If, as I and many others believe, Divisions are the greatest single, positive, underutilised organisational health resource in our nation, and funding should match their potential for a much larger role in primary care health service delivery, then policymakers and governments need to put this to the test by establishing clear goals, with attached performance measures and targeted benchmarks that are open and transparent to all. We all have a right to see if what appears to be true is based on empirical evidence. It might well set an example for other health policy initiatives, which would have to meet the same challenge: transparent accountability to the Australian community. The article by Scott and Coote is a step in the right direction.